|Year : 2020 | Volume
| Issue : 1 | Page : 37-42
Anxiety and depression in menopausal transition: A hospital-based study from Kashmir
Shabir Ahmad Dar1, Zaid Ahmad Wani1, Bilal Ahmad Bhat1, Shanoo Sheikh2, Junaid Nabi1, Aaliya Khanam1, Deeba Nazir1, Mudasir Nazir3
1 Department of Psychiatry, Government Medical College, Srinagar, Jammu and Kashmir, India
2 Department of Health and Rehabilitation, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia
3 Department of Obstetrics and Gynaecology, Government Medical College, Srinagar, Jammu and Kashmir, India
|Date of Submission||25-Feb-2019|
|Date of Acceptance||12-Aug-2019|
|Date of Web Publication||16-Dec-2019|
Shabir Ahmad Dar
Department of Psychiatry, Government Medical College, Srinagar - 190 010, Jammu and Kashmir
Source of Support: None, Conflict of Interest: None
Background: Menopausal transition (MT) is the period of irregular menstrual activity which directly precedes menopause and is characterized by widely fluctuating hormone levels and reproductive, metabolic, and psychological disturbances. We aimed to study the prevalence of psychiatric comorbidity among ambulatory women in MT. Materials and Methods: One hundred consecutive ambulatory women in MT were assessed using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria by means of the Mini-International Neuropsychiatric Interview, English version 5.0.0. The diagnosis of MT was made according to the Stages of Reproductive Aging Workshop. Results: About 28% of the cases had major depressive disorder (MDD), 14% had anxiety disorders, and 7% had anxiety with depression. A statistically significant difference in psychiatric comorbidity was found between the age groups of 45–50 years and 51–55 years. There was a statistically significant difference between onset of menarche and psychiatric comorbidity. Women in the late MT had statistically significant sleep disturbances. Conclusion: A high prevalence of mental disorders was observed which included MDD and other anxiety disorders. The results suggested that screening and appropriate management for psychiatric disorders should be part of the routine evaluation that would help in early recognition of symptoms and reduction in discomfort of these symptoms.
Keywords: Anxiety, depression, menopausal transition, psychiatric comorbidity
|How to cite this article:|
Dar SA, Wani ZA, Bhat BA, Sheikh S, Nabi J, Khanam A, Nazir D, Nazir M. Anxiety and depression in menopausal transition: A hospital-based study from Kashmir. Med J DY Patil Vidyapeeth 2020;13:37-42
|How to cite this URL:|
Dar SA, Wani ZA, Bhat BA, Sheikh S, Nabi J, Khanam A, Nazir D, Nazir M. Anxiety and depression in menopausal transition: A hospital-based study from Kashmir. Med J DY Patil Vidyapeeth [serial online] 2020 [cited 2020 Jul 9];13:37-42. Available from: http://www.mjdrdypv.org/text.asp?2020/13/1/37/272887
| Introduction|| |
Natural menopause is the period of permanent cessation of menses or amenorrhea for >12 consecutive months in the absence of pregnancy and lactation. Perimenopause, the time of transition into menopause (MT), is defined by the World Health Organization and the North American Menopause Society as the 2–8 years preceding menopause and the 1-year period after final menstruation.,
Resulting from the loss of follicular activity, it represents the transition into menopause and is characterized by periodic irregular menstrual activity or prolonged amenorrhea lasting for <12 months at a time. During this time, a multitude of physical and emotional symptoms tend to appear which may be related to the endocrine changes driving this transition.
Women in the perimenopausal phase experience acute perimenopausal symptoms. Most commonly reported symptoms are hot flushes, heart palpitations, night sweats, dyspareunia, increased vaginal itching and dryness, headache, sleep disturbances, urinary incontinence, and fatigue. The prevalence of these reported symptoms varies from early to late perimenopause. In studies of Europoid populations, up to 85% of women report these symptoms and are more likely to experience other physical and emotional symptoms. There is a great variation among countries in the proportion of women reporting hot flushes. Estimates within countries also vary widely. Studies of Asian populations tend to report the lowest rates.
Studies in Thailand and Japan have reported rates of 6% and 12%, respectively, and studies in Africa have reported rates of 30%–80%. There does seem to be an increase in psychiatric symptoms including depression, anxiety, and psychosomatic symptoms, in the years immediately preceding the complete cessation of menses. Depressive symptoms, in particular, have been examined repeatedly in conjunction with perimenopause, though with a wide range of results. Novaes et al. found that 49.5% of perimenopausal women had psychiatric morbidity and almost one-third met the diagnostic criteria for a depressive disorder. More generally, the results from a study by Schmidt et al. suggest that women's susceptibility to major depressive disorder (MDD) increases as their estrogen levels decline, and women with both unipolar and bipolar depression have been shown at increased risk for mood episodes during periods of hormonal fluctuation.
Perimenopausal women, who are usually between 45 and 55 years of age, are also more likely to experience “exit” or “loss” events, such as the death of a loved one, divorce, or a child leaving home than they were at a younger age. Therefore, these life changes and anxiety-provoking experiences may sufficiently account for an increased prevalence of depressive symptoms during perimenopause.
As menopausal health demand priority in Indian scenario due to an increase in life expectancy and growing population of menopausal women, large efforts are required to educate and make these women aware of menopausal symptoms. This will help in early recognition of symptoms, reduction of discomfort and fears, and enable to seek appropriate medical care if necessary. Health problems, aging parents, financial worries, career questions, adolescent offspring, and marital issues are all common concerns during this period. Since there is a paucity of literature on anxiety and depression in MT in Kashmir, hence the current study was undertaken to assess the prevalence of anxiety and depression in women of MT aged 45–55 years.
| Materials and Methods|| |
The present study was conducted in the Postgraduate Department of Psychiatry in collaboration with the Postgraduate Department of Obstetrics and Gynaecology, Government Medical College, Srinagar, Jammu and Kashmir, India. It was an observational, hospital-based, cross-sectional, noncontrolled study which was conducted over a period of 1½ year, from April 2017 to August 2018. It was initiated the following approval by the Institutional Ethics Committee and the Board of Research Studies. One hundred consecutive ambulatory patients were recruited through purposive sampling who were diagnosed as being in perimenopause by a consultant gynecologist in the age group of 45–55 years. Informed written consent in locally understandable language was taken from each patient, and each was given freedom of choice to accept or refuse participation in the study. Each was briefed about the study before participation. Patients in perimenopause were classified if the following events occurred during the previous period: patients having variable cycle length (>7 days different from normal menstrual cycle length, which is 21–35 days) (early perimenopause) or by ≥2 skipped cycles and an interval of amenorrhea ≥60 days (late perimenopause). The above criteria were consistent with a construct used to characterize the MT by the Stages of Reproductive Aging Workshop.
Patients with uncontrolled chronic physical illnesses such as hypertension, hypothyroidism, and diabetes mellitus were excluded from the study. Those who were not willing, those who had undergone surgical menopause, those with a past history of psychiatric illnesses, and those on corticosteroids or oral contraceptives were also excluded from the study. Detailed history, physical examination, and relevant investigations were done before screening for any psychiatric diagnosis.
All of these cases were further interviewed for sociodemographic variables such as age, marital status, educational status, employment, type of family, domicile, age of menarche, and stage of perimenopause. All the cases were evaluated to investigate the psychiatric comorbidity using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria by means of the Mini-International Neuropsychiatric Interview (MINI, English version 5.0.0) administered by a qualified psychiatrist. The choice of MINI as an instrument was based on its high levels of reliability and validity, which have been reported in several studies.
The MINI is a structured interview tool, designed to evaluate the presence of psychiatric disorders according to Axis I, of the DSM-IV.
Data about various parameters were entered into Microsoft Excel. Descriptive analysis was carried out with the SPSS version 21 Software Statistical package for the social sciences; IBM software, NY, USA. The analysis was performed with a significance level of <0.05 and a confidence level of 95%.
| Results|| |
A total of 103 perimenopausal women visited us, out of which 3 refused to consent and therefore were excluded from the study. Of the studied samples, 49% had comorbid psychiatric disorders which included MDD (28%) and anxiety disorders (14%), and 7% were diagnosed as having combined anxiety and depression. [Table 1] shows the sociodemographic characteristics and distribution of psychiatric comorbidity in the studied population. Women in the age group of 45–50 years had 42.25% psychiatric comorbidity in comparison to 51–55 years, where it was 69.56%, and the difference was statistically significant. Likewise, no statistically significant difference was found in rest of the parameters [Table 1].
|Table 1: Sociodemographic characteristics and distribution of psychiatric morbidity|
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There was a statistically significant difference between onset of menarche and psychiatric comorbidity. The study results also revealed that women in the late perimenopausal stage showed significantly higher psychiatric morbidity [Table 2] and [Table 3].
|Table 2: Stage of perimenopause of study sample and psychiatric morbidity|
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The most common complaints reported by the studied samples included irritability (41.55%) and body aches (39.8%), followed by headache (35.06%). Women in the late perimenopause had statistically significant sleep disturbances [Table 4].
|Table 4: Perimenopausal complaints in relation to stage of perimenopause|
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The transition into menopause is characterized by a complex set of changes associated with the progressive decline of the ovarian function. Population-based studies have shown that vasomotor symptoms, sleep disturbances, and estrogen-based sexual complaints are particularly prevalent among peri- and postmenopausal women compared with premenopausal women.,
In the Harvard Study of Moods and Cycles, women with no history of depression were prospectively assessed, and an increased risk (twofold) for the development of significant depressive symptoms (defined as the Center for Epidemiologic Studies Depression Scale scores >24) was observed in women entering perimenopause compared with age-matched women who remained premenopausal.
Our patients in perimenopause exhibited high rates of psychopathology with 49% of the samples suffering from a psychiatric condition. In the study done in Maharashtra, India, by Jagtap et al., almost half (44.44%) of those in perimenopause had a comorbid psychiatric illness and hence match our results of about 49.0%. This is in agreement with earlier studies on perimenopausal women, reporting an overall psychiatric morbidity of 49.5%.
The main findings of our study were high rates of depression, anxiety disorders, and combined anxiety and depression. It has been found that certain periods of time associated with hormone fluctuations across the female reproductive lifecycle represent windows of vulnerability for new onset and/or recurrent depression. MDD was the highest individual psychiatric comorbidity present in 28% of the studied samples. The high rate of depression in women with perimenopause corroborates with earlier studies. Studies have reported rates of depressive symptoms in MT ranging from 8% to 40%, and hence, the results are in unison with our results.,,
The rate of depression is clearly high in perimenopausal women attending menopause clinics, sometimes reaching as high as 44%, thus contradicting our results. The Penn Ovarian Aging Study prospectively assessed women entering perimenopause and found an increased risk for depressive symptoms (fourfold) and MDD (more than twofold).
In community-based studies, it was found that depressive symptoms were more common among perimenopausal women, especially the women who had more serious vasomotor symptoms such as night sweats, flushing, and sexual dysfunction., This increase in depressive symptoms might be the result of dysphoria caused by vasomotor symptoms as well as the increasing psychosocial stressors within the perimenopausal period. According to the domino theory of depression during the perimenopausal period, sleep problems, dysphoria, irritability, and difficulties in concentration were consequences of vasomotor symptoms such as hot flashes and night sweats.
Changing hormone levels could constitute a trigger for depressive symptoms in vulnerable midlife women. Estrogen receptors are widely distributed throughout the brain; the effects of estrogen have been observed in the hypothalamus, prefrontal cortex, hippocampus and brain stem, and brain regions known to be closely involved in the regulation of mood, core body temperature, and cognition.,,,
Likewise, Freeman conducted a longitudinal cohort study which also showed that the likelihood of depressed mood in the MT is approximately 30%.
Later the onset of menarche, higher was the psychiatric comorbidity present in these women. It had been found that serum estrogen levels to be on higher side in early menarche compared with women in late menarche that might be one of the reasons of higher psychiatric comorbidity in the late perimenopause.
Besides, serum estrogen had been found to be effective in alleviating symptoms of depression in postpartum  and perimenopausal women. The findings of significantly higher psychiatric comorbidity in the late perimenopause in comparison to the early perimenopause corroborate with other earlier studies., The higher prevalence of depression in the late perimenopause seemed to be the hormonal events which characterize the late menopause transition and may lead to the onset of this form of depression.
| Discussion|| |
The transition into menopause is a complex series of physiologic events that lasts an average of 5 years and includes variations in the endocrine function that progress from increased estradiol secretion during the early MT, estrogen withdrawal, and finally, hypogonadism during the perimenopause (i.e., late MT and 1st-year postmenopause). In up to 80% of women, these endocrine events lead to hot flushes  that can disrupt sleep.
Difficulty in initiating sleep has been shown to correlate strongly with anxiety, with nonrestorative sleep also correlating strongly with depression. Difficulty in initiating sleep leads to anxiety, irritability, and nonrestorative sleep problems which in turn may manifest as depression. One of the major causative factors of depression is insomnia. The low estrogen and progesterone levels in menopausal women increase the risk of insomnia and mood disturbances in postmenopausal women. Insomnia is also associated with depression in perimenopausal women. Insomnia results from sleep disruption, and depression follows insomnia.
Perimenopausal complaints reported by our women were in accordance with an earlier Indian study in which the most frequent menopausal symptoms reported were somatic complaints while vasomotor symptoms were less frequently reported, which is in consistent with our study results.
| Conclusion|| |
A high prevalence of mental disorders was observed which included MDD and other anxiety disorders. The results suggested that screening and appropriate management for psychiatric disorders should be part of the routine evaluation that would help in early recognition of symptoms and reduction in discomfort of these symptoms.
It was a hospital-based study; therefore, its results cannot be generalized for the whole community. The number of participants enrolled in our study was not estimated by any statistical tool. The study was conducted in a single tertiary care center. Hormonal assays of the studied population could have been done.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]