Risk of Erectile Dysfunction after Primary Obsessive-Compulsive Disorder: A Nationwide Population-Based Study

doi:10.21203/rs.3.rs-3583039/v1

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Risk of Erectile Dysfunction after Primary Obsessive-Compulsive Disorder: A Nationwide Population-Based Study

https://doi.org/10.21203/rs.3.rs-3583039/v1

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Objective: Erectile dysfunction (ED) in patients with OCD (obsessive-compulsive disorder) has been investigated in very few limited studies. This study aimed to investigate the association between OCD and subsequent ED.

Methods: In this population-based retrospective cohort study, we used Taiwan’s National Health Insurance Research Database to analyze patients who were newly diagnosed with OCD between 2000 and 2016, We included 21,656 patients with OCD aged over 18 years old, with a 1:1 ratio by age and index year matched with patients in a non-OCD comparison group, for the risk of ED. Cox proportional hazards analysis was used to estimate the association between OCD and subsequent psychogenic ED. Results :After a 7-year follow-up, the incidence rate of psychogenic ED was higher in the OCD patients when compared with the non-OCD control group (3.39 vs.1.49 per 100,000 per person-year). Patients with OCD had a higher risk of developing psychogenic ED than the non-OCD cohort after the adjustment of the confounding factors (adjusted HR = 4.05, 95% confidence interval (CI) [2.06, 7.99], p < .001). This is the first study using a comprehensive nationwide database to analyze the association between psychogenic ED and OCD in Taiwan. After adjusting for the confounding factors, patients with OCD have a significantly higher risk of developing psychogenic ED.

Conclusions: Patients with OCD should be encouraged to take sexual history as part of their routine clinical assessment and appropriate preventive mental measures to maintain mental and sexual health.

Obsessive-Compulsive Disorder

Erectile dysfunction

Cohort study

National Health Insurance Research Database

The World Health Organization has ranked obsessive-compulsive disorder (OCD) as one of the 10 most debilitating illnesses for the general population. OCD is also currently listed by the WHO among other anxiety-based disorders as an important public health issue and its lifetime prevalence of 1–3%¹, which is a major mental health issue as one of the most serious conditions of human life and also impacts sexual health reducing the overall quality of human life².

Obsessive-compulsive disorder (OCD) is a psychiatric condition characterized by recurrent distressing thoughts and repetitive behaviors or mental rituals performed to reduce anxiety, which has been commonly associated with alterations of some neurotransmitters such as serotonin and dopamine. A study showed that patients with OCD were related to an increased overall risk of cerebrovascular, cardiovascular diseases, ischemic heart diseases, and transient ischemic attacks³.

Increasingly studies have shown that obsessive-compulsive disorder and erectile dysfunction have the same comorbidities (including metabolic syndrome, cardiovascular disease, obesity, and diabetes)⁴. Some study results support the view that inflammation may play an important role in the pathophysiology of OCD⁵. Konuk’s study also showed that OCD patients showed increases in TNF-α and IL-6 levels compared to the healthy controls⁶. OCD patients with increased levels of pro-inflammatory cytokines (IL-1, IL-6, and TNF-α), proinflammatory cytokines, and C reactive protein (CRP)⁶, might benefit from anti-inflammatory intervention.

Erectile dysfunction is a complex phenomenon influenced by many factors, including the socio-cultural context, interpersonal relationships, communication skills, underlying psychiatric disorder, pharmacological treatment, and other cognitive factors. All these inflammatory factors are related to each other and interact with each other.

Erectile dysfunction is frequently associated with loss of self-esteem and can impact significantly on the quality of life and well-being of both members of a couple⁷. The prevalence and severity of ED increase with age^8,9. ED is a condition with prevalence rates of 3.9% in men between the ages of 25- to 39, rising to 32.3% in those men aged 50 to 70 years⁹. Based on this high prevalence of ED, extensive investigations into the clinical and pathophysiologic mechanisms of sexual dysfunction have been carried out during the last decade¹⁰. Velurajah’s systematic review points that a high prevalence of ED in the anxiety disorder population and evidence that suggests ED may be more severe in this population¹¹. Bandelow et al. found that increased TNF-α level is associated with reduced 5-HTT activity, which is relevant to OCD pathophysiology¹². The development of erectile dysfunction has been associated with diabetes, hypertension, hyperlipidemia, depression, and metabolic syndrome¹³. Moreover, erectile dysfunction is considered a marker of cardiovascular disorders¹⁴. Erectile dysfunction (ED) can be seen as an active inflammatory cycle and that inflammation has a central role in the entire atherosclerotic process. As an inflammatory marker, the serum C-reactive protein (CRP)/albumin ratio (CAR) may link to ED and its severity¹⁵. Some studies report their support for this but also suggest that erectile dysfunction could be a disease of low-grade systemic inflammation^16,17. Risk factors for OCD and erectile dysfunction (ED) are similar, as might be expected given their shared etiologic and pathophysiologic origins.

Therefore, OCD and ED share many risk factors, either constitutional disorders or psychological factors. However, no study has discussed the association between OCD and ED. Erectile dysfunction has not had much attention in research concerning OCD, and ED in patients with OCD has been investigated in very few limited studies. The aim of this study was to evaluate the prevalence of ED in patients with OCD. We conducted a nationwide population-based cohort study by analyzing data from the National Health Insurance Research Database of Taiwan for assessing the association between OCD and the subsequent development of organic and psychogenic ED.

The present study conducted a nationwide cohort study from Taiwan’s National Health Insurance Research Database (NHIRD). Taiwan’s National Health Insurance Program, established in 1995, is a compulsory universal insurance program and covers approximately 99% of the 23 million Taiwanese residents. We used the Longitudinal Health Insurance Database 2000 (LHID 2000) which can be an element of NHIRD for this study. LHID 2000 included all medical claims from 2000, Jan. to 2016, Dec. of 2 million beneficiaries who were randomly sampled from among all enrollees in the NHI. The Institutional Review Board of the China Medical University in central Taiwan has approved the proposal which was in accordance with the Declaration of Helsinki. Cases of psychogenic ED were defined by the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnostic code 302.72. The index year was defined as the date on which the patient visited the clinics that sought medical management. The identities of all the patients were converted to surrogate numbers by the NHRI. Exclusion criteria included patients who underwent a major operation (such as radical prostatectomy and radical cystectomy), all spinal (cord, plexus, sacral) injuries, drug dependence, before the index ED recorded to date, diagnosed with OCD before 2000 Jan, incomplete demographic data, and cancer history.

Study Design and Sampled Participants

This study was of a population-based, matched-cohort design, we included patients with newly diagnosed OCD aged over 18 years, retrospectively, selected from the longitudinal insurance database from the index year between January 1, 2000, and December 31, 2016, in keeping with the ICD-9-CM. The control group consisted of patients without OCD (ICD-9-CM 300.3) that were randomly chosen from the database at a ratio of 1:1, with age- and index-year matched.

ED was classified as psychogenic ED (ICD-9-CM 302.74) and organic ED (ICD-9-CM 607.84). Comorbidities during this study included anxiety (ICD-9-CM 300.0, 300.2-300.3, 308.3, 309.31), bipolar disorder (ICD-9-CM 296.0-296.1, 296.4-296.8), depression (ICD-9-CM 296.2-296.3, 300.1, 311), chronic obstructive pulmonary disease (COPD) (ICD-9-CM 491–492, 496), hypertension (ICD-9-CM 401–405), diabetes mellitus (DM) (ICD-9-CM 250), hyperlipidemia (ICD-9-CM 272), alcohol-related illness (ICD-9-CM 291, 303, 305, 571.0-571.3, 790.3, V11.3), with references to previous studies about ED.

This was a retrospective cohort study. Male patients aged > 18 years or older newly diagnosed with OCD between 1 January 2000 and 31 December 2016 were identified. Patients who had OCD before 2000, ED before tracking, female patients, and were younger than 18 years were excluded. The comparison group (patients without OCD) was randomly chosen with the same exclusion criteria from the database at a ratio of 1:1 (Fig. 1). Two groups were matched by age and index year.

Statistical Analysis

All data were analyzed by Statistical Product and Service Solutions (SPSS Inc., Chicago, IL). The baseline characteristics and comorbidities of the OCD cohort and non-OCD cohort were compared. Two sample t-tests and a Chi-square test were used to evaluate the difference in age and comorbidities between the OCD and non-OCD groups. The overall, sex-, age-, and comorbidity-specific incidence rates (per 10,000 person-years) of ED were calculated for each cohort. The possible risk factors leading to ED were studied in a Cox regression model (or called the proportional hazard model) to estimate the hazard ratio and 95% confidence intervals (CIs). The Cox regression model was used to adjust the risk rate of ED between the OCD and non-OCD control group by the modification of age, urbanization level, occupation, insured premiums, and comorbidities. The Kaplan–Meier method and Log-rank test were used to estimate the risk of ED in the two groups. A P value < 0.05 was considered statistically significant.

There were 2,041 who were diagnosed with OCD, and 2041 patients without OCD in the control group, total of 4082 samples were collected, and we established an OCD cohort of 2,041 patients with OCD, and a comparison cohort of 2,041 people without OCD after the matches were included, 4082 participants were aged from 18 to 65. The OCD and comparison cohorts had similar distributions of age, with an approximate mean age of 35 years. Demographic statistics and comorbidities are reported in Table 1. All comorbid medical problems, anxiety, bipolar disorder, and antidepressants used in the OCD group were significantly higher than in the control group. In the seven-year follow-up period, Table 1 showed that except for comorbidities, there was no significant difference in the demographic characteristics between the OCD group and the non-OCD control group.

We collected a total of 70 psychogenic ED patients. Patients with OCD had a higher risk of developing psychogenic ED than non-OCD controls (adjusted HR = 4.05, 95% confidence interval (CI) [2.06, 7.99], p < .001), after adjusting the confounding factors such as age, urbanization level, occupation, insured premiums, and comorbidities. The risk of psychogenic ED in the OCD group was higher than that in the non-OCD group for both the 18–34 and 50–65 age (adjusted HR = 7.48, 95% CI [1.65, 34.0], p = .009 and 5.44, 95% CI [1.85, 16.0], p = 0.002, respectively) (Table 2), and with or without hypertension, diabetes, hyperlipidemia, COPD, depression, anxiety, and bipolar disorder, the risk of psychogenic ED in the OCD group was higher than in the non-OCD group (Table 2).

The adjusted HR of psychogenic ED in Table 2 was obtained by the Cox regression model. Table 3 showed the HR of adjusted factors, and the risk of psychogenic ED was higher in both the 35–49 and 50–65 age group than in the 18–34 age group (adjusted HR = 2.62, 95% CI [1.38, 4.99], p = 0.003 and adjusted HR = 5.72, 95% CI [2.88, 11.4], p < 0.001, respectively). Some demographics, such as occupation, insured premiums, and urbanization were not significant to the risk of psychogenic ED. Except for OCD and age, some comorbidities, such as hypertension, diabetes, hyperlipidemia, COPD, alcohol-related illness, depression, and bipolar disorder were not significant to the risk of psychogenic ED. The risk of psychogenic ED in the group without antidepressants was higher than in the group with antidepressants (adjusted HR = 0.25, 95% CI [0.14, 0.46], p < 0.001) (Table 3).

The Kaplan–Meier method was used to evaluate cumulative incidence. The cumulative incidence rate of ED in the OCD group was higher than the non-OCD cohort control (0.05% and 0.02%, respectively, Log-rank test p < 0.001) (Fig. 2).

Sexuality is a natural component of human behavior and has a key role in the quality of life and well-being¹⁸, but sexuality has not had much attention in research with respect to OCD. The mechanism of ED that leads to how psychogenic factors such as anxiety and depression lead to ED is not fully understood. These sexual problems could be through the mental health disorder itself or the psychotropic medications used to treat them¹⁹.

Previous studies have focused on anxiety, depression or medical problems, and erectile dysfunction relationships; Several classical studies report that sexual dissatisfaction and sexual dysfunction in OCD can range from 54–73% of patients²⁰. Therefore, this study focused on the relationship between OCD and psychogenic erectile dysfunction^21,22. This is also the first study to use a nationwide database to analyze the association between psychogenic ED and OCD in Taiwan. Twenty-one thousand six hundred fifty-six individuals matched by age and index year for comparison were enrolled. The OCD patients were more likely to have psychogenic ED when compared with the non-OCD controls (adjusted HR 4.05, 95% CI [2.06, 7.99], p < .001) after adjusting for the confounding factors such as age, occupation, insured premiums, the urbanization of residence and comorbidity.

Three age groups, particularly aged 50–65 years revealed a higher risk of development of the subsequent psychogenic ED. This suggests that the prevalence of erectile dysfunction increases with age. Kaplan–Meier analysis revealed that the OCD group had a significantly higher rate of ED than the control groups during the 7-year follow-up period. Raise’s study results suggest that certain areas of sexual functioning may be impacted by OCD symptomatology and may in turn have a greater negative impact on quality of life²³. In a recent study on ED and psychopathology, erectile function was significantly correlated with depression, anxiety, and obsessive-compulsive symptoms. ED has both organic and psychogenic causes; the psychiatric etiology of ED cannot be asserted quite so clearly, and the mechanism of how psychogenic factors such as anxiety and depression leads to ED is not fully understood. This is the first study to use a nationwide database to analyze the association between psychogenic ED and OCD in Taiwan. Kaplan–Meier analysis revealed that the OCD group had a significantly higher rate of psychogenic ED than the control groups during the 7-year follow-up period. A clinical study points out psychogenic ED should be considered in patients with physical and mental health problems, psychological trauma, relationship problems, partner dissatisfaction, family or social pressures, and depression²⁴. Sexual response is an impaired quality of life outcome in OCD that should be assessed in routine clinical practice²⁵.

Obsessive-compulsive disorder (OCD) is a common and chronic mental illness. It is also one of the most serious causes of disability and impaired quality of life in family and social relationships^26,27, Kendurkar and Kaur also point out that sexual dysfunction was more prevalent among patients with OCD (50%) in comparison with healthy controls (30%)²⁸. Our study showed that the incidence rate of psychogenic ED was higher in OCD patients when compared with the non-OCD control group (HR = 4.05, P < 0.001), or 0.02% (48 in 2041) in the OCD subjects and 0.01% (22 in 2,041) in the non-OCD control group.

The possible mechanisms between OCD and psychogenic ED are complex and may be associated with a variable multifactor. People with OCD have social skill deficits and are often dissatisfied and avoidant in their relationships, have difficulties in interpersonal relationships, are often comorbid with OCD, and are less likely to get married²⁹. Many patients with OCD who do not respond to a single medication may require a combination of drugs like antipsychotics and other SSRIs, further complicating the situation with respect to sexual side effects³⁰. Some studies also point out SSRIs may delay ejaculation and can cause decreased libido and erectile dysfunction^31,32. Sexual dysfunction is also a common reason for patients stopping antidepressant or antipsychotic medicines, often without telling their prescriber.

Psychiatric factors, patients with OCD with common comorbid depression and anxiety, might be considered a possible factor in the relationship between OCD and sexual dysfunction. Torres’s studies suggest that over 50% of patients with OCD have at least one comorbid psychiatric disorder, most commonly an anxiety disorder or major depressive disorder. Moreover, alcohol use disorder is more frequent in OCD than in the general population³³.

In this study, the OCD subjects with or without hyperlipidemia, COPD, hypertension, diabetes, depression, anxiety, and bipolar disorder were associated with a risk of psychogenic ED higher than non-OCD subjects, but it is hard to say whether OCD alone is a risk factor for ED. Psychiatric illness has been associated with sexual dysfunctions in men, this could be through the mental health disorder itself or taking psychiatric medication to treat them, and has negative implications for self-esteem³⁴. Sexual dysfunction is a common, often unknown side effect of treatment with antidepressants and antipsychotics. Steketee’s study showed that patients with OCD are complicated by factors such as lower rates of marriage, difficulties in intercourse, and lesser sexual experience³⁵. Sexual obsessive thoughts about self-impurity and compulsive behavior, elusion³⁶, and aversion³⁷ could play a role in sexual dysfunction in OCD patients. While obsessive thinking provokes anxiety, disgust, or guilt, compulsive behavior is repetitively performed to cope with the unpleasant feelings evoked by the former, even though relief is often only temporary³⁸. Erectile dysfunction is a complex problem influenced by many factors, including biopsychosocial factors, underlying psychiatric disorders, pharmacological treatment, relationship problems, stress, and other cognitive factors. All these aspects are interlinked and work by influencing and interacting with each other. Thus, in this study, we try to look at the aspects of OCD that are relevant from the sexual point of view. Relationship problems are some of the common causes of sexual problems or poor quality of sex³⁹. Another important reason to investigate sexual life in OCD is the fact that depressive symptoms are very common among patients with OCD⁴⁰. Depression could induce impairment in sexual function, leading to erectile problems. Comorbid depression is frequent in OCD and is considered a possible factor in the relationship between OCD and sexual dysfunction.

Limitations

Although this study is based on the large population data and the result revealed the association between OCD and psychogenic ED, there are some limitations in the present study that should be addressed. First, diagnoses of OCD and ED were identified by the ICD-9-CM codes, due to factors such as culture, customs, religion, etc. in Taiwan, most people are less willing to discuss sex issues, which makes it even more difficult for OCD patients, which may have reported less OCD in ED patients of those seeking medical help in Taiwan as compared to studies conducted in Europe countries, so the relative correlation may be underestimated. Second, we used the Longitudinal Health Insurance Database 2000 (LHID 2000) which can be an element of NHIRD for this study. Under the influence of many factors in the early stage, ordinary people are less willing to discuss sexual problems, and clinicians do not pay attention to them, resulting in NRIRD lacking personal information such as body mass index, lifestyle, smoking, and alcohol consumption, which may also be associated with ED, which might reduce the utility of the study results. Third, patients with ED and OCD may seek folk medicine, traditional Chinese medicine, or private therapy instead of visiting a hospital. Due to the culture, religious conflict, and embarrassment, the diagnosis can be underestimated.

Psychogenic erectile dysfunction in OCD is a subject that has not been given enough attention in research despite a strong possible link between some OCD features and sexual functioning. Erectile dysfunctions are commonly found in patients with OCD. They can be part of the disease process of OCD and also can be an impairment on quality of life. OCD should be considered a predisposing factor in clinical practice while treating patients with erectile dysfunction. Physicians should be aware that ED is prevalent among patients with OCD, and take sexual history as part of their routine clinical assessment.

Overall, sexual functioning should always be kept in mind when it comes to OCD patients, as sexual dysfunction can have a profound negative impact on the quality of life of the patient and can even lead to the patient discontinuing the treatment, so treating a patient with OCD and SD should be prompt and also by maintaining a minimum effective dose of psychotropic drugs would help prevent poor compliance with medication, improve self-esteem and enhance overall treatment success.

Funding

This study did not receive any funds.

Availability of data and materials

The datasets used during the current study are available from the corresponding author on reasonable request.

Consent for publication

Not applicable.

Conflicts of Interest

The authors have no potential conflicts of interest to disclose.

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Table 1. Demographic characteristics of the non-Obsessive Compulsive-Disorder group and Obsessive-Compulsive Disorder group between 2000-2016.
	Obsessive-Compulsive Disorder
	No (N =2041)	Yes (N =2041)
Variable	N (%)	N (%)
Age (mean±SD)^t (years)	35.2±13.2	35.7±12.3
18-34	1141(55.9)	1138(55.8)
35-49	573(28.1)	573(28.1)
50-65	327(16.0)	330(16.2)
Occupation
White	1007(49.3)	1008(49.4)
Blue	409(20.0)	410(20.1)
Others	625(30.6)	623(30.5)
Insured premiums
<20000	635(31.1)	633(31.0)
20000-40000	873(42.8)	875(42.9)
>40000	533(26.1)	533(26.1)
Urbanization
1	1173(57.5)	1169(57.3)
2	739(36.2)	745(36.5)
3	129(6.32)	127(6.22)
Comorbidity
Hypertension	218(10.7)	376(18.4)
Diabetes	104(5.10)	198(9.70)
Hyperlipidemia	209(10.2)	404(19.8)
COPD	101(4.95)	229(11.2)
Depression	24(1.18)	436(21.4)
Anxiety	77(3.77)	502(24.6)
Bipolar disorder	6(0.29)	149(7.30)
Medications
Antidepressants	244(12.0)	1785(87.5)
Follow time for ED (mean±SD)^t (years)	7.22±4.61	6.94±4.68
t: t-test COPD=chronic obstructive pulmonary disease, ED = erectile dysfunction,

Table 2. Comparisons of incidence of Psychogenic Erectile dysfunction between patients with and without OCD
	Non-OCD				OCD			Crude		Adjusted ^a
Variable		Event	Person-Year	IR	Event	Person- Year	IR	HR (95% CI)	P-value	HR (95% CI)	P-value
All	22		14744	1.49	48	14157	3.39	2.27(1.37, 3.76)	.001	4.05(2.06, 7.99)	<.001
Age
18-34	3		8019	0.37	14	7713	1.82	4.84(1.39, 16.8)	.01	7.48(1.65, 34.0)	.009
35-49	9		4365	2.06	15	4222	3.55	1.73(0.76, 3.94)	.20	2.08(0.64, 6.80)	.22
50-65	10		2361	4.24	19	2222	8.55	2.01(0.94, 4.33)	.07	5.44(1.85, 16.0)	.002
Comorbidity
Hypertension
No	18		13311	1.35	36	11705	3.08	2.28(1.29, 4.01)	.004	3.81(1.79, 8.15)	<.001
Yes	4		1434	2.79	12	2452	4.89	1.73(0.56, 5.38)	.34	3.98(0.89, 17.8)	.07
Diabetes
No	19		14127	1.34	41	12962	3.16	2.35(1.37, 4.06)	.002	3.71(1.78, 7.72)	<.001
Yes	3		618	4.86	7	1196	5.85	1.22(0.32, 4.73)	.77	8.55(1.30, 56.1)	.03
Hyperlipidemia
No	15		13492	1.11	37	11647	3.18	2.85(1.57, 5.20)	<.001	4.19(1.83, 9.56)	<.001
Yes	7		1252	5.59	11	2510	4.38	0.80(0.31, 2.06)	.64	3.09(0.95, 10.0)	.06
COPD
No	-		-	1.42	37	12828	2.88	2.03(1.18, 3.50)	.01	3.10(1.42, 6.74)	.004
Yes	-		-	2.91	11	1329	8.27	2.76(0.61, 12.5)	.19	8.75(1.35, 56.7)	.02
Depression
No	22		14647	1.50	39	11673	3.34	2.23(1.32, 3.76)	.003	4.34(2.19, 8.60)	<.001
Yes	0		97	0.00	9	2484	3.62
Anxiety
No	17		14368	1.18	37	11681	3.17	2.70(1.52, 4.79)	<.001	5.31(2.51, 11.2)	<.001
Yes	5		377	13.3	11	2477	4.44	034(0.12, 0.97)	.04	0.83(0.20, 3.37)	.79
Bipolar disorder
No	22		14727	1.49	44	13456	3.27	2.19(1.31, 3.66)	.003	3.66(1.83, 7.34)	<.001
Yes	0		18	0.00	4	701	5.71
Medications
antidepressants
No	19		12449	1.53	17	1690	10.1	6.50(3.37, 12.5)	<.001	2.62(1.11, 6.16)	.03
Yes	3		2295	1.31	31	12468	2.49	1.89(0.58, 6.20)	.29	2.06(0.60, 7.09)	.25

^aadjusted by age, urbanization level, occupation, insured premiums, and comorbidities

OCD: Obsessive-Compulsive Disorder; IR: per 1000 person-years; HR: Hazard Ratio; CI: Confidence Interval

“- “: Due to personal information (less than 3 records), the table cannot be displayed

Table 3. The hazard ratio of Psychogenic ED and 95% confidence intervals adjusted by the demographic factors and comorbidities of Cox regression model
Characteristics	Event no. (n=70)	Person- years	IR	Crude		Adjusted^a
Characteristics	Event no. (n=70)	Person- years	IR	HR (95% CI)	p-value	HR (95% CI)	p-value
OCD
No	22	14745	1.49	1.00		1.00
Yes	48	14157	3.39	2.27(1.37, 3.76)	0.001	4.05(2.06, 7.99)	<0.001
Age Group
18-34	17	15733	1.08	1.00		1.00
35-49	24	8587	2.79	2.58(1.40, 4.87)	0.002	2.62(1.38, 4.99)	0.003
50-65	29	4583	6.33	5.86(3.24, 10.7)	<0.001	5.72(2.88, 11.4)	<0.001
Occupation
White	32	14078	2.27	1.00		1.00
Blue	20	6215	3.22	1.42(0.82, 2.51)	0.20	0.96(0.54, 1.70)	0.88
Others	18	8610	2.09	0.92(0.52, 1.64)	0.78	0.77(0.43, 1.38)	0.38
Insured premiums
<20000	18	8706	2.07	1.00		1.00
20000-40000	36	12080	2.98	1.44(0.82, 2.55)	0.20	1.48(0.84, 2.60)	0.18
>40000	16	8117	1.97	0.95(0.49, 1.88)	0.90	1.03(0.52, 2.02)	0.94
Urbanization
1	39	16446	2.37	1.00		1.00
2	28	10539	2.66	1.12(0.69, 1.82)	0.65	1.08(0.67, 1.76)	0.75
3	3	1917	1.57	0.66(0.21, 2.15)	0.49	0.69(0.21, 2.24)	0.54
Comorbidities
Hypertension
No	54	25016	2.16	1.00		1.00
Yes	16	3887	4.12	1.91(1.12, 3.42)	0.02	0.85(0.45,1 .62)	0.63
Diabetes
No	60	27089	2.21	1.00		1.00
Yes	10	1813	5.51	2.49(1.29, 4.95)	0.007	1.17(0.54, 2.54)	0.70
Hyperlipidemia
No	52	25140	2.07	1.00		1.00
Yes	18	3763	4.78	2.31(1.38, 4.05)	0.002	1.03(0.54, 1.96)	0.94
COPD
No	13	26996	2.12	1.00		1.00
Yes	57	2016	6.45	3.04(1.68, 5.61)	<0.001	1.39(0.72, 2.68)	0.33
Alcohol-related illness
No	67	28127	2.38	1.00		1.00
Yes	3	775	3.87	1.63(0.52, 5.28)	0.39	0.91(0.28, 2.97)	0.87
Depression
No	61	26320	2.32	1.00		1.00
Yes	9	2582	3.49	1.50(0.74, 2.99)	0.27	1.11(0.53, 2.34)	0.78
Anxiety
No	54	26049	2.07	1.00		1.00
Yes	16	2854	5.61	2.71(1.49, 4.61)	<0.001	1.96(1.07, 3.61)	0.03
Bipolar disorder
No	76	28183	2.70	1.00		1.00
Yes	4	718	5.56	2.28(0.83, 6.30)	0.11	1.24(0.42, 3.64)	0.70
Medications
antidepressants
No	36	14139	2.55	1.00		1.00
Yes	34	14763	2.30	0.90(0.57, 1.46)	0.71	0.25(0.14, 0.46)	<0.001
^aadjusted by age, urbanization level, occupation, insured premiums, and comorbidities OCD: Obsessive-Compulsive Disorder; IR: per 1000 person-years; HR: Hazard Ratio; CI: Confidence Interval

No competing interests reported.

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Risk of Erectile Dysfunction after Primary Obsessive-Compulsive Disorder: A Nationwide Population-Based Study

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