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68 Sexual functions in women with and their healthy spouses ______Original article / Araştırma

Sexual functions in women with bipolar disorder and their healthy spouses

Ali Metehan ÇALIŞKAN,1 Duygu GÖKTAŞ,1 Mehmet ARSLAN,1 İkbal İNANLI,1 Saliha ÇALIŞIR,1 İbrahim EREN1 ______

ABSTRACT

Objective: The aim of this study was to compare the sexual problem levels of female patients with bipolar disorder (BD) and their healthy spouses with those of healthy couples and to investigate potential factors that predict sexual problems. Methods: Sixty female outpatients with BD in remission and their healthy spouses were included in the study. All patients were under . Forty-five healthy couples comprised the control group. All participants were examined on a variety of clinical measures, including , marital adjustment, and sexual satisfaction. Results: Sexual satisfaction, communication and problems were higher for patients than for female controls. frequency, communication and total sexual problems were higher for patients’ spouses than for male controls. Logistic regression analyses for females revealed that sexual satisfaction was associated with age, depressive symptoms, and marital adjustment rather than presence of disorder. The sexual satisfaction was associated with marital adjustment rather than being spouse of a patient for males. Conclusions: After controlling for confounding factors, sexual problems of patients and their spouses are similar to those of controls. Treating the subsyndromal depressive symptoms of patients and using interventions to increase marital adjustment may improve the sexual functions of both patients and their spouses. (Anatolian Journal of 2019; 20(1):68-75)

Keywords: bipolar disorder, sexual functions, sexuality, marital adjustment

Bipolar bozukluk hastası kadınlarda ve sağlıklı eşlerinde cinsel işlevlerin değerlendirilmesi

ÖZ

Amaç: Bu çalışmanın amacı, bipolar bozukluk (BB) hastası kadınların ve sağlıklı eşlerinin cinsel işlev sorunlarını sağlıklı kontrollerle karşılaştırmak ve cinsel sorunları etkileyen olası öngördürücüleri belirlemektir. Yöntem: Çalışmaya BB’li 60 kadın hasta ve sağlıklı eşleri alındı. Tüm hastalar psikiyatrik tedavi görüyordu. Kontrol grubu olarak 45 sağlıklı çift alındı. Tüm katılımcılar sosyodemografik veriler, depresif belirtiler, evlilik uyumları ve cinsel işlevleri açısından değerlendirildi. Bulgular: Hastalarda cinsel doyum, iletişim ve orgazm sorunları sıklığı kadın kontrollerden daha yüksek saptandı. Hasta eşlerinde cinsel ilişki sıklığı, iletişim ve toplam cinsel sorun sıklığı erkek kontrollerden daha yüksek saptandı. Kadınlar için yapılan lojistik regresyon analizinde, cinsel sorunların yaş, depre- sif belirtiler ve evlilik uyumu ile ilişkili olduğu; ancak BB’nin olması ile ilişkili olmadığı saptandı. Erkekler için yapılan analizde, cinsel sorunların evlilik uyumu ile ilişkili olduğu, hasta eşi olmakla ilişkili olmadığı saptandı. Sonuç: Karış- tırıcı etkenler kontrol edildikten sonra, BB’li hastaların ve eşlerinin cinsel sorun sıklığının kontrollere benzer olduğu görülmüştür. Hastaların subsendromal depresif belirtilerinin tedavi edilmesi ve evlilik uyumunu artırmaya yönelik girişimlerde bulunulması hem hastaların, hem de eşlerinin cinsel işlevlerinde iyileşme sağlayabilir. (Anadolu Psiki- ______

1 Department of Psychiatry, Konya Training and Research Hospital, Konya, Turkey Correspondence address / Yazışma adresi: Mehmet ARSLAN, MD, Babaeski State Hospital, Dindogru district, street number 434, No.2, 39200 Babaeski/Kırklareli, Turkey E-mail: [email protected] Received: May, 15th 2018, Accepted: July, 20th 2018, doi: 10.5455/apd.299185 Anatolian Journal of Psychiatry 2019; 20(1):68-75

Çalışkan et al. 69 ______yatri Derg 2019; 20(1):68-75)

Anahtar sözcükler: Bipolar bozukluk, cinsel işlevler, cinsellik, evlilik uyumu ______

INTRODUCTION partners, so that a sexual problem of one partner can lead to in the other Bipolar disorder (BD) is a chronic disorder char- partner. Besides, sexual dysfunction may also acterized by recurrent depressive and manic/ cause partners sexual dysfunction via effecting hypomanic episodes that negatively affect social marital adjustment negatively. The aim of the and professional functionality.1 Various studies present study was to evaluate sexual function- have shown that most patients with BD also nality in female patients with BD and in their experience subsyndromal symptoms in euthy- healthy husbands and to investigate potential mic periods and that those symptoms are asso- factors affecting sexual functionality. ciated with decreased functionality in many areas.2-4 The literature on sexual functionality in METHODS BD is quite limited, and most data are derived from studies conducted several decades ago. Study setting and subjects

A negative association has been reported This study was conducted in the Konya Training between BD and sexual functionality.5,6 Hariri et and Research Hospital Psychiatry Clinic. al. reported that patients with BD in remission Subjects were selected among outpatients who experienced more sexual problems than did sequentially applied to the Mood Disorders Unit healthy controls.7 Likewise, Sorensen et al. from January 2015 to August 2015.Seventy two found that the sexual distress level was higher in married heterosexual female outpatients who female patients with BD than in controls.8 were treated in the Mood Disorders Unit and diagnosed with BD-I or II in remission according Psychotropic drugs used in BD treatment are to DSM-IV-TR, along with their healthy spouses known to cause sexual dissatisfaction.9,10 or physical disease were planned to be included Furthermore, subsyndromal symptoms experi- in the study. Twelve couples were not included enced during euthymic periods and the negative as they refused to take part in the study. Thus, consequences of the disorder can negatively 60 female patients and their healthy spouses affect sexual functionality.11 In addition, epi- were included in the study. The control group sodes are also reported to affect sexuality was 45 married healthy heterosexual couples through increases in and risky who were selected randomly. sexual behaviors during hypomanic and manic periods and decreases in sexual desire during Inclusion criteria for patients diagnosed with BD depressive periods.12 were: age between 18 and 65 years, being married to the same spouse for at least one year Self-reporting of sexual dysfunctions in the and being sexually active during the past one psychiatric patient population tends to be low month, being in the euthymic period for a mini- and is mostly disregarded by clinicians.13,14 How- mum six months (Hamilton Depression Rating ever, sexual dissatisfaction is associated with Scale [HDRS] score 7 or below, Young declines in quality of life, increased interpersonal Rating Scale [YMRS] score 5 or below) and relationship problems, impairments in marital using the same treatment for a minimum of two adjustment and treatment non-adherence.8,11,15 months. These intervals were determined ac- Sexual dissatisfaction, therefore can negatively cording to the arrangement of the final mainte- affect functionality and the course of BD. More- nance treatment. over, episodes can also be triggered by in BD, and sexual dysfunction can be a source of Inclusion criteria for the patients’ spouses were stress that triggers the episodes. To our know- age between 18 and 65 years and being physi- ledge, no study has yet been carried out in this cally and psychiatrically healthy. Healthy coup- area. les meeting the criteria for patients’ spouses were included as controls. To date, very few research studies have as- sessed sexual functionality in the partners of Exclusion criteria for all participants were any patients with BD, although a decline in the sexual known other medical diseases (e.g. , satisfaction level has been reported for the hypertension, thyroid disease, urological, infec- patients’ partners following the onset of the dis- tious, neurological and gynecological disorders order.16 Sexual functions are mutually affected in that can lead to sexual dysfunction), mental Anadolu Psikiyatri Derg 2019; 20(1):68-75

70 Sexual functions in women with bipolar disorder and their healthy spouses ______retardation, a history of drug addiction or abuse, v22.0 for Windows. and being pregnant or in postpartum period for Descriptive statistics, included the average, females. Patients with a history of sexual dys- standard deviation (SD) and median, were used function or hypersexuality before BD diagnosis for continuous data, whereas frequency and or diagnosed with any psychiatric Axis I disorder percentages were used for discrete data. The other than BD were also excluded. Kolmogorov-Smirnov/Shapiro-Wilk test was Informed signed consent was obtained from all conducted to evaluate the compliance of the participants for the research. Ethical approval data with a normal distribution. The chi-square/ was obtained from the Ethics Committee of the Fisher’s exact test was used to identify the differ- Selçuk University Faculty of Medicine ence between the frequencies of the discrete (2014/218). data. The two groups were compared using the Student’s t-test for continuous data with a normal Assessment instruments distribution and the Mann Whitney U test for Considering the objectives of the study, a continuous data without a normal distribution. sociodemographic data form was created by the The variables predicting the existence of sexual researchers and applied individually to the pa- problems were identified using logistic regres- tients, patients’ spouses and the control group. sion analysis for females and males. The vari- We administered the Hamilton Depression ables that were found statistically significant Rating Scale (HDRS, 17-item version) to assess (p<0.05) in the univariable logistic regression depressive symptom severity, the Young Mania were included in the multivariable logistic regres- Rating Scale (YMRS, 11-item version) to assess sion model (Enter Method). Age was also in- manic symptom severity, the Marital Adjustment cluded in the logistic regression models. Sexual Scale (MAS) to assess marital quality and the problems in one partner can affect the other Golombok Rust Inventory of Sexual Satisfaction partner, so all participants were matched with the (GRISS) to assess the sexual satisfaction level. GRISS total score of their partners and the All scales were used in the Turkish forms and the GRISS total score of the partner was also in- validity and reliability of all scales have been cluded in the regression analysis as a con- approved.17-20 founding factor. The Hosmer-Lemeshow test was used for the goodness of fit of the model. The MAS is a scale consisting of 15 items de- The significance level was taken as p<0.05 (two- signed by Locke and Wallace to measure marital tailed). quality.21 Higher scores from the scale indicates higher marital adjustment. RESULTS The GRISS is a scale designed to assess the quality of sexual intercourse in heterosexual The study group consisted of 49 (81.7%) pa- couples. It has two individual forms for females tients diagnosed with BD-I and 11 (18.3%) pa- and males, each consisting of 28 questions. The tients diagnosed with BD-II, all in remission. The female and male forms both include seven sub- average onset age of the disorder was 29.27± dimensions, with the following five being com- 10.61 years and the duration of disorder was mon to both forms: avoidance, satisfaction, com- 164.38±123.54 months. The average number of munication, touch and intercourse frequency. manic episodes, depressive episodes and total The female form includes and anor- episodes were 4.18±5.33, 4.80±6.46 and 12.02± gasmia, while the male form includes premature 12.38, respectively. All patients were under and impotence sub-dimensions. The medication when included in the study, with 14 raw scores can be subsequently converted into (23%) being treated with only mood stabilizers, standard scores ranging from 1 to 9, with scores 32 (53%) with a combination of mood stabilizers of 5 or above indicating sexual problems. and atypical antipsychotics, seven (12%) with only atypical antipsychotics, three (5%) with a The YMRS was applied to patients only, while combination of atypical antipsychotics and anti- the other scales were applied to all participants. depressants, two (3%) with a combination of The psychiatrists involved in the study carried mood stabilizers and and two out psychiatric assessment. (3%) with a combination of mood stabilizers, Statistical analysis antidepressants and atypical antipsychotics.

Statistical analyses were conducted using SPSS Patients were compared to healthy females (Statistical Package for the Social Sciences) while patients’ spouses were compared to Anatolian Journal of Psychiatry 2019; 20(1):68-75

Çalışkan et al. 71 ______healthy males. No statistically significant differ- cation, BMI or duration of marriage. The employ- ence was identified between the patients and ment ratio was lower in patients (p=0.005). healthy females or between the patients’ Details are given in Table 1 and 2. spouses and healthy males in terms of age, edu-

Table 1. Comparison of sociodemographic variables of patients and female controls ______

Patients (n=60) Female controls (n=45) Sociodemographic variables n % n % z/t/χ2 p ______

Age (year) 42.78±10.85 (41) 41.42±10.29 (44) 0.650a 0.517 Education Primary 45 75.0 34 75.6 Secondary/high school 14 23.3 7 15.6 3.595c 0.194 University 1 1.7 4 8.9 Body mass index 31.43±7.10 (30.39) 29.73±6.15 (30.46) -1.046a 0.296 Employment Employed 5 8.3 12 26.7 Unemployed 55 91.7 31 68.9 9.634c 0.005* Pensioner 0 0 2 4.4 Duration of marriage (month) 262.63±142.06 (217) 234.93±141.07 (240) -0.897b 0.370 ______a: Student’s t test; b: Mann-Whitney U test; c: Chi-square exact test. Continuous data are mean±standard deviation. *: Employed: patients>controls; Unemployed: patients

Table 2. Comparison of sociodemographic variables of spouses of patients and male controls ______

Spouses of patients (n=60) Male controls (n=45) Sociodemographic variables n % n % z/t/χ2 p ______

Age (year) 47.42±11.35 (45.50) 45.80±10.69 (45.0) -0.748 a 0.454 Education Primary 30 50.0 17 37.8 Secondary/High School 25 41.7 19 42.2 3.485 b 0.175 University 5 8.3 9 20.0 Body Mass Index 26.14±4.22 (25.39) 27.15±4.24 (27.44) -1.603 a 0.109 Employment Employed 42 70.0 34 75.6 Unemployed 3 5.0 2 4.4 0.408c 0.816 Pensioner 15 25.0 9 20.0 Duration of Marriage (month) 262.63±142.06 (217) 234.93±141.07 (240) -0.897a 0.370 ______a: Mann-Whitney U test; b: Chi-square test; c: Chi-square exact test. Continuous data are mean±standard deviation

In the patient group, the HDRS was statistically males (p<0.001). Problems in sexual intercourse significantly higher and the MAS score was frequency, communication and the GRISS total statistically significantly lower than in healthy were significantly higher in the patients’ spouses females (p=0.032, p<0.001 respectively). Prob- than in healthy males (p=0.001, p=0.002, lems in sexual communication, satisfaction and p=0.003 respectively). No difference was iden- anorgasmia were statistically significantly higher tified in terms of other variables. The results are in patients than in healthy female controls summarized in Table 4. (p=0.018, p=0.019, p=0.001 respectively). No The variables predicting the existence of sexual difference was identified in terms of GRISS total problems were identified using logistic regres- and the other subscales (Table 3). sion analysis for females and males. The vari- The MAS scores were statistically significantly ables that were identified statistically significant lower in the patients’ spouses than in healthy (p<0.05) in the univariable logistic regression Anadolu Psikiyatri Derg 2019; 20(1):68-75

72 Sexual functions in women with bipolar disorder and their healthy spouses ______were included in the multivariable logistic regres- the partners were also included in the models. sion model. The age and sexual satisfaction of The model applied to females revealed that,

Table 3. Comparison of clinical and sexual satisfaction variables of patients and female controls ______

Patients (n=60) Female controls (n=45) Clinical variables n % n % z/t/χ2 p ______

HDRS 1.88±1.40 (2) 1.33±1.28 (1) -2.14a 0.032 MAS 43.42±9.30 (45) 50.02±7.09 (51) -4.23a <0.001 Sexual problem according to GRISS Frequency Yes 49 81.7 30 66.7 3.11b 0.078 No 11 18.3 15 33.3 Communication Yes 34 56.7 15 33.3 5.62b 0.018 No 26 43.3 30 66.7 Touch Yes 41 68.3 25 55.6 1.80b 0.180 No 19 31.7 20 44.4 Satisfaction Yes 25 41.7 9 20.0 5.51b 0.019 No 35 58.3 36 80.0 Avoidance Yes 33 55.0 26 57.8 0.08b 0.776 No 27 45.0 19 42.2 Anorgasmia Yes 29 48.3 8 17.8 10.52b 0.001 No 31 51.7 37 82.2 Vaginismus Yes 0 0 2 4.4 2.72b 0.181 No 60 0 43 95.6 Total Yes 35 58.3 19 42.2 2.67b 0.102 No 25 41.7 26 57.8 ______a: Mann-Whitney U test; b: Chi-square test. Continuous data are mean±standard deviation. HDRS: Hamilton Depression Rating Scale; MAS: Marital Adjustment Scale: GRISS: Golombok Rust Inventory of Sexual Satisfaction

Tablo 4. Comparison of clinical and sexual satisfaction variables of spouses of patients and male controls ______

Spouses of patients (n=60) Male controls (n=45) Clinical variables n % n % z/t/χ2 p ______

HDRS 1.15±1.68 (0) 0.82±1.05 (0) -0.388a 0.698 MAS 42.65±9.41 (45) 50.07±4.74 (50) -4.406 a <0.001 Sexual problem according to GRISS Frequency Yes 45 75.0 20 44.4 10.18b 0.001 No 15 25.0 25 55.6 Communication Yes 34 56.7 12 26.7 9.40b 0.002 No 26 43.3 33 73.3 Touch Yes 27 45.0 12 26.7 3.70b 0.054 No 33 55.0 33 73.3 Satisfaction Yes 14 23.3 5 11.1 2.59b 0.107 No 46 76.7 40 88.9 Avoidance Yes 10 16.7 2 4.4 3.80b 0.051 No 50 83.3 43 95.6 ED Yes 21 35.0 8 17.8 3.82b 0.051 No 39 65.0 37 82.2 PE Yes 23 38.3 17 37.8 0.003b 0.954 No 37 61.7 28 62.2 Total Yes 36 60.0 14 31.1 8.60b 0.003 No 24 40.0 31 68.9 ______a: Mann-Whitney U test: b: Chi-square test. Continuous data are mean±standard deviation. HDRS: Hamilton Depression Rating Scale; MAS: Marital Adjustment Scale: GRISS: Golombok Rust Inventory of Sexual Satisfaction; ED: ; PE: . Anatolian Journal of Psychiatry 2019; 20(1):68-75

Çalışkan et al. 73 ______

Table 5. Logistic Regression Analysis to Predict Sexual Dissatisfaction ______

95% CI for EXP(B) p OR Lower Upper R2 HL p ______

Model for females Age <0.001 1.133 1.065 1.205 0.577 0.116 Group (patient vs. control) 0.308 0.545 0.170 1.748 HDRS 0.003 2.232 1.320 3.773 MAS <0.001 0.848 0.773 0.931 Spouses GRISS total 0.310 1.768 0.588 5.322 Constant 0.559 4.273 Model for Males Age 0.077 1.046 0.995 1.100 0.388 0.099 Group (spouses of patient vs. control) 0.447 1.454 0.555 3.810 MAS <0.001 0.854 0.783 0.932 Spouses GRISS total 0.714 1.229 0.407 3.710 Constant 0.032 119.11 ______

Dependent variable: absence or presence of sexual dissatisfaction. OR: Odds ratio; HL: Hosmer and Lemeshow. Model for females: χ2=59.48, df:5, p<0.001. Model for males: χ2=36.13, df:4, p<0.001. HDRS: Hamilton Depression Rating Scale; MAS: Marital Adjustment Scale; GRISS: Golombok Rust Inventory of Sexual Satisfaction.

after adjusting the confounding factors, sexual in terms of sexual dysfunction.8 Hariri et al. re- problems were associated with age, depressive ported that female patients with BD had a higher symptom level and marital adjustment while no problem level in only with vaginismus when association was found with presence of BD. The compared to controls, with no other differences model applied to males identified that sexual identified in other subscales.7 In contrast to problems were associated with marital adjust- these findings, a study by Dell’Osso et al. using ment but was not associated with being a spouse the Mood Spectrum Self-Report Questionnaire of patient (Table 5). reported that a higher lifelong sexual dysfunction rate in patients with BD than in healthy controls, DISCUSSION after controlling for age and gender.5 Factors such as the scales used, sociocultural features Our results revealed that sexual problems were of the study population, age, gender, presence identified in more than half of the female patients of any comorbid disease, and medication used with BD. The literature on sexual functionality in complicate the interpretation of results when BD is quite limited. A study carried out in the assessing sexual functionality. Turkish population by Hariri et al. reported that Our results also demonstrate that depressive the sexual dissatisfaction ratio was 57.3% in symptoms and marital incompatibility were patients with BD.7 In an another study using the higher in patients than in healthy female controls. GRISS revealed that %40 of female patients with The multivariate analysis for females revealed BD experienced sexual problems.22 that sexual satisfaction was associated with age, In our study, frequency of sexual problems ac- depressive symptom level and marital adjust- cording to GRISS total score was similar be- ment rather than presence of BD after controlling tween patients with BD and controls. The GRISS the confounders. Similarly, Namlı et al. evalu- subscales analysis identified that patients with ated patients with BD in remission and reported BD experienced more problems in terms of sexu- that sexual satisfaction was associated with al communication, satisfaction and anorgasmia. marital adjustment rather than presence of According to these results, although patients had disorder.22 Various studies have demonstrated problems at certain sexual domains, total sexual that sexual dissatisfaction was associated with satisfaction was similar to control group. Studies depression and marital adjustment.23-26 In the that evaluate sexual dysfunction in patients with literature, reported results indicate that the levels BD report inconsistent results. Sorenson et al. of depressive symptoms that cannot meet the found that the prevalence of sexual distress was threshold for syndromal depression are also as- higher in female patients with BD than in a sociated with sexual dysfunction.27,28 According control group, while no difference was reported to these result, poor sexual function identified in Anadolu Psikiyatri Derg 2019; 20(1):68-75

74 Sexual functions in women with bipolar disorder and their healthy spouses ______the patient group may be due to high depressive study population make comparisons of findings symptom level and poor marital adjustment. difficult. Our study has several limitations. The After controlling these variables, sexual dissatis- lack of psychiatric evaluation of patients and faction was not associated with presence of BD. control subjects with a structured clinical inter- Nevertheless, this result was surprising, as all view such as SCID-I is among the major limita- patients were under psychotropic treatments tions of our study. Our sample size was small. known to cause sexual dissatisfaction. Ac- levels were also not carried out. All cording to these results, interventions to treat patients were under medication when included in depressive symptoms and marital problems may the study. Another limitation is the study’s cross- decrease patients sexual problems. sectional design, which precludes inference of any causality relation from the findings. Additi- The number of studies assessing the sexual onally, only the couples who were able to main- functionality of patients’ spouses is quite limited. tain their marriages were included in the study, A study evaluating the spouses of patients with so this limits the generalizability of the findings. BD in remission (28 females, 37 males) sug- gested a decline in sexual satisfaction level in CONCLUSIONS patients’ spouses following the onset of the disorder.16 Similarly, our results revealed a high- Sexuality is a sensitive subject that is not easy er problem level in sexual intercourse frequency, for patients to discuss clearly. Evaluation of communication and GRISS total in patients’ sexual functions is important for the treatment spouses than in controls. management of patients with BD. Sexual prob- The multivariate analysis for males revealed that lems have a negative effect on quality of life and only impaired marital adjustment was associated can impair treatment adherence of patients. with sexual problems rather than being a spouse Based on the findings from the present study, the of patient with BD. Likewise, Lam et al. reported treatment of subsyndromal depressive symp- a positive correlation between sexual satisfac- toms of patients and interventions to increase tion and marital adjustment in spouses of their marital adjustment may decrease sexual patients with BD.29 Interventions to treat marital problems of both the patients and their spouses. problems may also decrease sexual problems of The present study is clinically important as it spouses of patients. assesses sexually active patients and their Sexual dissatisfaction often occurs as the result spouses together. Further studies are needed to of a complicated and multidirectional interaction. characterize the sexuality and the causality rela- Factors such as varying measurement tools tionships in patients with BD and their spouses. used in studies or sociocultural features of the

Authors’ contributions: A.M.Ç.: finding the issue, planning, conduction of the research; D.G.: planning, conduc- tion of the research, literature review; M.A.: finding the issue, conduction of the research, literature review, statistical analysis, writing of the manuscript; İ.İ.: literature review, statistical analysis, writing of the manuscript; S.Ç.: planning, conduction of the research, literature review; İ.E.: finding the issue, planning, writing of the manuscript.

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