Halt the ED-Depression Spiral


Men with erectile dysfunction (ED) often have comorbid symptoms of depression and anxiety. (1), (2), (3), (4), (5) These psychological symptoms may have etiological significance, or they may occur in reaction to ED symptoms. (6) In one study of 120 men presenting to a sexuality clinic, 33 percent reported high levels of depression and anxiety, with major depression being the most common diagnosis.(7) Of note, only about one-third of these men had been identified by their urologist as having a psychological concern. (7) In another study of 103 men with ED, 63 percent had a detectable psychiatric diagnosis, including 25 percent with depressive disorders, 12 percent with anxiety disorders, and 7 percent with depression-anxiety comorbidity. (8)

Depression is a frequent psychological comorbidity in men with ED. (4), (9) Three large, well-designed, population-based studies of aging men in the US, Finland, Brazil, Japan, and Malaysia have demonstrated the association between ED and depression. (2), (3), (10) Data from the Massachusetts Male Aging Study confirm that men aged 40 to 70 years with clinically significant depressive symptoms are nearly twice as likely to report ED than their nondepressed peers, controlling for important sociodemographic and medical factors. (2) ED is associated with a higher incidence of depressive symptoms independent of age, marital status, and comorbid medical conditions. (1) Men with depression and ED have lower libido than men with ED alone, and they are less likely to discuss their ED with their partners. (1), (8) The association between ED and depression is considered a bidirectional relationship in which the two conditions reinforce each other in a downward spiral. (2)

When studying men with prostate cancer, some authors have argued that depression or distress related to ED is mitigated as patients focus on the lifesaving nature of their treatment. (11) Nevertheless, data collected at MSK confirm depressive symptoms, ED “bother,” and loss of masculine identity in men with ED following prostate cancer treatments. We analyzed data from 339 men with prostate cancer and found a significant relationship between ED and depressive symptoms. (12) Further, in a longitudinal analysis of 183 men following prostate cancer surgery, we found that ED bother was a significant concern, and that men reported lower “general happiness in life” as a result of ED after radical prostatectomy (RP). (13)


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Anxiety and Sexual Performance

Anxiety is also an important concern, and it can play a role in the persistence of ED. For many men, erectile problems heighten sexual anxieties because of increased concerns about erectile response and durability leading up to and during sexual encounters. (5) This heightened focus on performance and self-conscious feelings are cognitive distractions that exacerbate problems with arousal and performance. (14), (15) These pressures increase the likelihood of failure and reinforce the pressure to perform during successive encounters, resulting in a vicious cycle of failure and escalating performance anxiety. (5) Ultimately, a man’s anticipation of failure may lead to his avoiding sex altogether, which may also interfere with other aspects of intimacy in his relationship.

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ED’s Effects on Relationships

Both partners are affected by the changes in their relationship that result from ED; they must adjust to those changes both as individuals and as a couple. Men and their partners report regret and feelings of loss in the face of sexual dysfunction. (16) Partner and relationship factors are important considerations in assessing men’s reactions to ED and the impact ED may have on their psychological well-being and quality of life.

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Avoidance of Treatment

Given the psychological consequences of ED, it is not surprising that many men have difficulty accepting that they have ED and delay pursuing treatment. (17) Although the embarrassment related to ED may be mitigated in men whose ED is caused by a medical condition or treatment (e.g., prostate cancer or certain prescription medications), many men delay seeking treatment, hoping that their ED will improve spontaneously. Only 50 percent of men who report an interest in ED treatment actually pursue it, (18) and a growing body of literature shows poor adherence to ED treatments.

Disappointment, shame, and relationship strain may adversely affect men’s ability to commit to and sustain the use of medications for ED. Data indicate that 50 to 80 percent of men discontinue their use of medical interventions (e.g., pills, injections, vacuum devices) for ED within a year. (19), (20) Phosphodiesterase-5 (PDE5) inhibitors are used to treat about 90 percent of men who seek ED treatment; however, despite the safety and efficacy of these agents, dropout rates are roughly 30 to 50 percent. (21), (22), (23) Although ED treatment may be discontinued for a number of reasons, men with a pattern of avoidance may be particularly prone to poor adherence. Avoidance may lead to chronic forms of ED and further prolong or exacerbate the negative effects of ED on emotional and relational well-being.

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Assessment and Referral

It is beyond the scope of clinicians treating ED to directly address and treat significant distress; however, assessing general levels of distress and mental health history may provide insight into their patients’ propensity for psychological difficulties. It is important for the clinician to determine whether a patient’s psychological functioning will permit a focused approach to ED treatment, or whether adjunct medical or psychosocial therapy should be started to hasten the recovery of erectile function. (24) A psychologist or mental health professional may be able to help address underlying psychosocial factors related to sexual difficulties, support the ED treatment plan, and promote good adherence.

Appointments are available five days a week. For further information about counseling services for patients struggling with issues of treatment-related sexual dysfunction or about the Psychiatry Service at MSK, please call Dr. Christian Nelson’s office at 646-888-0200 or visit www.mskcc.org.

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  1. Shabsigh R, Klein LT, Seidman S, et al. Increased incidence of depressive symptoms in men with erectile dysfunction. Urology 1998;52:848-852.
  2. Araujo AB, Durante R, Feldman HA, et al. The relationship between depressive symptoms and male erectile dysfunction: Cross-sectional results from the Massachusetts Male Aging Study. Psychosom Med. 1998;60:458-465.
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