Background: Sexual dysfunction is remarkably prevalent amongst psychiatric patients than general population. This might be due to either the nature of the illness itself or the unwanted effect of the medication they are taking for the illness which limits the capability of forming interpersonal and sexual relationships. This issue is rarely raised in developing countries, and the aim of this study was to assess magnitude and factors contributing to sexual dysfunction among patients with Schizophrenia. Method: Hospital based cross sectional study was conducted at Amanuel Mental Specialized Hospital from January to June 2017. The sample required for this study was determined by using single population proportion formula and the final sample size was 423; and systematic random sampling was used to select participants. We used Change in Sexual Functioning Questionnaire to measure sexual dysfunction. The collected data was cleaned, interred in to Epi data and transferred to SPSS version 20 for farther analysis. The OR with 95% CI was used to measure association and P-value < 0.05 was used as statistically significant. Result: A total of 422 patients with Schizophrenia were involved in the study. The prevalence of General Sexual dysfunction was 82.7%; and in male and female patients the prevalence was 84.5 and 78.6% respectively. Marital status (Unmarried, Divorced and widowed, history of relapse and poor quality of life were associated significantly to global sexual dysfunction. Conclusion: The magnitude of Sexual dysfunction was found to be high among patients with schizophrenia and it is associated with different factors like unmarried, divorced, widowed, relapse and poor quality of life. Treating physicians should be conscious to sexual dysfunction during evaluation and treatment of patients with Schizophrenia. Special attention should be given to single, divorced, widowed patients and patients with history of relapse to improve quality of life of this patients. Keywords: Sexual dysfunction, Schizophrenia, Amanuel hospital Background among men are erectile dysfunction and premature Sexual life is a natural and complex component of hu- ejaculation. Any problem in main area of sexual behav- man behaviors that is determined by many physiological ior; interest, arousal, orgasm/ejaculation and like can and psychological factors. Sexual dysfunction is a public arise as the result of either pathophysiological or psycho- health issue which affects an estimate of 43% women logical mechanisms . and 31% men in US . The commonest dysfunction Sexual dysfunction is extremely prevailing in psychi- among women is sexual desire dysfunction complained atric patients than general population. This is related to by around 30 % of women. The commonest dysfunctions either the nature of the illness itself (negative symptoms like avolition, anhedonia and blunted affect) or the un- wanted effect of the medication they are taking for the * Correspondence: email@example.com illness (effect on prolactin secretion and obesity) which Amanuel Mental Specialized Hospital Research and Training Department, Addis Ababa, Ethiopia Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Fanta et al. BMC Psychiatry (2018) 18:158 Page 2 of 9 limits the capability of forming interpersonal and sexual Population relationships . All patients with Schizophrenia who are on follow up at The peak age of onset of schizophrenia in both AMSH are the source populations and people with sexes is during the reproductive period. Consequently Schizophrenia in the age group 18 & above who were on impaired sexual functioning among persons with treatment at AMSH during the study period were study schizophrenia can affect their ability to have a family, population. and, thus, to fulfill traditional social expectations . The role of antipsychotic drugs in sexual functioning Eligibility criteria of people with schizophrenia is becoming a recent All patients with Schizophrenia in age group 18 and concern of researchers since this side-effect may de- above were included in the study and the patients in ex- crease adherence to treatment, especially among acerbation phase were excluded from the study. males, because they are more concerned about sexual functioning than females) . Sample size Sexual dysfunction has many impacts on patients The minimum number of sample required for this study with Schizophrenia. It has direct or indirect associ- wasdetermined by using single population proportion ation with quality of life, adherence, difficulty to form formula and the final sample size for this study with 10% and maintain family, and lastly may develop depres- nonresponse rate was 423. sion and suicidality [3, 5, 6]. Despite the importance and high prevalence of the Sampling procedure problem, this patients do not inform the problem either Systematic random sampling technique with interval of due to feeling of discomfiture or for the reason that they 11 was used to select the participants from 4885 patients do not view it as a treatable problem . In other hand with schizophrenia came for follow up during data col- psychiatrists and other specialists significantly under- lection period. value or even neglect the existence of the problem prob- ably due to embarrassment of talking about sexual Study variables problems with patients, lack of time and viewing difficul- The outcome variable for this study was Sexual Dysfunc- ties in this area as minor compared to psychotic symp- tion. Socio-demographic factors, duration of the illness, toms. In spite of these realities there are limited or no duration on treatment, medication, dosage and fre- researches conducted in this country regarding sexual quency, comorbid known chronic medical illness, history dysfunction and its influence on patients with Schizo- of admission and relapse, adherence to drug, Quality of phrenia. Therefore, this study aims to evaluate the life, Suicide, Depression and history of substance use prevalence of sexual dysfunction among patients with were explanatory variables for this study. schizophrenia and see if there is any association between socio-demographic factors, different clinical factors like Instruments medication related factors, co-morbid physical or psychi- The gold standard instrument which is Structured Clin- atric conditions, and substance use and sexual dysfunc- ical Interview for DSM- ΙѴ-TR axis Ι disorders (SCID) tion among patients with Schizophrenia. was used to confirm a diagnosis of Schizophrenia. Sexual dysfunction was measured by using Changes in Sexual Methods Functioning Questionnaires (CSFQ-14). It has separate Study design and study period forms for female (CSFQ –F-C) and for Male Institutional based cross sectional study was conducted (CSFQ-M-C) Clinical Version. It contains14 items and is from January to June 2017. used to assess the presence/absence of sexual dysfunc- tion in study participants. All the 14 items should be an- Study area swered on a five Likert scale to assess global sexual The study was conducted at Amanuel Mental Special- dysfunction. The score < =47 for male and < =41 for fe- ized Hospital (ASMH) located in the country’s capital, male indicates the presence of global sexual dysfunction. Addis Ababa. Amanuel mental specialized hospital is the The tool can also measure the sexual dysfunction com- only mental specialized hospital where patients mainly ponents: Pleasure (Item 1), Desire/frequency (Item 2 and afflicted with severe mental illness, including schizo- 3), Desire/interest (Item 4, 5 and 6), Arousal/erection phrenia, are treated. The hospital gives service for pa- (Item 7, 8 and 9) and Orgasm/ejaculation (Item 11, 12 tients from all over the country. It has a case load of and 13) It has Cronbach’s α of 0.91 and 0.93 for male more than 10,000 patients per month and schizophrenia and female scales, respectively [7, 8]. WHOQOL-BREF is the number one diagnosis, diagnosed in more than was used to measure quality of life. This instrument is 60% of the patients visiting the hospital. cross culturally validated and currently in use in Fanta et al. BMC Psychiatry (2018) 18:158 Page 3 of 9 Fig. 1 Antipsychotic Medications prescribed for the participants different languages . PHQ-9 was used to measure de- Data processing and analysis pression in patients with schizophrenia. This instrument Data was coded and entered to Epi data and transferred has sensitivity of 86% and specificity of 67%in diagnosing to Statistical Package for Social Sciences version 20 depression . Eight –item Morisky medication adher- (SPSS-20) for further analysis. Descriptive statistical ana- ence Scale was used to measure medication adherence. lysis was used to estimate the frequencies and percent- It is valid and reliable with Cronbach’s α of 83%; and, ages of the variables. Bivariate and multivariate logistic sensitivity and specificity of 93 and 53% respectively regression analysis was used to see the association be- . The English version of the instruments was trans- tween outcome and explanatory variables. The strength lated to local language and back retranslated to English of the association was measured by odds ratio with 95% by language professionals and psychiatrists. CI and P-value less than 0.05 was considered as statisti- cally significant. Data quality control Ethical consideration 17 masters level mental health students were hired for Ethical clearance was obtained from Amanuel Mental data collection and two masters level mental health pro- Specialized Hospital Ethical Review Committee. The fessionals were hired to supervise the data collectors. Four Item Abbreviated Mental Test (AMT4) was used The data collectors were given a two days training on to measure the capacity of the patient to give consent. questionnaire and way of assessment. Pre-test was con- Then the purpose, importance and confidentiality of the ducted 15 days before the start of actual data collection information gathered was explained to each of the com- to know the time needed to complete one questionnaire petent participant before the start of interview. Partici- and to know whether the questionnaire used is under- pants were also informed that they will never get any standable to the study participants or not. The data col- benefit because of participation in the study and no lected during the pre-test was not included in the final harm on them if they would not agree to participate or analysis. withdraw from participation during the data collection Fig. 2 Medications prescribed for comorbid psychiatric problems Fanta et al. BMC Psychiatry (2018) 18:158 Page 4 of 9 Table 1 Distribution of participants by socio-demographic factors and clinical factors No. Variables Variables category Frequency (422) Percentage (100%) 1 Age 18–24 35 8.3 25–34 174 41.2 35–44 150 35.5 > = 45 63 14.9 2 Sex Female 132 31.3 Male 290 68.7 3 Marital Status Married 154 36.5 Single 224 53.1 Divorced and Widowed 44 10.4 4 Ethnicity Oromo 140 33.2 Amhara 126 29.9 Gurage 98 23.2 Others* 58 13.7 5 Religion Orthodox 228 54 Protestant 79 18.7 Muslim 115 27.3 6 Educational Status No formal education 31 7.3 Primary school 137 32.5 High School 164 38.9 Diploma 46 10.9 Degree and above 44 10.4 7 Occupation Private 135 32 Governmental 42 11.1 Unemployed 142 33.6 Others(House wife, Daily labourers) 98 23.2 8 Residence Urban 353 83.6 Rural 69 16.4 9 Frequency of Chlorpromazine per day Once/day 149 81.0 >= 2 35 19 10 Frequency of Haloperidol per day Once/day 46 75.4 > = 2 15 24.6 11 Frequency of Trifluoperazine per day Once/day 3 60 > = 2/day 2 40 12 Frequency of Fluphenazineper day Once/month 91 98.9 > = 2/month 1 1.1 13 Frequency of Resperidone per day Once/day 71 64.5 > = 2/day 39 35.5 14 Frequency of Olanzapine per day Once/day 5 62.5 > = 2/day 2 37.5 15 Frequency of Thioridazine per day Once/day 20 100 > = 2/day 0 0 16 Duration of the illness <=5 years 174 41.2 6-10 years 119 28.2 > = 11 years 129 30.6 Fanta et al. BMC Psychiatry (2018) 18:158 Page 5 of 9 Table 1 Distribution of participants by socio-demographic factors and clinical factors (Continued) No. Variables Variables category Frequency (422) Percentage (100%) 17 Duration on treatment <=5 years 207 49.1 6-10 years 103 24.4 > = 11 years 112 26.5 18 Admission No 254 60.2 Yes 168 39.8 19 Number of admission <=1 96 57.1 > = 2 72 42.9 20 Relapse No 226 53.6 Yes 196 46.4 21 Number of relapse <=1 96 49 > = 2 100 51 22 Depression No 346 82 Yes 76 18 23 Non-Adherence No 203 48.1 Yes 219 51.9 24 Poor Quality of life No 217 51.4 Yes 205 48.6 Yes 0 0 25 Suicidal Ideation No 373 88.4 Yes 49 11.6 26 Suicidal Attempt No 406 96.2 Yes 16 3.8 process. Finally, their willingness to be involved in the participants 290(68.7%) were male and 132(31.3%) were study was asked and written consent was obtained. female in gender. The mean age of the participants is At the time of data collection the investigator, super- 35.46 with ± 9.25 standard deviation. Majority of the visor and data collectors followed ‘code of ethics’ and participants 353(83.6%) were from urban area. The most obeyed the rules & regulations of the hospital. Partici- frequently prescribed antipsychotic drug is chlorpromaz- pant’s privacy was kept strictly at the time of data ine 184(43.6%) followed by Resperidone 111 (26.3%) collection. (Fig. 1). Amitriptyline is the most frequently prescribed drug among the medications ordered for other comorbid Result psychiatric conditions 42(41.6%) followed by Fluoxetine A total of 422 patients with schizophrenia participated 27(26.7%) (Fig. 2). Most of the participants take their on the study with response rate of 99.76%. Among the medications once in twenty four hours (Table 1). Among Fig. 3 Magnitude of Chronic Medical Illness among Patients with Schizophrenia Fanta et al. BMC Psychiatry (2018) 18:158 Page 6 of 9 Fig. 4 Magnitude of Substance Use among Patients with Schizophrenia the study participants, 23(5.5%) were found to have at dysfunction among male participants was 246(84.5%) least one comorbid other medical illness. The most fre- with 95% confidence interval of (80.3, 88.7) and it was quently occurring chronic medical illness in patients 103(78.6%) with 95% confidence interval of (71, 84.7) in with Schizophrenia is Diabetes Mellitus 10(2.4%) female Schizophrenic patients (Fig. 5). Erectile dysfunc- followed by Tuber Closes (TB) 8(1.9%) (Fig. 3). Among tion 277(95.2%) is highly prevalent followed by pleasure the substance users 71(16.8%) use cigarette and khat dysfunction 274(94.2%) in male participants (Fig. 6). In users were 71(16.8%) (Khat and Cigarette are equally female participants who had sexual dysfunction the most consumed) (Fig. 4). The median score of duration of the prevalent sexual dysfunction was pleasure dysfunction illness is 7 years with inter quartile range of 6, and the 125(94.7%) followed by arousal/excitement dysfunction median score of duration on treatment is 6 years with 123(93.2%) (Fig. 7). inter quartile range of 10. The median score for fre- quency of admission is 1 with inter quartile range of 1, and the median score for frequency of relapse is 2 with Bivariate and multivariate analysis inter quartile range of 2. The mean score of Quality of After bivariate logistic regression analysis, five vari- Life of the participants is 60.59 with standard deviation ables (Marital status, Resperidone use, Relapse, of ± 9.43 (Table 1). Depression and Quality of life) met the requirement to proceed to multivariate logistic regression analysis. Prevalence of sexual dysfunction among patients with After multivariate analysis, marital status, history of schizophrenia relapse, and quality of life were found to be signifi- The prevalence of General sexual dysfunction among cantly associated with global sexual dysfunction. Com- the study participants was 349(82.7%) with 95% confi- pared to the married ones, being single, [aOR 4.19, dence interval of (78.9, 86.3). The overall sexual 95% CI (2.30, 7.64)], and being divorced [aOR 2.86, Fig. 5 Global sexual Dysfunction and sexual Dysfunction across Male and Female participants Fanta et al. BMC Psychiatry (2018) 18:158 Page 7 of 9 Fig. 6 Components of Sexual Dysfunction among male participants 95% CI (1.03, 7.90)] were significantly associated with significant difference may be explained by socio-cultural Generalsexualdysfunction.History of relapse, [aOR difference and difference in measurement instrument to 2.21, 95% CI (1.25, 3.91)], and poor quality of life, assess sexual dysfunction. In case of the study conducted [aOR 5.57, 95% CI (2.79, 11.09)] were also signifi- in Britain, they used Sexual Functioning Questionnaire cantly associated with General sexual dysfunction at (SFQ) to assess sexual dysfunction, and the study con- p-value< 0.05 (Table 2). ducted in Iran used Arizona Sexual Experience Scale (ASEX) [12, 13]. Discussion Prevalence of sexual dysfunction among male Schizo- This study found that magnitude of General sexual dys- phrenic patients in our study which is 84.5% in lines function, and sexual dysfunction across male and female with the study conducted by Macdonald in which the patients with Schizophrenia is extremely high and needs magnitude of sexual dysfunction in male Schizophrenic immediate intervention. The prevalence of general sex- patients is 82% . Magnitude of sexual dysfunction ual dysfunction among patients with Schizophrenia in among female schizophrenic patients in this study which this study is supported by the comparative study con- is 78.6% is lower than that of Macdonald in which ducted in Egypt on paranoid and non-paranoid schizo- prevalence of sexual dysfunction among female schizo- phrenic patients in which Prevalence of general sexual phrenic patients is 92%, and is higher than that of USA dysfunction was 80% in patients with paranoid schizo- and Turkey in which prevalence of female sexual dys- phrenia and 86.7% in patients with non-paranoid Schizo- function is 59 and 68% respectively [14–16]. The reason phrenia . The magnitude of general sexual for the discrepancy is probably due to difference in cul- dysfunction in this study is very high when compared to ture and living style which may differ in different coun- the study conducted in Britain and Iran which was 45 tries and population. Difference in measurement tool to and 31.1% respectively [12, 13]. The reason for this assess sexual dysfunction in this particular population is Fig. 7 Components of Sexual Dysfunction among Female Participants Fanta et al. BMC Psychiatry (2018) 18:158 Page 8 of 9 Table 2 Factors Associated With Sexual Dysfunction Among Patients With Schizophrenia At Amanuel Mental Specialized Hospital/2017 Explanatory Variables Sexual Dysfunction Bivariate and Multivariate Analysis P-Value variables category Absent Present Bivariate Analysis Multivariate Analysis COR (95% CI) aOR (95% CI) Marital Status Married 44 110 1:00 1:00 Single 23 201 3.49(2.01,6.10) 4.19(2.30,7.64) 0.000 Divorced and 6 38 2.53(1.00,6.6.42) 2.86(1.03,7.90) 0.043 Widowed Resperidone No 62 249 1.00 1.00 Yes 11 100 2.264(1.15,4.48) 1.69(0.82,3.51) Relapse No 30 196 Yes 43 153 1.84(1.10,3.06) 2.21(1.25,3.91) 0.007 Depression No 67 279 1.00 1.00 Yes 6 70 2.80(1.17,6.72) 1.49(0.58,3.83) Quality of life Good 60 157 1.00 1.00 Poor 13 192 5.64(2.99,10.66) 5.57(2.79,11.09) 0.000 also possible reason for observed difference. In case of Olfson and Kandrakonda S [18, 19]. This may be due to USA they used the Global Impression of Sexual the fact that an inproper sexual functioning may affect Function (GISF) and in Turkey they used Arizona Sexual maintaining a satisfying intimate relationship which is Experience Scale (ASEX) to assess sexual dysfunction the major component of Quality of life. [15, 16]. Another possible reason for the difference might be criterion used to include the participants in the Conclusion study. The study conducted in USA included patients Prevalence of Sexual dysfunction is found to be high who were on conventional antipsychotics and Resperi- among patients with Schizophrenia and it needs special done where as in our study all schizophrenic patients on attention. The current prevalence of general sexual dys- any antipsychotic medication were included in the study function among Schizophrenic patients in our study is . Sample size difference across the studies is also high. Regarding sexual dysfunction across sex, male and possible reason for the discrepancy. Among the factors female sexual dysfunction was also high. Among the hy- hypothesized to be contributing factors to sexual dys- pothesized factors to be risk factors for sexual dysfunc- function, unmarried participants were four times more tion, marital status (single, divorced, widowed), history likely to develop sexual dysfunction compared to mar- of relapse and poor quality of life were significantly asso- ried participants and Divorced and widowed participants ciated with sexual dysfunction. were three times more likely to develop sexual dysfunc- tion compared to married participants. This finding is supported by the study conducted in Nigeria . The possible reason for the association is that the infrequent Recommendation sexual activity in single and divorced/widowed individ- To Amanuel Mental Specialized Hospital. uals probably decreases frequency of sexual desire. Hav- All Psychiatrists and mental health specialists have to ing history of relapse exposes two times more to sexual be conscious to sexual dysfunction which is highly dysfunction compared to the patients without history of prevalent among the patients they are treating, and all relapse. This may be explained by, the more the relapse patients who are on follow up at this hospital for the is frequent the more the illness becomes deteriorated case of Schizophrenia should be screened for sexual dys- with predomination of negative symptoms of Schizo- function. The overall treatment and care delivered by phrenia which potentially affect sexual performance. The the hospital should focus on improving quality of life by need for higher doses of antipsychotics in case of fre- diagnosing and managing sexual dysfunction properly, quent relapse is also another possible reason for this sig- rather than focusing only on decreasing the symptom nificant association. In this study sexual dysfunction is of the illness. Special consideration should be given found to be highly associated with poor quality of life. to a patients with history of relapse, single, widowed This result is supported by the study conducted by and divorced. Fanta et al. BMC Psychiatry (2018) 18:158 Page 9 of 9 Abbreviations 6. Hashem A.H., Abd El-Gawad T., Ezzat M., Assal A., Goueily T. and El Rakhawy AMSH: Amanuel Mental Specialized Hospital; CSFQ: Changes in Sexual M. A comparative study of sexual function in paranoid versus non-paranoid Functioning Questionnaires; PHQ-9: Patients Health Questionnaire nine; schizophrenic patients and its relation to serum prolactin Level.Current SD: Sexual Dysfunction; SMI: Severe Mental Illness; SPSS: Statistical Package of psychiatry. Vol 13. No. 2. July 2006. Social Science; USA: United States of America; WHOQOL: World Health 7. Maria Paz Garcia-Portilla, MD, PhD et al. Psychometric properties of the Organization Quality of Life Spanish version of the changes in sexual functioning questionnaire short- form (CSFQ-14) in patients with severe mental disorders. International Society for Sexual Medicine J Sex Med 2011;8:1371–1382.. Acknowledgements 8. Liu-Seifert H, Kinon BJ, Tennant CJ, Sniadecki J, Volavka J. Sexual dysfunction We are grateful to the data collectors and supervisors for their unreserved in patients with schizophrenia treated with conventional antipsychotics or effort. Our gratitude also goes to Amanuel Mental Specialized Hospital for risperidone. Neuropsychiatr Dis Treat. 2009 Apr 8;5:47–54. funding this study. Finally we are grateful to the study participants for their 9. Oyekanmi AK, Adelufosi AO, Abayomi O, Adebowale TO. Demographic and patience. clinical correlates of sexual dysfunction among Nigerian male outpatients on conventional antipsychotic medications. BMC research notes. 2012 Jun Funding 7;5(1):1. Funding for this study was provided by Amanuel Mental Specialized 10. Olfson M, Uttaro T, Carson WH, Tafesse E. Male sexual dysfunction and Hospital. quality of life in schizophrenia. J Clin psychiatry. 2005 Mar;66(3):331–8. 11. Kandrakonda S, Jally MR, Kesava Reddy SR, Miryala G. Prevalence of sexual Availability of data and materials dysfunction in patients with mental illness receiving psychotropic The datasets used and/or analysed during the current study are available medication. AP J Psychol Med. 2014;15(2):235–9. from thecorresponding author on reasonable request. 12. CLAYTON ELMaAH. Reliability and construct validity of the changes in sexual functioning questionnaire short-form (CSFQ-14):. Journal of Sex & Authors’ contributions Marital Therapy,. 2006;32:43–52. Departments of Psychiatric Medicine & Health TF involved in designing and coordinating overall progress of the study; KH, Evaluation Sciences, University of Virginia, Charlottesville, Virginia, USA. 1 2 DA , GH and DA equally contributed in the design of the study, performed 13. WHO. WHOQOL, user manual, division of mental health and prevention of the statistical analyses and critically revised the manuscript. All authors read substance abuse. Geneva, Switzerland.. 1998. and approved the final manuscript. 14. Gelaye B, et al. Validity of the patient health Questionnaire-9 for depression screening and diagnosis in East Africa. Psychiatry Res. 2013 December 15; Ethics approval and consent to participate 210(2) https://doi.org/10.1016/j.psychres.2013.07.015. Ethical clearance was obtained from Amanuel Mental Specialized Hospital 15. Morisky E, Ang A, Wood M. Predictive validity of a medication adherence Ethical Review Committee. The Four Item Abbreviated Mental Test (AMT4) measure in an outpatient setting. J Clin Hypertens (Greenwich). 2008;10: was used to measure the capacity of the patient to give consent. Then the 348–54. purpose, importance and confidentiality of the information gathered was 16. Smith S, O'KEANE VE, Murray R. Sexual dysfunction in patients taking explained to each of the competent participant before the start of interview. conventional antipsychotic medication. Br J Psychiatry. 2002 Jul 1;181(1):49–55. Their willingness to participate in the study was asked and written consent 17. Ahmadzadeh G, Shahin A. Sexual dysfunctions in the patients hospitalized was obtained. Participant’s privacy was kept strictly at the time of data in psychiatric wards compared to other specialized wards in Isfahan, Iran, in collection. 2012. Advanced biomedical research. 2015;4–225. 18. Macdonald S, Halliday J, MacEwan T, Sharkey V, Farrington S, Wall S, Competing interests McCreadie RG. 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Published: May 29, 2018