C 2004) Archives of Sexual Behavior, Vol. 33, No. 6, December 2004, pp. 539–548 (


Lifetime Depression History and Sexual Function in Women at Midlife Jill M. Cyranowski, Ph.D.,1,7 Joyce Bromberger, Ph.D.,2 Ada Youk, Ph.D.,3 Karen Matthews, Ph.D.,4 Howard M. Kravitz, D.O., M.P.H.,5 and Lynda H. Powell, Ph.D.6 Received December 23, 2003; revision received May 6, 2004; accepted May 6, 2004

We examined the association between lifetime depression history and sexual function in a communitybased sample of midlife women. Specifically, 914 women aged 42–52 who were participants in the Study of Women’s Health Across the Nation completed a self-report assessment of their sexual behaviors, sexual desire, sexual arousal, and sexual satisfaction over the past 6 months. On the basis of the Structured Clinical Interview for the DSM-IV, participants were categorized into 1 of 3 lifetime major depressive disorder (MDD) history groups: no MDD history, single episode MDD, and recurrent MDD. In line with previous reports, women with a history of recurrent MDD reported experiencing less frequent sexual arousal, less physical pleasure, and less emotional satisfaction within their current sexual relationships. Although the groups did not differ in their reported frequency of sexual desire or partnered sexual behaviors, lifetime depression history was associated with increased rates of self-stimulation (masturbation). Associations between lifetime depression history and lower levels of physical pleasure within partnered sexual relationships and higher rates of masturbation remained significant following control for current depressive symptoms, study site, marital status, psychotropic medication use, and lifetime history of anxiety or substance abuse/dependence disorder. Future research is needed to characterize the temporal and etiologic relationships among lifetime depressive disorder, current mood state, and sexual function in women across the lifespan. KEY WORDS: depression; women; sexual behavior; sexual satisfaction; Study of Women’s Health Across the Nation.

Gitlin, 1995; Hirschfeld, 1999). In depressed women, common sexual difficulties include decreased sexual desire (Clayton, McGarvey, Clavet, & Piazza, 1997; Cyranowski, Frank, Cherry, Houck, & Kupfer, 2004; Kennedy, Dickens, Eisfeld, & Bagby, 1999; Piazza et al., 1997; Zajecka et al., 2002), sexual arousal difficulties (Cyranowski et al., 2004; Kennedy et al., 1999; Piazza et al., 1997; Zajecka et al., 2002), orgasmic difficulties (Cyranowski et al., 2004; Kennedy et al., 1999), reduced sexual satisfaction (Zajecka et al., 2002), and reduced sexual pleasure (Clayton et al., 1997). Recent research, moreover, suggests that the sexual difficulties observed in depressed women persist following treatment of the acute depressive episode. Zajecka et al. (2002) found that 35% of chronically depressed women continued to report sexual problems following 12 weeks of treatment with psychotherapy and/or nefazodone. Cyranowski et al. (2004) observed persistently elevated levels of sexual problems among recurrently

INTRODUCTION Alterations in sexual function have long been noted to be associated with depression (Baldwin, 1996; 1 Departments

of Psychiatry and Psychology, University of Pittsburgh, Pittsburgh, Pennsylvania. 2 Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania. 3 Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania. 4 Departments of Psychiatry, Psychology, and Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania. 5 Departments of Psychiatry and Preventive Medicine, Rush University Medical Center, Chicago, Illinois. 6 Departments of Preventive Medicine and Psychology, Rush University Medical Center, Chicago, Illinois. 7 To whom correspondence should be addressed at Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, 3811 O’Hara Street, Pittsburgh, Pennsylvania 15213; e-mail: [email protected].

539 C 2004 Springer Science+Business Media, Inc. 0004-0002/04/1200-0539/0


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depressed women after 1 year of effective psychotherapy treatment with or without adjunctive antidepressant medication. In a related line of research, Schreiner-Engel and Schiavi (1986) found that women with inhibited sexual desire reported significantly elevated rates of lifetime depressive disorder as compared with matched controls, despite the fact that both groups were depressionfree at the time of assessment. These findings raise the possibility that a lifetime history of depressive disorder, independent of current depressive symptoms, may increase women’s risk of sexual difficulty or dysfunction. The current study was designed to examine the association between lifetime depression history and sexual function in women at midlife. Specifically, we compared reports of recent sexual behavior, sexual function, and sexual satisfaction among a community-based sample of midlife women with and without lifetime histories of major depressive disorder (MDD). We hypothesized that women with a lifetime history of depression would report diminished sexual function and satisfaction as compared with never-depressed women. Because recurrent MDD is typically associated with a more severe form of illness and greater interpersonal dysfunction, we hypothesized that women with a lifetime history of recurrent MDD would report the poorest levels of sexual function and satisfaction. Importantly, we hypothesized that these associations would persist even after controlling for differences in current depressive symptoms.

METHOD Participants The study group consisted of middle-aged women who were participants at three sites of the Study of Women’s Health Across the Nation (SWAN), a multisite longitudinal study of middle-aged women’s health. SWAN participants in Chicago, IL, Newark, NJ, and Pittsburgh, PA who were available for a psychiatric interview within 9 months of the SWAN baseline assessment were recruited to take part in an ancillary Mental Health Study. In all, 227 women in Chicago, 257 in Newark, and 438 in Pittsburgh participated. SWAN was designed to track changes in reproductive hormones and health outcomes among a communitybased multiethnic sample of women transitioning through menopause. Of the 922 Mental Health Study participants,

914 (99%) also provided data regarding their current sexual function and behavior (as part of the SWAN protocol), and were included in the current analyses. Mean age of the study sample was 46.0 years (SD = 2.68). The design and sampling procedures of SWAN have been described in detail elsewhere (Sowers et al., 2000). In brief, at the three Mental Health Study sites, potential participants were identified via random digit dialing, voter registration lists, random sampling of a complete community census, and snowballing. Snowballing consisted of asking women who had completed the screening interview to provide the names of five women who were age-eligible and who lived in the target area, and was used in Newark because of the difficulty in obtaining the requisite number of participants through random digit dialing (associated, in part, with the high proportion of households without telephones in this community). Eligibility criteria required to enter SWAN included aged 42–52 years, having an intact uterus, having had at least one menstrual period in the previous 3 months, no use of reproductive hormones in the previous 3 months, and selfidentifying with one of the site’s designated racial/ethnic groups. Overall, approximately 50% of those eligible entered the cohort study. On the basis of the telephone screening interview, compared to eligible nonparticipants, participants were more likely to be African American, employed, better educated, and healthier (reporting fewer sleep problems, lower body mass index, fewer smokers, and better overall health) and less likely to be Hispanic. The groups were similar for marital status, hot flashes, feeling blue/depressed, and tense. Each study site adhered to its Institutional Review Board’s guidelines for human research. Participants were provided with complete study information, and written informed consent was obtained prior to subjects’ participation in both the core SWAN study and the ancillary Mental Health Study. Baseline assessments obtained through the SWAN protocol included questions about demographic, medical, reproductive and menstrual history, depressive symptoms, psychosocial function, and sexual function and behavior. Questions were administered either orally by trained staff or were part of paper-and-pencil assessments. Sexuality questionnaires were completed separately by participants during the baseline visit, and completed questionnaires were returned to staff in sealed envelopes at the end of this visit. All study forms and materials were available in English and Spanish and bilingual staff was used, as appropriate. Translations were prepared for the study (initial translation, back translation, and revision).

Lifetime Depression History and Sexual Function in Women at Midlife Measures Psychiatric Assessment Psychiatric diagnoses were determined by the Structured Clinical Interview for Diagnosis of DSM-IV Axis I Disorders (SCID-IV), administered by trained clinical interviewers as part of the Mental Health Study 2–9 months following the baseline SWAN assessment. The SCID has been used with many different ethnic groups and its reliability has been demonstrated in numerous studies (Spitzer, Williams, Gibbon, & First, 1992; Williams et al., 1992). Interviewers included an MD, four master’s level clinical social workers, and a master’s degree candidate in social work who were supervised by psychiatrists or a psychiatric epidemiologist. Extensive training was used to ensure and monitor consistency of SCID administration, symptom elicitation, and diagnostic decision-making across the sites. All SCID interviews were audiotaped to facilitate supervision and assessment of interrater reliability. Interrrater reliability for lifetime SCID diagnoses, assessed in a systematic sample of 36 audiotaped interviews (stratified across interviewers), ranged from good to very good: κ = .81 for major depressive disorder, .78 for substance dependence, and .82 for any phobia or panic disorder. For the purpose of the current study, lifetime history of depressive disorder was defined as the occurrence of depression prior to the SWAN baseline assessment. Participants were categorized into three groups based on their lifetime history of major depressive disorder (MDD): (1) no history of MDD; (2) MDD, single episode; and (3) MDD, recurrent. Of the study sample, 68.1% reported no lifetime history of MDD, 15.3% reported a single MDD episode, and 16.6% reported a history of recurrent (two or more) lifetime depressive episodes. Other pertinent SCID data included as control variables were lifetime history of one or more Axis I anxiety disorders (including panic disorder, agoraphobia, social phobia, specific phobia, obsessive–compulsive disorder, generalized anxiety disorder, or anxiety disorder not otherwise specified), and lifetime history of alcohol or substance abuse or dependence disorder. Both of these were included as categorical (yes/no) variables.

Assessment of Sexual Behavior, Function, and Satisfaction Sexual outcome variables were assessed via selfreport questionnaire completed as part of the SWAN

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baseline assessment battery. This questionnaire included items designed to assess sexual activity and function in women with or without current sexual partners. Questionnaire items were derived from several sources, including the Massachusetts Women’s Health Study (Avis, 2000), the National Health and Social Life Survey (Laumann, Gagnon, Michael, & Michaels, 1994), the National Survey of Family Growth (Abma, Chandra, Mosher, Peterson, & Piccinino, 1997), and the Women’s Health Initiative Daily Life Form (Women’s Health Initiative Study Group, 1998). The questionnaire assessed multiple domains of sexual behavior and function as experienced over the past 6 months, including sexual behavior frequency, sexual function, and sexual satisfaction. Partnered Sexual Behaviors. All respondents were asked whether they had engaged in sexual activities with a partner during the past 6 months (yes/no). Those who responded affirmatively rated the frequency with which they engaged in specific partnered sexual activities during the past 6 months, including (1) kissing or hugging, (2) sexual touching or caressing, and (3) sexual intercourse. Sexual behavior frequencies were rated on a 5point Likert scale (not at all, once or twice per month, about once a week, more than once a week, and daily). Masturbation. All respondents rated the frequency with which they engaged in masturbation (selfstimulation) during the past 6 months, rated on a 6-point Likert scale ranging from not at all to daily. Sexual Desire. All respondents were asked to rate their frequency of sexual desire. Specifically, respondents were asked, “During the past 6 months, how often have you felt a desire to engage in any form of sexual activity, either alone or with a partner?” Responses were rated on a 5-point Likert scale, ranging from not at all to daily. Sexual Arousal. Women who endorsed partnered sexual activity during the past 6 months were asked to rate “How often did you feel aroused during sexual activity?” on a 5-point Likert scale ranging from never to always. Physical Pleasure. Women who endorsed partnered sexual activity during the past 6 months were asked to rate “How physically pleasurable was your relationship with your main partner?” on a 5-point Likert scale ranging from not at all pleasurable to extremely pleasurable. Emotional Satisfaction. Women who endorsed partnered sexual activity during the past 6 months were asked to rate “How emotionally satisfying was your relationship with your main partner?” on a 5-point Likert scale ranging from not at all satisfying to extremely satisfying.

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Demographic and Clinical Covariates Current depressive symptoms were assessed as part of the baseline SWAN interview with the Center for Epidemiologic Studies Depression (CES-D) Scale, a 20-item scale that asks about the frequency of being bothered by depressive symptoms during the previous week (Radloff, 1977). This scale was developed to screen for clinical depression in community samples, and a cutpoint of ≥16 has been commonly used to identify potential clinical depression (Boyd, Weissman, Thompson, & Myers, 1982; Comstock & Helsing, 1976). Differences in pertinent demographic, medical, psychiatric, and psychosocial variables were tested among the MDD history groups. Demographic characteristics evaluated included ethnicity, age, education, income, marital status, and sexual orientation (see Table I). At each SWAN site, roughly half of the women enrolled Table I. Characteristics of the Sample (N = 914) Variable Age 42–45 46–49 50–53 Ethnicity Caucasian African American Hispanic Education
N

%

445 364 105

48.7 39.8 11.5

504 243 167

55.1 26.6 18.3

81 785

9.4 90.6

159 312 428

17.7 34.7 47.6

454 400

53.2 46.8

601 227 86

65.8 24.8 9.4

724 175

80.5 19.5

7 10 887 3

0.8 1.1 97.8 0.3

were non-Hispanic Caucasian and half were of one predetermined ethnic background; in the current sample this included African American participants (recruited from the Pittsburgh, PA, and Chicago, IL sites) and Hispanic participants (recruited from the Newark, NJ site). Current psychotropic medication use was assessed, defined as use of medications in the past month (yes/no) for nervous conditions (including tranquilizers, sedatives, sleeping pills, or antidepressants). Menopausal status was categorized according to bleeding patterns, defined as premenopausal (no decrease in predictability of menses onset in prior 12 months) or early perimenopausal (menstrual period in past 3 months, but less predictable onset of menses in the last 12 months). These categories are similar to the Stages of Reproductive Aging Workshop (STRAW) recommendations (Soules et al., 2001) for distinguishing the late reproductive years (premenopause) from the early phase of the menopausal transition (early perimenopause). Finally, current relationship satisfaction was assessed with a single item, in which respondents were asked to rate “the degree of happiness, all things considered, of your relationship with your significant other” on a 7-point scale ranging from extremely unhappy to perfect.

Statistical Analyses Subjects were categorized by SCID-defined lifetime depression history (no MDD history, single episode MDD, and recurrent MDD). These depression groups were then compared across relevant demographic and clinical characteristics using chi-square tests and t tests. Variables showing a statistically significant (p ≤ .05) association with lifetime depression history were considered as covariates in subsequent regression models. Multiple ordinal logistic regression analyses using a proportional odds model were performed to examine the association between lifetime depression history and the sexual outcomes of interest, both with and without control for current depression (CES-D), study site, and the set of empirically identified covariates. The statistical significance of lifetime depression history was assessed using a likelihood ratio (LR) chi-square statistic. To summarize the relationship between lifetime depression history and the sexual outcomes, bar plots of the predicted probabilities from the full regression models are presented for outcomes that showed a significant association with MDD history after multivariate adjustment. For all analyses, p values of <.05 were considered significant. All analyses were performed using Stata Statistical Software (StataCorp, 2003).

Lifetime Depression History and Sexual Function in Women at Midlife RESULTS

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Comparing Sexual Outcomes Across the MDD History Groups

Demographic and Clinical Differences Among the MDD History Groups Demographic characteristics of the sample are reported in Table I. The depression history groups did not differ with respect to age, race, education, income, menopausal status, or current reports of relationship happiness. Because of the relatively small proportion of participants reporting a homosexual (1.1%) or bisexual (0.3%) sexual orientation, there was inadequate power to detect group differences on this variable. The depression history groups did differ with respect to marital status, with the never-depressed women most likely, and the recurrently depressed women least likely, to report being currently married. The depression history groups also differed with respect to current depression scores, with 23.2% of the no MDD history group, 35.7% of the single episode MDD group, and 50.0% of the recurrent MDD group reporting CES-D scores ≥16 [χ 2 (2) = 45.33; p < .0001]. The groups also differed with respect to current psychotropic medication use and lifetime history of anxiety and substance abuse/dependence disorders. Specifically, women with a history of recurrent MDD were most likely to report current psychotropic medication use, a lifetime history of one or more anxiety disorders, and a lifetime history of drug or alcohol abuse or dependence (see Table II).

Of the sample, 80.5% endorsed engaging in partnered sexual activities during the past 6 months; this endorsement of recent sexual activity did not differ across the MDD history groups. The MDD history groups did not differ in their frequencies of partnered sexual behaviors, including kissing and hugging, sexual touching and caressing, and sexual intercourse. The MDD history groups did, however, differ in their reports of masturbation, with the recurrent MDD group reporting the highest, and the never-depressed group reporting the lowest, frequency of masturbation. This effect remained significant even after controlling for current depression (CES-D), marital status, psychotropic medication use, anxiety and substance abuse/dependence history, and study site (see Table III, Fig. 1). Post hoc tests indicated that the recurrent MDD group significantly differed from the no MDD group (p < .05); the single MDD and no MDD groups marginally differed (p = .05); and the recurrent and single MDD groups did not differ. The MDD history groups did not differ in their reported frequency of sexual desire. The groups did, however, differ in their subjective reports of sexual arousal, as well as their reports of physical pleasure and emotional satisfaction experienced within their main partner relationship (see Table III). Specifically, the recurrent MDD group reported the least frequent arousal, and the lowest

Table II. Clinical and Demographic Differences Among the Never Depressed, Single Episode MDD, and Recurrent MDD Groups Never depressed (N = 622) Variable Current CES-D

Psychotropic use No Yes Lifetime history of anxiety disorder No Yes Lifetime drug/alcohol abuse or dependence No Yes Marital status Married Divorced, separated Never married

Single episode (N = 140)

Recurrent (N = 152)

M

SD

M

SD

M

SD

F or χ 2

10.3

9.3

13.5

10.1

17.6

12.0

F (2, 913) = 34.7, p < .00001

N

%

N

%

N

%

583 39

93.7 6.3

129 11

92.1 7.9

113 39

74.3 25.7

χ 2 (2) = 49.1 p < .0001

486 136

78.1 21.9

105 35

75.0 25.0

90 62

59.2 40.8

χ 2 (2) = 23.0 p < .0001

532 90

85.5 14.5

114 26

81.4 18.6

107 45

70.4 29.6

χ 2 (2) = 19.4 p < .0001

428 135 59

68.8 21.7 9.5

88 41 11

62.9 29.3 7.9

85 51 16

55.9 33.6 10.5

χ 2 (4) = 12.1 p = .017

Note. The depression history groups did not significantly differ in age, race, education, income, or menopausal status.

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Table III. Sexual Outcomes by Depression History Group: Results From Proportional Odds Regression Models Odds ratios controlling for full modela

Simple odds ratios Variable Frequency of masturbation No MDD history Single MDD Recurrent MDD Sexual desire No MDD history Single MDD Recurrent MDD Sexual arousal No MDD history Single MDD Recurrent MDD Physical pleasure No MDD history Single MDD Recurrent MDD Emotional satisfaction No MDD history Single MDD Recurrent MDD

OR

95% CI

LR χ 2 (2)

p

OR

95% CI

LR χ 2 (2)

p

ref 1.50 1.76

1.05–2.14 1.25–2.46

13.16

.001

ref 1.48 1.67

1.03–2.13 1.16–2.41

9.86

.007

ref 1.03 0.83

0.74–1.42 0.60–1.15

1.40

ns

ref 1.12 1.10

0.80–1.56 0.78–1.57

0.62

ns

ref 1.06 0.62

0.73–1.54 0.43–0.90

6.93

.03

ref 1.11 0.65

0.76–1.61 0.45–0.97

5.31

.07

ref 0.96 0.41

0.66–1.39 0.28–0.60

21.69

<.001

ref 1.02 0.50

0.70–1.50 0.33–0.76

11.27

.004

ref 0.90 0.48

0.62–1.31 0.33–0.70

14.73

.001

ref 1.02 0.64

0.70–1.49 0.42–0.96

4.86

.09

a Full

model includes control for continuous CES-D score, study site, marital status, psychotropic medication use, lifetime anxiety disorder history, and lifetime substance abuse/dependence history.

Fig. 1. Predicted probability of masturbation frequency by lifetime depression group, controlling for current depression, marital status, psychotropic medication use, lifetime anxiety disorder history, lifetime substance abuse/dependence history, and study site. Note. No women reported masturbating daily; hence, this response category was omitted from the figure. MDD: major depressive disorder.

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Fig. 2. Predicted probabilities of physical pleasure within main sexual relationship by lifetime depression group, controlling for current depression, marital status, psychotropic medication use, lifetime anxiety disorder history, lifetime substance abuse/dependence history, and study site. Note. MDD: major depressive disorder.

levels of physical pleasure and emotional satisfaction among the three groups. After controlling for current depressive symptoms and the empirically identified set of covariates, the effect of MDD history on sexual arousal and emotional satisfaction was reduced to nonsignificant trends (p = .07 and .09, respectively). In contrast, the effect of MDD history on reports of physical pleasure within the partnered relationship remained significant even after controlling for current depressive symptoms, marital status, psychotropic medication use, anxiety and substance abuse/dependence history, and study site (p = .004; see Fig. 2). Post hoc tests indicated that although recurrent MDD group significantly differed from both the single MDD and no MDD groups, the single MDD and no MDD history groups did not differ from one another. To evaluate whether increased rates of masturbation were associated with diminished reports of physical pleasure with partnered sex, post hoc Pearson product– moment correlations were obtained between these variables in both the full sample (r = .06, ns) and the subsample of patients with a lifetime depression history (r = .11, ns). DISCUSSION In this community-based sample of midlife women, lifetime history of major depression was associated with

subjective reports of sexual arousal, physical pleasure, and emotional satisfaction within women’s main partner relationship. Specifically, women with a history of recurrent MDD reported feeling less aroused during sexual activity and described their main sexual relationship as less physically pleasurable and less emotionally satisfying, as compared with the never-depressed and single episode MDD groups. These findings extend recent reports suggesting that sexual difficulties may persist beyond remission of the acute depressive episode, particularly among women with chronic or recurrent mood disorders (Cyranowski et al., 2004; Zajecka et al., 2002). Converging data support an association between current depressive symptoms and decreased reports of sexual desire, sexual arousal, and sexual satisfaction. Not surprisingly, women with a history of recurrent MDD endorsed the highest levels of depressive symptoms at the time they completed sexual self-reports. Thus, depressive symptoms at midlife may, in part, explain the relationships obtained between lifetime MDD history and current sexual function. Indeed, the effect of lifetime MDD history on reports of sexual arousal and emotional satisfaction was no longer significant after controlling for current depressive symptoms, underscoring the association between self-reported sexual and emotional function in women (see also Dunn, Croft, & Hackett, 1999).

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Notably, the association between MDD history and lower levels of physical pleasure within the main sexual relationship remained significant even after controlling for current depressive symptoms, marital status, psychotropic medication use, lifetime history of anxiety and substance abuse/dependence disorders, and study site. This finding, although provocative, must be interpreted with caution. It is possible that the lower levels of physical pleasure reported by the recurrently depressed group were attributable to residual depressive symptoms that simply were not captured by the CES-D instrument. Other mechanisms may also be postulated to explain this relationship. For example, women with a history of MDD or dysthymia are less likely to be stably married and report poorer marital satisfaction even when they are not depressed (Hammen & Brennan, 2002). Persistent deficits in interpersonal function may adversely impact the sexual relationships of women with a history of recurrent mood disorder. Indeed, recent survey research indicates that marital difficulties are prominently associated with reported decrements in arousal, orgasm, and sexual satisfaction among women (Dunn et al., 1999). Although the MDD history groups did not differ in reported relationship happiness, this single item may have been unable to discriminate subtle differences in marital function across the MDD history groups. Given the crosssectional nature of the current data, it is also possible that impairments in sexual function contribute to women’s depressive symptoms over time. Alternately, both recurrent depression and sexual problems may share common physiological mechanisms (such as central serotonergic dysfunction), or common psychosocial diatheses (such as the early experience of sexual abuse, which has been associated both with depression and sexual dysfunction in adulthood). Approximately 80% of the sample reported engaging in sexual activities with a partner in the previous 6 months. Women with and without a lifetime history of MDD did not differ in reported frequency of partnered sexual behaviors (such as kissing and hugging, sexual touching and caressing, and sexual intercourse). This finding is not surprising, given the fact that the frequency of such behaviors may be driven, to a large extent, by the sexual partner’s behavioral preferences or the couple’s established pattern of sexual interaction. In contrast, lifetime depression history was associated with an increased frequency of masturbation, with the recurrent MDD group reporting the highest, and the never-depressed group reporting the lowest, masturbation frequencies. This association remained significant even after controlling for current depressive symptoms, marital status, psychotropic medication use, lifetime history of

anxiety and substance abuse/dependence disorders, and study site. This finding, although unexpected, is not entirely novel. A recent report comparing sexual function among college women with high versus low Beck Depression Inventory (BDI) scores indicated that women with high (≥20) BDI scores reported a greater desire to engage in masturbation and were more likely to have engaged in masturbation in the past month, as compared with women with low (≤3) BDI scores (Frohlich & Meston, 2002). To our knowledge, the current study is the first to document differences in masturbation reported among midlife women with and without a lifetime history of MDD. One possible explanation of this finding is that women with a lifetime history of MDD use masturbatory behaviors to compensate for decrements in physical pleasure experienced with partnered sex. Post hoc analysis, however, did not show a significant relationship between reports of pleasure with partnered sex and masturbation frequency. Frohlich and Meston (2002) speculated that masturbation may provide depressed individuals with a reliable form of pleasure or function as a form of self-soothing behavior. Although group differences in masturbation frequency persisted after controlling for current depressive symptoms, it remains possible that women with a lifetime history of MDD develop a set of self-soothing strategies in which they continue to engage beyond the acute mood episode. Given previous research indicating decrements in sexual desire among depressed women, the lack of group differences in sexual desire was unexpected. These null findings may, in part, be measurement related. In the current study, sexual desire was assessed via responses to a single item asking women to rate how often they “felt a desire to engage in any form of sexual activity, either alone or with a partner.” This assessment did not include other indicators of sexual desire (such as sexual thoughts or fantasies, desired frequency of sex, level or strength of desire, or receptiveness to the partner’s sexual initiation). It is also possible that simultaneously rating desire for masturbation and desire for partnered sex obscured study results. For example, Frohlich and Meston (2002) obtained differential associations between depression and college women’s desire for masturbation (which was higher for women with high BDI scores) versus their desire for partnered sex (which did not differ between women with high vs. low BDI scores). These results raise the intriguing possibility of a dissociation between desire for partnered sex versus desire for masturbation among currently or previously depressed women, which should be evaluated in future research.

Lifetime Depression History and Sexual Function in Women at Midlife There are several limitations to the current study. First, certain aspects of women’s sexual function, including orgasmic function and the subjective experience of vaginal lubrication with sex (a marker of sexual arousal), were not assessed. Second, the current study did not conduct structured interviews to diagnose sexual dysfunction, nor did it inquire about women’s subjective level of distress regarding reported sexual difficulties. Recent research indicates that only a portion of women reporting sexual difficulties are distressed about these (Bancroft, Loftus, & Long, 2003). Thus, we cannot speak to the potential level of DSM-defined sexual dysfunction in this midlife sample. Third, women were asked to recall their sexual function over the past 6 months, which may have allowed for some level of memory bias. However, because our models controlled for current depressive symptoms at the time of questionnaire completion, the effects of mood-congruent recall should have been limited with the current study design. Finally, the current study did not assess women’s lifetime history of sexual function. Hence, we cannot determine onset or course of changes in sexual function with respect to mood disorder history. Further research is needed to better characterize the potential temporal and etiologic relationships between recurrent unipolar depression and women’s sexual function. To our knowledge, this report represents the first to examine directly the association between lifetime depression history and sexual function in a sample of midlife women. Strengths of the study include the rigorous, interview-based assessment of lifetime psychiatric history, as well as the size, age, and community-based nature of the study sample. The study findings were also strengthened by use of multiple controls when examining the relationship between lifetime depression history and current sexual function, including control for concurrent depressive symptoms. Recent, clinic-based research highlights the persistence of sexual difficulties in women following effective antidepressant and/or psychotherapeutic treatment (Cyranowski et al., 2004; Zajecka et al., 2002). Supporting these clinic-based findings, the current community-based study indicates that women with a lifetime history of recurrent MDD report diminished sexual arousal, physical pleasure, and emotional satisfaction within their main sexual relationship. Clinically, these findings underscore the need to address potential sexual problems among depressed patients both during and following mood episodes, and to assess lifetime mood disorder history among women presenting with sexual problems. Future research is needed to characterize the nature of these relationships among lifetime depressive disorder, current

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mood state, and sexual function in women across the lifespan.

ACKNOWLEDGMENTS The Study of Women’s Health Across the Nation (SWAN) was funded by the National Institute on Aging (U01 AG012495, U01 AG012505, U01AG012531, U01 AG012535, U01 A012539, U01 AG012546, U01 AG012553, U01 AG012554), the National Institute of Nursing Research (U01 NR04061), and the NIH Office of Research on Women’s Health. Supplemental funding from The National Institute of Mental Health is also gratefully acknowledged. Study sites for the Mental Health Study include University of Pittsburgh, Pittsburgh, PA (R01 MH59689, Joyce T. Bromberger, PI); Rush University Medical Center, Chicago, IL (R01 MH59770, Howard M. Kravitz, PI); and New Jersey Medical School, Newark, NJ (R01 MH59688, Adriana Cordal, PI). SWAN clinical centers included in this report: Rush University Medical Center, Chicago, IL (U01 AG012505, Lynda Powell, PI); University of Medicine and Dentistry – New Jersey Medical School, Newark, NJ (U01 AG012535, Gerson Weiss, PI); and the University of Pittsburgh, Pittsburgh, PA (U01 AG012546, Karen Matthews, PI). The SWAN Coordinating Center was located at the New England Research Institutes, Watertown, MA (U01 AG012553, Sonja McKinlay, PI, 1995–2001) and/or the University of Pittsburgh, Pittsburgh, PA (U01 AG012546, Kim Sutton-Tyrrell, PI, 2001 to present). SWAN Steering Committee Chairs have included Chris Gallagher (1995– 97), Jenny Kelsey (1997–2002), and Susan Johnson (2002 to present). We acknowledge the NIH Program Offices that supported this work, including the National Institute on Aging, Bethesda, MD (Sherry Sherman, 1994 to present; Marcia Ory, 1994–2001), and the National Institute of Nursing Research, Bethesda, MD (Carole Hudgings, 1997–2002; Janice Phillips, 2002 to present). Finally, we thank the study staff at each site and all the women who participated in SWAN.

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