Sexual dysfunctions are cognitive, affective, and behavioral problems that prevent an individual or couple from engaging in or enjoying satisfactory intercourse[1].Male sexual dysfunctions in general and premature ejaculation in particular are condition that affects a large number of men worldwide, and likely to have an impact on couple which may lead to the low level of individual well-being and mental health.[2] Premature ejaculation (PE) is a common male sexual dysfunction[3]. Premature ejaculation (PE) is one of the most common male sexual disorders and has been estimated to occur in 4-39% of men in the general community.[4-11]. Recently studies have revealed that the prevalance of PME can be as high as 43.4% [12]. PME is broadly defined as occurrence of ejaculation prior to the wishes of both sexual partners , usually before or immediately after entering vagina. Men with PE complain about decreased sexual self-confidence and psychological comorbidities. Thus, it seriously impair male health and couples’ sexual relationships [13]. Early ejaculation is often disappointing and can lead to anxiety, loss of sexual confidence and low self esteem [14]. PME has been shown to have a significant negative psychological impact on men and is often associated with low self esteem, helplessness and increased frustration [15,16]. Individual psychological factors such as depression, stress, anxiety, and negative cognitive processing are strongly associated with the onset and maintenance of male sexual difficulties. Several studies have shown that impaired sexual function in men with PE is significantly associated with depression[17]. Depressed persons have a increased risk of developing PME and higher prevalence of depression is found particularly in PME patients[18]. Further PME patients have decreased self esteem, and decreased satisfaction in sexual life, which may secondarily lead to depression[19,20]. The relationship between GAD ,Depression and PME can be further explained by the fact that serotonin is the key neurotransmitter in all these conditions. [21,22]. The prevalence rate of comorbid depression in PME is also about 25%[23,24]. We tested the hypothesis that premature ejaculation can lead to neurotic and depressive disorders.The present study is a noninterventional, cross-sectional, self-reported based psychological investigation analysis that was carried out at the outpatient clinic in Psychiatric OPD at District Hospital during months of 1st january 2018 to 30th September of 2018 with the complaint of inability to control ejaculation sufficiently long enough during intravaginal containment were screened for the diagnosis of premature ejaculation (PME). PME was evaluated using DSM-5 diagnostic Criteria ‘As persistent or recurrent onset of orgasm and ejaculation with minimal sexual stimulation before, on, or shortly after penetration and before the person wishes. And cause(s)marked distress or interpersonal difficulty and PE not exclusively due to the direct effects of a substance’[25,26].Before being asked the subjects to participate, a formal consent was obtained from all of them.A total 156 subjects who fulfilled the above mentioned criteria were included in the study.Demographic information was collected using a socio-demographic profile Subjects were evaluated for diagnosis of depression,anxiety and stress using DASS 21 The DASS-21 is a 21-item self-report questionnaire designed to measure the severity of a range of symptoms common to DAS. It is a generic scale that shows strong internal consistency and reliability for each subscale (DAS) and it has been prevalidated in various group of patients. In completing the DASS, the individual is required to indicate the presence of a symptom over the previous week. Each item is scored from 0 (did not apply to me at all over the last week) to 3 (applied to me very much or most of the time over the past week). There are four possible answers in terms of severity or frequency, organized in a scale from 0 to 3. The result is obtained by adding up the scores of the items for each of the three subscales.
The depression subscale assesses symptoms like inertia; anhedonia; dysphoria; lack of interest/involvement; self-depreciation; devaluation of life; and discouragement. The anxiety subscale evaluates excitation of the autonomous nervous system; musculoskeletal effects; situational anxiety; and subjective anxiety experiences. Finally, the stress subscale assesses difficulty to relax; nervous excitation; easy perturbation/agitation; irritability/exaggerated reaction; and impatience.
Calculation of extent of DAS in individual cancer patient is done with corresponding number of questionnaire which is specific (each subclass contained 7 questions) for DAS. Higher score correspond to more severe psychological disorder that is reflected in critical functioning of the DASS is to assess the severity of the core symptoms of DAS [27]. Beck Depression Inventory (BDI-II,21 item, Hindi Version is a 21-item measure of depressive symptoms. For each item, participants chose the statement that best reflected how they felt. Responses to the individual items were then summed, with scores ranging from 0 to 63. Scores of 0 to 10 indicated minimal depression, scores of 11 to 17 indicated mild depression, and scores of 18 to 63 indicated moderate to severe depressive symptoms. BDI has a high coefficient of alpha (α= 0.80) and its construct validity has been established which differentiate depressed from non-depressed. The test-re-test reliability and internal consistency is .82 and .79 respectively [28,29] .Fisher’s exact test, ANOVA, chi-square test and unpaired t- test were used to analyse the data. Male patients of age 20 to 50 were included in study. Patients who are undergoing for treatment for any psychiatric illness, who have undergone any significant surgical intervention, abusing substances except nicotine and known cases of diabeties and high blood pressure were excluded from study.
Results:
Table 1- Socio-demographic characteristics of study population
N
%
Locality
Urban
106
67.8
Rural
50
32.2
Religion
Hindu
134
85.9
Muslim
22
14.1
Family
Joint
55
35.2
Nuclear
101
64.8
Age
<20
14
8
20-30
47
30.3
31-40
64
41.1
>40
31
19.6
Literacy
Illiterate
0
0
Upto primary
8
5.3
Matriculation
28
17.8
Graduation
81
51.1
Poat graduation
39
25
Table 1 is showing sociodemographic characteristic of the study population . Almost two third patients were from urban background.85.9 % were Hindu by religion,64.8% were residing in nuclear families . A 41.1% patients were in age group of 31to 40 years and half of them were educated upto graduation .
Table 2 Results of DASS Scale
DASS(subscales)
Mild
Moderate
Severe
Very Severe
DASS(D)
(46)
11
26
8
1
DASS(A)
(55)
19
31
14
1
DASS (S)
(73)
27
31
13
2
Table 2 is showing scores on DASS subscales . Thirty percent patient of PME were having depression on DASS(D) subscale, more than half of them were moderately depressed. Thirty five percent individuals were anxious on DASS(A) subscale and sixty percent of them were having moderate level of anxiety.On stress subscale of DASS 47% of PME patients were positive for stress. Very few patients (n=4) fall in very severe category on DASS subscales. Majority were in moderate category on the score of this scale .
Table 2 Locality wise Distribution of depressed patients
LOCALITY
N
%
MEAN BDI SCORE
p value
SUBJECTS WITH CLINICAL DEP.
%
p value
URBAN
106
67.8
12.7
T=2.11
p=0.2
25
23.68
X2 =0.5 p=0.82
RURAL
50
32.2
10.3
11
22.24
TOTAL
156
100
12.39
36
Table 3,is showing locality wise distribution of depressed patients .Though two third of patients were from urban background but we found statically non significant difference in BDI scores .23.68% urban and 22.24 % rural patients were clinically depressed (BDI>14) ,but with a p value of .82 this difference was non significant.
Table 4. Age wise Distribution of depressed patients
Age
N
%
Mean BDI Score
Subjects with clinical depression
P value
<20
14
8
9
F=6.9
P=0.01
3
X2
=8.06
P=0.04
20-30
47
30.3
13.3
18
31-40
64
41.1
9.2
11
>40
31
19.6
7.6
5
Table 4 is illustrating age wise distribution of depressed individual among PME patients. There is significant difference both in mean BDI scores and clinical depression with a p value of 0.01 and 0.04 respectively. Scores were higher in age group of 20 to 30 years .It seems that individuals in this age range were more depressed than others.
Table 5. Education wise Distribution of depressed patients
Literacy
N
%
Mean BDI Scores
Subjects with clinical depression
Illeterate
0
–
–
–
–
–
X2 =2.36
P=0.5
Up to primary
8
5.3
8.9
F=o.786
3
Vi-X
28
17.8
11
P=0.5
11
Xi- grad
81
51.7
10.7
14
Table 5 is showing education wise distribution of PME patients .Statically non significant difference was found among different education strata.
Discussion
Premature Ejaculation (PE) known as problem of the orgasm phase of the male sexual response cycle and widely believed to be the most common male sexual dysfunction[1].Male sexual dysfunctions in general and premature ejaculation in particular are condition that affects a large number of men worldwide, and likely to have an impact on couple which may lead to the low level of individual well-being and mental health[2].PME is widely believed to be the most common male sexual dysfunction that estimated prevalence range from 21 to 32.5% in men aged 18-59[3,4,5,6,7,8,9,10,11].Men suffering with PME experience frustration, anger, dissappointment, insecurity, inadequacy, guilt, humiliation, fear and failure [14].PME has been shown to have a significant negative psychological impact on men and is often associated with low self esteem, helplessness and increased frustration [15,16].Out of 156 patients included in the study 106 were urban and 50 belonged to rural localities. The clinic is located in a urban locality and the total number of patients visiting the hospital is dominated by urban patients so is reflected by the distribution of PME patients.The mean BDI-II score of urban patients was 12.7 and that of rural patients was 10.3. no significant difference was noted between scores of the two groups. On DASS 21 (D) subscales we found 29% were having clinically depressed, on anxiety subscales 35% were significantly anxious, around 48% were stressed on stress subscales.23.68% of urban and 22.2% of rural patients were having clinical depression (BDI-II score>14) and the difference in the prevalence was not significant. Our study found out that 23.2% of all patients visiting the outpatient department for treatment of PME were suffering from depression as estimated by BDI-II score more than 14. In our study, subjects in the age group 31-40 yrs were having most no. of PME cases (41.1%) followed by age group 21-30 yrs(30.3%). 19.6% of subjects having age >40 yrs who visited the clinic were having PME. Son et all (2011) found that Asian males within the age group 30-40 yrs are most sexually active and thus the proportion of those having sexual dysfunction is higher[30]. Although, the prevalence of PME increases with increasing age[14],only 19.6% of patients older than 40 yrs reported PME in this sudy. In a culture where sexual activity in older age is not considered ‘essential’ and virtues like self-control’ and indifference to materialistic pleasure are desirable, we didn’t expect people more than 40 yrs to come to psycho-sexual clinic in larger proportions. Moreover, older people tend to learn to live with such problems[31].There was no significant difference in the prevalence of depression among the groups reflecting that depression associated with PME is not related to AGE.We tried to find out any correlation with educational qualification and prevalence of depression among PME patients.51.8% of all subjects belonged to the group consisted of patients who were educated up to graduate level while up to primary level group had only 5.3% of the cases. Two possible explanations can be given, Firstly, illiterate people , due to lack of awareness about specialty facilities in the hospital were less aware about psycho-sexual clinic. Secondly more of urban patients were visiting the clinic and the literacy status of urban population is better than rural population .There was no significant difference between the prevalence of depression among the 5 groups consisted on the basis of educational status. Thus it was clear that there was no correlation between literary status of patients and prevalence of depression in patients of PME.