*Corresponding Author:

Prof. Bener A
Department of Biostatistics and Medical Informatics, Cerrahpaşa Faculty of Medicine, Istanbul University, 34098 Cerrahpasa, Istanbul, Turkey.
E-mail: abdulbari.bener@istanbul. edu.tr

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CitationBener A, Saleh NM, Bakir A, Bhugra D. Depression, anxiety, and stress symptoms in menopausal arab women: Shedding more light on a complex relationship. Ann Med Health Sci Res 2016;6:224-31.

Abstract

Keywords

Anxiety, Complex relationship, Depression, Diseases, Menopause, Physical activity, Postmenopausal, Protective factors, Stress (Depression Anxiety Stress Scales 21)

Introduction

Menopause is the cessation of a woman’s reproductive ability, the opposite of menarche and it is usually a natural change; it typically occurs in women in midlife, during their late 40s or early 50s, signaling the end of the fertile phase of a woman’s life.[1-5] The transition from a potentially reproductive to a nonreproductive state is normally not sudden or abrupt, may occur over a number of years, and is a consequence of biological aging.[3-7] Age at natural menopause is an important research issue because of the suspected links between it and risk for certain diseases.[2,5]

Menopause is the cessation of a woman’s reproductive ability, the opposite of menarche and it is usually a natural change; it typically occurs in women in midlife, during their late 40s or early 50s, signaling the end of the fertile phase of a woman’s life.[1-5] The transition from a potentially reproductive to a nonreproductive state is normally not sudden or abrupt, may occur over a number of years, and is a consequence of biological aging.[3-7] Age at natural menopause is an important research issue because of the suspected links between it and risk for certain diseases.[2,5] In the last decade, researchers have begun studying the relationship between menopausal ages and depression, anxiety, and stress.[8-13] Most of these studies have focused on the psychological effects of coping with the disease, including pain, difficulties in ability to function and fractures, which may occasionally require surgery and prolonged rehabilitation.[2-4] Most recent meta-analyses supported a significant correlation of depression, anxiety, and stress with an increase in menopausal age.[5,14] This situation may explain a condition characterized by increase in an individual’s anxiety level.

The reported association between menopausal ages and depression, anxiety, and stress have been controversial.[5-17] The objective of the current study was to determine the correlation between depression, anxiety, and stress in menopausal and postmenopausal women and shedding more light on a complex relationship.

Subjects and Methods

This is a cross-sectional primary health care (PHC) centers based study conducted in the State of Qatar. The survey was conducted among Qatari national and Arab women aged 45–65-year-old. To support the PHC, 22 health centers were established covering all the districts of Qatar to provide health services. Every health center provides PHC services to the people in that surrounding catchment area.

PThe questionnaire had four parts. The first part included the sociodemographic details of the patients, the second part the medical and family history of the patients, the third part was obstetric variables, and the fourth was the diagnostic screening questionnaire. The Depression Anxiety Stress Scales (DASS-21) questionnaire is a quantitative measure of distress on the basis of three subscales of depression, anxiety, and stress.[10,11,18,19] The DASS 21 is a brief 21 item version of the full DASS, which originally consisted of 42 items. Each of the three DASS-21 scales contains seven items representing the dimensions of depression, anxiety, and stress. The DASS consists of three self-report scales that have been designed to measure the negative emotional scales of depression, anxiety and stress. Each question has 3 subscales ranging between 0 and 3 and the rating scale is as follows: 0 for “did not apply to me at all,” 1 for “applied to me to some degree, or some of the time,” 2 for “applied to me to a considerable degree, or a good part of the time,” and 3 for “applied to me very much, or most of the time.” Scores for the DASS-21 sub-scales of depression, anxiety and stress were derived by totaling the scores for each sub-scale and multiplying by two. We classified women according to the recommended scoring system using cut-off values to classify participants into the following categories: normal (0–9 for depression and 0–7 for anxiety), mild (10–13 for depression and 8–9 for anxiety), moderate (14–20 for depression and 10–14 for anxiety), severe (21–27 for depression and 15–19 for anxiety), and extremely severe (≥28 for depression and ≥20 for anxiety). We have referred to women within the “normal” range on the DASS-21 for depressive or anxiety symptoms as nondepressed or nonanxious, respectively. Women, who scored in the “mild” to “extremely severe” ranges, were referred to as depressed or anxious. Analysis is based on this dichotomy (i.e., “normal range” vs. “mild to extremely severe” symptoms). A score of DASS ≥10 was used to distinguish women suffering from depression, a score of DASS ≥8 for anxiety disorders and a score of DASS ≥15 for stress.

Data collection took place from July 2012 to March 2014. The sample size was determined on previous reported prevalence rate [2,3,5] and sample size of 1468 subjects would be required for this study. Of the 22 PHC centers available, we selected 12 health centers on a random sampling basis, of these, 10 were located in urban and 2 in semi-urban areas of Qatar. Each participant was provided with brief information about the study and was assured of strict confidentiality. Finally, subjects were selected by systematically sampling design 1-in-2 sampling procedure used and a representative sample of 1468 women aged 45–65 years were approached and 1101 women agreed to participate (75.0%) and responded to the study. The survey instrument was initially tested for validation on 100 patients through face to face interview who visited the health centers. Internal consistency in this study was explored for each scale of the DASS-21, and Cronbach’s alpha coefficients were adequate: Depression (0.81), anxiety (0.75) and stress (83) scales respectively, confirming a high level of consistency among the different Likert items in this scale.

To assess total number of medical conditions, participants were asked: “Has a doctor ever told you that you have any of the following conditions or have you had any of the following procedures?” Participants could mark as many as applied.

Statistical test

Data were analyzed using SPSS version 21 (Chicago IL,USA) statistical software. Student’s t-test was used to ascertain the significance of differences between mean values of two continuous variables and confirmed by nonparametric Mann–Whitney test. The Chi-square and Fisher’s exact tests (two-tailed) were performed to test for differences in proportions of categorical variables between two or more groups. Multivariate regression analysis using the forward inclusion and backward deletion method was used to assess the relationship between dependent and independent variables and to adjust for potential confounders and orders the importance of risk factors (determinants) for menopausal depression, anxiety, and stress. All statistical tests were two-sided and P < 0.05 was considered statistically significant.

Results

1101 women agreed to participate and were included in the study. The mean age and standard deviation of the menopausal and postmenopausal age were 49.55 (3.12) and 58.08 (3.26) (P < 0.001). Figure 1 shows the distribution and classification of menopausal women on the DASS-21 questionnaire: Prevalence and their 95% confidence interval (95%).

Figure 1: Classification of menopausal women on the Depression Anxiety Stress Scales-21 Questionnaire: prevalence and their 95% confidence interval (95%)

Table 1 shows the sociodemographic characteristics of studied subject by menopausal and postmenopausal status. There were statistically significant differences between menopausal stages with regards to age, ethnicity, educational status, occupation status, and place of living.

Table 1: The sociodemographic of studied subject by menopause and postmenopausal according to depression (n=1101)

Table 2 shows the lifestyle characteristics of the participants by menopause and postmenopausal according to depression. There were statistically significant differences between menopausal stages with regards to body mass index, systolic and diastolic blood pressure (BP), Vitamin D deficiency, and diseases.

Table 2: The lifestyle characteristics of studied subjects by menopause and postmenopausal status (n=1101)

Table 3 reveals the association of depression, anxiety, and stress with sociodemographic characteristics in menopause and postmenopause women. Depression and anxiety were more common among postmenopause women. Furthermore, there were no differences between the groups regarding the frequency of certain levels of stress among menopause and postmenopause.

Table 3: Association of depression, anxiety and stress with stressful life events in menopause and postmenopausal women

Table 3: Contd...

Table 4 presents the lifestyle characteristics of the participants by menopause and postmenopausal according to depression, anxiety, and stress. There were no any significant differences between menopause and postmenopause stage. Figure 2 presents Venn diagram showing the overlapping of depression, anxiety and stress among menopausal in Qatar.

Table 4: The lifestyle characteristics of studied subjects by menopause and postmenopausal status according to depression. anxiety, and stress

Figure 2: Venn diagram showing the overlapping of depression, anxiety and stress among menopausal in Qatar (n = 1101)

Table 5 gives multivariate regression analyses for depression, anxiety, and stress and associated covariates. As can be seen from this table that age in years, diastolic BP, consanguinity, regular exercise were predictor for depression. Meanwhile, diastolic BP, occupation, and physical activity considered the main risk factors for anxiety. Furthermore, age in years, occupation and sheesha smoking habits were considered as the main risk factors associated with stress.

Table 5: Correlates of menopause with depression, anxiety, and stress using multivariate regression analysis in (n=1101)

Discussion

Menopause produces very complex changes during this stage of life which include other changes such as psychological and social changes.[2,3] A recent study from Finland[1] and the United States[17] showed that due to postmenopause depression predicted increased bone loss. In Finland self-reported,[1] sleep problems observed more common in postmenopausal women than in premenopausal women, and the difference is more pronounced during workdays than during leisure days. These observations suggest that postmenopausal women have the capacity for a good sleep but are more vulnerable to sleep problems related to work-related stress. The negative impact of depressive symptoms on postmenopausal women was observed to be independent of body weight or other behavioral factors such as calcium compliance or exercise.[17] Unfortunately, the current study showed that only over one-third of women involved in physical exercise or regular activity.

More recently, study in Vietnam the results highlighted the importance of considering psychosocial factors, life style, and chronic disease management in providing health guidance for peri- and post-menopausal women to enhance their quality of life and reduce the risk of depressive symptoms.[1,20-22] This is consistent with this study outcome.

In contrast, there are protective factors that reduce the risk of depression. Interpersonal protective factors include adequate social support, which may protect against the onset of depression or may result in a more benign course of depression.[16,23] Another potential protective factor is physical activity. Individuals who engage in regular physical activity have less depression over time.[24] Preliminary evidence from randomized controlled trials suggests that regular aerobic exercise may be an effective intervention for adults with mild-moderate depression,[25] and that aerobic exercise may be as effective as sertraline or cognitive-behavioral therapy. Physical activity may also serve as a buffer for the effect of stress on depression.[16] Although it is well-established that certain stressors and protective factors are associated with changes in depression symptoms over time, less is known about effect moderation.

Most recently study in United States reported[16] that stressors at baseline, including verbal abuse, physical abuse, care giving, social strain, negative life events, financial stress, low income, acute pain, and a greater number of chronic medical conditions, were all associated with higher levels of depression symptoms at baseline and new onset elevated symptoms at 3 years follow-up among postmenopause women. In addition, social support and physical activity were associated with lower levels of depressive symptoms. Similarly, more social support at baseline increased the association between financial stress, income, and pain on new-onset depression 3 years later. Physical activity similarly moderated the effect of care giving, income, and pain on depression symptoms at baseline. Present results are consistent with other previous reported studies. [13 ,21-27]

McEwen and Sapolsky[26] have suggested that engagement in a more socially and emotionally supportive environment results in lower levels of physiologic arousal; this in turn protects against cognitive decline and depression secondary to direct positive stimulatory effects on the brain. Fortunately,the social environment is modifiable. For example, one can directly increase social support through participation in support groups or other organizations that promote social bonds such as religious or civic groups. Alternatively, behavioral health specialists can also indirectly help to increase an older individual’s social support through teaching of skills directed at gaining needed support.[27] Similarly, physical activity was associated with lower depression levels, both concurrently and prospectively, and therefore may still be useful in decreasing the likelihood of depression as women age. The present research highlighted the importance of considering psychosocial factors, life style, and chronic disease management in providing health guidance for peri-menopausal women and postmenopausal women to enhance their quality of life and reduce the risk of depressive and stress symptoms, this consistent with the previous reported studies. [6-9,13,28] Furthermore, the current data suggest that there is a strong association between depression, anxiety and stress symptoms high rates in menopause and postmenopausal women: These findings are confirmative with some previous reported studies. [6-9,13,21-28]

Limitations and strengths

One of the strengths of this study was the large sample size; this is particularly important in order to have sufficient power to examine interaction effects. This study based on a large representative’s sample. There are several limitations of this study. First, this is cross sectional study and thereby, subjects might be misclassified in this analysis. Second, the study sample was based on PHC clinics visits. Third, the majority of the study sample was Arab women and of relatively high socioeconomic and education status; hence, the results may not be generalizable to the population of all midlife women. This cohort is also diverse in terms of geographic region of the country and race/ethnicity. Results must also be interpreted in the context of study limitations.

Conclusion

A large number of factors were associated with experiencing menopausal and psycho-social problems and which had negative effects on the quality of life among Arabian women. Depression, anxiety and stress should be considered as an important risk factors for osteoporosis.

Acknowledgements

The authors would like to thank the Hamad Medical Corporation for their support and ethical approval (HMC RC#8222/08).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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