If you are asking whether depression or erectile dysfunction (ED) comes first, you are asking the right question to bring to a doctor. The research shows the two are linked in both directions. A 2018 meta-analysis could not determine the direction of causality, and a 2000 review notes that cause and effect can be hard to separate in an individual patient. Here is what the studies found, how strong they are, what is still open, and what to do next.
What is erectile dysfunction?
NIDDK’s erectile dysfunction overview says ED prevents males from getting or keeping an erection that is firm enough for sex. It also says ED is not a routine part of aging. The NIDDK describes three common patterns:
| Pattern | What it looks like |
|---|---|
| Sometimes, not every time | An erection is possible, but not reliably |
| Not lasting long enough | An erection comes, but does not last long enough for sex |
| Never | Unable to get an erection at any time |
What is psychogenic impotence?
Psychogenic impotence is the term you will often see for erectile dysfunction whose main cause is psychological. Doctors usually call it psychogenic ED. The research gives a rough sense of how common this is: a BMJ Clinical Evidence review on erectile dysfunction estimates that 20% of cases have psychological causes.
A ClinicalTrials.gov registration summarizes two clues. Psychological causes tend to be more prevalent in younger, otherwise healthy men, and preserved nocturnal erections are a key clinical indicator suggesting a psychogenic origin. That is something a clinician weighs during an assessment, not a home test. The 2016 Nature Reviews Disease Primers review describes ED as multidimensional, with organic, relational and psychological components, so the causes can overlap.
Which comes first, depression or erectile dysfunction?
The research points to a two-way link, and it cannot pin down the starting point for one man. The most complete summary is a 2018 systematic review and meta-analysis in The Journal of Sexual Medicine by Liu and colleagues. It identified 49 eligible publications. Depression was associated with a higher risk of ED (pooled odds ratio 1.39, 95% CI 1.35 to 1.42). ED was associated with depression (pooled odds ratio 2.92, 95% CI 2.37 to 3.60). The authors wrote that “this study was unable to determine the direction of causality between ED and depression.”
| Study | What it looked at | What it found |
|---|---|---|
| 2000 review in Postgraduate Medicine | Depression and ED in clinical practice | The association is firmly established. In most men with major depression, successful reversal of the depressive syndrome brought back erectile capacity. In minor depression, restoring erections could improve mood. |
| 2007 review in Urologic Clinics of North America | Depression and ED together | The two clearly are associated. Antidepressants affect erectile function negatively, and the interplay between the two is underappreciated. |
| 2018 meta-analysis in The Journal of Sexual Medicine | 49 eligible publications | Depression linked to ED (pooled OR 1.39, 46 publications with 48 studies). ED linked to depression (pooled OR 2.92, 5 publications with 6 studies). Variation between studies was high for the depression-to-ED group, and causality was not determined. |
The 2000 review also notes that it can be hard to tell cause from effect in an individual patient. That is why the timeline matters. When did the erections change, and when did your mood change? Bring both dates to your visit.
How are depression and erectile dysfunction connected?
The studies describe several associations, and they often overlap. None of them is a single chain that explains every case.
- Antidepressants. A 2006 review on ED in depression and under antidepressant treatment reports that ED appears to be one of the principal reasons people stop antidepressant treatment. WebMD’s coping guide for ED and depression adds that some antidepressants can cause or worsen ED.
- Depression and erections move together. The 2000 review reports that in most patients with major depression, successful reversal of the depressive syndrome results in a return of erectile capacity, though cause and effect can be hard to separate in an individual.
- Physical health, a separate set of causes. A 2013 Lancet review on erectile dysfunction lists diabetes and hypertension as classical causes of ED, and obesity, limited exercise and lower urinary tract symptoms as lifestyle factors linked to ED. These are established causes of, or factors linked to, ED.
What about anxiety and erectile dysfunction?
Anxiety appears in the same picture. The Nature Reviews review notes that most patients with ED have symptoms of depression and anxiety related to sexual performance, and that these symptoms affect the partner’s sexual experience and the couple’s quality of life. The 2000 review also notes that depressed patients are more likely to drop out of ED treatment, which is one reason mood belongs in the conversation with your doctor.
Does erectile dysfunction get worse with age?
MedlinePlus’s erectile dysfunction topic says ED becomes more common as men get older, but it is not a natural part of aging. The NIDDK says ED is not a routine part of aging. The 2011 BMJ review estimates that 30% to 50% of men aged 40 to 70 may be affected, with age, smoking and obesity as the main risk factors.
What age is most common for ED?
The studies most often point to men over 40. The 2013 Lancet review describes ED as affecting mainly men older than 40, and the BMJ estimate covers men aged 40 to 70.
Can men in their 40s still get hard?
ED is not a routine part of aging, so if your erections are not firm enough for sex in your 40s, that is worth raising with a doctor. The 2011 BMJ review estimates that ED may affect 30% to 50% of men aged 40 to 70. It gives no separate figure for men in their 40s, so that range is not a measure of your own risk. A doctor can assess any erection concern at any age.
Can a man with erectile dysfunction satisfy a woman?
The research treats ED as a shared question rather than one partner’s problem. The Nature Reviews review says ED affects a partner’s sexual experience and the couple’s quality of life. A 2014 Internal Medicine Journal review on erectile dysfunction describes sexual problems as a source of considerable morbidity, both for individuals and within relationships. Whether a man with ED can satisfy a partner is a question to take to a clinician or couples therapist, who can talk it through with you both.
How can a partner help a man with erectile dysfunction?
If you are supporting a partner with ED, the research points to a few practical steps:
- Make it easy to talk. NIDDK notes that you may find ED uncomfortable to discuss, but a healthy sex life is part of healthy living. A 2019 Primary Care review on erectile dysfunction notes that many men do not self-report ED symptoms, so the conversation may need to start with you.
- Encourage a doctor visit. MedlinePlus says that if you have ED, you should tell your doctor, because ED can be a sign of health problems.
- Support the habits linked to ED. MedlinePlus says exercise, losing weight or stopping smoking may help. NIDDK says a healthy diet can lower the risk of developing ED or improve ED symptoms.
- Keep mood in view. If he seems persistently sad, hopeless or flat, include that in the doctor visit. Depressed patients are more likely to drop out of ED treatment, according to the 2000 review.
- Consider couples therapy. WebMD lists couples therapy as one type of talk therapy used for ED and depression.
What are the treatment options for depression and erectile dysfunction?
NIDDK says health care professionals treat the underlying causes of ED and then focus on improving sexual function. It also says choosing an ED treatment is a personal decision. For depression, WebMD says treatment may include medication, psychotherapy, or a combination of both.
Two findings matter most here. The 2006 review says oral phosphodiesterase inhibitors are an option for ED that comes from depression and from antidepressant medication. It also notes that avoiding or switching antidepressants is problematic, because it may lead to an increase in depressive symptoms. The 2000 review found that in most men with major depression, reversing the depressive syndrome brought erectile capacity back.
Any change to an antidepressant, and any new ED medicine, is a question for the prescriber who manages your care.
How is erectile dysfunction evaluated?
NIDDK says health care professionals diagnose ED with a medical, sexual and mental health history, a physical exam, and lab and other tests. The 2019 Primary Care review says diagnosis is made in the primary care office, and that treatment should be guided by patient preference, with a goal of improving quality of life and reducing chronic disease risk.
Because ED can be linked to heart health, the 2013 Lancet review says cardiovascular assessment of a non-cardiac patient presenting with ED is now recommended. It also calls ED a strong predictor for coronary artery disease.
When should you see a doctor?
See a doctor if your erections are not firm enough for sex, in any of the patterns above. Also see a doctor if low mood, hopelessness or loss of interest does not lift. WebMD notes that without treatment, depression symptoms can persist for months or even years, and that appropriate treatment can help most people get back on track. The 2000 review warns that untreated depression can be life-threatening. If mood feels dangerous to you or to someone you love, get emergency help now.
What should you ask your doctor?
- Is my erection problem mainly physical, mainly psychological, or both?
- Should I be screened for depression? The 2018 meta-analysis authors say patients reporting ED should be routinely screened for depression.
- Could any of my medicines, including an antidepressant, be affecting my erections?
- Do I need a cardiovascular assessment or lab tests?
- Which treatment options fit my situation, and what does each involve?
- Where can I get talk therapy, including couples therapy?
Where to go from here
Start with the doctor visit and the conversation at home. Those answer the question that matters most: what is driving the erections, and what is driving the mood. If you are also reading about supplements for mood, our guide to supplements for depression support covers the research and safety questions, and our overview of mental health supplements explains what studies say about anxiety and depression.
By the Global MH Summit Research Team