INTRODUÇÃO: O objetivo deste estudo foi avaliar a sintomatologia depressiva em mulheres climatéricas com a escala de depressão CES-D (Center for Epidemiological Studies Depression Scale), do National Institute of Mental Health (EUA). MÉTODO: Estudo transversal com 151 mulheres entre 40 e 65 anos de idade, usuárias de serviço de ginecologia geral em unidade de atenção básica à saúde no Rio de Janeiro. Aplicou-se a escala CES-D e um questionário estruturado para a obtenção de dados sociodemográficos, clínicos e ginecológicos. O nível de corte > 15 pontos na CES-D foi considerado como indicativo de quadro depressivo. RESULTADOS: A média de pontuação da amostra foi de 9,2 pontos (desvio padrão = 9,0). Os itens mais pontuados da escala foram relativos à insônia, tristeza e desânimo. Não houve associação significativa entre os escores e o período climatérico, características sociodemográficas, clínicas ou ginecológicas, exceto para as mulheres com presença de sintomas psíquicos, histórico depressivo pregresso e uso atual de antidepressivos (p = 0,000). Entre as 32 mulheres (21%) com pontuação > 15 na CES-D, 72% referiram episódio depressivo pregresso. Dentre as participantes sem histórico depressivo, as perimenopáusicas apresentaram escores > 15 com maior freqüência. CONCLUSÃO: Essa casuística, oriunda de serviço não-especializado em menopausa ou saúde mental, revelou baixas pontuações médias na escala de sintomas depressivos CES-D, e o item insônia foi o mais pontuado. O histórico de depressão foi fator de associação com a alta pontuação na escala, mas não a fase climatérica em que a mulher se encontrava. A maior freqüência de pontuação acima do nível de corte nas mulheres sem histórico depressivo pregresso que estavam na perimenopausa sugere a maior vulnerabilidade, nessa fase, a episódios depressivos novos.
Climatério; menopausa; depressão
INTRODUCTION: The objective of this study was to evaluate depressive symptoms in climacteric women using the Center for Epidemiological Studies Depression Scale (CES-D) from the National Institute of Mental Health (USA). METHOD: This is a cross-sectional study carried out in a gynecological outpatient unit in Rio de Janeiro, Brazil, including 151 climacteric women between 40 and 65 years of age. The CES-D was used to assess depressive symptoms and a structured interview obtained sociodemographic, clinical and gynecological data. A score above 15 points on the CES-D was considered as a cut-point for depressive state. RESULTS: Mean CES-D score was 9.2 points (standard deviation = 9.0). Insomnia, sadness and despondency had the highest scores. There was no significant association between CES-D scores and the climacteric period, sociodemographic, clinical or gynecological characteristics, except for women with psychiatric symptoms, history of depression or on antidepressants (p = 0.000). In 32 women (21%) who scored > 15 on the CES-D, 72% had already suffered from a depressive state. Women with no history of depressive disorder scored more frequently above 15 when they were perimenopausal. CONCLUSION: This sample of climacteric women, from a non-specialized mental or menopausal health service, had low mean scores on the CES-D, with the item insomnia being the most highly scored. History of a previous depressive episode, but not the woman's climacteric period, was a risk factor for higher scores on the CES-D. In the group of women with no history of depression, the perimenopausal women had more scores above the cut-point. This fact may suggest that the perimenopause is a period of higher susceptibility to new onset of depressive episodes.
Climacteric; menopause; depression
Depressive symptoms in climacteric women evaluated by the Center for Epidemiological Studies Depression Scale*
Rita de Cássia Leite FernandesI; Marcia RozenthalII
IMSc. Physician, Brazilian Health Department.
IIPhD. Associate professor, Escola de Medicina e Cirurgia, Universidade Federal do Estado do Rio de Janeiro (UNIRIO), Rio de Janeiro, RJ, Brazil.
INTRODUCTION: The objective of this study was to evaluate depressive symptoms in climacteric women using the Center for Epidemiological Studies Depression Scale (CES-D) from the National Institute of Mental Health (USA).
METHOD: This is a cross-sectional study carried out in a gynecological outpatient unit in Rio de Janeiro, Brazil, including 151 climacteric women between 40 and 65 years of age. The CES-D was used to assess depressive symptoms and a structured interview obtained sociodemographic, clinical and gynecological data. A score above 15 points on the CES-D was considered as a cut-point for depressive state.
RESULTS: Mean CES-D score was 9.2 points (standard deviation = 9.0). Insomnia, sadness and despondency had the highest scores. There was no significant association between CES-D scores and the climacteric period, sociodemographic, clinical or gynecological characteristics, except for women with psychiatric symptoms, history of depression or on antidepressants (p = 0.000). In 32 women (21%) who scored > 15 on the CES-D, 72% had already suffered from a depressive state. Women with no history of depressive disorder scored more frequently above 15 when they were perimenopausal.
CONCLUSION: This sample of climacteric women, from a non-specialized mental or menopausal health service, had low mean scores on the CES-D, with the item insomnia being the most highly scored. History of a previous depressive episode, but not the woman's climacteric period, was a risk factor for higher scores on the CES-D. In the group of women with no history of depression, the perimenopausal women had more scores above the cut-point. This fact may suggest that the perimenopause is a period of higher susceptibility to new onset of depressive episodes.
Keywords: Climacteric, menopause, depression.
Mood changes are complaints frequently reported to specialists in menopause clinics, but existence of an association between decline in ovarian function and women's mental health is still controversial.1,2 An old psychiatric terminology used the expression "involutional melancholy" 1 to classify depression that affected some women during menopause. However, other stressors that are characteristic of this period of life may contribute to climacteric depressive states, and not only senescence or hormonal decline. Community studies indicate that depressive symptoms in middle-aged women are associated with factors such as attitude toward menopause, woman's general health, anxiety, relationship problems, presence of other climacteric symptoms, and history of depressive episode.2-4
According to a definition by the World Health Organization,5 menopause is the last menstruation, which occurs at 50 years of age in average, and can only be recognized 12 months after amenorrhea. The climacteric establishes the passage from reproductive life to non-reproductive life, starting at about 40 years of age and ending on the sixth decade for most women. Its main biological aspect is reduction in production of sexual steroid hormones by ovarian follicles, especially estrogen and progesterone. Perimenopause is the period that starts with the first menstrual irregularities, in average at 45 years of age, and extends until 1 year after menopause. During perimenopause there are fluctuations of hormonal serum levels and more frequency of vasomotor symptoms, such as hot flashes and night sweats. Increased frequency of mood disorders in this stage is still being discussed.2,4,6,7
The high rates of depressive symptoms obtained in studies performed in clinics specialized in menopause or in mental health8-11 were not corroborated by community-based studies. It was suggested that perimenopause could be a period of higher risk for mood disorders, but it does not necessarily represent a risk period for major depression.12,13 In 2000, Woods et al.14 published data from a population study on woman's health performed in Seattle (WA, USA), in which 508 women were annually followed using the Center for Epidemiological Studies Depression Scale (CES-D). The most frequent pattern was low scores throughout time, which corresponds to a low intensity of depressive symptoms. A recent study by Freeman et al.4 evaluated a group of 231 community women through 8 years of climacteric using the CES-D. As they entered perimenopause, half of the women had significant depressive symptoms and 59 developed major depression. The study concluded that transition from perimenopause to menopause is associated with a five-fold increase in risk of depression.
In Brazil, studies carried out by specialized clinics also indicated high prevalence of depressive symptoms in climacteric women. De Lorenzi et al.3 found 73.2% of melancholy or sadness using Kupperman's menopausal index, one of the most widely used instruments by gynecologists to evaluate climacteric symptoms. In a sample from mental health and menopause services, Soares15 found 49.5% of intense depressive symptoms using the Self Report Questionnaire (SRQ-20). Veras et al.16 recently found significant rates of anxiety disorders (34.9%) and major depression (31.4%) at the menopause outpatient clinic of a teaching institution in Rio de Janeiro using the Mini International Neuropsychiatric Interview (MINI).
Diagnosing depression and measuring severity of depressive symptoms reported by individuals are different tasks. The so-called screening scales are a simple and fast method to identify individuals supposedly affected or vulnerable to depression. Scoring in a scale indicates presence of depressive syndrome, although being inadequate to classify the patient within a nosological diagnosis of depression. Measurement of depressive symptoms using symptom scales is a resource that aids clinicians and also a method used in studies evaluating depressive characteristics in the population.
The screening scale of depression CES-D, developed by the National Institute of Mental Health (USA), aims at identifying depressive symptoms in population studies.17,18 Its use extends to the investigation of relationships between depressive symptoms and demographic and psychosocial variables and to the identification of risk factors. In Brazilians such scale has never been used with the aim of investigating depressive symptoms in the climacteric. It was translated and validated by Silveira & Jorge17 in a study on adolescents and by Tavares,19 who studied the psychometric characteristics of CES-D in the elderly compared with the GDS (Geriatric Depression Scale). Using a cut-off point > 15 points in CES-D, that author found good internal consistency for the scale (alpha = 0.86), with high sensitivity (74.6%) and specificity (73.6%) rates to detect cases of depression that had been identified by GDS. Some characteristics of CES-D might make it a good measurement instrument for depressive symptoms in climacteric women, because it has simple application and investigation of cognitive, somatic, psychomotor depressive symptoms, as well as those relative to interpersonal relationships.
The main goal of this study was to describe CES-D scores in a group of climacteric women using basic health care services. The secondary objective was to verify existence of an association between mean scores in the depression scale and sociodemographic, gynecological and clinical characteristics of the sample.
This was a cross-sectional study conducted between January and May 2007 with users of the general gynecology outpatient clinic of Policlínica Antônio Ribeiro Netto (PARN), who were invited to participate according to order of arrival. Inclusion criterion was age between 40 and 65 years of age, a period that, according to the WHO, includes women starting decline of ovarian follicular activity to hormonal homeostasis.5 This study is part of a study on cognition during the climacteric;20 for that reason, the exclusion criterion was current or past history of stroke. The project was approved by the Research Ethics Committee of the Municipal Health Department of Rio de Janeiro. The sample was comprised of 151 women that agreed to participate and that signed a consent form.
Analysis of sociodemographic data included age, schooling level, family income per capita and marital status. Gynecological data included current characteristics of the menstrual cycle, number of pregnancies, number of live children, gynecological surgeries, and use of hormonal replacement. Participants that had no change in menstrual pattern in the past year were considered premenopausal; those that reported irregular cycles, longer or shorter, or amenorrhea lasting less than 12 months were classified as perimenopausal, and those who had no menstruation for more than 1 year were classified as postmenopausal. Participants with the clinical condition were all that answered a structured questionnaire by reporting presence of diabetes mellitus, hypertension, dyslipidemia, and neurological and psychiatric diseases. Body mass index (BMI) was calculated by dividing weight (kg) by squared height (m). Presence of nervousness, irritability, depression or insomnia was investigated, and positive answer to any of these items was considered positive for psychic symptoms. History of depressive episodes was evaluated by the following question: "Have you ever had depression or taken medication for depression?".
The depression scale CES-D was applied by the researcher to all participants. It is comprised of 20 items about depressive symptoms over the past 7 days (Table 1). Each answer has four alternatives (never or rarely, sometimes, often and always) and corresponding scores (0, 1, 2 and 3). Items 4, 8, 12 and 16 (positive) are inversely scored. Final score ranges from 0 to 60 points and corresponds to the sum of all answers. CES-D items include questions regarding mood (items 3, 4, 6, 8, 9, 10, 12, 16, 17 and 18), psychosomatic symptoms (items 1, 5 and 11), symptoms related to social interactions (items 14, 15 and 19), and symptoms related to motor initiative (items 2, 7, 13 and 20). Scale score > 15 points was used as cut-off point to indicate presence of significant depressive symptoms.4,17,19 Mean scores were compared between climacteric subgroups and the characteristics of women with scores above the cut-off point were analyzed.
Collected data were recorded and analyzed in the Epi-Info®, version 3.3.2 (2005). Categorical variables were evaluated as to their frequency. Continuous variables with normal distribution were compared using the analysis of variance (ANOVA), and non-parametric variables were compared using the Kruskal-Wallis test, calculating means and standard deviation. Linear regression and calculation of Pearson's correlation coefficient (r) were used to verify association between variables. Significance level was set in 5% (p < 0.05) for all statistical tests.
Participants' mean age was 51.8 years (standard deviation - SD = 6.6), 6.8 years of schooling (SD = 3.8), 6% were illiterate, and mean family income per capita was 1.3 (SD = 0.8) (Table 2). Most had their own income and a husband. Of the 39 women (26%) who had used hormonal replacement, 2/3 did it for a period shorter than 1 year. There was a high number of women with one or more chronic metabolic or cardiovascular diseases, especially overweight and obesity (BMI > 25) and hypertension.
About 20% of climacteric women reported presence of some current psychiatric symptom and 34% reported previous depressive episode. During the study, 12% of the participants were using anxiolytics and 11% were using antidepressants; one woman reported having schizophrenia and was using neuroleptics (0.7%). The only neurological disease reported was epilepsy, which affected three participants (2%). Smoking was reported by 10%, and frequent alcoholism (> once a week) by only 2.6%.
The climacteric period was unknown in 15 participants because they were hysterectomized. Among non-hysterectomized women (n = 136), a little more than half of the sample was in the postmenopause (53%), 23% in the perimenopause and 24% in the premenopause. The group of younger, premenopausal women had higher schooling level. Hypertension and dyslipidemia were more frequent in postmenopausal women. Frequency of current psychic symptoms was also higher in the postmenopausal group, but past history of depression predominated in the premenopausal group. Consumption of anxiolytics and/or antidepressants tended to increase during postmenopause. There were no significant differences as to alcohol consumption between different climacteric stages and in hysterectomized women. Smoking was reported by 10% of the sample, and perimenopausal and hysterectomized women had the lower index.
Mean CES-D score was 9.2 points (SD = 9.0), ranging between 0 and 50 points. Schooling level had weak positive association with presence of depressive symptoms, with Pearson's correlation coefficient (r) = 0.14. There was also a slight negative association between CES-D scores and age (r = -0.1). The other sociodemographic, clinical and gynecological variables had no significant association with CES-D score, except for significantly higher scores in women with presence of psychic symptoms in relation to those that did not report such symptoms (means 14.9 vs. 7.7, respectively; p = 0.001), in women with history of depression in relation to those with no previous depression (means 14.0 vs. 6.8, respectively; p = 0.000) and in women taking antidepressants in relation to those not taking them (means 18.5 vs. 8.1, respectively; p = 0.000).
Analysis of mean CES-D scores according to climacteric period did not show statistically significant differences (p = 0.741), being < 10 points in all groups (Table 3). The lowest mean score was obtained by postmenopausal women. A total of 32 women had scores > 15 points in the CES-D, which accounted for 21.2% of the sample. Distribution among known climacteric groups was similar: 21% of premenopausal, 26% of perimenopausal and 18% of postmenopausal women had scores above the cut-off point (p = 0.945).
Both groups with scores below and above 15 points in the scale of depressive symptoms had no significant differences in mean age and schooling. The other sociodemographic, clinical and gynecological factors had no different frequencies of occurrence between groups. The only exceptions were highest frequencies of psychic symptoms and history of depression in women of the group with scores > 15 points: 37.5 and 71.9%, respectively. Of women with scores above the cut-off point (> 15), there was lower frequency of history of depression in perimenopausal women (Table 4), that is, to 62.5% of perimenopausal women with high CES-D scores, this could represent the first depressive episode.
Analysis of scores obtained in the 20 items of the scale showed that the highest mean score was reached in item 11 (My sleep was restless), followed by two items regarding mood, numbers 18 (I felt sad) and 3 (I felt that I could not shake off the blues with help from my family or friends). In the group of women with CES-D scores > 15, number 18 was the item with the highest mean, followed by number 6 (I felt depressed) and 11. In the group with CES-D scores > 15, number 11, relative to sleep, was the item with the highest mean, followed by items relative to mood, number 18 and 3.
This study found CES-D mean score of 9.2 points (SD = 9.0) in climacteric women. There were no significant associations between scores and climacteric period (premenopause, perimenopause, postmenopause). Such finding is an agreement with a longitudinal study by Woods et al.,14 who used the same scale and found no evidence of increased depressive symptoms caused by different climacteric stages.
Most other sociodemographic, clinical and gynecological factors had no association with CES-D scores in the sample. There was no significant association between intensity of depressive symptoms and age, income, marital status, schooling, parity, use of hormonal replacement therapy, number of pregnancies or live children, and presence of diabetes, hypertension, dyslipidemia or overweight/obesity. As expected, women who reported current psychic symptoms, current use of antidepressants and history of depression had significantly higher scores. Other authors reported history of depression as a major risk factor for depressive symptoms in the climacteric.1-4,9,11,13
During the woman's reproductive period (between menarche and menopause) there are three occasions of increased likelihood of having major depression: menarche, pregnancy and perimenopause.1,21,22 There may be an association between mood changes and hormonal environment, especially driven by the hypothalamus-pituitary-adrenal axis and by brain effects of sexual hormones, which influence human brain response to the environment.21,23-25
Mood changes and increased frequency of depression associated with certain periods of endogenous changes of ovarian steroids and use of oral contraceptives favor the hypothesis of a direct effect of such hormones on the regulation of central monoaminergic activity.21,24,25 Evidence of sexual steroid action on brain physiology stems from basic laboratory research, population studies and clinical trials. Studies on animals showed existence of estrogenic receptors in cortical and cerebellar regions, hippocampus, hypothalamus, limbic system and amygdala.22,24 Because of their binding to intracellular receptors, sexual hormones have genomic effects that include change in sequence of gene transcription that regulate the synthesis and metabolism of neurotransmitters and that modulate neural growth factor receptors. Their non-genomic action occurs at the level of cell membrane, allowing for modulation of systems that regulate serotonin (down-regulation of 5-HT2 receptors), noradrenaline or dopamine.24,26
Follicular and ovulatory stages of the menstrual cycle, characterized by peaks of estrogen and luteinizing hormone levels, are correlated to higher feeling of well being, while symptoms of tension and depression increase in the premenstrual period, when estrogen levels are reduced.1,21 Some women (about 5%) have cyclic premenstrual depression that is sufficiently strong to meet the criteria of premenstrual dysphoric disorder.1 Pregnancy and puerperium are also followed by higher incidence of depressive conditions, and clinical trials showed improvement in postpartum depression using estrogenic therapy.2 Use of transdermal 17-estadiol for the treatment of perimenopausal depressive conditions was also successful when used alone or in combination with serotonin uptake inhibitors, and was considered as an independent effect on improvement of vasomotor symptoms.7,15,25,27 Such findings reinforce the theory of an association between fluctuations of gonadal steroid levels in the female organism and mood changes.1,23
There was no association between score > 15 in the CES-D scale, obtained by 21% of the sample, and sociodemographic, clinical and gynecological factors, but history of depression was present in a large part of this group (72%). Such finding is in agreement with many authors that suggested that different factors may influence occurrence of climacteric depressive symptoms, among them history of depression.1-4,9,11,13 Among Brazilian authors, Soares15 investigated women at a specialized clinic for menopause using the SRQ-20, and found 49.5% of significant depressive symptoms. Subsequent psychiatric analysis of these patients showed that 60% of them had diagnosis of major depressive episode. A household study carried out in Campinas28 showed high prevalence of psychological symptoms (82% of nervousness), evaluated by a structured questionnaire, whose intensity or frequency were not only correlated to menopausal status, but also to psychosocial factors. De Lorenzi et al.3 investigated climacteric symptoms in 254 patients receiving care at a climacteric outpatient clinic and found irritability (87.1%), arthralgias and myalgias (77.5%) and melancholy and sadness (73.2%) as the most predominant symptoms using Kupperman's menopausal index. They also found a significant association between intensity of such symptoms and factors such as physical activity, smoking, BMI, number of pregnancies and attitudes toward menopause. In women perceiving menopause as an advantageous event, psychological symptoms were less intense, while in those with negative attitudes toward menopause such symptoms were significantly more intense.
Analysis of scores found in the sample of this study in terms of CES-D subitems showed that sleep disorder had the highest score, followed by sadness and despondency. They still had the highest frequency after excluding women with scores > 15. Such finding corroborates those found in studies in climacteric symptoms in which irritability, sadness, insomnia, and hot flashes are among the most frequent complaints.3,6,14,27,28
In general, studies that found high incidence of depressive disorders in the climacteric are conducted in clinics specialized in mental health or menopause, and could be biased by naturally more symptomatic patients. However, a recent American study by Freeman et al.4 followed community women with no history of depression from pre-climacteric to menopause. This study found increased chance of a diagnosis of depression when women enter perimenopause (odds ratio = 2.50). The study, due to its methodological design, which 1) adjusted for confounding factors, 2) evaluated community women using random selection, 3) excluded women with past history of depressive episode, 4) followed hormonal serum levels and 5) analyzed participants' evolution (reference was their own performance before perimenopause), reinforced the theory of higher vulnerability of women to depressive symptoms and to major depression specifically during perimenopause.
Analysis of the sample, divided by known climacteric periods, showed 32 women with > 15 points in the CES-D scale (21%), with similar frequencies within premenopause, perimenopause and postmenopause periods. When such score was analyzed in relation to history of depression, more than 62% of perimenopausal women had negative history, therefore depressive episodes might be considered new. Such finding corroborates the results found by Freeman et al.,4 in which the highest risk of new depression was found in perimenopause.
In summary, data from the literature suggest that presence of depressive symptoms in some women in the transition period from reproductive life to non-reproductive life originates from a group of sociocultural, individual and biological factors that, in combination, might favor occurrence of mood changes and depression.
Some limitations in this study should be mentioned. The climacteric should ideally be characterized by hormonal dosages. Selection of women only according to chronological criteria might have included some that did not have decline in ovarian function yet. This study, however, was based on systematized studies of the World Health Organization report, which indicate that most women have insidious onset of production of ovarian estrogens at the fourth decade of life, reaching significant levels and inactivation of hormonal receptors around 65 years of age. Two other issues should also be stressed: evaluation of previous depressive episodes without using a standardized diagnostic instrument might have biased the result of this variable; and the small number of participants in different climacteric stages among those who had scores above the cut-off point in the CES-D scale might have determined an insufficient statistical power to detect differences between subgroups. However, investigation of existing associations between scale score and history of depression and the climacteric period was not the main goal of this study. The data were presented with the aim of contributing to further studies, indicating trends that should be corroborated using a better defined measurement of the variable history of depression and a larger sample. Although participants are not representative of the total universe of climacteric women, they may be closer to represent women that seek the type of institution used in the study, a public primary health care unit.
In this study there were low mean scores of climacteric women in the CES-D scale, which is in agreement with other studies carried out in non-specialized clinics. There was no association between intensity of depressive symptoms and sociodemographic, clinical and gynecological factors, except for a predictable higher score for women with history of depression and more psychic complaints. About 20% of the sample reached > 15 points in the CES-D scale, suggesting a prevalence of depression in this climacteric sample similar to that obtained for the general female population. In the group of women who scored above the cut-off point, 72% had suffered from depression, suggesting that history of depression is one of the risk factors for presence of depressive symptoms in this period of a woman's life. More than 60% of the participants in the perimenopause and that reached > 15 points in the CES-D denied history of depression, which corroborates the hypothesis that there is increased vulnerability to the first depressive episode in this specific stage of the climacteric, previously reported by other authors.
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Endereço para correspondência:Rita de Cássia Leite FernandesRua Marquês de Abrantes, 171/502, FlamengoCEP 22230-060, Rio de Janeiro, RJE-mail:
Este estudo foi realizado no Instituto Fernandes Figueira, Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, RJ.
Publication in this collection
17 Mar 2009
Date of issue
20 July 2008
14 Aug 2008