International Journal of Impotence Research (2004) 16, 299–302 & 2004 Nature Publishing Group All rights reserved 0955-9930/04 $30.00 www.nature.com/ijir Case Report A case–control study of erectile dysfunction among men diagnosed with panic disorder WA Blumentals1*, A Gomez-Caminero1,*, RR Brown1, V Vannappagari2 and LJ Russo1 1Worldwide Epidemiology, GlaxoSmithKline Pharmaceuticals, Collegeville, Pennsylvania, USA; and 2Department of Epidemiology, University of North Carolina at Chapel Hill, McGavran-Greenberg Hall, Chapel Hill, North Carolina, USA The association between panic disorder and erectile dysfunction (ED) among men was examined in the Integrated Healthcare Information Services National Managed Care Benchmark Database (IHCIS). The IHCIS is a fully de-identified, HIPAA compliant database and includes complete medical history for more than 17 million managed care lives; data from more than 30 US health plans, covering seven census regions; and patient demographics, including morbidity, age and gender. A total of 60 949 ED cases and 243 796 controls were included for analysis. Unconditional logistic regression analyses were first performed to assess the crude risk of ED, and adjusted risks of ED that accounted for comorbid conditions and comedications. A second set of analyses measured the crude and adjusted risks after restricting the patient population to men who were diagnosed with panic disorder at least 1 month prior to an ED diagnosis. In the first set of analyses, men with panic disorder were observed to have more than a two-fold increase in risk for ED (OR ¼ 2.29, 95% CI ¼ 2.03, 2.58). After adjusting for comorbid conditions, a 52% increase in risk of ED was observed (OR ¼ 1.52, 95% CI ¼ 1.34, 1.72). Following subsequent adjustment for comorbidities and comedications, a 33% increased risk of ED was detected (OR ¼ 1.33, 95% CI ¼ 1.17, 1.51). In the second set of analyses studying panic disorder that preceded ED, only a 13% higher risk was noted (OR ¼ 1.13, 95% CI ¼ 0.97, 1.31). However, after adjusting for comorbid conditions, a 25% reduction in risk was observed (OR ¼ 0.75, 95% CI ¼ 0.64, 0.88). A 35% risk reduction was seen after adjusting for comorbidities and comedications (OR ¼ 0.65, 95% CI ¼ 0.56, 0.77). International Journal of Impotence Research (2004) 16, 299–302. doi:10.1038/sj.ijir.3901147 Introduction in the development and maintenance of sexual dysfunction.1 Kaplan3 found a high prevalence of panic disorder Approximately 5–20% of men are estimated to have among patients with active sexual aversion, but the moderate–to-severe erectile dysfunction (ED) and up study did not look into the association between ED 1 to 70% of them are not treated. The prevalence of and panic disorder. Sbrocco et al,4 in their case ED also varies depending on the age of study report involving three men with panic disorder participants, from 2 to 9% in men younger than and ED hypothesized that there is a significant over- 40 y; 10–71% among men older than 70 y to 18–86% lap between panic disorder symptoms and sexual 2 among men older than 86 y. Variability in the arousal sensations, which may lead to sexual prevalence of ED may reflect differences in defini- avoidance in patients with panic disorder. In their 1,2 tions, methodology, and study populations. assessment of 35 patients with erectile difficulties The long-standing psychological assumption is they found that three patients also had panic that anxiety and sexual arousal are mutually disorder. For these three cases, retrospective reports inhibitive and that chronic anxiety is important indicated that the erectile problems were preceded by panic attacks. Nevertheless, these were case reports and thus can be viewed as a preliminary study requiring additional research. 5 *Correspondence: WA Blumentals, PhD, 5421 Balsam Figueira et al retrospectively assessed the sexual Place, #203 Mason, OH 45040, USA. function and sexual history of 30 patients with E-mail: [email protected] social phobia and 28 patients with panic disorder. Received 16 June 2003; revised 9 August 2003; accepted 8 A semistructured interview was used to make the September 2003 diagnosis of panic disorder and social phobia. Panic disorder and ED WA Blumentals et al 300 Participants were interviewed to collect informa- tics, psychotropics, central nervous system depres- tion on sexual history. Panic disorder patients sants, and narcotic analgesics; benign prostatic reported a significantly higher number of sexual hyperplasia, prostate cancer, hypertension, depres- disorders as compared to social phobia participants sion, diabetes, diabetic neuropathy, hyperlipidemia, (21/28 vs 10/30). Sexual aversion disorder was most multiple sclerosis, Parkinson’s disease, spinal cord frequently found in panic disorder patients (12/28) injury, and renal failure. Among men diagnosed and premature ejaculation was most common in the with panic disorder, those patients with the follow- social phobia group (9/19). Out of the 14 male ing were excluded: acute stress reaction, transient patients with panic disorder and sexual disorders, adjustment reaction, neurasthenia, psychophysiolo- one reported ED. The study had a small sample size, gical disorders, and separation anxiety. These con- the problem of recall bias, and only one patient with ditions could potentially exacerbate the true both panic disorder and ED. Hence, it is difficult to association between panic disorder and ED. draw any conclusions about the relationship between 6 the two. Okulate et al studied the prevalence and Analysis predictors of ED among 829 Nigerian military men ranging in age from 18 to 69 y. ED was assessed using the International Index of Erectile Function Ques- All risk analyses were performed utilizing uncondi- tionnaire; and the Patient Health Questionnaire was tional logistic regression models with SASs statis- used to screen for depression, alcohol abuse, and tical software. Two sets of analyses were performed. panic disorder (based on DSM-IV criteria). A total of The first set did not consider when panic disorder 329 out of 829 men (40%) had ED, and 10/829 (1%) was diagnosed in relation to the ED diagnosis date, had panic disorder. Of the 329 men with ED, two had and the second set of analyses was restricted to men panic disorder. Multivariate analysis indicated that with a diagnosis of panic disorder at least 1 month panic disorder was not a predictor of ED. However, before a diagnosis of ED. In both sets of analyses, since only two men experienced panic disorder and crude and adjusted odds ratios were computed. ED, no conclusions can be reached from this analysis. The adjusted odds ratios were based on models This study seeks to better understand the magni- that adjusted for all likely disease comorbidities; tude of association between panic disorder and ED and subsequently, comorbidities and comedications. and attempts to elucidate any causal link that may exist between the two disorders. Results Materials and methods As seen in Table 1, the mean age of cases in the first set of analyses was 51.6 y compared to a mean age of A case–control study was conducted to assess the relationship between panic disorder and ED among patients observed in the Integrated Healthcare Table 1 Descriptive characteristics of the cases and controls— Information Services National Managed Care Bench- first set of analyses mark Database (IHCIS) from January 1, 1997 through Study population Cases Controls March 31, 2002.. (n ¼ 304 745) (n ¼ 60 949) (n ¼ 243 796) Cases Age at ED diagnosis Mean age in y (s.d.) 51.6 (11.5) 56.6 (11.4) Panic disorder 427 (0.7%) 750 (0.3%) A total of 427 patients with panic disorder and ED Cigarette smokers 2076 (3.4%) 4751 (1.9%) were identified based on ICD-9 diagnosis codes in Prostate cancer 4014 (6.6%) 9013 (3.7%) Hypertension 23 316 (38.3%) 89 928 (36.9%) the IHCIS, of which only 210 had the panic disorder Depression 2235 (3.7%) 4113 (1.7%) diagnosis at least 1 month prior to the ED diagnosis. Diabetes 11 190 (18.4%) 34 194 (14.0%) Diabetic neuropathy 1509 (2.5%) 3301 (1.4%) Hyperlipidemia 24 026 (39.4%) 82 781 (34.0%) Controls Multiple sclerosis 288 (0.5%) 544 (0.2%) Parkinson’s disease 215 (0.4%) 1138 (0.5%) Spinal cord injury 703 (1.2%) 2297 (0.9%) Controls. were matched to cases using a 5-y window Renal failure 813 (1.3%) 3530 (1.4%) on age, where the age of a case was determined at ED Diuretic users 5578 (9.2%) 22 326 (9.2%) diagnosis date. Four times the number of cases were Psychotropic users 8718 (14.3%) 23 073 (9.5%) Central nervous system 74 (0.1%) 298 (0.1%) selected, and thus 243 796 controls were included depressant users for analyses. Narcotic analgesic users 16 567 (27.2%) 44 600 (18.3%) Potential confounding variables included age at ED diagnosis; cigarette smoking; ever use of diure- s.d. ¼ standard deviation. International Journal of Impotence Research Panic disorder and ED WA Blumentals et al 301 Table 2 Association between panic disorder and ED—first set of Table 3 Descriptive characteristics of the cases and controls— analysesa second set of analyses Association OR (95% CI) Study population Cases Controls (n ¼ 304 518) (n ¼ 60 722) (n ¼ 243 796) Model 1: Panic disorder and ED (crude) 2.29 (2.03, 2.58) Model 2: Panic disorder and ED (adjusted 1.52 (1.34, 1.72) Age at ED diagnosis for disease risk factors) Mean age in y (s.d.) 51.6 (11.5) 56.6 (11.4) Model 3: Panic disorder and ED (adjusted 1.33 (1.17, 1.51) Panic disorder 210 (0.3%) 750 (0.3%) for disease risk factors and medications) Cigarette smokers 2063 (3.4%) 4751 (1.9%) Prostate cancer 3991 (6.6%) 9013 (3.7%) a Model 2 is adjusted for: age at ED index date, cigarette smoking, Hypertension 23 217 (38.2%) 89 928 (36.9%) Depression 2172 (3.6%) 4113 (1.7%) benign prostatic hyperplasia, prostate cancer, hypertension, Diabetes 11 162 (18.4%) 34 194 (14.0%) depression, diabetes, diabetic neuropathy, hyperlipidemia, multi- ple sclerosis, Parkinson’s disease, spinal cord injury, and renal Diabetic neuropathy 1505 (2.5%) 3301 (1.4%) failure.