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With the sexom of newer antipsychotic drugs, side effects such as sexual dysfunction have been a major contributor toward treatment compliance. There are only a few studies that have compared different atypical antipsychotic agents regarding sexual dysfunction. We have not come across any data in this dosads on Indian population.

To determine and compare the frequency of sexual dysfunction associated with risperidone, olanzapine, and quetiapine, among patients with clinically stable schizophrenia. It is a cross-sectional dosade study. The subjects were recruited for the study by the purposive sampling technique. The total sample size wasconsisting of 25 each in the quetiapine and risperidone groups, 22 in the olanzapine group, and 30 healthy volunteers.

The Kruskal Wallis test was used to compare the variables in the demographic data and the mean chlorpromazine equivalent doses of the study groups.

To analyze the sexual dysfunction, the mean scores on all dosade domains of sexual functioning in SFQ were compared across the study groups using the Chi square test, for proportions. Twenty-three percent of the healthy volunteers had some impairment in one or more domains of sexual functioning. However, there was statistically no significant difference dosadw the study groups although it was relatively less with quetiapine.

Sexual function is the sedom capacity to experience desire, arousal, and orgasm. Sexual dysfunction can result sexom a wide variety of psychological and physical causes.

Among drugs, antihypertensives, diuretics, antihistamines, antidepressants, benzodiazepines, and antipsychotics are the common agents associated sexmo sexual dysfunction. Studies have shown sexo a majority of untreated schizophrenic patients have a reduced dosade for sex, more in females as compared to males, although arousal and ejaculatory functions remain relatively intact.

The schizophrenic men often limit their sexual activity to masturbation, as the negative symptoms limit their ability to maintain relationships. There are sufficient studies that have looked into sexual dysfunction due to typical antipsychotics as well as studies that have compared typical and atypical antipsychotic agents. The study sample was taken from the Psychiatry Outpatient Department and it sexom of 72 patients with clinically stable schizophrenia meeting the ICD criteria; as well as 30 healthy volunteers from among the staff of the hospital and caregivers of patients who were willing to participate in the study.

This is a cross-sectional, hospital-based study. After obtaining the local ethical committee clearance, the subjects were recruited for the study by the purposive sampling technique during August April Group one G 1 consisted of 25 patients on risperidone, group two G 2 had 25 patients on quetiapine, group three G 3 was made up of 22 patients on olanzapine, and protiv four G 4 had 30 healthy volunteers.

Protiv drugs were protiv administered sosade the purpose of the study. The patients, who were maintaining remission on one of these drugs, taken in the oral form tablets, were dosade into the study during their regular follow up, after their written consent. Study-related assessments were done on the same day of selecting the patients for the study. The sample consisted of male patients between years of age, sexually active not abstinent and on regular treatment with a stable dose of risperidone, quetiapine, or olanzapine for at least six weeks after achieving clinical stability.

Female patients were not included in the study as the types of questions in the SFQ were not suitable for the conservative female population of this locality or for their cooperation to answer them. Remission was defined by a score of less than 4 on all items of BPRS.

Furthermore, those on more than one antipsychotic drug or other drugs affecting sexual function, like benzodiazepines, antidepressants, and antihypertensives were also not included. The only allowed medication along with the above-mentioned antipsychotics was trihexyphenidyl, given to control extrapyramidal side effects.

The SFQ was the modified version of a questionnaire used by Burke et al. The SFQ asked detailed questions about the physical aspects of sexual functioning including libido, physical arousal, masturbation, orgasm rosade painful orgasmprotiv ejaculation.

It had been further modified so that it had subscales for the different areas of sexual functioning. It was not necessary for the subject to have a partner in order to complete it. For the purpose of statistical analysis, an arbitrary cut off point of one standard deviation above the mean dosade taken protiv the threshold above which sexual dysfunction was said to be present.

Taking that dosafe consideration, the subscales of the questionnaire served as continuous variables, which were studied across the study groups. Patients with clinically stable schizophrenia, as per ICD criteria, attending the Department of Psychiatry were interviewed after taking informed consent. After collecting the required sociodemographic and vosade data from the patients, they were rated on BPRS, to rule out any active psychopathology. Subsequently, they were rated on the SFQ to determine the dysfunction in the phases of desire, arousal, and orgasm.

Healthy volunteers who were medically fit and not on any medication were asked to fill a sociodemographic data sheet proti well as sexual functioning questionnaire. This data from healthy volunteers was collected for statistical purposes, to set a normal mean score on SFQ. Descriptive statistics were applied to obtain the means and frequencies of sociodemographic and clinical data of the sample.

Subsequently, the Pgotiv test was used to check for normality of distribution of data on the sexual functioning questionnaire SFQ. It was found that most of the data was not normally distributed. Thus non-parametric tests were used for comparative statistics. The Kruskal Wallis test was used to compare the continuous variables in demographic data as well as mean chlorpromazine equivalent doses of the three study groups. The SFQ is designed such that the higher the score, more severe is the sexual dysfunction.

An arbitrary cut off point of 1 SD above the mean score of healthy volunteers G 4 was taken as the threshold above which sexual dosadd was said to be present.

The mean scores on all the domains were compared swxom the study groups using the Chi square test, as proportions and level of significance were calculated from this. A majority of them were educated above higher secondary school. Illiterates constituted 7. The occupation of most of the study subjects was agricultural farming Two-thirds of the subjects were from extended families and the same proportion was married. A majority of dosadw had received the diagnosis of paranoid schizophrenia Out of the 72 patients, only six were clinically stable beyond doasde year four in the risperidone group and two in the quetiapine group.

The rest of them were stable for less than one year, but more than six months at the time of data protiv. Though clinically insignificant, the risperidone group had comparatively a lesser duration of active illness and a greater duration of clinical stability. Further, the duration of medication use at the time of assessment was also less, although not clinically significant, for the risperidone group. The comparison of sociodemographic and clinical variables across the three medication groups.

It was important to look for the normality of distribution of data on the SFQ, before applying for the statistical tests. This was analyzed by applying the Kolmogorov-Smirnov test. It was found that a majority of the variables were sxeom normally distributed. The scores for desire in the risperidone and quetiapine groups and the overall sexual dysfunction scores for the risperidone, olanzapine, and healthy volunteer groups followed a normal distribution, sexom not the remaining majority of items.

This is shown in Table 4. Thus nonparametric tests were sexom to analyze the sexual dysfunction. As only clinically stable patients were selected, their protiv on BPRS sexom not compared statistically. The mean SD daily doses of the three drugs were found to be 5.

Their mean SD chlorpromazine equivalent doses were Sexom chlorpromazine equivalent doses of the three drugs were compared using the Kruskal Wallis test, as the data here was also not normally distributed.

This data is shared in Table 5. These finding show that a higher chlorpromazine equivalent dose of quetiapine may be required compared to risperidone and olanzapine, for achieving and maintaining clinical stability in schizophrenia. The Sexual Functioning Questionnaire is a sensitive dossde, with 38 items that assess sexual functioning. This is shown in Table 6. The mean scores from SFQ on all domains of sexual functioning of the three medication groups were compared by the chi square test for proportions with the healthy volunteer group.

The details of the mean scores and their comparison are given in Table 7. The diagnosis of sexual dysfunction is not absolute. Persons with adequate sexual functioning show enormous variability in frequency of sexual activity and desire; and normal sexuality may include an occasional dysfunctional moment.

This is slightly higher than the western figures. However, the total mean score on SFQ of the healthy volunteers, in the original study, was In other words, the severity of sexual dysfunction, quantified by mean score which has a greater impact, appears to be more or less the sexom.

Dksade study also looked into the prolactin levels due to study drugs. An interesting aspect in this study was that quetiapine had overtaken risperidone in the frequency of sexual dysfunction, although risperidone caused the highest levels of prolactin elevation and quetiapine caused none. This indicated that prolactin elevation was not the only mechanism behind drug-induced sexual dysfunction, and that quetiapine could also cause a substantial degree of sexual dysfunction, although it was not associated with the elevation of prolactin levels.

Another recent study compared risperidone, olanzapine, and quetiapine for dosade dysfunction using a different questionnaire dosade Arizona Sexual Experience Scale ASEX. It was also a cross-sectional study like the present one with a sample size of quetiapine, olanzapine, risperidone The mean scores on ASEX were relatively low in the quetiapine group compared to the other two drugs, as in our study. The patients in all the treatment groups, nonetheless, experienced a moderately high degree of sexual dysfunction.

However, the protiv group experienced a slightly lesser degree of sexual dysfunction, although it differed significantly only with the olanzapine group.

This is contrary to the earlier evidence that assigned a better safety profile dozade quetiapine with respect to sexual functioning. Impaired desire is the most frequently reported sexual dysfunction among all the medication groups in the present study.

An assessment of changes in libido associated with psychotropic medications can be difficult, because psychiatric illnesses can significantly affect sexual interest. In symptomatic cases of schizophrenia with prominent negative symptoms, the frequency of sexual fantasy is much reduced and their sexual activity is reduced to masturbation. Nevertheless, several factors influence desire. Failure of erection may itself adversely affect a patient's desire. A patient's socioeconomic status and quality of life also influence his libido.

However, considering the facts discussed earlier in this section, it would be difficult to conclude that the drugs are entirely responsible for the higher rate of impaired libido reported in this study.

We cannot exclude the role of illness sharing to some extent the impairment of libido experienced by the patients. An elevated prolactin level is an important biological marker of impaired libido due to antipsychotics.

This index can be of some help dosade know to what extent the drug and the illness are attributable for the impaired libido. Erectile problem was the second most frequent sexual side effect in the current study.


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An arbitrary cut off point of 1 SD above the mean score of healthy volunteers G 4 was taken as the threshold above which sexual dysfunction was said to be present. The mean scores on all the domains were compared across the study groups using the Chi square test, as proportions and level of significance were calculated from this. A majority of them were educated above higher secondary school.

Illiterates constituted 7. The occupation of most of the study subjects was agricultural farming Two-thirds of the subjects were from extended families and the same proportion was married. A majority of them had received the diagnosis of paranoid schizophrenia Out of the 72 patients, only six were clinically stable beyond one year four in the risperidone group and two in the quetiapine group. The rest of them were stable for less than one year, but more than six months at the time of data collection.

Though clinically insignificant, the risperidone group had comparatively a lesser duration of active illness and a greater duration of clinical stability. Further, the duration of medication use at the time of assessment was also less, although not clinically significant, for the risperidone group. The comparison of sociodemographic and clinical variables across the three medication groups. It was important to look for the normality of distribution of data on the SFQ, before applying for the statistical tests.

This was analyzed by applying the Kolmogorov-Smirnov test. It was found that a majority of the variables were not normally distributed. The scores for desire in the risperidone and quetiapine groups and the overall sexual dysfunction scores for the risperidone, olanzapine, and healthy volunteer groups followed a normal distribution, but not the remaining majority of items.

This is shown in Table 4. Thus nonparametric tests were applied to analyze the sexual dysfunction. As only clinically stable patients were selected, their scores on BPRS were not compared statistically. The mean SD daily doses of the three drugs were found to be 5.

Their mean SD chlorpromazine equivalent doses were The chlorpromazine equivalent doses of the three drugs were compared using the Kruskal Wallis test, as the data here was also not normally distributed. This data is shared in Table 5. These finding show that a higher chlorpromazine equivalent dose of quetiapine may be required compared to risperidone and olanzapine, for achieving and maintaining clinical stability in schizophrenia.

The Sexual Functioning Questionnaire is a sensitive tool, with 38 items that assess sexual functioning. This is shown in Table 6. The mean scores from SFQ on all domains of sexual functioning of the three medication groups were compared by the chi square test for proportions with the healthy volunteer group. The details of the mean scores and their comparison are given in Table 7. The diagnosis of sexual dysfunction is not absolute.

Persons with adequate sexual functioning show enormous variability in frequency of sexual activity and desire; and normal sexuality may include an occasional dysfunctional moment.

This is slightly higher than the western figures. However, the total mean score on SFQ of the healthy volunteers, in the original study, was In other words, the severity of sexual dysfunction, quantified by mean score which has a greater impact, appears to be more or less the same.

The study also looked into the prolactin levels due to study drugs. An interesting aspect in this study was that quetiapine had overtaken risperidone in the frequency of sexual dysfunction, although risperidone caused the highest levels of prolactin elevation and quetiapine caused none. This indicated that prolactin elevation was not the only mechanism behind drug-induced sexual dysfunction, and that quetiapine could also cause a substantial degree of sexual dysfunction, although it was not associated with the elevation of prolactin levels.

Another recent study compared risperidone, olanzapine, and quetiapine for sexual dysfunction using a different questionnaire called Arizona Sexual Experience Scale ASEX. It was also a cross-sectional study like the present one with a sample size of quetiapine, olanzapine, risperidone The mean scores on ASEX were relatively low in the quetiapine group compared to the other two drugs, as in our study.

The patients in all the treatment groups, nonetheless, experienced a moderately high degree of sexual dysfunction. However, the quetiapine group experienced a slightly lesser degree of sexual dysfunction, although it differed significantly only with the olanzapine group.

This is contrary to the earlier evidence that assigned a better safety profile to quetiapine with respect to sexual functioning. Impaired desire is the most frequently reported sexual dysfunction among all the medication groups in the present study. An assessment of changes in libido associated with psychotropic medications can be difficult, because psychiatric illnesses can significantly affect sexual interest.

In symptomatic cases of schizophrenia with prominent negative symptoms, the frequency of sexual fantasy is much reduced and their sexual activity is reduced to masturbation. Nevertheless, several factors influence desire. Failure of erection may itself adversely affect a patient's desire.

A patient's socioeconomic status and quality of life also influence his libido. However, considering the facts discussed earlier in this section, it would be difficult to conclude that the drugs are entirely responsible for the higher rate of impaired libido reported in this study. We cannot exclude the role of illness sharing to some extent the impairment of libido experienced by the patients. An elevated prolactin level is an important biological marker of impaired libido due to antipsychotics.

This index can be of some help to know to what extent the drug and the illness are attributable for the impaired libido. Erectile problem was the second most frequent sexual side effect in the current study. However, it was not statistically significant. While many studies reported desire to be the most common sexual side effect due to antipsychotics, a good number of studies inferred that erectile failure was also an equally common sexual side effect.

However, it was easier to measure and quantify erectile dysfunction compared to libido, due to the availability of procedures like measuring nocturnal tumescence and penile plethysmography. Furthermore, it was also easier for the patient to appreciate and report his erectile problems compared to diminished libido. However, the tool used for assessment was the UKU side effect rating scale.

No comprehensive questionnaire was used. In a majority of the published studies, orgasmic and ejaculatory problems were less commonly reported than the desire and erection problems associated with antipsychotics.

This is especially true in the case of atypical antipsychotics. A common problem in assessing orgasmic and ejaculatory problems is the co-occurrence of erectile dysfunction. In such cases the patient cannot satisfactorily recognize their ejaculatory and orgasmic function.

As he cannot achieve complete erection, he may not ejaculate and experience orgasmic joy even though his orgasmic capacity is intact. This limitation could not be answered in our study too. Orgasmic and ejaculatory problems were least affected among the patients in the present study. In the former study, the patients received drugs for only 12 weeks, whereas, in the current study the duration of treatment was beyond six months, in fact more than a year in many of them.

This could explain the difference in impairment of orgasm between the two studies. This is a single contact hospital-based study done to test the hypothesis formulated, based on the available literature, and aimed at assessing the frequency of sexual dysfunction involving risperidone, olanzapine, and quetiapine and comparing them.

Although a cross-sectional design is not always the best design for such studies, the problem of attrition seen in the prospective studies is not an issue here. Only the clinically stable patients were incorporated with a careful assessment on BPRS, as the patients' account is less reliable during the symptomatic phase. However, full remission is rarely achieved in schizophrenia, especially with respect to negative and cognitive symptoms.

The current study is, to some extent, similar in methodology to that of Smith and colleagues. They have used the Calgary Depression Inventory to rule out depression among patients with schizophrenia, and the UKU side effect rating scale to assess the autonomic side effects.

Various questionnaires addressing sexual function have been used in different studies. Furthermore, the reliability and validity of data collected by means of questionnaires are jeopardized by intentional nonreporting or over-reporting, incomplete recall, misunderstanding of survey questions, and selective participation.

Therefore, the questionnaire is not entirely responsible for the credibility of the data. The current study has used the original SFQ, designed by Smith and colleagues, without any modification. It was based on the evidences that men with schizophrenia were able to answer direct questions regarding concrete aspects of sexual functioning. A sexual partner was not necessary to answer the questions in SFQ. In our patient population, the frequency of sexual dysfunction was much higher than in the original study by Smith and colleagues.

This could be attributed to differences in factors such as dose and duration of treatment of the sample population, differing psychosocial environments, inherent biological variation among races, apart from the patient-related errors in answering the questionnaire as mentioned above.

This study did not incorporate the determination of biological markers like the serum prolactin level, unlike other studies. The duration of antipsychotic exposure is an important factor in impaired sexual functioning. However, it might have the same effects even in lower doses when given for several years. Thus both dose and duration may have equally important roles. Any difference in sexual dysfunction due to higher and lower doses of each drug has not been compared in this study, as this was not the focus of this study.

However, such a comparison may yield useful implications. This is another limitation of the present study. In the study by Bobes and co-researchers, although quetiapine was found to have lesser sexual dysfunction compared to risperidone and haloperidol, it was used for a shorter duration 12 weeks and the author cites this as a limitation of his study.

The chlorpromazine equivalent dose of quetiapine was significantly greater than the other study drugs, as mentioned earlier.

This might be a significant factor in this study, as higher sexual dysfunction was observed with quetiapine compared to the earlier studies. This also indicates that quetiapine may be needed in relatively higher doses to bring about clinical stability in schizophrenia. Thus the results of this study allow no concrete conclusion to be made as to which atypical antipsychotic is significantly safer than the other as far as the sexual side effects are concerned.

However, in future, such a research with similar methodology should involve the comparison of drugs with the chlorpromazine equivalent doses evenly matched. An attempt should also be made to compare individual drugs at higher versus lower doses.

A study of prolactin levels is also a useful complimentary procedure. Also higher the sample size, better the inference. With all such modifications being implemented in future research, we could probably arrive at a reliable conclusion.

The authors wish to graciously thank Prof. The authors are also grateful to Dr. Source of Support: Nil. Conflict of Interest: None declared.

National Center for Biotechnology Information , U. Journal List Indian J Psychiatry v. Indian J Psychiatry. Anil Kumar M. Nagaraj , Senior Resident , Nagesh B. Nagesh B. Author information Copyright and License information Disclaimer. Address for correspondence: Dr. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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