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Table of Contents
ARTICLE
Year : 2015  |  Volume : 16  |  Issue : 2  |  Page : 30-35

Predictors of anxiety and depression among postmenopausal women


1 Health Coordinator, Kendriya Vidyalaya, Mumbai, India
2 Professor, College of Nursing, CMC, Vellore, India
3 Professor, Dept of Obstetrics & Gynaecology, CMC, Vellore, India

Date of Web Publication23-May-2020

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  Abstract 


The concept of quality of life among postmenopausal women is a growing concern among health care professionals. A quantitative approach with descriptive design was undertaken to assess the predictors of anxiety and depression among postmenopausal women which have a negative effect on quality of life. A total of 200 postmenopausal women were selected using convenience sampling technique. Data were collected using Hamilton Anxiety Rating Scale and Hamilton Depression Rating Scale. The findings revealed that most of the subjects had anxiety (63%) and depression (52.5%). The predictors of anxiety and depression were found to be age, education, occupation, marital status, number of children, age at menarche, age at menopause, and duration of menopause. It necessitates the need to educate postmenopausal women and also that the challenging needs of these women be addressed and attended to.

Keywords: menopause, anxiety, depression, postmenopausal women


How to cite this article:
Mathew N, Sony A, Chandy R. Predictors of anxiety and depression among postmenopausal women. Indian J Cont Nsg Edn 2015;16:30-5

How to cite this URL:
Mathew N, Sony A, Chandy R. Predictors of anxiety and depression among postmenopausal women. Indian J Cont Nsg Edn [serial online] 2015 [cited 2022 Nov 30];16:30-5. Available from: https://www.ijcne.org/text.asp?2015/16/2/30/284858






  Introduction Top


A woman plays versatile roles in her entire life span. She undergoes significant changes in her life. When her reproductive years end, her body and psyche experience a host of physical and emotional changes, starting from about the age of 45.Women now live longer and aging carries with it the baggage of degenerative changes in all the tissues of the body. In addition to these, women are also subjected to the fall-outs of an aging ovary - estrogen and progesterone deficiency: The “Menopausal Syndrome”.

Menopause is a natural phenomenon and one of the life’s important milestones. As menopause is related to postbirth changes, it should be tackled with caution and care; however, sometimes increasing age and diminishing qualities of life make the menopausal condition more difficult to handle due to the lack of proper understanding, sound medical advice, and good social support (Santwani, Shukla, Santwani, & Thaker, 2010).

A wide variety of symptoms are reported in midlife women during menopause transition including hot flashes, night sweats, vaginal dryness, urinary incontinence, alterations in mood, sleep disturbances, changes in sexuality, cognitive difficulties like forgetfulness, and somatic complaints. While not every menopausal women reports symptoms, approximately 85% of women report at least one symptom and 10% visit a health care provider regarding these concerns (Woods & Mitchell, 1996).

The life expectancy for an Indian woman is 66 years. The life expectancy after 60 years for an Indian woman is 18 years (United Nations, 2011). Thus it implies that menopausal health demands are a priority in Indian scenario due to increasing life expectancy and growing population of women who spend one third of their life in a “Hormone Deficient” state. A significantly higher proportion of postmenopausal women suffer from vasomotor symptoms, urge incontinence, loss of sexual desire, and multiple somatic symptoms (Aaron, Muliyil, & Abraham, 2002).

There are many possible reasons why psychological changes are apparent following menopause. The most obvious reason being the physiological changes. The brain is the target organ for gonadal steroids. The progressive loss of ovarian estrogen and progesterone exposure can precipitate hot flashes, decline in libido, sleep disturbances, affective complaints, and decreased memory, despite stable or improved life circumstances (Clayton & Ninan, 2010). Activities of serotonin, acetylcholine, and nor-epinephrine in menopausal women are decreased, and their association with depression is a possibility.

In a cross-sectional study done by Lee (2003) on 325 people from public health centre in Inchon, it was found that above half of these sampled people were in depressed state (64%) and the mean score of depression was found to be 12.71. There were significant differences in the depression state according to presence of life partner, economic status, activity level, and smoking. A positive correlation existed between depression and climacteric symptoms. Stepwise multiple regression analysis revealed that the most powerful predictor was climacteric symptoms. Climacteric symptoms, presence of life partner, smoking, and activity level accounted for 45% of the variance in postmenopausal women’s depression.

In a community-based retrospective study conducted by Go vil (2010) on 247 women in district Moradabad in Uttar Pradesh, it was found that 53.4% women had anxiety and insomnia and 37.9% women suffered from severe depression. Worrying needlessly, frequent mood swings, and unhappiness were the symptoms which were on the higher side among natural menopausal women.

In 1990, total population of postmenopausal women throughout the world was 476 million. It is expected that the total postmenopausal women by the year 2030 will be 1200 million approximately (Aso, 2015).

A Norwegian epidemiological study showed that a 12 month prevalence of major depression in women was 9.7% and the lifetime prevalence was found to be 24%. Women were nearly 2.5 times more likely than males to have a lifetime affective disorder (Chadda & Sood, 2010).

Host of studies have been conducted to measure anxiety and depression of postmenopausal women from western world with different socio-cultural realities which may influence not only the perception of quality of life but also the experience of menopause at different stages of menopause. Very few studies have been done and limited literature is available for Indian population. Hence there is a need for systematic approach to uncover the attributes and predictors of anxiety, depression, and quality of life of menopausal women from an Indian perspective. This study may help health professionals especially nurses to gain an insight into the problems faced by menopausal women and help them to provide care and support to this group of vulnerable population. Postmenopausal women in this study are those who have attained menopause i.e., who had experienced their last bleeding more than one year earlier.


  Objectives Top


The objectives of the study were to

  • determine the predictors of anxiety in postmenopausal women
  • determine the predictors of depression in postmenopausal women
  • associate the demographic and clinical variables with anxiety and depression



  Methods Top


Design and Sampling

A quantitative approach with descriptive design was undertaken. The sample size was determined using statistical power analysis and the calculated sample size was 200. The study was conducted among 200 postmenopausal women attending to women admitted in the obstetric and gynaecologic wards of Christian Medical College, Vellore and those who fulfilled the inclusion criteria were included in the study using convenience sampling technique.

Instruments

The data were collected using two standardized tools. Part A consisted of socio demographic and clinical data. The other tools used were Hamilton Anxiety Rating Scale (HAM-A) and Hamilton Depression Rating Scale (HAM-D).

HAM-A measures the severity of anxiety symptoms. It consisted of 14 items. Each item was scored on a scale of 0 (not present) to 4 (severe), with a total score range of 0-56 and was interpreted as < 14 - normal, 14-17 - mild anxiety, 18-24 - moderate anxiety, and > 25 - severe anxiety. The HAM - A is the most widely used semi-structured assessment scale in treatment outcome studies of anxiety. Internal scale consistency is high (coefficient alpha = .92) and the mean item-to-total scale correlation is .65. The test-retest reliability is .96 (Hamilton, 1959).

HAM-D is used for determining a patient’s level of depression. It consisted of 17 items. Eight items were scored on a 5-point scale, ranging from 0 (not present) to 4 (severe). Nine items were scored from 0-2. The scores were summed and interpreted as follows, 0-7 - normal, 8-13 - mild depression, 14-18 - moderate depression, 19-22 - severe depression and >23 - very severe depression. The HAM-D has been the gold standard for the assessment of depression for more than 40 years. Internal reliability ranged from .46 to .97, and 10 studies reported estimates of .70. The inter-rater reliabilities ranged from .82 to .98. The test retest reliability for the HAM-D ranged from .81 to .98 (Hamilton, 1960).

Data Collection and Analysis

The study was conducted after obtaining approval from the Institutional Ethical Committee. Permission to conduct the study was obtained from the Nursing Superintendent, the Head of Obstetrical and Gynecological Departments and the Head of Maternity Nursing Department. The purpose of the study and voluntary nature of participation was explained to the participants, confidentiality was assured, and written informed consent was obtained. The researcher interviewed 4-5 women per day. Each interview took approximately 40-45 minutes. Descriptive statistics were used to describe the demographic variables and clinical variables of the subjects. Chi-square test was done to determine the association between socio-demographic and clinical variables with anxiety and depression. Only significant variables from univariate analysis were selected for multivariate analysis. Logistic regression was used to determine the predictors of anxiety and depression.


  Results and Discussion Top


The demographic data showed that the majority of the participants (52.5%) were in the age group of 51-60 years and 36% were illiterates. Most of them (52%) were home makers, 71% were married and living with husband, and 73% had 3-5 children. Thirty eight percentage of the participants had co-morbidities like hypertension and diabetes and 41.5% had a BMI of < 25. The mean age for Menarche was 14.2 ± 1.84 years and the mean age for Menopause was 46.2 ± 4.8 years.

The distribution of anxiety is shown in [Figure 1]. The study reported that 63% of postmenopausal women had anxiety and 37% did not have.
Figure 1: Distribution of anxiety among postmenopausal women

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According to [Table 1], the first predictor of anxiety in postmenopausal women is level of education. It was found that women who had middle school education were 2.7 times more likely to have anxiety as compared to those who had secondary school and above education. Also, illiterate postmenopausal women were 2.26 times more likely to have anxiety as compared to those who had secondary and above education. These findings are in agreement with the study done by Nissar and Sohoo (2009) wherein the mean scores for somatic and psychological symptoms assessed using the Menopause Specific Quality of Life (MENQOL) questionnaire were high in postmenopausal women who were less educated, poor, and had high parity.
Table 1: Multivariate Analysisfor Predictors of Anxiety

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It was also found in the present study that subjects involved in unskilled work were 6.42 times more likely to have anxiety as compared to those who were involved in skilled work which was statistically significant. This may be attributed to low self esteem and extreme hard work involved in performing unskilled work. The researcher found that they were also dissatisfied with the returns from their work and the anxiety developed due to the inability to fulfill the needs and desires.

The duration of menopause was found to be a predictor for anxiety. The study revealed that postmenopausal women whose duration of menopause ranges from 5-10 years had 48% less chance of having anxiety as compared to those whose duration of menopause was 10 years were 39% less likely to have anxiety. These findings are in contrast to the findings of the study done by Kalarhoudi, Taebi, Sadat, and Saberial (2011) where subjects who had < 5 years of duration of Menopause had lower mean scores assessed using MENQOL questionnaire, 2.65 ± 1.22 in the psychosocial domain as compared to those who had > 5 years of duration of menopause.

The last predictor for anxiety in postmenopausal was the number of children. It was found that with every 1 unit increase in the number of children, postmenopausal women were 20% less likely to have anxiety. Similar findings were reported in a study done by Kalarhoudi et al. (2011) where the mean score for psychosocial domain was higher (2.79 ± 1.17) in subjects who had 1-2 children and the mean score decreased to 2.67 ± 1.22 in subjects who had more than 3 children. Earlier in Indian society, having more number of children implied that it was a well to do family. In addition, preference for a male child still dominates the minds of Indian society, so having more number of children ensured that at least one child would be a boy. Having borne more than 3 children, these women felt a sense of satisfaction and were involved in caring for more number grandchildren which itself left little room to be anxious.

The current study also revealed that 52.5% postmenopausal women had depression as shown in [Figure 2].
Figure 2: Depression among postmenopausal women

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The first predictor of depression was unveiled to be the level of education. It was found that postmenopausal women who were illiterate were 2.3 times more likely to develop depression as compared to those who had secondary and above level of education. It was also found that postmenopausal women involved in unskilled work like coolies and manual laborers were 2.72 times more likely to develop depression as compared to those who were involved in skilled work. The last predictor for depression was found to be the age at menopause; with every 1 unit increase in age at menopause, postmenopausal women were 1.06 times more likely to have depression (see [Table 2]).
Table 2: Multivariate Analysisfor Predictors ofDepression

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These findings are in harmony with the findings of another study by Clayton and Guico (2008) wherein it was suggested that even in women without a history of depression, the risk of a new onset of depression were double or more during the menopausal transition.

Limitations

The study was limited to women attending to patients admitted in Obstetrical and Gynecological wards of CMC, Vellore. There may have been a bias due to the tendency of the subjects to give socially acceptable responses

Implications

The findings of this study will help professionals to identify the vulnerable groups and especially focus on their incompetencies. The knowledge about the prevalence of menopausal symptoms will enable health care providers to render focused, sensitive, and competent care. The findings will also remind health workers to re-examine their styles of communication and consider how well they give information and listen to what is really happening to their patients. Since postmenopausal women often hesitate to avail health care, it is imperative that the challenging needs of these women be addressed and attended to.

Since information needs of the postmenopausal women were found to be paramount because of the enormity of symptoms and underestimation of the need to avail health care, a multi- lingual pamphlet about menopausal symptoms and tips for their management would be of great help to these women. Keeping this in mind, the researcher has prepared such a pamphlet in three languages. Nurse administrators and teachers are challenged to take steps to educate both the nursing staff and students about the issues and concerns of postmenopausal women and to be sensitive about these issues identified in the study. The distressing findings of this study warrant other similar studies to discover in depth information about the concerns of postmenopausal women.


  Conclusion Top


Menopause is an inevitable event occurring in all women who reach mid-life. It is a very sensitive but an underestimated issue. Many women enter menopause in a positive manner but some encounter difficulties making them vulnerable to anxiety and depression. Menopausal symptoms can result in anguishing situations that warrant detailed studies pertaining to their concerns and issues. It can be considered as a challenge to effectively meet the magnitude of needs for postmenopausal women. The present study unveils few among the vast number of predictors for anxiety and depression. While caring for menopausal women nurses can include assessment of anxiety and depression. Patient teaching can address menopausal symptoms and tips for management. In order to practice evidence based nursing to intervene in their problems and concerns, further research is required to assess effectiveness of nursing care in prevention of complications among postmenopausal women who exhibit predictors of anxiety and depression.

Conflicts of Interest: The authors have declared no conflicts of interest.



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  References Top

1.
Aaron, R., Muliyil, J., & Abraham, S. (2002). Medico-social dimensions of menopause: A cross-sectional study from rural south India. The National Medical Journal of India, 15(1), 14 - 17.  Back to cited text no. 1
    
2.
Aso, T. (2015). Demography of the menopause and pattern of climacteric symptoms in the East Asian Region. Retrieved from http://www.gfmer.ch/Books/bookmp/ 24.ht.  Back to cited text no. 2
    
3.
Chadda, R. K., & Sood, M. (2010). Indian research on women and psychiatry. Indian Journal of Psychiatry, 52(1), 229232.  Back to cited text no. 3
    
4.
Clayton, A., & Guico, P. C. (2008). Recognition of depression among women presenting with menopausal symptoms. Menopause, 15(4), 758 - 767.  Back to cited text no. 4
    
5.
Clayton, A. H., & Ninan, P. T. (2010). Depression or menopause: Presentation and management of major depressive disorder in peri-menopausal and postmenopausal women. Journal of Clinical Psychiatry, 12(1). doi: 10.4088/PCC.08r00747blu. Retrieved from http ://www.ncbi.nlm.nih.gov/pmc/articles /PMC2882813.  Back to cited text no. 5
    
6.
Govil, D. (2010). Health needs of middle aged population: an unaddressed link. Jaipur, India: Indian Institute of Health Management Research. Retrieved from http://epc2010. princeton. edu/papers/100861.  Back to cited text no. 6
    
7.
Hamilton, M. (1959). The assessment of anxiety states by rating. British Journal of Medical Psychology, 32, 50-55.  Back to cited text no. 7
    
8.
Hamilton, M. (1960). A rating scale for depression. Journal of Neurology, Neurosurgery and Psychiatry 23, 56- 62.  Back to cited text no. 8
    
9.
Kalarhoudi, A. M., Taebi, M., Sadat, Z., & Saberi, F. (2011). Assessment of quality of life in menopausal periods: A population study in Kashan, Iran. Kowsar Journals, 13(11), 811 - 817.  Back to cited text no. 9
    
10.
Lee, Y. W. (2003). Depression in postmenopausal women. Journal of Korean Academy of Nursing, 33(4), 472 - 479.  Back to cited text no. 10
    
11.
Nisar, N., & Sohoo, N. A. (2009). Frequency of menopausal symptoms and their impact on the quality of life of women: A hospital based survey. Journal of Pakistan Medical Association, 59, 752 - 756.  Back to cited text no. 11
    
12.
Santwani, K., Shukla, V. D., Santwani, M. A., & Thaker, G. (2010). An assessment of Manasika Bhavas in menopausal syndrome and its management. Ayu, 31(3), 311 - 318.  Back to cited text no. 12
    
13.
United Nations. (2011). World population prospects: The 2010 revision, United Nations population division. New York: United Nations.  Back to cited text no. 13
    
14.
Woods, N. F., & Mitchell, E. S. (1996). Patterns of depressed mood in midlife women: Observations from the Seattle Midlife Women’s Health Study. Research in Nursing and Health, 19(2), 111 - 23.  Back to cited text no. 14
    


    Figures

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    Tables

  [Table 1], [Table 2]



 

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