PhD researcher Miriam Forbes is looking into the relationships between depression, anxiety and sexual problems over time. It's well known that they are closely related, but despite the fact that symptoms of these disorders will affect the majority of us in our lifetime, the exact relationships between the disorders are poorly understood.
Counter-intuitively, preliminary research has suggested that depression and anxiety are only related to sexual problems for women, not men.
Forbes is in the middle of a longitudinal study examining relationships between the varying symptom levels of the disorders in the general population. The confidential online study is looking at how mood, stress and our sex lives relate and is now open to anyone over the age of 16 wishing to participate.
For more information on her study please visit: www.moodstressandsex.com
Question: Can you talk about your current study involves?
Miriam Forbes: Our current study is looking at the relationships between low mood, stress, and sexual difficulties over time. We're measuring levels of these constructs, and some related constructs (relationship strength, social support, life events), at six separate time points to track changes over time and to see whether we can draw any causal conclusions about the relationships.
Question: You're looking into the relationships between depression, anxiety and sexual problems over time; over what period of time are you conducting this study?
Miriam Forbes: Respondents complete the six questionnaires either weekly or monthly. This will let us look at the time scale that the relationships work on.
Question: How are you going about collecting this information?
Miriam Forbes: We're advertising as widely as possible to recruit participants. They complete anonymous online questionnaires according the the time schedule they selected.
Question: What are volunteer participants expected to do, for the study?
Miriam Forbes: Participants complete six questionnaires, which take about fifteen minutes each. At each completed time point they go into the draw for a $100 cash card.
Question: What results do you expect to see from the study?
Miriam Forbes: There's very little research that lets us know what to expect. My gut feeling is that the relationships will be messy, and reflect shared underlying characteristics, rather than having a one-directional/causal relationship come out.
Question: What do we currently know about the exact relationships between the disorders: depression, anxiety and sexual problems?
Miriam Forbes: Everyone knows that mood, stress and our sex lives are related, but the picture isn't as simple as you might think, and we really only have a general impression of what the whole picture might look like.
More than half of the Australian population will experience clinical levels of symptoms of depression, anxiety and/or sexual dysfunction in their lifetime. (e.g., in a representative national survey of the Australian population, it was found that 55% of men and 60% of women reported at least one presenting sexual problem for several of the last twelve months.) At a sub-clinical level, these disorders affect everyone in the form of low mood, stress and worry, and the peaks and troughs of our sex lives.
The symptoms of depression, anxiety and/or sexual dysfunction commonly co-occur, and this comorbidity is particularly important because of the detrimental effect when they are combined. Comorbidity between depression and anxiety is related to increased chronicity, poorer treatment outcomes and greater psychopathology (Brown, Schulberg, Madonia, Shear, & Houck, 1996; Gorman, 1996; Hirschfeld, 2001). When sexual dysfunctions are also present, quality of life is further reduced, long-term outcomes are worse, and patients are more likely to drop out of treatment (Michael & O'Keane, 2000; van Lankveld & Grotjohann, 2000).
Even though these disorders have such a strong negative impact for so many people, we don't know how they're related to each other, or whether one type of disorder is actually causing another.
Some studies have found that depression and anxiety mean people are less likely to be in the mood for sex, find it harder to get (and stay) aroused, find it harder to orgasm (women), or control orgasm (premature ejaculation; men), and/or are more likely to experience sexual pain. For some people depression and/or anxiety will have the opposite effect, and actually lead to increased sexual desire and activity, which is known as -self-soothing' (people seek intimacy to soothe their depression/anxiety symptoms).
Other studies have found that sexual dysfunction can make people feel worried that something is wrong with them, worried about their sex lives and not being able to meet their partner's needs, anxious that the symptoms won't pass, down about themselves or that they are a failure, etc. (i.e. feel depressed and/or anxious). Almost all research on these relationships is based on cross-sectional research, so we have very little information on real causal relationships.
Without a clear causal relationship, the combination of shared cognitive and affective characteristics, treatment response, and high comorbidity rates suggest a shared underlying factor.
Our preliminary research (from an earlier study) has suggested that depression, anxiety and sexual dysfunction symptoms (i.e. mood, stress and sex) are closely related for women, and may actually share an underlying factor. If the disorders share a common core, then we can treat that core factor, rather than the diverse symptoms of all the different disorders, with new transdiagnostic treatments.
SSRIs, SNRIs, tricyclic antidepressants, and MAOIs (the most common medications used to treat depression and anxiety) are actually known to cause sexual dysfunction. If we can treat an underlying factor the disorders share, this would pre-empt the exacerbating effect of these pharmacotherapies on sexual problems.
This same research suggests that depression and anxiety are closely related in men, but that sexual problems are almost entirely unrelated to mood and stress levels. This is in contrast to a lot of other research, and despite the effects performance anxiety and fear of failure are expected to have on erectile function. Similarly, relationship expectations around desire, and erectile function and orgasmic function (erectile dysfunction and premature ejaculation) for men are thought to lead to depression for sexually dysfunctional men.
There are a few relevant research findings around these gender differences. Specifically, young men are particularly likely to experience increased arousal during negative mood states, and it has been suggested that the relationship between sexual problems, depression, and anxiety disorders is weaker for men than for women. Our sample over-represented men with tertiary education (59% of the sample), who tend to be less likely to report sexual dysfunction symptoms, so our study may have under-estimated the relationships in the general population. Even so, the relationships we found for men between sexual problems and depression and anxiety were close to zero.
The relationships are obviously complex, and everyone will experience them differently. There may be more differences within genders than between them; just because men are from Mars and women are from Venus doesn't mean they're all the same – look at the diversity of people here on the third rock!
Basically, it's crazy we don't know more about these relationships that affect all of us on a day-to-day basis, and more than half of the Australian population at clinical symptom levels. So with our current research, we're trying to untangle these relationships and figure out whether there are causal associations between the symptoms of these disorders. A better understanding of the relationships between these disorders will have significant implications for treatment.
Question: What are some of the symptoms of these disorders?
Miriam Forbes: At a symptom level, we're basically looking at low mood, stress and sexual difficulties. The specific disorders' symptoms we're looking at include: depression, generalised anxiety (worry), social phobia, panic disorder, OCD, and sexual dysfunctions (desire, arousal, orgasm and pain disorders for women; desire, erectile dysfunction and premature ejaculation for men).
Question: Do you believe that depression and anxiety are only related to sexual problems for women, not men?
Miriam Forbes: Not strongly, but it was interesting to see in our preliminary research that we found almost zero relationships between the sexual problems variables and the mood and anxiety disorder variables. There are a bunch of measurement issues that may have contributed to this, but the fact that the relationships were entirely non-existent suggests that they must have been very weak (and weaker than for women) to start with.
Question: How common is it that one type of disorder causes another; eg. sexual problems causing anxiety or anxiety causing sexual problems? Or is it that they relate on an even deeper level?
Miriam Forbes: In this case, my theory is that they are related at a deeper level, but may be 'causing' each other in a bi-directional way (i.e., they both feed into each other). It is quite common for one disorder to cause another, but the DSM (used by psychologists, etc. to diagnose disorders) includes criteria for most disorders that they can't be diagnosed if they're 'caused' by another disorder. So if someone is experiencing erectile dysfunction as a result of diagnosed depression, the erectile dysfunction will be considered a symptom of the depression, rather than a disorder in its own right.
Interview by Brooke Hunter