Sexual dysfunction and schizophrenia: psychiatrists' attitudes and training needs

AIMS AND METHOD

We conducted a survey of the knowledge, attitudes and practicesof sexual dysfunction and schizophrenia of general adult psychiatristsin Leicestershire and Lincolnshire mental health trusts.

RESULTS

Two-thirds of psychiatrists that we interviewed do not routinelyenquire about sexual dysfunction in their patients and only17% felt competent in assessing sexual dysfunction, despite88% agreeing that good sexual function is important to patients.Most practitioners (81.6%) have had no training in this areaand wanted some.

CLINICAL IMPLICATIONS

Sexual dysfunction is under-recognised and possibly under-treated; suggestions on how to address this are made in this paper.

Introduction

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Introduction

Sexual dysfunction is a common and distressing symptom in schizophrenia, with rates of up to 86–96% reported in more recent studies (Macdonald et al, 2003), and persisting throughout the courseof the illness. Fortier et al (2003) reported a higher incidenceof sexual dysfunction among young adults and long-stay patientswith schizophrenia. The high rates could be caused by illnessvariables and treatment. Bitter et al (2005), in a large studyof antipsychotic-naïve patients with schizophrenia, foundhigh rates of sexual dysfunction at initiation, and at 3 monthsand 6 months of treatment with antipsychotic medication. Putativemechanisms for sexual dysfunction in schizophrenia includemedication-related effects, such as elevation of plasma prolactinlevels, sedation owing to antihistaminergic effects, adrenergic effects and serotonergic blockade. Illness variables includenegative symptoms mediated by low libido, direct effects ofpsychosis and abnormalities in the limbic system (Baldwin & Mayers, 2003;Malik, 2007). Sexual dysfunction is implicated as a major factorcausing non-compliance (Fakhoury et al, 2001; Perkins, 2002).Patients often find it hard to complain and physicians may findit difficult to enquire about the problem (Clayton, 2001).

However, sexual dysfunction in schizophrenia can be addressedin a number of ways. These may include thorough assessmentto exclude physical pathology, medication changes includingthe use of new atypicals, dose reduction, switching medicationsand referrals to specialists.

The extent to which staff enquire about sexuality in peoplewith schizophrenia has depended on their general attitude tothe importance of sexual issues in schizophrenia which hasvaried over the years (Kelly & Conley, 2004). In the past,people with schizophrenia were stopped from procreation, and excessive masturbation was once considered as a possible causeof schizophrenia (Eerlinmayer-Kimmling et al, 1969; Akhtar et al, 1977). Another study (Pinderhughes et al, 1972) showed that professionalsbelieved people with schizophrenia were unable to manage theirsexuality and that staff were reluctant to discuss sexual issueswith them.

Psychiatrists have an important role in effectively addressingthese problems. As patients are often reluctant to talk aboutdifficulties in their sexual life, it has been observed thatthey are more likely to open up when physicians raise thisissue (Montejo-Gonzalez et al, 1997). Smith et al (2002)argued that clinicians should routinely enquire about sexualdysfunction in their patients, but it is unclear what the trainingexperiences and attitudes of psychiatrists are. Identifyingthese will help improve the care patients receive.

Method

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Method

Questionnaire
We drafted a 14-item self-report questionnaire assessing psychiatrists’views on sexual dysfunction and schizophrenia, which was generatedafter a literature review and focus group discussion (see online data supplement). An initial pilot study was completed amongcolleagues at Pilgrim Hospital Boston and the community mentalhealth team in Lincolnshire.

The areas covered by the questionnaire included demographic characteristics, knowledge, attitudes, practice and desirabilityfor training in the management of sexual dysfunction in schizophrenia.Responses were assessed using a five-point Likert scale.

Participants
The population sampled included trainees and consultants workingin general adult psychiatry in Leicestershire Partnership NationalHealth Service (NHS) Trust and Lincolnshire Partnership NHSFoundation Trust. Questionnaires were distributed at localpsychiatry academic meetings and by post. All 142 doctors workingin general adult psychiatry were eligible for the study, whichwas anonymous. The Leicestershire ethics committee approvedthe study. Data were collected and analysed using SPSS version12 for Windows.

Results

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Results

Sample characteristics
We obtained 76 responses (53.5%) out of the 142 distributedquestionnaires; 54 from male and 22 female psychiatrists. Twenty-tworespondents (28.9%) had practised psychiatry for less than3 years and 42 (55.2%) for more than 9 years.

Attitudes
The majority of respondents (n=54; 68%) felt comfortable assessing sexual dysfunction, 19 (25.3%) felt unsure about it and 5 (6.7%)reported not feeling comfortable making assessments, with nosignificant differences between psychiatrists with less thanor greater than 3 years’ experience. As many as 52 respondents(69.7%) preferred patients to volunteer information about theirsexual dysfunction, rather than asking them themselves.

Psychiatrists were also asked to rate how important they thoughtgood sexual functioning was to their patients. A great majority(n=67, 88.2%) recognised it was important, 31 (40.8%) stronglyagreed, 36 (47.4%) agreed and 8 (10.5%) were unsure. Only oneperson did not respond (1.3%) to this question. Clinicians’attitudes to enquiring about sexual dysfunction are illustratedin Table 1.

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Table 1. Clinicians’ attitudes to enquiring about sexual dysfunction

Practice
Participants reported having seen on average 48 patients withschizophrenia in the last year (range 0–300 patients).We assume that consultant adult psychiatrists would see largernumbers of patients while newer trainees would see fewer.

For all psychiatrists the average number of patients seen witherectile dysfunction was about four in the previous year. Itwas not possible to determine the gender distribution of peoplewith schizophrenia seen by psychiatrists in the study overthis period.

More than half of the psychiatrists in the study (n=50, 65.8%) reported that they do not routinely enquire about sexual dysfunctionof their patients with schizophrenia. Their reasons are presentedin Table 2.

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Table 2. Common reasons for non-enquiry

Knowledge
Respondents were asked to estimate the percentage of peoplewith schizophrenia they routinely see that suffer with sexualdysfunction: the mean score was 38.4% (s.d=25).

Training
As regards training in the management of sexual dysfunctionin schizophrenia, 62 psychiatrists (81.6%) had not had any;60 respondents (78.9%) agreed they would want training, with19 (26.3%) agreeing strongly that this was required.

Discussion

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Discussion

To our knowledge, this is the first study on the managementof sexual dysfunction in schizophrenia that uses a questionnaireto assess the domains of knowledge, attitudes, practice andtraining needs of psychiatrists. The items on the questionnairemay not comprehensively capture everything that is needed toassess these categories comprehensively. It cannot be assumedthat responses reflect participants’ actual practicesand attitudes in real life, as they were based on completedself-report questionnaires and are not free from social desirabilitybiases. Also, the questionnaire had not been previously validated.We recognise the difficulties in sampling this population,which may affect the study’s generalisability, but we believe the number of responses and the relative high responserate allows us to comment on current psychiatric practice.The response rate (53.5%) is reasonable given the topic underinvestigation and the survey methodology; lower response ratesare not unusual in postal questionnaires (Kazantis et al, 2005).

The study makes some important observations. First, psychiatristsdo not routinely enquire about sexual dysfunction (two-thirdsin our study). Invariably the rate of identification of erectiledysfunction is low – in this study it is about 20% assuminga gender ratio of 1:1, while the expected rate would be atleast 30–50% (Macdonald et al, 2003).

Second, the study identifies some of the reasons for not askingabout sexual dysfunction routinely. These include lack of confidenceof healthcare professionals in asking these questions, lackof confidence in available treatment, risk of upsetting vulnerablepeople and time constraints. The findings are consistent withthe findings of Stevenson (2004) and Gott et al (2004).

This paper additionally demonstrates a marked change in attitudesfrom previous surveys (Eerlinmayer-Kimmling et al, 1969; Akhtaret al, 1997). Psychiatrists in our study generally recognisedthe importance of sexual functioning to their patients, hadgood knowledge and helpful attitudes in this area.

Finally, the study demonstrates the need for training in orderto deliver effective treatments to people with sexual dysfunctionin schizophrenia. Effective treatments exist, but most of thepsychiatrists have not had training in this area, althoughthey are willing to. One way of ensuring adequate trainingis the development of a training package with a pilot programmethat should involve all staff. Another way of addressing this problem would be to establish a specialised clinic, but effectivenessof a sexual dysfunction clinic would need to be evaluated.There is also a need to increase recognition and awarenesson part of the psychiatrists, patients and carers. This couldbe done through regular dissemination of information on the impact of the problem and available treatments, the routineuse of brief questionnaires for people with schizophrenia addressingthis issue, and the determination of pathway to care for theseproblems.

Pharmaceutical companies have had their role in promoting theawareness of obesity in schizophrenia. They could have a similarrole in the promotion of training, research and treatment forsexual dysfunction associated with schizophrenia.

Acknowledgments

The study was approved by the Leicestershire research ethicscommittee.

References

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