Impact of depressive and anxiety disorders over menopause manifestations

Abstracts

OBJETIVO: Determinar, pela primeira vez, em uma amostra ambulatorial brasileira, o impacto dos diagnósticos psiquiátricos sobre os sintomas da menopausa presentes no índice de menopausa de Blatt-Kupperman (B-K). MÉTODOS: Avaliamos consecutivamente, através do instrumento diagnóstico estruturado MINI 4.4 e da entrevista psiquiátrica tradicional, mulheres (n = 86) em atendimento no ambulatório de menopausa do Instituto de Ginecologia da Universidade Federal do Rio de Janeiro. As pacientes incluídas no estudo (n = 48) foram avaliadas pela escala B-K até 6 meses antes ou depois da entrevista pelo MINI e divididas em dois grupos: o grupo com algum transtorno depressivo-ansioso (GTDA) (n = 26) e o grupo-controle (GC) (n = 22). RESULTADOS: O GTDA apresentou uma pontuação significativamente maior do que o GC na escala de B-K (22,6 versus 13,7). Entre os sintomas significativamente mais intensos no GTDA estão parestesia e melancolia. Além disso, observamos que as pacientes do GTDA queixavam-se de um maior número de sintomas do que as pacientes do GC (6,8 vs. 4,8). Entre os sintomas significativamente mais relatados no GTDA, estão parestesia, fraqueza e melancolia. CONCLUSÃO: Apesar da limitação da pequena amostra, pudemos observar o significativo viés dos transtornos depressivos e ansiosos sobre as pacientes em tratamento por queixas referentes à menopausa. Por esse motivo, o perfil sintomático de cada paciente deve ser sempre observado, evitando o ginecologista basear-se na intensidade global dos sintomas do B-K para decidir sobre o tratamento.

Depressão; ansiedade; menopausa; índice de Blatt-Kupperman

BRIEF COMMUNICATION

Impact of depressive and anxiety disorders over menopause manifestations

Andre Barciela Veras^I; Arabella Rassi^II; Livia Mitsue Gomes Yukizaki^III; Luisa Duarte Novo^III; Flávia Schueler Franco^III; Antonio Egídio Nardi^IV

^IMSc. Researcher

^IIResidence in Psychiatry. Researcher

^IIIMedical Student. Scientific Initiation Student

^IVProfessor. Associate professor, Faculdade de Medicina, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil

Correspondence

ABSTRACT

OBJECTIVE: To establish for the first time in a Brazilian outpatient sample the impact of depressive and anxiety disorders over the symptoms of the Blatt-Kupperman menopausal index (B-K).

METHODs: Women (n = 86) receiving care in the menopause clinic at Instituto de Ginecologia da Universidade Federal do Rio de Janeiro were consecutively assessed using a structured diagnostic instrument (MINI 4.4) and a traditional psychiatric interview. Patients included in the study (n = 48) were assessed using the B-K scale within 6 months before or after the MINI. The total sample was divided into the anxiety and depressive disorder group (GTDA) (n = 26) and the control group (CG) (n = 22).

RESULTS: B-K total scores were greater in the GTDA comparing with the CG (22.6 vs. 13.7). Paresthesia and melancholia were significantly more severe in the GTDA. GTDA patients also complained of a greater number of symptoms (6.8 vs. 4.8) than the GC. Paresthesia, weakness and melancholia were significantly more present in the GTDA.

CONCLUSION: Although the small sample limitation we could observe a great bias of depressive and anxiety disorders over menopause outpatients. For that reason, the symptomatic profile of each patient must always be observed by the gynecologist, avoiding exclusive observation of B-K total score to decide about the treatment.

Keywords: Depression, anxiety, menopause, Blatt-Kupperman index.

Introduction

Menopause is known as a period of global changes in women's body and mind. Among psychological symptoms, mood is one of the most affected structures. During this period, women who had any anxiety and depressive disorder throughout their lives are more likely to have another episode,¹ whereas others can feel, for the first time, insomnia, irritability, mood changes, absence of sexual desire and fatigue.² Some of these symptoms are part of the Blatt-Kupperman menopausal index (B-K),³ one of the most widely used instruments in clinical practice to quantify menopausal symptoms and evaluate evolution through time.⁴

Besides being common complaints in menopause, emotional symptoms are the most frequent complaints among Brazilian women searching for gynecological care. In a Brazilian household survey including 367 women, Pedro et al.⁵ observed that intensity of psychological symptom is positively related to search for treatment. Whitehead et al.⁶ also observed that severity of anxiety, irritability and "depression" was the main differential among women searching or not for treatment. Such bias in search for treatment may lead to a concentration of women affected by a depressive or anxiety disorder in gynecology and menopause clinics.

After observing a high incidence of depressive and anxiety disorders at the menopause clinic at Instituto de Ginecologia da Universidade Federal do Rio de Janeiro in a previous study, we tried to determine, for the first time in a Brazilian outpatient sample, the likely strong influence of psychiatric diagnosis on menopause symptoms present in B-K.

Methods

Women (n = 86) receiving care in the menopause clinic at Instituto de Ginecologia da Universidade Federal do Rio de Janeiro were consecutively assessed using a structured diagnostic instrument (MINI 4.4⁸) and a psychiatric interview, with the aim of determining data published in a previous study.⁷ Demographic and gynecological and psychiatric history variables were also collected. All assessments were performed by the same psychiatrist. B-K scale was further obtained from patients' medical charts. All scales were applied by the same gynecologist. Patients included in the study (n = 48) were assessed using the B-K scale within 6 months before or after the MINI. Patients whose gynecological assessment of menopause symptoms had been performed 6 months before or after psychiatric assessment were excluded. We believed that a temporal difference between assessments higher than that period could compromise associations between data from applied instruments.

Patients were divided into two groups. The anxiety and depressive disorder group (GTDA), comprised of 26 women, and the control group (CG), comprised of 22 women without any psychiatric diagnosis by MINI and with no history of any psychiatric treatment at assessment.

B-K is composed of 11 symptoms, which are categorized by a 4-point scale, where 0 = absent and 3 = severe. Some symptoms have a higher value: Hot flashes have weight 4, and nervousness, insomnia and paresthesia have weight 2. Total score is categorized as mild (15-20), moderate (21-35) and severe (> 35).³

Instituto de Ginecologia da Universidade Federal do Rio de Janeiro is located in the downtown area of Rio de Janeiro. It is characterized for being a low complexity center that aims at providing care to the neighboring population. Since it is a public hospital, most patients have low economic and cultural level.

All patients were informed about the objectives of this study and agreed to participate in the interview. The protocol was approved by the local ethics committee, and the patients signed an informed consent form.

Mean and standard deviation (SD) were used to evaluate descriptive data of normal distribution variables, and median and percentages 25 and 75% for non-normal distribution variables. Chi-square and Fisher's exact tests were used to compare categorical variables, and Student's t and Mann-Whitney tests to compare continuous variables between groups. P < 0.1 and > 0.05 was considered as tendency, and p ≤ 0.05 was considered as statistically significant.

Results

Among women included in the study (n = 48), we observed 33.3% of anxiety disorders and 18.7% of depressive disorders as main diagnoses. In GTDA (n = 26), more than half of women had at least one comorbidity (53.8%).

Comparisons of demographic, gynecological and psychiatric data between GTDA and CG can be seen in Tables 1 and 2. Difference between groups was not statistically significant.

Table 1-
Click to enlarge

Table 2-
Click to enlarge

B-K total scores were significantly greater in the GTDA comparing with the CG (22.6 vs. 13.7). Paresthesia and melancholia were significantly more severe in the GTDA. In addition, GTDA patients also complained of a greater number of symptoms (6.8 vs. 4.8) than the GC. Paresthesia, weakness and melancholia were significantly more present in the GTDA. Comparisons of each symptom in each group are shown in a Tables 3 and 4.

Table 3- Click to enlarge

Table 4 - Click to enlarge

Discussion

We observed that, besides complaining more intensely of menopause symptoms, patients with depressive or anxiety disorders complain of a larger number of physical and psychic symptoms. A similar observation was described by many studies on the relation between anxiety and depression and somatizations in primary care services. Waal et al.,⁹ in a cross-sectional study including 1,458 patients, observed odds ratios higher than six for presence of symptoms such as lack of energy, fatigue and forgetfulness among patients with more depressive and anxiety symptoms. In a recent study, conducted in outpatient setting for menopause cares, Callegari et al.¹⁰ observed significantly higher levels of somatic and psychic symptoms among depressed patients. However, when such a strong influence is seen on an instrument used in clinical practice for therapeutic guidance and follow-up, some issues should be raised.

1) Validity of B-K, previously questioned by Alder et al.,⁴ seems even more fragile as a consequence of the results found in this study.

2) Despite the influence of menopause on mood, discussed in the literature in studies conducted in community individuals,¹¹ among outpatients, such relation seems more important when considered inversely.^5,12 For that reason, use of B-K in a clinical setting needs to be associated with a correct identification of mental disorders.

3) Without that, patients with moderate to severe depressive or anxiety disorders will be submitted to hormone replacement therapy, which will have little efficacy, delaying use of antidepressants or anxiolytics.

Naturally, melancholy was the most specific symptom of presence of any depressive or anxiety disorder, being 6.8 times more prevalent among GTDA patients. Other symptoms usually found in diagnostic manuals to characterize depressive or anxiety disorders were more intense, such as insomnia, or more prevalent, such as weakness, in GTDA. There was also a tendency of more intense and prevalent complaints of hot flashes in GTDA, which is commonly found with higher significance in other studies^14,15 and that is probably not statistically significant due to our small sample.

Limb numbness (paresthesia) was the most significantly reported and more intense somatic symptom among GTDA patients. It was the second most reported symptom by this group, whereas it was in the seventh position in the CG. This shows the ability of depressive and anxiety disorders of also enhancing somatic complaints. Particular intensification of paresthesia deserves special attention. This is justified because frequent somatic symptoms in depressive or anxiety disorders, such as palpitation and vertigo,^16,17 were not significantly more prevalent in GTDA, and another frequent symptom, headache,^16,17 was even less prevalent and less intense in GTDA, despite both not being statistically significant. The fact that paresthesia stood out seems to be a particularity of our sample, and may have been influenced by factors such as culture, socioeconomic condition,¹⁸ concentration of depressive and anxiety disorders with prevalent somatic symptoms in primary care centers and how the service was provided.¹⁹

Although the small sample limitation, we could observe a great bias of depressive and anxiety disorders over menopause outpatients. For that reason, the symptomatic profile of each patient must always be observed by the gynecologist, avoiding exclusive observation of B-K total score to decide about the treatment. We believe that the present study was able to contribute to identify symptoms more related to mental disorders among Brazilian women in outpatient follow-up for menopause.

References

• 1. Stewart DE, Boydell KM. Psychologic distress during menopause: associations across the reproductive life cycle. Int J Psychiatry Med. 1993;23:157-62.
• 2. Hay AG, Bancroft J, Johnstone EC. Affective symptoms in women attending a menopause clinic. Br J Psychiatry. 1994;164:513-6.
• 3. Kupperman HS, Wetchler BB, Blatt MH. Contemporary therapy of the menopausal syndrome. JAMA. 1959;171:1627-37.
• 4. Alder E. The Blatt-Kupperman menopausal index: a critique. s. 1998;29:19-24.
• 5. Pedro AO, Pinto-Neto AM, Costa-Paiva L, Osis MJ, Hardy E. Procura de serviço médico por mulheres climatéricas brasileiras, Brasil. Rev Saude Publica. 2002;36(4):484-90.
• 6. Whitehead M. The Pieter Van Keep memorial lecture. In: Berg G, Hammar M, editors. The modern management of the menopause: a perspective for the 21st century. New York: Parthenon; 1994. p. 1-13.
• 7. Veras AB, Rassi A, Valença AM, Nardi AE. Prevalência de transtornos depressivos e ansiosos em uma amostra ambulatorial brasileira de mulheres na menopausa. Rev Psiquiatr RS. 2006;28:130-4.
• 8. Sheehan DV, Lecrubier Y, Janavs J, Knapp E, Weiller E, Sheehan M, et al. Mini International Neuropsychiatric Interview Version 4.4 (MINI). Tampa: University of South Florida; 1996.
• 9. de Waal MW, Arnold IA, Spinhoven P, Eekhof JA, van Hemert AM. The reporting of specific physical symptoms for mental distress in general practice. J Psychosom Res. 2005;59:89-95.
• 10. Callegari C, Buttarelli M, Cromi A, Diurni M, Salvaggio F, Bolis P. Female psychopathologic profile during menopausal transition: A preliminary study. Maturitas. 2007;56:447-51.
• 11. Maartens LW, Knottnerus JA, Pop VJ. Menopausal transition and increased depressive symptomatology: a community based prospective study. Maturitas. 2002;42:195-200.
• 12. Wojnar M, Drozdz W, Araszkiewicz A, Szymanski W, Nawacka-Pawlaczyk D, Urbanski R. [Prevalence of depressive disorders among perimenopausal women seeking gynecological services]. Psychiatr Pol. 2003;37:811-24.
• 13. Soares CN, Arsenio H, Joffe H, Bankier B, Cassano P, Petrillo LF, et al. Escitalopram versus ethinyl estradiol and norethindrone acetate for symptomatic peri- and postmenopausal women: impact on depression, vasomotor symptoms, sleep, and quality of life. Menopause. 2006;13:780-6.
• 14. Freeman EW, Sammel MD, Lin H, Gracia CR, Kapoor S, Ferdousi T. The role of anxiety and hormonal changes in menopausal hot flashes. Menopause. 2005;12:258-66.
• 15. Juang KD, Wang SJ, Lu SR, Lee SJ, Fuh JL. Hot flashes are associated with psychological symptoms of anxiety and depression in peri- and post- but not premenopausal women. Maturitas. 2005;52:119-26.
• 16. Hamilton, M. The assessment of anxiety states by rating. Br J Med Psychol. 1959;32:50-5.
• 17. Hamilton, M. A rating scale for depression. J Neurol Neurosurg Psychiatry. 1960;23:56-62.
• 18. Thomas, JL; Brantley, PJ. Factor structure of the center for epidemiologic studies depression scale in low-income women attending primary care clinics. Eur J Psychol Assess. 2004;20(2):106-15.
• 19. Simon GE, VonKorff M, Piccinelli M, Fullerton C, Ormel J. An international study of the relation between somatic symptoms and depression. N Engl J Med. 1999;341:1329-35.

Publication Dates

• Publication in this collection
  01 Mar 2008
• Date of issue
  Dec 2007

History

• Received
  25 July 2007
• Accepted
  30 July 2007