Background: Depression and erectile dysfunction (ED) have a complex and bi-directional relationship. We examined the relationships between erectile dysfunction and depressive symptoms or diagnosed depression, sexual activity and sexual satisfaction. Methods: A population survey of men aged 40–70 years was carried out in Brazil, Italy, Japan and Malaysia in 1997–1998. A questionnaire was used to collect life style, sexual behaviors and medical data. Depressive symptoms were assessed using the Center for Epidemiologic Studies Depression Scale. ED was classified as moderate or complete if the men reported they were ‘‘sometimes’’ or ‘‘never’’ able to achieve and maintain an erection satisfactory for sexual intercourse. Only men with a sexual partner and not taking psychoactive drugs were considered. Results: Diagnosed depression was reported by 2.0% of the men, depressive symptoms by 21.0%. The prevalence of moderate or complete ED was 17.8%. Sexual satisfaction related to the frequency of sexual intercourse and inversely related to depressive symptoms. Depressive symptoms were positively associated with being single (odds ratio [OR] 1.7), widowed, separated or divorced (OR 2.2), moderate or complete ED (1.8), heart disease (1.6) and smoking (1.6), and negatively associated with age, physical activity and frequency of sexual intercourse. Limitations: Cross-sectional studies cannot establish a temporal cause–effect relationship. However, the confirmation of known associations reassures about the validity of the original findings. Conclusions: The findings suggest that depressive symptoms are linked to ED by the mediation of decreased sexual activity and the dissatisfaction generated by the inability to have a healthy sexual life