Bidirectional Relationship Between Depression and Erectile Dysfunction Rahman Shiri,* Juha Koskimäki, Teuvo L. J. Tammela, Jukka Häkkinen, Anssi Auvinen and Matti Hakama From the Tampere School of Public Health (RS, AA, MH) and Medical School (TLJT), University of Tampere and Department of Urology, Tampere University Hospital (JK, TLJT, JH), Tampere, Finland Purpose: We specified the interrelationship between depressive mood and erectile dysfunction. Materials and Methods: The target population consisted of men who were 50, 60 or 70 years old and residing in the study area in Finland in 1994. Questionnaires were mailed to 3,143 men in 1994 and to 2,837 men 5 years later. The followup sample consisted of 1,683 men who responded to the baseline and followup questionnaires. Results: Erectile dysfunction was strongly associated with untreated and treated depressive symptoms. The prevalence OR adjusted for potential confounders was 2.6 (95% CI 1.8 –3.8) for untreated and 3.3 (95% CI 1.6 –7.1) for treated depressive symptoms at the beginning of followup. The incidence of erectile dysfunction was 59/1,000 person-years (95% CI 39 –90) in men with depressive mood and 37/1,000 person-years (95% CI 32– 43) in those free of the disorder. Compared with men free of depressive symptoms who did not use medication for psychological disorders at study entry the adjusted incidence density ratio of erectile dysfunction was 4.5 (95% CI 2.2–9.2) in men with treated depressive symptoms and 1.2 (0.7–2.1) in those with untreated depressive symptoms. The incidence of depressive mood was 20/1,000 person-years in men with erectile dysfunc- tion and 11/1,000 person-years in those free of erectile dysfunction. The adjusted incidence density ratio of depressive mood was 1.9 (95% CI 1.1–3.3) in men with erectile dysfunction compared with those free of it at entry. Conclusions: Moderate or severe depressive mood or antidepressant medication use may cause erectile dysfunction and erectile dysfunction independently may cause or exacerbate depressive mood. Key Words: penis, impotence, antidepressive agents, antipsychotic agents, depression E rectile dysfunction and depression are common chronic conditions. 1–4 The 2 conditions have a nega- tive effect on quality of life in patients and their partners. Previous cross-sectional studies demonstrated an association between depression and ED. 4–6 Few prospective studies regarding the relationship be- tween depression and ED have been published to date. 7,8 They showed no association between depressive symptoms and the incidence of ED. However, these findings were based on only small numbers of depressed men at baseline. In addition, little is known about the effect of ED on the inci- dence of depression in the general population. We performed a population based, prospective study in Finnish men 50 to 70 years old at baseline to verify this asso- ciation and assess the causal directions between depression and ED, ie the risk of ED is higher in men with depressive mood than in those free of depression or the incidence of de- pressive mood is higher in men with ED than in those free of it. MATERIALS AND METHODS Details on TAMUS have been previously described. 2 TAMUS is a population based followup study based on a comprehensive sample of men born in 1924, 1934 or 1944 and residing in Tampere or 11 adjacent municipalities in Finland in 1994. Information on the target population of 3,143 men was obtained by a mailed self-administered ques- tionnaire, comprising items on sociodemographic status, medical conditions and medications, life-style factors, erec- tile capacity and concern about erection problems. A total of 2,198 men (70%) completed baseline question- naires during the first quarter of 1994 (see figure). Of them 379 were excluded from study, including 244 due to missing data on erectile function, 122 because of missing information on depressive symptoms and 13 who were institutionalized or unable to respond independently. Therefore, 1,819 men were included for estimating prevalence at study entry (ta- ble 1). Similar questionnaires were mailed 5 years later in May 1999 to 2,837 men. Between 1994 and 1999, 262 men had died, 6 had emigrated and 38 no longer had a permanent address in the population register. Altogether 2,133 men (75%) returned the questionnaires. Overall 1,683 men, representing 59% of those alive and eligible, responded to baseline and followup inquiries. Of them 241 were excluded because of missing data on erectile function in the baseline or followup survey and 62 were excluded as a result of missing information on depressive mood. Thus, 1,380 men were included in the followup sam- ple. The effect of depressive mood on the incidence of ED was assessed in 1,085 men free of moderate or complete ED at Submitted for publication March 1, 2006. Supported by the Medical Research Fund of Tampere University Hospital. * Correspondence: Klaneettitie 1 D 105, Fin-00420 Helsinki, Fin- land (telephone: +358-44-0602780; e-mail: r_shiri@yahoo.com). 0022-5347/07/1772-0669/0 Vol. 177, 669-673, February 2007 THE JOURNAL OF UROLOGY ® Printed in U.S.A. Copyright © 2007 by AMERICAN UROLOGICAL ASSOCIATION DOI:10.1016/j.juro.2006.09.030 669