Depression in climacteric women: analysis of a sample receiving care at a university hospital in Maranhão, Brazil

Abstracts

Introduction: The climacteric is a transition period between reproductive and non-reproductive ages that leads to biopsychossocial changes in women who experience it. However, association between a larger prevalence of depression in this period is still controversial. The objective of this study was to assess the prevalence of depression in climacteric women receiving care at a university hospital in a Northeastern Brazilian municipality and to identify associated factors. Method: A prospective, analytic study of 70 climacteric women was performed. Diagnosis of depression was performed according to the International Classification of Diseases diagnostic criteria through a minimal 3-month follow-up period. The following variables were investigated: educational level, marital status, personal income, Hamilton Depression Rating Scale, presence and intensity of climacteric symptoms, menopause (natural or surgical), financial dependence on the partner, family history of depression, previous history of postpartum depression, depressive episodes, premenstrual dysphoric disorder, sexual function disorders, and positive or negative attitudes toward menopause. Results: A percentage of 34.3% of the patients had depression, and 70.8% were classified as mild intensity according to Hamilton scale. There was no statistically significant association between socioeconomic variables, reduced sex drive and family history of depression and presence of depression. Conversely, presence of vasomotor symptoms (p = 0.03), insomnia (p < 0.001), menopause (p = 0.05), history of postpartum depression (p = 0.04), premenstrual dysphoric disorder (p = 0.05), and negative attitude toward menopause (p = 0.001) were statistically associated with depression. Conclusions: There was a high prevalence of depression in assessed women. Multiple factors (impact of menopause, psychiatric history and personal impressions of menopause) are responsible for its occurrence.

Depression; Hamilton scale; postpartum depression; menopause

Introdução: O climatério, período de transição entre a fase reprodutiva e não-reprodutiva, ocasiona mudanças biopsicossociais nas mulheres que o vivenciam. A associação entre a maior prevalência de depressão nesse período é, no entanto, ainda controversa. O objetivo deste estudo foi avaliar a prevalência de depressão em mulheres climatéricas atendidas em um hospital universitário numa cidade da Região Nordeste do Brasil e identificar fatores associados. Método: Foi realizado um estudo prospectivo e analítico de 70 mulheres climatéricas. O diagnóstico de depressão foi dado segundo critérios diagnósticos da Classificação Internacional de Doenças em um período de seguimento mínimo de 3 meses. Foram investigadas as seguintes variáveis: escolaridade, situação conjugal, renda pessoal, gravidade da depressão segundo escala de Hamilton, presença e intensidade de sintomas climatéricos, menopausa (natural ou cirúrgica), dependência econômica do parceiro, antecedentes familiares de depressão, história prévia de depressão pós-parto, episódios depressivos e transtorno disfórico pré-menstrual, alterações da função sexual e visão positiva ou negativa da menopausa. Resultados: Um percentual de 34,3% das pacientes apresentou depressão, sendo 70,8% destas na categoria leve da escala de Hamilton. Não houve associação estatisticamente significante entre variáveis socioeconômicas, diminuição da libido e antecedentes familiares de depressão com a presença de depressão. Houve associação entre a presença de depressão e pacientes com sintomas vasomotores (p = 0,03), insônia (p < 0,001), menopausa (p = 0,05), com histórico de depressão pós-parto (p = 0,04) e transtorno disfórico pré-menstrual (p = 0,05) e visão negativa da menopausa (p = 0,001). Conclusões: Foi encontrada uma alta prevalência de depressão nas pacientes estudadas. Múltiplos fatores (impacto da menopausa, antecedentes psiquiátricos e visão pessoal sobre a menopausa) foram associados ao seu surgimento.

Climatério; depressão; escala de Hamilton; depressão pós-parto; menopausa

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BRIEF COMMUNICATION

Depression in climacteric women: analysis of a sample receiving care at a university hospital in Maranhão, Brazil

Mari-Nilva Maia da Silva^I; Luciane Maria Oliveira Brito^II; Maria Bethânia da Costa Chein^III; Luiz Gustavo Oliveira Brito^IV; Paula Andréa de Albuquerque Salles Navarro^V

^IPhysician. Graduate student in Neurology, Universidade de São Paulo (USP), São Paulo, SP, Brazil.

^IIPhD in Gynecology, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil. Associate professor of Gynecology, Universidade Federal do Maranhão (UFMA), São Luís, MA, Brazil.

^IIIPhD in Gynecology, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil. Associate Professor of Gynecology, UFMA.

^IVAssistant physician, Department of Obstetrics and Gynecology, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil.

^VPhD in Gynecology, FMRP-USP. Professor of Gynecology, FMRP-USP.

^{Correspondence}

ABSTRACT

INTRODUCTION: The climacteric is a transition period between reproductive and non-reproductive ages that leads to biopsychossocial changes in women who experience it. However, the association between a larger prevalence of depression in this period is still controversial. The objective of this study was to assess the prevalence of depression in climacteric women receiving care at a university hospital in a Northeastern Brazilian municipality and to identify associated factors.

METHOD: A prospective, analytic study of 70 climacteric women was performed. Diagnosis of depression was performed according to the International Classification of Diseases diagnostic criteria through a minimal 3-month follow-up period. The following variables were investigated: educational level, marital status, personal income, Hamilton Depression Rating Scale, presence and intensity of climacteric symptoms, menopause (natural or surgical), financial dependence on the partner, family history of depression, previous history of postpartum depression, depressive episodes, premenstrual dysphoric disorder, sexual function disorders, and positive or negative attitudes toward menopause.

RESULTS: A percentage of 34.3% of the patients had depression, and 70.8% were classified as mild intensity according to Hamilton scale. There was no statistically significant association between socioeconomic variables, reduced sex drive and family history of depression and presence of depression. Conversely, presence of vasomotor symptoms (p = 0.03), insomnia (p < 0.001), menopause (p = 0.05), history of postpartum depression (p = 0.04), premenstrual dysphoric disorder (p = 0.05), and negative attitude toward menopause (p = 0.001) were statistically associated with depression.

CONCLUSIONS: There was a high prevalence of depression in assessed women. Multiple factors (impact of menopause, psychiatric history and personal impressions of menopause) are responsible for its occurrence.

Keywords: Climacteric, depression, Hamilton scale, postpartum depression, menopause.

INTRODUCTION

The climacteric, a period between the reproductive and non-reproductive stage of women, has an expansion process due to progressive aging of the world population. Nowadays, in developed countries 95% of women experience menopause, and 50% reach 75 years of age. In underdeveloped and developing countries, 86% of women born in the 1970's will live more than 75 years.¹

It is known that this condition is associated with a growing hypoestrogenism, in which the production deficiency of this hormone causes a series of clinical (genital atrophy, vasomotor symptoms, insomnia, increased loss of bone mass) and psychological changes (emotional lability, irritability).² Estrogens have a property of mood increase by a complex mechanism, not completely understood, involving neurotransmitters. Therefore, hypoestrogenism might be associated with mood depression, favoring the occurrence of depressive episodes and influencing incidence of depression.³

Prevalence of depression is 21% in women, twice more prevalent than in men. It is considered a subtype of affective disorder that can be unique or recurrent, with psychic (depressive mood, fatigue, reduced ability of thinking, of making decisions), physiological (sleep, appetite and sexual interest disorders) and behavioral (social withdrawal) symptoms.⁴

Recent studies associating depression with climacteric have not confirmed the idea that there is higher prevalence in menopause.⁵ However, studies present both high⁶ and low⁷ prevalence rates of depression. Other studies stress the influence of personal psychiatric history,⁸ and anthropological studies⁹ show that the same phenomena are experienced in different forms according to culture.

Due to the lack of data on this issue and to absence of sample data from other Brazilian regions other than the South and Southeast, this study aims at finding the prevalence of depression in women attended at a climacteric clinic in a city in the Brazilian northeast and identifying associated factors.

METHOD

Seventy women during and after the menopause period who attended the Climacteric Office of Hospital Universitário Materno-Infantil (HUMI) were prospectively and consecutively evaluated from August 2002 to April 2003. No patient was excluded from the study.

A protocol record was applied after the individuals were informed of the study content and accepted to participate by signing a consent form. The project was approved by the Research Ethics Committee of HUMI (no. 125).

As diagnostic criteria of depression, the International Classification of Diseases, 10th revision (ICD-10) was used through semi-structured interview, always performed by the same rater, previously trained in a meeting with the Gynecology and Psychiatry staff of HUMI. After confirming the disease by a minimal period of 3 months of follow-up, the patients were classified according to their severity using Hamilton scale: mild - scores between 7 and 17; moderate - between 18 and 24; severe - more than 24.

As diagnostic criteria of premenstrual dysphoric disorder (PMDD), an adaptation of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) was used, in which PMDD was characterized by several symptoms that should be present in the last three cycles, on the week prior to menstruation and with relief on the postmenstrual week. Surveyed emotional symptoms were sadness, anger, irritability, nervousness, confusion, social withdrawal, and tiredness; and physical symptoms were mastalgia, abdominal distension, headache, swelling in hands and legs, weight gain, and joint or muscle pain. ICD-10 was used for the diagnosis of postpartum depression (PPD) applying the Edinburgh Postnatal Depression Scale (EPDS) for its screening.

Investigated variables were marital status, presence of menopause, type of menopause, educational level, family income, economic dependence on the partner, PMDD and PPD, family history of psychiatric disorders, presence of vasomotor symptoms (hot flashes) and insomnia, change in libido, dyspareunia, representation of menopause (patient's view on menopause, as a positive or negative event regarding presence of or forthcoming menopause).

Data were stored in the database Epi-Info 2002. Fisher's test was used for frequencies between binomial variables. Significance level was set in 5%.

RESULTS

There was prevalence of 34.3% (n = 24) of patients with depression, which were not statistically different from the rest as to mean age (45.23±6.32) and occurrence of menopause (51.47±3.15). Table 1 summarizes the main findings of this study.

A division of the patients according to Hamilton scale resulted in 70.8% (n = 17) with mild depression; 20.8% (n = 5) moderate depression; and 8.4% (n = 2) severe depression. Most patients (77.2%) had a partner, were not economically dependent on their partners (54.3%), although 35.8% had no own income; 32.9% of the patients had an excellent educational level. Regarding presence of menopause, 32.8% (n = 23) were in this situation; 11 (47.8%) patients due to surgical cause and 12 (52.2%) due to natural causes, with no statistical difference between type of menopause and presence of depression (p = 0.27). However, there was an association between depression and the fact that the patient was in menopause.

History of PPD was prevalent in 31.4% of the women. Presence of PMDD was 44.3%, the same percentage of previous depressive episodes. Family history of depression was reported by 25.7% of the patients.

Vasomotor symptoms (hot flashes) and insomnia were strongly associated with presence of depression, whereas reduction in sexual desire was marginally associated with it (p = 0.09). There was also statistical association of presence of depression with previous history of PPD, PMDD and depressive episodes, except for family history of depression.

When asked about their view on menopause, those who had a negative view had higher prevalence of depression, which was statistically significant.

DISCUSSION

This study found a high prevalence of women with depressive disorders in the climacteric (34.3%), higher than that found in other studies,¹⁰ but low when compared with others.^11,12 In other studies¹³ investigating women attended at menopause clinics, 33% of depression cases were moderate and/or severe, a similar percentage to the 29.2% of moderate and/or severe cases we found using Hamilton scale, both in patients during and after the menopause. The small sample and the fact that the patients were attended at the same clinic limit generalization of results for other populations, although it does not invalidate its importance in initial analysis of the prevalence of this disease.

Transition into menopause seems to act not as the cause of mood symptoms, but as a facilitator. Menopause, in this study, proved to be associated with occurrence of depression (p = 0.05). Hormonal and sociocultural factors and comorbidities may act alone or combined as triggers of depressive symptoms, especially in the postmenopause. Variation of steroid hormones and opioid peptides in the climacteric period seems to interfere with the regulation of the hypothalamic thermoregulatory system, whose dysfunction may favor occurrence of vasomotor symptoms,^1,2 and therefore, the more intense they are the worse is quality of life and the higher is the possibility of new depressive episodes. This seems to apply to the data of this study, when it was shown that presence of vasomotor symptoms was associated with depression.

It should be stressed that the methodology (cross-sectional study) prevented the establishment of a cause/effect relationship between studied variables. In this sense, when the variables insomnia and depression were analyzed, it was not possible to claim that presence of insomnia favors triggering of depressive condition, that depression per se is associated with or favors occurrence of insomnia or that both act in combination favoring or increasing manifested symptoms. Thus, as to the association between insomnia with a higher prevalence of patients with depressive disorders, it is not known whether this information represents a diagnostic item in the set of traits characterizing depression or whether it is an expected finding in patients with climacteric symptoms. Hence the need of a multivariate analysis, with larger samples, to eliminate this potential bias.

Sexuality in climacteric women undergoes changes as this period advances, and in most of them there is reduction in libido. In this study, reduced libido was observed in 72.9% of women and was marginally associated with depression. Nievas et al.¹⁰ observed, in 23 of 30 (76.6%) women, a relative or absolute reduction of sexual desire in the climacteric period before and after the menopause.

In terms of socioeconomic aspects, unemployment is a highly predictive factor of depression symptoms in many studies.¹⁴ However, such association was not seen in this study analyzing the patient's personal financial income and economic dependence on the partner, variables that expressed social inclusion.

Psychiatric history was considerable: prevalence of PPD was 31.4%; previous depressive episodes and PMDD was 44.3%; and family history of depression was 25;7%; they were all (except for family history of depression) statistically associated with current presence of depression.

In a study conducted by Veras et al.,¹¹ the presence of family history (46.1%) considerably increased risk of developing depression, an association that was not seen in this study; on the other hand, there was no relation with history of previous episodes. Prevalence of PPD was similar to that found in other studies,^15,16 higher than the average reported in the literature (10-20%). There are few studies⁵ showing the relationship between PMDD and depression, but this issue is controversial. In this study, there was a statistically significant association between them.

Such indexes draw attention to the need of capacitating health professionals for the early identification of these nosologies, considered as a public health problem due to their prevalence.

The patient's view on menopause was a variable associated with depression from the negative perspective. Such information shows an extremely important cultural factor associated with depression: the idea that menopause represents a final point in women's personal and professional life. A study of 2,565 women¹⁷ showed that the negative view on menopause is related to severity of climacteric symptoms, as well as worse social conditions. However, once again, it should be stressed the methodological limitation in establishing a cause/effect relationship (negative view on menopause favoring occurrence of depression), so that the presence of depression alone, by favoring a negative view of life as a whole, might also favor a negative view on menopause.

Depression compromises the quality of life of women, and can exclude them from social experience and health care. Further studies in outpatient populations are needed, as well as an interface between gynecology and psychiatry. Formation of health professionals able to deal with mental disorders is necessary, so that part of the increasing female population, as a consequence of growth of population global life expectancy, and that has no medical assistance can be properly treated.

REFERENCES

1. Nelson HD. Menopause. Lancet. 2008;371:760-70.

2. Vieira CS, Navarro PAA. Como diagnosticar e tratar: síndrome climatérica. Rev Bras Med. 2007;64:99-109.

3. Demetrio FN, Veras Filho AHG. Efeito da terapia de reposição estrôgenica no humor de mulheres menopausadas. Disponível em: http://www.hcnet.usp.br/ipq/revista/28_2/artigos/art72.htm.

4. Porto JA. Depressão: conceito e diagnóstico. Rev Bras Psiquiatr. 1999;21:6-11.

5. Favarato MECS, Aldrighi JM, Fraguas Junior R, Pires ALR, Lima SMRR. Sexualidade e climatério: influência de fatores biológicos, psicológicos e sócio-culturais. Reprod Clim. 2001;15:199-202.

6. Vesco KK, Haney EM, Humphrey L, Fu R, Nelson HD. Influence of menopause on mood: a systematic review of cohort studies. Climacteric. 2007;10:448-65.

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10. Nievas AF, Furegato ARF, Iannetta O, Santos JLF. Depressão no climatério: indicadores biopsicossociais. J Bras Psiquiatr. 2006;55:274-9.

11. Veras AB, Rassi A, Vaneca AM, Nardi AE. Prevalência de transtornos depressivos e ansiosos em uma amostra ambulatorial brasileira de mulheres na menopausa. Rev Psiquiatr RS. 2006;28:27-38.

12. Pedro AO, Pinho-Neto AM, Costa-Paiva LHS, Osis MJD, Hardy EE. Síndrome do climatério: inquérito populacional domiciliar em Campinas, SP. Rev Saude Publica. 2003;37:735-42.

13. Takamatsu K, Fujii E, Ohta H, Nakamura K. Mental health of patients visiting an outpatient menopause clinic. Int J Fertil Womens Med. 2003;48:252-9.

14. Woods NF, Smith-DiJulio K, Percival DB, Tao EY, Mariella A, Mitchell S. Depressed mood during the menopausal transition and early postmenopause: observations from the Seattle Midlife Women´s Health Study. Menopause. 2008;15:223-32.

15. Ruschi GEC, Sun SY, Mattar R, Chambô Filho A, Zandonade E, Lima VJ. Aspectos epidemiológicos da depressão pós-parto em amostra brasileira. Rev Psiquiatr RS. 2007;29:274-80.

16. Da-Silva VA, Moraes-Santos AR, Carvalho MS, Martins ML, Teixeira NA. Prenatal and postnatal depression among low income Brazilian women. Braz J Med Biol Res. 1998;31:799-804.

17. Avis NE, McKinlay SM. The Massachusetts Women´s Health Study: an epidemiologic investigation of the menopause. J Am Med Womens Assoc.1995;50:45-9, 63. v30n2a11

Received June 15, 2008.

Accepted July 7, 2008.

Financial support: Program of Scientific Initiation Scholarship Implementation (PIBIC) of the National Counsel of Technological and Scientific Development (CNPq).

Publication Dates

• Publication in this collection
  06 Jan 2009
• Date of issue
  Aug 2008

History

• Received
  15 June 2008
• Accepted
  09 July 2008