The associations between menopausal ... - Wiley Online Library

Psychiatry and Clinical Neurosciences 2009; 63: 678–684

doi:10.1111/j.1440-1819.2009.02001.x

Regular Article

The associations between menopausal syndrome and depression during pre-, peri-, and postmenopausal period among Taiwanese female aborigines pcn_2001

Ju-Yu Yen, MD,1,2,3,4 Mei-Sang Yang, Mao-So Fang, RN6

RN, PhD,5*

678..684

Mei-Hua Wang,

RN,5

Chien-Yu Lai,

RN5

and

1 Department of Psychiatry, Kaohsiung Municipal Hsiao-Kang Hospital, 3Graduate Institute of Medicine, College of Medicine, 4Department of Psychiatry, Faculty of Medicine, College of Medicine, 5College of Nursing, Kaohsiung Medical University, 2Department of Psychiatry, Kaohsiung Medical University Hospital, Kaohsiung and 6Department of Nursing, College of Medicine and Life Science, Chung Hwa University of Medical Technology, Chung Hwa, Taiwan

Aim: The aim of the study was to evaluate the association between physiological menopausal symptoms and depression during the pre-, peri-, and postmenopausal period among female Taiwanese aborigines. Methods: A total of 672 Taiwanese aboriginal women, aged 40–60 years, were recruited in the interviewing study and classified as pre-, peri-, and postmenopausal according to menstrual bleeding patterns in the previous 12 months. Then, the postmenopausal symptoms, depression, self-perceived health, family support, and associated demographic variables were assessed by questionnaire based on the results of interviewing by research assistants. Results: The results revealed that perimenopausal statuses are associated with depression and women with a perimenopausal status had a higher prevalence of depression than those with a premenopausal

ENOPAUSE SYNDROME HAS been reported to be a worldwide women’s mental health problem.1 It results in physiological and psychological difficulty that might need to be managed by medical and psychological intervention. Depression is another important mental health problem that impairs personal functioning and affects one in four

M

*Correspondence: Mei-Sang Yang, RN, PhD, College of Nursing, Kaohsiung Medical University, 100 Shih Chuan 1st Road, Kaohsiung 807, Taiwan. Email: [email protected] Received 20 October 2008; revised 23 April 2009; accepted 2 May 2009.

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status. A higher score on physiological postmenopausal symptoms was found to be significantly associated with depression. Furthermore, somatic symptoms were associated with depression for pre-, peri-, and postmenopausal statuses. Moreover, sexual dysfunction and vasomotor symptoms were associated with depression only in the premenopausal status and postmenopausal status, respectively.

Conclusion: Depression should be routinely evaluated for female Taiwanese aborigines consulting with physicians for menopause symptoms, especially for somatic symptoms. Furthermore, attention should be provided to premenopausal women with sexual dysfunction and postmenopausal women with vasomotor symptoms for depression. Key words: depression, epidemiology, public health, female, mental health.

women in their lifetimes.2 It has been suggested that estrogen deficiency may increase the susceptibility for depression.1 Thus, the depression of women at the age of menopause transition is an important women’s mental health concern. In recent years, great advances have been developed worldwide to improve female life. Female rights have had more attention paid to them in recent years in Taiwan, however, lack of resources and traditional culture in rural areas restrict the improvement of female rights and life. The woman usually needs to carry a triple burden of productive, reproductive, and caring work in such areas, especially aboriginal

© 2009 The Authors Journal compilation © 2009 Japanese Society of Psychiatry and Neurology


women. Lower income, substandard education, poor health status,3 and higher substance exposure,4 which have been reported to be associated with depression in female aborigines, may result in the higher suicide rate among them.5 Thus, depression should be emphasized in order to improve mental health and prevent suicide among female aborigines. Yet, aborigines in rural areas have poorer access to mental health services due to geographic isolation3 and attach a social stigma toward psychiatric disorders.6 Thus, effectively identifying and treating female aborigines suffering from depression should be an important mental health issue. A previous report has found an association between depression and menopausal symptoms.7 This association might suggest an association between depression and estrogen deficit. Moreover, it might also indicate that menopausal women suffer from menopausal symptoms and experience a severe psychological impact. Thus, it is important to evaluate whether menopausal status or menopausal symptoms determine the risk of depression. Furthermore, several psychosocial factors have been reported for women who are more likely to experience depression during the perimenopausal period. These include family dysfunction, lower educational attainment, economic stress, and smoking.8 These factors should be controlled in analysis for the association between depression and menopausal status or menopausal symptoms. It has been reported that 25% of depressive patients perceived a high level of social stigma attached to psychiatric disorders in Taiwan.9 In addition, being female10 and having a lower education level9 were associated with higher levels of stigma. In rural areas, the misunderstanding of mental illness would delay or preclude necessary psychiatric treatment. However, the women would visit a clinic in order to relieve the uncomfortable symptoms of menopause.11 Effective intervention of menopausal symptoms, for example, hormonal replacement therapy, might also provide help for depression.12 Screening and identifying the depression of women who contact health professionals for menopausal symptoms might be an effective way to provide mental health service to depressive female aborigines at the stage of menopausal transition. Providing the information about the association between physiological menopausal symptoms and depression to health professionals is important to help them to identify depression in postmenopausal women.

Postmenopausal syndrome and depression

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Thus, it is important to evaluate such symptoms of female aborigines with different menopausal statuses and their association with depression. The aim of the study was to evaluate the differences between depression, menopausal symptoms, and the association of physiological menopausal symptoms and depression between the pre-, peri-, and postmenopausal periods among female Taiwanese aborigines.

METHODS Participants The participants were recruited from three townships in southern Taiwan. A total of 672 aboriginal women aged between 40–60 years (mean age: 49.43 ⫾ 5.33) were recruited in the interviewing study after informed consent was obtained. All the questionnaires were completed based on the result of household interviewing by regional public health nurses (the majority were aborigines) in the community health station who were trained to be interviewers. The study was approved by the Institutional Review Board of Kaohsiung Medical University.

Procedure Assessment instruments The definition of menopausal status: Menopausal status is classified according to menstrual bleeding patterns over the previous 12 months. It is categorized as: (i) premenopausal, at least 12 menses in the past 12 months with no change in regularity; (ii) perimenopausal, menses in the past 3 months with change in regularity, or 3 or more menses with change in regularity within the past 12 months; or (iii) postmenopausal, no menses within the past 12 months.13 The Greene Climacteric Scale (GCS): The GCS includes 21 symptom questionnaires that are rated by the woman herself by using a four-point rating scale.14 Symptoms 1–11 demonstrate psychological symptoms that include a subscale for anxiety (symptoms 1–6) and for depression (symptoms 7–11). Symptoms 12–8, 19–20, and 21 test somatic symptoms, vasomotor symptoms, and sexual dysfunction, respectively. The total Greene Climacteric score for a given subject is the sum of all 21 scores. The scale had been translated into the Chinese version and had a


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Cronbach’s alpha of 0.93.15 The Cronbach’s alpha of subscales was 0.72–0.88 in this study. In order to evaluate the psychological impact of the physiological aspects of menopausal symptoms, the somatic symptoms, vasomotor symptoms and sexual dysfunction are summed up to make a score of physiological menopausal symptoms. The Center for Epidemiological Studies’ Depression Scale (CES-D): The 20-item Mandarin-Chinese version16 of CES-D17 is a self-administered evaluation assessing participants’ frequency of depressive symptoms in the preceding week with scores ranging from 0 (none or very few) to 3 (always). Higher CES-D scores indicate more severe depression. The Cronbach’s alpha of CES-D in the present study was 0.80. In the study, those scoring 16 or greater are classified as having depression according to the study. Family APGAR Index. The name APGAR contains the first letters of five key functions: adaptability, partnership, growth, affection, and resolve. These functions were queried in this questionnaire. The family APGAR measures the satisfaction with aspects of family life. It was originally developed by Smilkstein,18 and the Chinese-translated version19 was used in this study. The 5-point response scales range from ‘never (0)’ to ‘always (4)’, and total scores range from 0–20. High score indicates high satisfaction with family life. Questionnaires for Health Perception: Three questions that asked about current health status, health state compared with others, and health state compared with half-a-year before were requested in this assessment. The 5-point response scales range from ‘very poor’ to ‘very good’ for the first question and ‘much poorer’ to ‘much better’ for the last two questions. The perceived health state is presented by the sum of the three questions. Higher score indicates better perceived health state. The Cronbach’s alpha of the three questions was 0.81 in this study. Questionnaire of demographic data (QDD): Age, education level, and job status are evaluated. Respondents with educational level higher than primary school are classified as the higher education group, and the rest are classified as the lower education group. Furthermore, frequency of religious activities, and smoking are also requested.

Statistical analysis All participants were encouraged to complete all questionnaires. Participant responses to the ques-


tions on menopausal status were included in the final statistical analysis. The first stage of analysis was to evaluate the association between depression and menopausal symptoms. The association between depression and menopausal status, educational level, religious activity, job, and smoking was evaluated by c2 analysis and post hoc pairwised comparison adjusted with Bonferroni correction. Then, the association between menopausal symptoms, APGAR score, health perception, and depression was evaluated by t-test. As the symptoms 1–11 in GCS implied anxiety and depression symptoms, the anxiety and depression subscale did not enter the regression analysis for association between depression and menopausal symptoms. Thus, the forward logistic regression analysis was utilized to evaluate the association between depression and physiological menopausal symptoms, APGAR score, and health perception under control of menopausal status, smoking, educational level, job, religious activity, and age. The secondary stage was to reveal the difference on the association between depression and the somatic symptoms, vasomotor symptoms and sexual dysfunction between different menopausal stages. The difference on the menopausal symptoms among pre-, peri-, and postmenopausal stage was evaluated with ANOVA. Then, the association between depression and the somatic symptoms, vasomotor symptoms and sexual dysfunction was evaluated by logistic regression for women in pre-, peri-, and postmenopausal stages, respectively. A P-value less than 0.05 was considered significant for all two-tailed tests, which were all performed using the SPSS software package.

RESULTS A total of 182 participants (38.3%) were classified as the depressive group. As shown in Table 1, the c2 analysis revealed that menopausal status was associated with depression. Post hoc pairwised comparison adjusted with Bonferroni correction demonstrated that women with a perimenopausal status had a higher prevalence of depression than those with a premenopausal status. Furthermore, the depressive female aborigines were less likely to have jobs and regular religious activities. The t-test demonstrated that women with depression had higher scores on the anxiety, depression, somatic, vasomotor, sexual dysfunction, physiological symptoms subscale and total scale on GCS in Table 1. Furthermore, they had lower




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Table 1. The association between depression and menopausal status, demographic data, smoking, menopausal symptoms, health perception and family APGAR index Depression

Variables Menopausal status Postmenopausal Perimenopausal Premenopausal Educational level >6 years ⬉6 years Religious activity Usual None or unusual Job with income Yes No Smoking Yes No The Greene Climacteric Scale Anxiety Depression Somatic Vasomotor symptoms Sexual dysfunction Total score Physiological menopausal symptoms† Health perception Family APGAR index

Yes (n = 182) Number (%) or Mean ⫾ SD

No (n = 293) Number (%) or Mean ⫾ SD

c2 or t

66(39.5) 43(48.3) 73(33.3)

101(60.5) 46(51.7) 146(66.7)

6.17*

57(33.9) 125(40.7)

111(66.1) 182(59.3)

2.12

78(33.6) 104(42.8)

154(66.4) 139(57.2)

4.23*

26(29.2) 156(40.4)

63(70.8) 230(59.6)

3.84*

17(43.6) 165(37.8)

22(56.4) 271(62.2)

0.50

6.98 ⫾ 3.96 5.12 ⫾ 2.93 7.76 ⫾ 4.43 1.41 ⫾ 1.41 0.95 ⫾ 0.85 14.49 ⫾ 7.60 10.12 ⫾ 5.65 6.74 ⫾ 2.20 9.48 ⫾ 3.19

2.70 ⫾ 2.65 2.06 ⫾ 2.07 3.62 ⫾ 3.07 0.55 ⫾ 0.82 0.50 ⫾ 0.78 5.78 ⫾ 4.93 4.67 ⫾ 3.84 8.55 ⫾ 2.00 11.12 ⫾ 2.95

12.74*** 12.20*** 10.98*** 7.56*** 5.88*** 13.54*** 11.37*** -9.12*** -5.65***

*P < 0.05; ***P < 0.001. † The somatic symptoms, vasomotor symptoms and sexual dysfunction are summed up to make a score of physiological menopausal symptoms. APGAR, adaptability, partnership, growth, affection, and resolve.

scores on the APGAR and health perception scales. Then, the logistic regression in Table 2 revealed the higher scores on physiological menopausal symptoms were significantly associated with depression under control of age, religious activity, educational level, job, smoking, menopausal status, family APGAR index, and health perception. As the physiological menopausal symptom was the first variable entering the model under selection of forward regression, this revealed that physiological menopausal symptoms were more associated with depression than other factors. Table 3 showed that women with a perimenopausal status had higher depression, somatic symptoms, and physiological menopausal symptoms than those with

a premenopausal status. Moreover, vasomotor symptoms, sexual dysfunction and physiological menopausal symptoms of the postmenopausal status were higher than those of the premenopausal status. Logistic regression in Table 4 revealed that somatic symptoms were associated with depression with a pre-, peri-, and postmenopausal status; however, the sexual dysfunction and vasomotor symptoms were associated with depression only in premenopausal and postmenopausal statuses, respectively.

DISCUSSION Depression has been reported to hasten perimenopause20 and perimenopause has also been reported to


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Table 2. The regression analysis for the association between depression and menopausal status, smoking, demographic data, health perception, family APGAR Index, and physiological menopausal symptoms

Age Perimenopausal Postmenopausal Smoking Job with income Religious activity Educational level >6 years Health perception Family APGAR index Physiological menopausal symptoms†

Wald c2

OR

95% CI

2.08 2.30 0.38 0.09 2.66 5.28* 0.80 18.77*** 19.51*** 61.37***

1.05 1.70 0.80 0.87 0.57 0.55 1.32 0.76 0.82 1.28

0.98–1.12 0.86–3.39 0.40–1.62 0.35–2.16 0.29–1.12 0.33–0.92 0.72–2.43 0.67–0.86 0.76–0.90 1.20–1.36

*P < 0.05; ***P < 0.001. † The somatic symptoms, vasomotor symptoms and sexual dysfunction are summed up to make a score of physiological menopausal symptoms. APGAR: adaptability, partnership, growth, affection, and resolve; CI, confidence interval; OR, odds ratio.

predispose depression.21 Corresponding to previous reports, depression was associated with menopause statuses and the female Taiwanese aborigines with a perimenopausal status had a higher prevalence and level of depression than those with a premenopausal status. The association between depression and perimenopausal status demonstrates that depression is also an important mental health issue for female Taiwanese aborigines going through the menopausal transition in rural areas. Similar to a previous study,22 physiological menopausal symptoms were the most associated factors for depression under control of psychosocial factors mentioned above in the present study. This result may also suggest that physiological menopausal symptoms cause female aboriginal suffering and need to be effectively treated. It might also indicate a possible biological linkage between depression and menopausal symptoms. Moreover, the result might also suggest that depression should be screened and intervened when a female aboriginal visits a clinic for menopausal symptoms.

Table 3. Comparisons of scores of CESD, subscales and total score of Greene Climacteric Scales under pre-, peri-, and postmenopausal statuses

CESD

Greene Climacteric Scale Somatic symptoms

Vasomotor symptoms

Sexual dysfunction

Total score

Physiological menopausal symptoms†

Mean ⫾ SD

d.f.

F

Post Hoc analysis (Bonferroni)

Pre Peri Post

13.29 ⫾ 7.13 15.80 ⫾ 8.23 14.27 ⫾ 8.08

2, 472

3.42*

Peri > Pre

Pre Peri Post Pre Peri Post Pre Peri Post Pre Peri Post Pre Peri Post

4.65 ⫾ 4.05 6.24 ⫾ 4.77 5.46 ⫾ 3.80 0.69 ⫾ 1.03 0.97 ⫾ 1.22 1.07 ⫾ 1.26 0.55 ⫾ 0.77 0.71 ⫾ 0.76 0.84 ⫾ 0.91 8.03 ⫾ 6.99 10.65 ⫾ 9.01 9.59 ⫾ 6.75 5.90 ⫾ 5.00 7.89 ⫾ 6.14 7.37 ⫾ 5.04

2, 483

5.13**

Peri > Pre

2, 490

5.62**

Post > Pre

2, 491

6.25**

Post > Pre

2, 477

4.72**

Peri > Pre

2, 482

6.19**

Peri > Pre Post > Pre

*P < 0.05; **P < 0.005. † The somatic symptoms, vasomotor symptoms and sexual dysfunction are summed up to make a score of physiological menopausal symptoms. CESD, Center for Epidemiologic Studies Depression Scale; Peri, perimenopausal; Post, postmenopausal; Pre, premenopausal.




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Table 4. The logistic regression analysis for the association between depression and somatic, vasomotor, and sexual dysfunction subscales in Greene Climacteric Scale under different menopausal statuses Premenopausal

Age Somatic symptoms Vasomotor symptoms Sexual dysfunction

Perimenopausal

Postmenopausal

Wald X2

OR

95%CI

Wald X2

OR

95%CI

Wald X2

OR

95%CI

3.10 25.33*** 0.01 6.77**

1.07 1.32 0.99 1.83

0.99–1.16 1.19–1.48 0.67–1.46 1.16–2.87

3.83* 7.94** 1.23 0.08

0.86 1.28 1.43 1.14

0.74–1.00 1.08–1.53 0.76–2.68 0.44–2.96

0.20 10.94** 8.45** 0.28

1.02 1.22 1.69 0.89

0.93–1.12 1.09–1.38 1.19–2.40 0.59–1.36

*P < 0.05; **P < 0.005; ***P < 0.001. CI, confidence interval; OR, odds ratio.

In this study, we also demonstrated that somatic symptoms were associated with depression across the menopausal stage. As the somatic symptoms of postmenopausal syndrome and depression overlapped, this association makes it difficult to determine whether the somatic symptoms are primary or secondary to menopausal transition or depressive disorder. For female Taiwanese aborigines under the influence of traditional culture, to complain of depression might bring social stigmatization. It has been suggested that women in rural areas tend to seek help for certain somatic problems, but not depression.23 Thus, the somatic complaint of a menopausal female Taiwanese aborigine should be further evaluated for menopausal symptoms and depression in clinical settings. Hot flush, a physiological symptom, has been reported to be the primary complaint in seeking medical care during the perimenopausal stage.24 In this study, vasomotor symptoms were found to be associated with depression and more prevalent among female aborigines with a postmenopausal status. Thus, for menopausal aboriginal women, vasomotor symptoms should attract more attention and be more effectively treated. Moreover, depression should be assessed for menopausal women consulting with primary care physicians for vasomotor symptoms. Our result revealed that sexual dysfunction was more severe during the postmenopausal period. However, it was associated with depression only during the premenopausal period. This might suggest that sexual dysfunction has a greater psychological impact on premenopausal female aborigines. It has been reported that postmenopausal women report decreased sexual desire and increased agreement with the belief that sexual interest declines with age.25 On the other hand, belief in having a satisfying sexual life

might still hold for premenopausal female aborigines. However, decrease of vaginal lubrication caused by estrogen decline, vaginal atrophy, reduced tissue elasticity, painful and/or unpleasant intercourse due to shortening and narrowing of the vaginal vault, diminished sensory response, and reduced androgen levels26 commences disturbing sexual activity. Thus, without adaptive coping or effective intervention, sexual dysfunction will cause more suffering for premenopausal female aborigines even though sexual dysfunction was less severe than it was for postmenopausal women. Accordingly, to address the evaluation and intervention of sexual dysfunction is important for premenopausal female aborigines. Our results should be interpreted in the light of three limitations. Firstly, the stigmatizing of mental health disorders might make female aborigines unwilling to admit their depression in the interviewing study. Secondly, the lack of language ability in female aborigines might have limited comprehensive communication for the content of questionnaires. Thirdly, the cross-sectional research design of the present study could not confirm causal correlations between menopausal symptoms and depression. In conclusion, the perimenopausal female aborigines had higher depression rates than premenopausal female aborigines. The psychosocial factors and menopausal symptoms, especially for physiological symptoms, should be effectively intervened and treated in female aborigines going through the menopausal transition. Furthermore, our results suggest depression should be routinely evaluated in female aborigines consulting with physicians for menopausal symptoms, especially for somatic symptoms. Furthermore, attention should be provided to premenopausal women with sexual dysfunction and postmenopausal women with vasomotor symptoms for depression.


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More training, appropriate tools, or information focus on menopausal symptoms and depression should be provided to general physicians and community public health nurses to accommodate a geographically available primary care service to screen, diagnose, and treat menopausal symptoms and depression for female Taiwanese aborigines going through the menopausal transition.

ACKNOWLEDGMENTS The authors wish to thank all the participants in the study and the nursing staff of the health stations involved in the study for their help in collecting data. This work was supported by grants from the National Science Council of Taiwan (NSC 92-2314B-037-088).

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