| |

Received: 14 May 2019    Revised: 26 June 2019    Accepted: 20 July 2019

DOI: 10.1111/and.13395

ORIGINAL ARTICLE

Associations between erectile dysfunction and psychological

disorders (depression and anxiety): A cross‐sectional study in a
Chinese population

Yongjiao Yang1 | Yuxuan Song2 | Yi Lu2 | Yawei Xu2 | Li Liu1 | Xiaoqiang Liu2

1
Department of Urology, The Second
Hospital of Tianjin Medical University,
Tianjin, China
2
Department of Urology, Tianjin Medical
University General Hospital, Tianjin, China
Correspondence
Xiaoqiang Liu, Department of Urology,
Tianjin Medical University General Hospital,
154 Anshan Road, Heping District, Tianjin
300052, China.
Email: liutjykdx@163.com
Funding information
This manuscript was funded by China
Natural Science Foundation of Tianjin City
(16JCZDJC34600).
Abstract
The present cross‐sectional survey was performed to evaluate the prevalences and
correlations of depression and anxiety among Chinese erectile dysfunction (ED)
men. Between February 2017 and January 2019, male patients with or without ED
treated in andrology clinic and urology clinic were enrolled in the investigation. All
enrolled patients were required to fill in the International Index of Erectile Function
Questionnaire (IIEF‐5), Patient Health Questionnaire (PHQ‐9) and Generalized
Anxiety Disorder 7‐item scale (GAD‐7) which intended to evaluate the diagnosis and
severity of ED, depression and anxiety respectively. Of the 958 included participants,
79.82% (613/768) and 79.56% (611/768) ED patients appeared to have anxiety and
depression; 13.68% (26/190) of men without ED had anxiety and depression. In ad‐
dition, young ED patients (age ≤35  years) and long ED duration patients (duration
>12 months) had higher incidences and severities of anxiety and depression (p < .05).
After adjusting the age, IIEF‐5 was negatively correlated with PHQ‐9 (adjusted
r = −.653, p < .001) and GAD‐7 scores (adjusted r = −.607, p < .001). The prevalences
of anxiety and depression were 79.82% and 79.56% in Chinese ED patients. The
prevalences and severities of anxiety and depression increased as the ED severity
increased. Based on the high incidences of anxiety and depression among Chinese
ED patients, clinicians are supposed to pay more attention to early diagnosis and
therapy of psychiatric symptoms for ED patients, especially among young patients
and patients with long ED duration.

KEYWORDS
anxiety, cross‐sectional study, depression, erectile dysfunction, psychological

1 |  I NTRO D U C TI O N
Erectile dysfunction (ED) is identified as inability to obtain or keep an
adequate erection to perform sexual life that can satisfy both sides
(1993). Now ED has been a common disease worldwide with high re‐
ported morbidity rate (Melman & Gingell, 1999; Najari & Kashanian,
2016). An estimated 41% ED patients were identified in Chinese men
older than 40 years (Zhang, Yang, Li, & Li, 2017). Numerous patho‐
physiology pathways can be comorbid and concomitant negatively
impacting on ED, and one of the pathophysiology is psychogenic
(Sáenz de Tejada et al., 2010). ED in turn may have an influence on
psychosocial health and may have an obvious impact on the qual‐
ity of life of the ED patient and his sex mate (Feldman, Goldstein,
Hatzichristou, Krane, & McKinlay, 1994; Salonia et al., 2012), with

Yongjiao Yang, Yuxuan Song and Yi Lu contributed equally to this work.

Andrologia. 2019;00:e13395. wileyonlinelibrary.com/journal/and © 2019 Blackwell Verlag GmbH  |  1 of 8

https://doi.org/10.1111/and.13395
 |
2 of 8       YANG et al.
63.1% of ED patients developing psychiatric symptoms (Mallis et al.,
2005).
Depression is strongly associated with ED; an estimated 25%
of men with depressive symptoms may suffer from ED (Seidman &
Roose, 2000; Williams & Reynolds, 2006). The correlations between
depression and ED are interactive: depression can reduce libido and
lead to ED (Meisler & Carey, 1991); in the mean time, unsatisfied
sexual life can trigger depression (Nicolosi, Moreira, Villa, & Glasser,
2004; Shabsigh, Zakaria, Anastasiadis, & Seidman, 2001). This cor‐
relation is promoted by the sexual side‐effects caused by antide‐
pressants (Balon, 2006; Williams & Reynolds, 2006). The association
between depressive symptoms and ED may still remain even if no
syndromal depression is diagnosed (Jern, Gunst, Sandnabba, &
Santtila, 2012; Strand, Wise, Fagan, & Schmidt, 2002).
Various anxiety disorders are identified to be correlated with ED.
Social phobia, a common kind of anxiety disorders linked with anxi‐
ety in social occasions, is closely related to ED in many investigations
(Blumentals, Gomezcaminero, Brown, Vannappagari, & Russo, 2004;
Figueira, Possidente, Marques, & Hayes, 2001; Okulate, Olayinka, &
Dogunro, 2003). Similarly, many patients with generalised anxiety
symptoms are more likely to develop ED (Kendurkar & Kaur, 2008).
Anxiety correlated with sex may be a vital risk factor to ED (Hedon,
2003; Morse & Morse, 1982) even in the absence of anxiety disorders.
In recent years, although many studies on the relationship between
ED and psychological problems have been conducted (Rowland, 2011;
Rowland & Cooper, 2011; Zhang et al., 2013), some problems have not
been entirely illustrated. It remains unknown how depression and anx‐
iety levels correlate with patients with different severities of ED by the
International Index of Erectile Function (IIEF‐5) Questionnaire (Rosen,
Cappelleri, Smith, Lipsky, & Peña, 1999) in Chinese men. Hence, in
order to identify depression and anxiety levels of men suffering from
different severities of ED, we randomly selected male populations at
andrology clinic and urology clinic in Tianjin of China and evaluated
the association between psychological distress and ED using validated
questionnaires and a multidisciplinary approach.
2 |  M ATE R I A L S A N D M E TH O DS
2.1 | Subjects
Tianjin is a municipality directly under the central government of
China including over 10 million residents. Between February 2017
and January 2019, a population‐based, observational, cross‐sec‐
tional study was conducted in two major hospitals (Second Hospital
of Tianjin Medical University and Tianjin Medical University General
Hospital) in Tianjin. A total of 1,072 men were contained from the
andrology clinic and urology clinic.
All enrolled patients followed these criteria: (a) male; (b) aged
≥18  years; and (c) married or living with a fixed sexual partner for
more than 6 months. Besides, the exclusive criteria were as follows:
(a) sexual dysfunction caused by Peyronie's disease or other organic
lesions of external genitalia; (b) previous pelvic cavity operation or
orchiectomy; (c) chronic kidney disease or cardiac disease; (d) history
of sertraline or other medicines that may influence their erection
and psychological symptoms; (e) being currently divorced or experi‐
encing major family changes; and (f) history of alcoholism within the
past 12 months.
2.2 | Research design
Face‐to‐face interviews that lasted for approximately 20–30 min at an‐
drology clinic and urology clinic were performed. All enrolled partici‐
pants should fill in a series of information: (a) baseline characteristics
(age, height, weight and calculated body mass index); (b) duration of
ED; (c) severity of ED, evaluated by IIEF‐5 (Rosen et al., 1999); (d) de‐
pression, evaluated by Patient Health Questionnaire (PHQ‐9; Kroenke,
Spitzer, & Williams, 2001); and (e) anxiety, evaluated by Generalized
Anxiety Disorder 7‐item scale (GAD‐7; Spitzer, Kroenke, Williams, &
Löwe, 2006).
All recruited patients volunteered to participate and were aware
of the procedures and signed informed consent before being en‐
rolled in our study. ED, depression and anxiety were evaluated by
IIEF‐5, PHQ‐9 and GAD‐7 respectively. This study was checked
and got approval from Tianjin Medical University Research Subject
Review Board.
2.3 | Measures
2.3.1 | International Index of Erectile Function‐5
International Index of Erectile Function‐5 evaluates the patient's
erection from five aspects including erectile function, orgasmic
function, sexual desire, intercourse satisfaction and overall satisfac‐
tion. A higher IIEF‐5 score (a maximum of 25) within 6 months indi‐
cated a worse sexual function of men. IIEF‐5 scores are divided into
five different dysfunction levels: no dysfunction (≥22), mild (17–21),
mild to moderate (12–16), moderate (8–11) and severe (≤7).
2.3.2 | Patient Health Questionnaire‐9
Patient Health Questionnaire‐9 is a valid and stable scale for evalu‐
ating the depressive symptoms in the past 2 weeks, and it contains
nine items based on the fourth version of Diagnostic and Statistical
Manual of Mental Disorders criteria (DSM‐IV). Moreover, PHQ‐9
scores (a maximum of 27) are divided into five different severity lev‐
els: severe (˃20), moderate to severe (15–20), moderate (10–14), mild
(5–9) depression and no (≤4) depression.
2.3.3 | Generalized Anxiety Disorder‐7
Generalized Anxiety Disorder‐7 is an effective and reliable measure‐
ment to evaluate the severity of anxiety symptoms with 2 weeks,
and it includes seven aspects depending on DSM‐IV. Thus, GAD‐7
scores (a maximum of 21) are divided into four different severity lev‐
els: severe (˃14), moderate (10–14), mild (5–9) anxiety and no (≤4)
anxiety.
YANG et al. |
      3 of 8

TA B L E 1   Demographic characteristics of men with and without ED (n = 958)

  Non‐ED (n = 190) Mild and mild‐to‐moderate ED (n = 487) Moderate and severe ED (n = 281) p‐value

Age 31.68 ± 7.89 33.11 ± 7.98 34.70 ± 8.22 .058

≤25 [n, (%)] 42 (22.11) 72 (14.78) 48 (17.08) .479
26–30 [n, (%)] 38 (20.00) 151 (31.01) 78 (27.76)
31–35 [n, (%)] 50 (26.32) 99 (20.33) 60 (21.35)
36–40 [n, (%)] 31 (16.31) 88 (18.07) 45 (16.01)
40> [n, (%)] 29 (15.26) 77 (15.81) 50 (17.80)
Weight 75.12 ± 11.52 76.06 ± 13.87 77.48 ± 12.82 .433
Height 175.78 ± 7.06 174.88 ± 5.72 175.29 ± 5.65 .529
BMI 24.29 ± 3.16 24.81 ± 3.90 25.19 ± 3.85 .304
Marriageable age 6.38 ± 3.27 6.81 ± 3.01 7.43 ± 3.35 .128

Abbreviations: BMI, body mass index; ED, erectile dysfunction; PE, premature ejaculation.

2.4 | Statistics analysis 3 | R E S U LT S

We used mean ± standard deviation (SD) to describe numeri‐
cal data and used counts and percentages to describe categori‐
cal data. The chi‐square test was used for comparison between
categorical data were evaluated by chi‐square test and numeri‐
cal data were estimated by Student's t test and one‐way ANOVA.
Correlations between the IIEF‐5 score and GAD‐7/PHQ‐9 score in
men were measured by partial correlation analysis. In considera‐
tion of the effect of age on ED, the correlations were also adjusted
for age (Xu et al., 2019; Zhang et al., 2017). All tests were two‐
tailed, and a statistic difference was assumed when p‐value was
<0.05. All statistical analyses were carried out through IBM SPSS
Statistics 23.0.
3.1 | Demographic characteristics
Ultimately, 958 men (age 33.23 ± 8.21 years ranging from 19 to
67) finished the investigation, and the returning rate is 89.37%
(958/1,072). We excluded 114 men for invalid answers (n = 32), in‐
complete data (n = 57) or uncorrected information (n = 25). Of all
enrolled men, 768 (80.17%) were diagnosed with ED. According to
IIEF‐5 scores, the distribution of various severities of ED in men
was as follows: Non‐ED, 19.83% (190/958); mild and mild to mod‐
erate ED, 50.84% (487/958); and moderate and severe ED, 29.33%
(281/958). Table 1 displayed the demographic characteristics of re‐
cruited men.

TA B L E 2   Prevalence and severity of depression and anxiety among men with and without ED

Non‐ED Mild and mild‐to‐moderate ED Moderate and severe

  (n = 190) (n = 487) ED (n = 281) p‐value

PHQ‐9 (depression)        
Nondepression [n, (%)] 164 (86.32) 106 (21.77) 51 (18.15)  
Prevalence of depression [n, (%)] 26 (13.68) 381 (78.23) 230 (81.85) <.001
Mild depression [n, (%)] 14 (7.37) 97 (19.92) 40 (14.23)  
Moderate depression [n, (%)] 6 (3.16) 240 (49.28) 37 (13.17)  
Moderate‐to‐severe depression [n, (%)] 6 (3.16) 28 (5.75) 18 (6.41)  
Severe depression [n, (%)] 0 (0.00) 16 (3.28) 135 (48.04) <.001
Total PHQ‐9 (depression) scores 3.80 ± 3.08 9.36 ± 5.13 14.93 ± 8.63 <.001
GAD‐7 (anxiety)        
Nonanxiety [n, (%)] 164 (86.32) 99 (20.33) 56 (19.93)  
Prevalence of anxiety [n, (%)] 26 (13.68) 388 (79.67) 225 (80.07) <.001
Mild anxiety [n, (%)] 14 (7.37) 92 (18.89) 39 (13.88)  
Moderate anxiety [n, (%)] 12 (6.32) 247 (50.72) 32 (11.39)  
Severe anxiety [n, (%)] 0 (0.00) 49 (10.06) 154 (54.80) <.001
Total GAD‐7 (anxiety) scores 4.64 ± 3.02 9.65 ± 4.86 14.17 ± 8.70 <.001

Abbreviations: ED, erectile dysfunction; GAD‐7, Generalized Anxiety Disorder‐7; PHQ‐9, The Patient Health Questionnaire‐9.
 |
4 of 8       YANG et al.

F I G U R E 1   Prevalence of anxiety and depression and PHQ‐9/GAD‐7 scores among men with and without ED. (a) Prevalence of anxiety
and depression among men with and without ED, (b) PHQ‐9/GAD‐7 scores among men with and without ED, ED, erectile dysfunction;
GAD‐7, Generalized Anxiety Disorder‐7; PHQ‐9, The Patient Health Questionnaire‐9; **p‐value <.001.

3.2 | Results for the IIEF‐5, PHQ‐9 and GAD‐7
The prevalences of anxiety and depression among ED men were
79.82% (613/768) and 79.56% (611/768) respectively. However,
among men without ED, 13.68% (26/190) had anxiety and 13.68%
(26/190) had depression. ED men had higher incidences of anxi‐
ety and depression than Non‐ED men (p < .001). The mean PHQ‐9
and GAD‐7 were higher in men with moderate and severe ED
(14.93 ± 8.63 and 14.17 ± 8.70 respectively), whereas they were
lower among men with mild and mild‐to‐moderate ED (9.36 ± 5.13
and 9.65 ± 4.86 respectively; see Table 2 and Figure 1a,b).
Moreover, obvious variations were identified in men with different
severities of ED in terms of results for the PHQ‐9 and GAD‐7 (p < .001).
The prevalences of mild, moderate and severe anxiety in men suffer‐
ing from mild and mild‐to‐moderate ED were 18.89%, 50.72% and
10.06%, while the prevalences of those in men with moderate and
severe ED were 13.88%, 11.39% and 54.80% respectively. The preva‐
lences of mild, moderate, moderate to severe and severe depression in
men with mild and mild‐to‐moderate ED were 19.92%, 49.28%, 5.75%
and 3.28%, whereas the prevalences of those in men with moderate
and severe ED were 14.23%, 13.17%, 6.41% and 48.04% respectively
(see Table 2 and Figure 2a,b). Men diagnosed with moderate and se‐
vere ED tended to appear more severe anxiety and depression than
men suffering from mild and mild‐to‐moderate ED.
3.3 | Association between age and
psychological problems
The mean PHQ‐9 and GAD‐7 were higher in men under 35 years
of age, whereas they were lower in men older than 35. In addition,
men under 35 years of age presented significantly higher incidences
of psychological problems than men aged over 35 (see Table 3 and
Figure 3).
3.4 | Association between duration of ED and
psychological problems
The mean PHQ‐9 and GAD‐7 were higher in men with a duration
within 12 months, whereas they were lower in men with a duration
for more than 12 months. In addition, men with a duration within
12 months presented significantly higher incidences of psychologi‐
cal problems than men with a duration for more than 12 months (see
Table 4 and Figure 4).
3.5 | Correlation between ED and
psychological problems
We performed partial correlation analysis to further estimate the
correlation between the results of IIEF‐5 score and PHQ‐9/GAD‐7

F I G U R E 2   Distribution of different severities of anxiety and depression by PHQ‐9 and GAD‐7 among men with and without ED.
(a) Distribution of different severities of depression by PHQ‐9, (b) distribution of different severities of anxiety by GAD‐7, ED, erectile
dysfunction; GAD‐7, Generalized Anxiety Disorder‐7; PHQ‐9, The Patient Health Questionnaire‐9
YANG et al. |
      5 of 8

TA B L E 3   Prevalence and severity of

Mild and mild‐to‐moderate ED Moderate and severe ED
depression and anxiety by age among men
with ED Variables (n = 487) (n = 281)

Age ≤35 (n = 322) >35 (n = 165) ≤35 (n = 186) >35 (n = 95)

PHQ‐9 (depression) scores 9.66 ± 5.14 8.78 ± 5.08 15.32 ± 8.30 14.15 ± 9.24
GAD‐7 (anxiety) scores 9.94 ± 4.90 9.07 ± 4.74 14.68 ± 8.81 13.18 ± 8.42
Prevalence of depression 260 (80.75) 121 (73.33) 160 (86.02) 70 (73.68)* 
[n, (%)]
Prevalence of anxiety [n, 261 (81.16) 127 (76.97) 157 (84.41) 68 (71.58)* 
(%)]

Abbreviations: ED, erectile dysfunction; GAD‐7, Generalized Anxiety Disorder‐7; PHQ‐9, The
Patient Health Questionnaire‐9.
*Compared with age ≤35 p‐value <.05.

scores. After adjusting the age factor, IIEF‐5 had a negative correla‐
tion with PHQ‐9 (adjusted r  =  −.653, p < .001) and GAD‐7 scores
(adjusted r = −.607, p < .001).
4 | D I S CU S S I O N
Although psychological symptoms are identified to exist in many
ED cases (Shamloul & Ghanem, 2013), the underlying mechanism
between psychological problems and ED has not been clarified. The
anxiety caused by the fear of failure and disappointment in sexual
life may be one of the most important psychogenic factors. Boddi
et al. (2014) demonstrated that lack of sexual privacy was associ‐
ated with ED even after adjusting for confounders. There are two
potential mechanisms for explaining psychogenic ED: (a) direct
inhibition of the spinal erection centre from the nervous system and
(b) excessive sympathetic outflow or increased levels of peripheral
catecholamine (Steers, 2000). ED is usually related to psychiatric
diseases, such as depression (Pastuszak, Badhiwala, Lipshultz, &
Khera, 2013), schizophrenia (Malik, 2007) and psychiatric symp‐
toms (Corona et al., 2008). It might be attributed to psychiatric drug
treatment (Matsui, Sopko, Hannan, & Bivalacqua, 2015).
In this present study, the prevalences of anxiety and depres‐
sion were 79.82% and 79.56% in Chinese ED patients, which were
3.07 and 3.06 times that in men without ED. Our findings about
the incidences of psychological disorders among ED patients were
similar to the results in one investigation conducted by Mallis et al.
(2005).
We identified a significant association of elevating anxiety and
depression with ED severity. In our study, the prevalences of anxiety

F I G U R E 3   PHQ‐9/GAD‐7 scores and prevalence of anxiety and depression by age among men with ED. (a) PHQ‐9 scores by age, (b)
GAD‐7 scores by age, (c) prevalence of depression by age, (d) prevalence of anxiety by age, ED, erectile dysfunction; GAD‐7, Generalized
Anxiety Disorder‐7; PHQ‐9, The Patient Health Questionnaire‐9; *p‐value <.05
 |
6 of 8       YANG et al.

TA B L E 4   Prevalence and severity of

Mild and mild‐to‐moderate ED Moderate and severe ED
depression and anxiety by duration of ED
Variables (n = 487) (n = 281)
among men with ED
Duration <12 months ≥12 months <12 months ≥12 months
(n = 180) (n = 307) (n = 69) (n = 212)
PHQ‐9 (depression) 7.64 ± 5.95 10.38 ± 4.30*  8.09 ± 6.37 17.15 ± 8.10* 
scores
GAD‐7 (anxiety) scores 8.23 ± 5.51 10.50 ± 4.23*  7.83 ± 5.76 15.94 ± 7.23* 
*
Prevalence of depres‐ 111 (61.67) 269 (87.62)   45 (65.22) 185 (87.26)* 
sion [n, (%)]
Prevalence of anxiety 123 (68.33) 263 (85.67)*  42 (60.87) 183 (86.32)* 
[n, (%)]

Abbreviations: ED, erectile dysfunction; GAD‐7, Generalized Anxiety Disorder‐7; PHQ‐9, The
Patient Health Questionnaire‐9.
*Compared with <12 months' p‐value <.001.

and depression increased with ED severity. Furthermore, the GAD‐7
and PHQ‐9 scores also increased with ED severity. We found that the
prevalences of severe anxiety and severe depression in men suffering
from moderate and severe ED were up to 54.80% and 48.04%, while
only 10.06% and 3.28% in men suffering from mild and mild‐to‐mod‐
erate ED; no severe anxiety and depression were observed in non‐ED
men. Our findings demonstrated that as the severity of ED increased,
both the severity and the incidence of psychological disorders would
increase.
Our study indicated that psychological disorders were more
common among men with ED under 35 years of age. Among men
with moderate and severe ED at the age of under 35 years, the prev‐
alence of depression was 86.02%, which was significantly higher
than that in men older than 35. We considered it may be related
to the burden of life and work pressure and high physiological de‐
mand of sexual life in young people. Most young people are under
lots of pressure from life and work and have more sexual demand.
Unsatisfactory erection in sexual life may add more pressure on
young people. Hence, the causes of high incidences of anxiety and
depression in young ED men might be due to the heavy burden of life
and work pressure. Many previous studies have shown that high life
and work pressure may have harmful effects on psychological health
(Harvey et al., 2017; Jiang et al., 2017, 2016; Tao, Zhang, Song, Tang,
& Liu, 2015).
Moreover, the results of our study suggested that the prev‐
alences of psychological disorders grew as the ED duration pro‐
gressed. Rates of anxiety and depression in men with a duration of
ED for over 12 months were significantly higher than that in patients
with a duration of ED within 12 months. Meanwhile, we found that
the mean scores of PHQ‐9 and GAD‐7 in patients with a duration
of moderate and severe ED for more than 12 months were up to
17.15 and 15.94, which were significantly higher than that in shorter

F I G U R E 4   PHQ‐9/GAD‐7 scores and prevalence of anxiety and depression by duration of ED among men with ED. (a) PHQ‐9 scores by
duration of ED, (b) GAD‐7 scores by duration of ED, (c) prevalence of depression by duration of ED, (d) prevalence of anxiety by duration of
ED, ED, erectile dysfunction; GAD‐7, Generalized Anxiety Disorder‐7; PHQ‐9, The Patient Health Questionnaire‐9; ** p‐value <.001
YANG et al.
duration patients. Not only the incidences but also the severities of
anxiety and depression significantly rose with the duration of ED.
Thus, our results demonstrated that longer duration of ED increased
the risks of anxiety and depression and facilitated the progression of
psychological disorders.
Furthermore, for IIEF‐5 and PHQ‐9/GAD‐7 scores, a negative
relationship was observed in all eligible men and it is a strong rela‐
tionship based on the adjusted r value. That is to say, the worse the
patient's ED, the more severe anxiety and depression the patient
would be likely to experience. Thus, our results supported the spec‐
ulation proposed by Waldinger (Waldinger & Schweitzer, 2010) that
ED may have a potential relationship with anxiety and depression.
Our research presented a new concept to figure out the effects of
ED on anxiety and depression. What's more, our conclusions were
substantially consistent with the perspectives which were put
forward by Serefoglu et al. (2011) and Waldinger and Schweitzer
(2010).
In addition, we found that moderate and severe ED patients were
older and more obese than men suffering from mild and mild‐to‐
moderate ED and patients without ED. We considered these factors
(advanced age and high BMI) to be correlated with elevated risk of
ED in male population.
However, several limitations in our study should be illustrated.
Although nearly 1,000 participants were enrolled in our final analy‐
ses, they are all from urology and andrology clinics, which resulted in
a bias in study population. Thus, considering the bias existed in study
population, further studies with more participants from psychiatric
clinics or psychology clinics and general population are warranted to
validate these results in general population, which is also the direc‐
tion of our future work. Moreover, as a multi‐centre cross‐sectional
investigation, its observational character would not permit us to de‐
termine a causal relation between anxiety/depression and ED as well
as other factors (e.g., age and ED duration), rather only associations.
In conclusion, the prevalences of anxiety and depression were
79.82% and 79.56% in Chinese ED patients. The prevalences and
severities of anxiety and depression increased as the ED severity
increased. In addition, we also found that the younger age and longer
duration of ED may increase the prevalences and severities of anx‐
iety and depression in ED patients. On the basis of the high preva‐
lence of anxiety and depression in Chinese ED patients, clinicians are
supposed to take care of early diagnosis and therapy of psychiatric
symptoms for ED patients, especially in young patients and patients
with long ED duration.
C O N FL I C T O F I N T E R E S T
No conflict of interest is reported in the manuscript.
AU T H O R C O N T R I B U T I O N S
YYJ and SYX involved in research design; YYJ and LY performed in‐
formation acquisition; XYW and LL analysed the data; YYJ, SYX, LY,
XYW, LL and LXQ wrote the manuscript.
|
      7 of 8
ORCID
Xiaoqiang Liu  https://orcid.org/0000-0002-4986-4243
REFERENCES
Anonymous (1993). NIH consensus conference. impotence. NIH consen‐
sus development panel on impotence. JAMA, 270, 83–90.
Balon, R. (2006). SSRI‐associated sexual dysfunction. American
Journal of Psychiatry, 163, 1504–1509. https​ ://doi.org/10.1176/
ajp.2006.163.9.1504
Blumentals, W. A., Gomezcaminero, A., Brown, R. R., Vannappagari,
V., & Russo, L. J. (2004). A case‐control study of erectile dys‐
function among men diagnosed with panic disorder. International
Journal of Impotence Research, 16, 299. https​://doi.org/10.1038/
sj.ijir.3901147
Boddi, V., Fisher, A. D., Maseroli, E., Rastrelli, G., Corona, G., Jannini, E.,
… Maggi, M. (2014). Lack of sexual privacy affects psychological and
marital domains of male sexual dysfunction. The Journal of Sexual
Medicine, 11, 431–438. https​://doi.org/10.1111/jsm.12382​
Corona, G., Ricca, V., Mannucci, E., Fisher, A. D., Lotti, F., Balercia, G., …
Maggi, M. (2008). T09‐O‐08 Association between psychiatric symp‐
toms and erectile dysfunction. Sexologies, 17, S118–S119. https​://doi.
org/10.1016/S1158-1360(08)72841-X
Feldman, H. A., Goldstein, I., Hatzichristou, D. G., Krane, R. J., &
McKinlay, J. B. (1994). Impotence and its medical and psycho‐
social correlates: Results of the Massachusetts male aging
study. Journal of Urology, 151, 54–61. https​ ://doi.org/10.1016/
S0022-5347(17)34871-1
Figueira, I., Possidente, E., Marques, C., & Hayes, K. (2001). Sexual dys‐
function: A neglected complication of panic disorder and social pho‐
bia. Archives of Sexual Behavior, 30, 369–377.
Harvey, S. B., Modini, M., Joyce, S., Milligansaville, J. S., Tan, L., Mykletun,
A., … Mitchell, P. B. (2017). Can work make you mentally ill? A sys‐
tematic meta‐review of work‐related risk factors for common mental
health problems. Occupational & Environmental Medicine, 74, 301–
310. https​://doi.org/10.1136/oemed-2016-104015
Hedon, F. (2003). Anxiety and erectile dysfunction: A global approach
to ED enhances results and quality of life. International Journal
of Impotence Research, 15, S16–S19. https​ ://doi.org/10.1038/
sj.ijir.3900994
Jern, P., Gunst, A., Sandnabba, K., & Santtila, P. (2012). Are early and
current erectile problems associated with anxiety and depression
in young men? A retrospective self‐report study. Journal of Sex
& Marital Therapy, 38, 349–364. https​ ://doi.org/10.1080/00926​
23X.2012.665818
Jiang, T., Ge, H., Sun, J., Li, R., Han, R., & Liu, J. (2017). Relationship be‐
tween occupational stress, 5‐HT2A receptor polymorphisms and
mental health in petroleum workers in the Xinjiang arid desert: A
cross‐sectional study. International Journal of Environmental Research
& Public Health, 14, 402. https​://doi.org/10.3390/ijerp​h1404​0 402
Jiang, Y., Tang, J., Li, R., Zhao, J., Song, Z., Ge, H., … Liu, J. (2016). Effect
of 5‐HT2A receptor polymorphisms, work stressors, and social
support on job strain among petroleum workers in Xinjiang, China.
International Journal of Environmental Research and Public Health, 13,
1258. https​://doi.org/10.3390/ijerp​h1312​1258
Kendurkar, A., & Kaur, B. (2008). Major depressive disorder, obsessive‐
compulsive disorder, and generalized anxiety disorder: Do the sexual
dysfunctions differ? Primary Care Companion to the Journal of Clinical
Psychiatry, 10, 299. https​://doi.org/10.4088/PCC.v10n0405
Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2001). The PHQ‐9:
Validity of a brief depression severity measure. Journal of
General Internal Medicine, 16, 606–613. https​ ://doi.org/10.104
6/j.1525-1497.2001.01600​9606.x
 |
8 of 8       YANG et al.
Malik, P. (2007). Sexual dysfunction in schizophrenia. Current Opinion
in Psychiatry, 20, 138. https​://doi.org/10.1097/YCO.0b013​e3280​
17f6c4
Mallis, D., Moysidis, K., Nakopoulou, E., Papaharitou, S., Hatzimouratidis,
K., & Hatzichristou, D. (2005). Psychiatric morbidity is frequently un‐
detected in patients with erectile dysfunction. Journal of Urology, 174,
1913–1916. https​://doi.org/10.1097/01.ju.00001​76746.73667.3c
Matsui, H., Sopko, N. A., Hannan, J. L., & Bivalacqua, T. J. (2015).
Pathophysiology of erectile dysfunction. Current Drug Targets, 16,
411–419.
Meisler, A. W., & Carey, M. P. (1991). Depressed affect and male sex‐
ual arousal. Archives of Sexual Behavior, 20, 541–554. https​ ://doi.
org/10.1007/BF015​50953​
Melman, A., & Gingell, J. C. (1999). The epidemiology and pathophysiol‐
ogy of erectile dysfunction. Journal of Urology, 161, 5–11. https​://doi.
org/10.1016/S0022-5347(01)62045-7
Morse, W. I., & Morse, J. M. (1982). Erectile impotence precipitated by
organic factors and perpetuated by performance anxiety. Canadian
Medical Association Journal, 127, 599.
Najari, B. B., & Kashanian, J. A. (2016). Erectile dysfunction. JAMA, 316,
1838. https​://doi.org/10.1001/jama.2016.12284​
Nicolosi, A., Moreira, E. D., Villa, M., & Glasser, D. B. (2004). A population
study of the association between sexual function, sexual satisfaction
and depressive symptoms in men. Journal of Affective Disorders, 82,
235–243. https​://doi.org/10.1016/j.jad.2003.12.008
Okulate, G., Olayinka, O., & Dogunro, A. S. (2003). Erectile dysfunc‐
tion: Prevalence and relationship to depression, alcohol abuse and
panic disorder. General Hospital Psychiatry, 25, 209–213. https​://doi.
org/10.1016/S0163-8343(03)00015-X
Pastuszak, A. W., Badhiwala, N., Lipshultz, L. I., & Khera, M. (2013).
Depression is correlated with the psychological and physical as‐
pects of sexual dysfunction in men. International Journal of Impotence
Research, 25, 194–199. https​://doi.org/10.1038/ijir.2013.4
Rosen, R. C., Cappelleri, J. C., Smith, M. D., Lipsky, J., & Peña, B. M. (1999).
Development and evaluation of an abridged, 5‐item version of the
International Index of Erectile Function (IIEF‐5) as a diagnostic tool
for erectile dysfunction. International Journal of Impotence Research,
11, 319–326. https​://doi.org/10.1038/sj.ijir.3900472
Rowland, D. L. (2011). Psychological impact of premature ejacula‐
tion and barriers to its recognition and treatment. Current Medical
Research & Opinion, 27, 1509–1518. https​://doi.org/10.1185/03007​
995.2011.590968
Rowland, D., & Cooper, S. (2011). Practical tips for sexual counseling and
psychotherapy in premature ejaculation. Journal of Sexual Medicine,
8, 342–352. https​://doi.org/10.1111/j.1743-6109.2011.02367.x
Sáenz de Tejada, I., Angulo, J., Cellek, S., González‐Cadavid, N., Heaton,
J., Pickard, R., & Simonsen, U. (2010). Pathophysiology of erectile
dysfunction. Journal of Sexual Medicine, 2, 26–39.
Salonia, A., Castagna, G., Saccà, A., Ferrari, M., Capitanio, U.,
Castiglione, F., … Montorsi, F. (2012). Is erectile dysfunction
a reliable proxy of general male health status? The case for the
International Index of Erectile Function—Erectile function do‐
main. Journal of Sexual Medicine, 9, 2708–2715. https​ ://doi.
org/10.1111/j.1743-6109.2012.02869.x
Seidman, S. N., & Roose, S. P. (2000). The relationship between depres‐
sion and erectile dysfunction. Current Psychiatry Reports, 2, 201–205.
https​://doi.org/10.1007/s11920-996-0008-0
Serefoglu, E. C., Yaman, O., Cayan, S., Asci, R., Orhan, I., Usta,
M. F., … Kadioglu, A. (2011). Prevalence of the complaint of
ejaculating prematurely and the four premature ejaculation syn‐
dromes: Results from the Turkish society of andrology sexual health
survey. The Journal of Sexual Medicine, 8, 540–548. https​ ://doi.
org/10.1111/j.1743-6109.2010.02095.x
Shabsigh, R., Zakaria, L., Anastasiadis, A. G., & Seidman, S. N. (2001).
Sexual dysfunction and depression: Etiology, prevalence, and treat‐
ment. Current Urology Reports, 2, 463–467. https​://doi.org/10.1007/
s11934-001-0040-x
Shamloul, R., & Ghanem, H. (2013). Erectile dysfunction. Lancet, 381,
153–165. https​://doi.org/10.1016/S0140-6736(12)60520-0
Spitzer, R. L., Kroenke, K., Williams, J. B. W., & Löwe, B. (2006). A
brief measure for assessing generalized anxiety disorder: The
GAD‐7. Archives of Internal Medicine, 166, 1092–1097. https​://doi.
org/10.1001/archi​nte.166.10.1092
Steers, W. D. (2000). Neural pathways and central sites involved in pe‐
nile erection: Neuroanatomy and clinical implications. Neuroscience
and Biobehavioral Reviews, 24, 507–516. https​ ://doi.org/10.1016/
S0149-7634(00)00019-1
Strand, J., Wise, T. N., Fagan, P. J., & Schmidt, C. W. Jr (2002). Erectile
dysfunction and depression: Category or dimension? Journal of Sex &
Marital Therapy, 28, 175–181. https​://doi.org/10.1080/00926​23025​
2851906
Tao, N., Zhang, J., Song, Z., Tang, J., & Liu, J. (2015). Relationship be‐
tween job burnout and neuroendocrine indicators in soldiers in the
Xinjiang arid desert: A cross‐sectional study. International Journal of
Environmental Research & Public Health, 12, 15154–15161. https​://
doi.org/10.3390/ijerp​h1212​14977​
Waldinger, M. D., & Schweitzer, D. H. (2010). The use of old and recent
DSM definitions of premature ejaculation in observational studies: A
contribution to the present debate for a new classification of PE in
the DSM‐V. Journal of Sexual Medicine, 5, 1079–1087.
Williams, K., & Reynolds, M. F. (2006). Sexual dysfunction in major de‐
pression. CNS Spectrums, 11, 19–23. https​://doi.org/10.1017/S1092​
85290 ​0 026729
Xu, Y., Zhang, Y., Yang, Y., Liu, L., Chen, Y., & Liu, X. (2019). Prevalence
and correlates of erectile dysfunction in type 2 diabetic men: A pop‐
ulation‐based cross‐sectional study in Chinese men. International
Journal of Impotence Research, 31, 9–14. https​ ://doi.org/10.1038/
s41443-018-0060-4
Zhang, X., Gao, J., Liu, J., Xia, L., Yang, J., Hao, Z., … Liang, C. (2013).
Prevalence rate and risk factors of depression in outpatients with
premature ejaculation. BioMed Research International, 2013, 317468.
https​://doi.org/10.1155/2013/317468
Zhang, X., Yang, B., Li, N., & Li, H. (2017). Prevalence and risk factors for
erectile dysfunction in Chinese adult males. Journal of Sexual Medicine,
14, 1201–1208. https​://doi.org/10.1016/j.jsxm.2017.08.009
How to cite this article: Yang Y, Song Y, Lu Y, Xu Y, Liu L, Liu
X. Associations between erectile dysfunction and
psychological disorders (depression and anxiety): A cross‐
sectional study in a Chinese population. Andrologia.
2019;00:e13395. https​://doi.org/10.1111/and.13395​