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Depressive Symptoms in Postmenopausal Women: Results from the MEDIS Study ab
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Ioanna G. Tsiligianni MD, MPH, PhD , Stefanos Tyrovolas PhD , c
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Vassiliki Bountziouka PhD , Akis Zeimbekis MD , Efthimios Gotsis c
c
c
MSc , George Metallinos MD , Dimitra Tyrovola MD , Evangelos c
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Polychronopoulos MD, PhD , Christos Lionis MD, PhD & Demosthenes Panagiotakos PhD
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Clinic of Social and Family Medicine, School of Medicine, University of Crete, Heraklion, Greece b
Agia Barbara Health Care Centre, Heraklion, Crete, Greece
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Department of Nutrition and Dietetics, Harokopio University, Athens, Greece d
Parc Sanitari Sant Joan de Déu, Fundació Sant Joan de Déu, CIBERSAM, Universitat de Barcelona, Sant Boi de Llobregat, Barcelona, Spain e
Health Center of Kalloni, General Hospital of Mitilini, Mitilini, Greece Accepted author version posted online: 02 May 2014.Published online: 07 Jul 2014.
To cite this article: Ioanna G. Tsiligianni MD, MPH, PhD, Stefanos Tyrovolas PhD, Vassiliki Bountziouka PhD, Akis Zeimbekis MD, Efthimios Gotsis MSc, George Metallinos MD, Dimitra Tyrovola MD, Evangelos Polychronopoulos MD, PhD, Christos Lionis MD, PhD & Demosthenes Panagiotakos PhD (2014) Depressive Symptoms in Postmenopausal Women: Results from the MEDIS Study, Women & Health, 54:5, 389-401, DOI: 10.1080/03630242.2014.897678 To link to this article: http://dx.doi.org/10.1080/03630242.2014.897678
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Women & Health, 54:389–401, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 0363-0242 print/1541-0331 online DOI: 10.1080/03630242.2014.897678
Depressive Symptoms in Postmenopausal Women: Results from the MEDIS Study IOANNA G. TSILIGIANNI, MD, MPH, PhD Downloaded by [Mount St Vincent University] at 21:46 05 October 2014
Clinic of Social and Family Medicine, School of Medicine, University of Crete, Heraklion, Greece; and Agia Barbara Health Care Centre, Heraklion, Crete, Greece
STEFANOS TYROVOLAS, PhD Department of Nutrition and Dietetics, Harokopio University, Athens, Greece; and Parc Sanitari Sant Joan de Déu, Fundació Sant Joan de Déu, CIBERSAM, Universitat de Barcelona, Sant Boi de Llobregat, Barcelona, Spain
VASSILIKI BOUNTZIOUKA, PhD Department of Nutrition and Dietetics, Harokopio University, Athens, Greece
AKIS ZEIMBEKIS, MD Health Center of Kalloni, General Hospital of Mitilini, Mitilini, Greece
EFTHIMIOS GOTSIS, MSc, GEORGE METALLINOS, MD, DIMITRA TYROVOLA, MD, and EVANGELOS POLYCHRONOPOULOS, MD, PhD Department of Nutrition and Dietetics, Harokopio University, Athens, Greece
CHRISTOS LIONIS, MD, PhD Clinic of Social and Family Medicine, School of Medicine, University of Crete, Heraklion, Greece
DEMOSTHENES PANAGIOTAKOS, PhD Department of Nutrition and Dietetics, Harokopio University, Athens, Greece
Data regarding the factors associated with depressive symptoms are limited, especially in postmenopausal women. The aim of this study was to investigate to what extent depressive symptoms were present in postmenopausal women, to explore characteristics associated with depressive symptoms and to determine if time since
Received August 6, 2013; revised February 6, 2014; accepted February 14, 2014. Address correspondence to Ioanna G. Tsiligianni, MD, MPH, PhD, Clinic of Social and Family Medicine, School of Medicine, University of Crete, Voutes, P.O. Box 2208, 71003, Heraklion, Crete, Greece. E-mail: [email protected] 389
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menopause was independently associated with depressive symptoms. Data collected within the Mediterranean Islands (MEDIS) Study, a health and nutrition survey of elderly people living on Mediterranean islands was used. A total of 851 postmenopausal women living in various Greek islands, Cyprus, and Malta participated in the study. Depressive symptoms were evaluated using the Geriatric Depression Scale (GDS). Age-adjusted logistic regression analysis showed that a year’s increase in the time since menopause increased the likelihood of postmenopausal women having severe depressive symptoms by 3% (odds ratio [OR] per 1 year = 1.03, 95% CI 1.001–1.05). This positive association was also evident when other potential confounding factors (i.e, living conditions, financial status, physical activity, adherence to the Mediterranean diet, smoking habits, and several clinical conditions) were also taken into account in multivariable analyses. Primary health care practitioners and public health care authorities could use the findings of this study to identify depressive symptoms early in postmenopausal women. KEYWORDS MEDIS
depressive
symptoms,
postmenopausal
women,
INTRODUCTION Depression is one of the most common mental diseases related to increased morbidity and mortality that impairs quality of life, especially in the elderly (D’Alisa et al, 2006; Sartorius et al, 1996). Symptoms usually include depressed mood, hopelessness, loss of interest and pleasure, sadness, worthlessness, and, often, sleep and appetite disorders (American Psychiatric Association (APA), 2000). According to the World Health Organization (WHO; n.d.), 350 million people suffer worldwide from depression, which is considered to be one of the leading causes of disability. A high prevalence of mild to severe depressive symptoms has also been observed in Greece, as reported in the ATTICA study (Pitsavos et al, 2003). Similarly, 25% of men and 35% of women were classified in the highest score category of the Geriatric Depression Scale (GDS; Fountoulakis et al., 1999), indicating intense depressive symptoms, as shown in another published Mediterranean Islands (MEDIS) Study (Mamplekou et al, 2010). In other studies, women were twice as likely as men to suffer from depressive symptoms (Bromberger & Kravitz, 2011). In an attempt to limit the consequences of depression, the WHO Mental Health Gap Action Programme (www.who.int/mental_health/ mhgap/en/) has been developed to increase services for mental health in low income countries.
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Menopause is an important phase in a woman’s life and is associated with a plethora of hormonal changes. It is a natural life-stage transition reflecting the end of reproductive capability. Women usually report hot flashes, night sweats and trouble sleeping during the perimenopausal period, which have been reported to be associated with depression (Avis et al., 2001; Freeman, 2010). Depressive symptoms have been reported to increase in women during early to late perimenopause and to decrease after menopause (Freeman et al., 2004). However, most studies have been focused on the perimenopausal period, while studies focused on depressive symptoms during the postmenopausal period and their determinants are still limited (Clayton & Ninan, 2010; Cohen et al., 2006; Lee, 2003; Schmidt, Haq, & Rubinow, 2004; Timur & Sahin, 2010). Determinants such as socioeconomic factors, educational level, smoking, living alone, body mass index (BMI), and diabetes have been mentioned to be associated with depressive symptoms; however, their role in depressive symptoms during the postmenopausal period needs further study (Godin, Elbejjani & Kaufman, 2012; Lorant et al., 2003; Miech & Shanahan, 2000; Nouwen et al., 2010; Potts, 1997; Wilhelm et al., 2003; Woo et al., 1994). A health and nutrition survey which aimed to evaluate bio-clinical., lifestyle, behavioral and dietary characteristics of elderly people living on certain Mediterranean islands, entitled the MEDIS Study, has been designed and implemented during the past years. Thus, studying depressive symptoms in this population was possible as was exploration of the extent to which depressive symptoms were associated with years since the final menstrual period. This observational study was used to determine rates of depressive symptoms among a sample of postmenopausal women and explored factors related to these symptoms.
METHODOLOGY Participants The MEDIS Study used a random, population-based, multistage sampling method with three age groups (65–75, 75–85, and >85 years) and two gender levels to select men (Mean = 75 ± 7 years) and women (Mean = 74 ± 7 years), from the Republic of Cyprus (Cyprus Island), Malta (West Mediterranean islands), and the islands of Mitilini, Lemnos, Samothraki, Ikaria, Syros, Naxos, Kassos (Aegean Islands), Crete (Crete island), Corfu, Zakynthos, Cephalonia (Ionian Islands), and Salamina (Saronikos Gulf) in Greece. The catchment area was all major towns in an Island (with the exception of Crete where villages from the Heraklion area were recruited), as well as some smaller villages to represent the referent population better. No population registry was used. The Cretan sample was based on people that visited medical practices involved in the Cretan practice-based research network.
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This sample was selected to be representative of those patients registered in each practice. This sample may not have been representative of the Cretan population, however, because it was derived from rural areas and a nonrandom sample of primary care practices across the Prefecture of Heraklion. For sample collection, individuals residing in assisted-living centers and those with a clinical history of cardiovascular disease (CVD) or cancer were not included. The target sample size was 300 people from Cyprus and Malta, and 150 from each of the other islands. Of the 2,400 people initially selected, 2,011 (83.8%) agreed to participate. Of these participants, 34% were living in rural areas on the islands. The participation rate varied according to island, from 75% to 89%. From these participants, 851 women were postmenopausal. The age at menopause was determined by self-report. A group of health scientists including physicians, dietitians, and nurses with experience in field investigation collected all the required information, using a quantitative questionnaire and standard procedures. The collected data were confidential., and the study followed the ethical considerations provided by the World Medical Association (52nd WMA General Assembly, Edinburgh, Scotland, October 2000). The Institutional Review Board approved the design, procedures and aims of the study. Before the interviews, participants were informed about the aims and procedures of the study and provided their written and signed consent.
Evaluation of Clinical Characteristics All the measurements taken in the different study centers were standardized. Weight and height were measured. Overweight was defined as body mass index (BMI; kg/m2 ) between 25 and 29.9 kg/m2 , while obesity was defined as BMI > 29.9 kg/m2 . Diabetes mellitus (type 2) was determined in accordance with the American Diabetes Association diagnostic criteria (American Diabetes Association, 2012). Participants who had blood pressure levels ≥140/90 mmHg or used antihypertensive medications were classified as hypertensive. Fasting blood lipids levels were also recorded, and hypercholesterolemia was defined as total serum cholesterol levels >200 mg/dL or the use of lipid-lowering agents according to the NCEP ATPIII guidelines (Grundy et al., 2005). Furthermore, female participants were asked whether they were postmenopausal., and time since menopause was recorded.
Evaluation of Dietary Habits, Sociodemographic, Other Lifestyle Characteristics To assess dietary habits, we used a valid semi-quantitative food-frequency questionnaire (Tyrovolas et al., 2010). To evaluate the level of adherence to the Mediterranean diet, we used the MedDietScore (possible range 0–55;
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Panagiotakos, Pitsavos, & Stefanadis, 2006). Higher values for this diet score indicate greater adherence to the Mediterranean diet. We also collected basic sociodemographic characteristics, such as age, gender, annual income (basic annual income was defined as 8,000 C per person according to the Greek Ministry of Economics), and lifestyle characteristics, such as smoking habits and physical activity status. To evaluate physical activity we used the shortened version of the self-reported International Physical Activity Questionnaire (IPA; Craig, Marshall, & Sjostrom, 2003). The frequency (times per week), duration (minutes per day) and intensity of physical activity during sports, occupation and/or leisure activities was also recorded. Then, participants were classified as inactive, minimally active, and health enhancing physical activity (HEPA active), a highly active category.
Assessment of Depressive Symptoms To assess depressive symptoms during the past month we used the shortened, self-reported GDS (translated and validated to Greek) with a total score ranging from 0–15 (GDS) (Fountoulakis et al., 1999). Higher values indicate more severe depressive symptomatology. We classified participants with GDS score >11 in the group of severe depressive symptoms, while those with GDS 8,000 euro (%) Current Smoker (%) Minimally or HEPA active (%) Obesity (%) Energy intake, kcal (Mean ± SD) Living alone (%)
Mild and low depression
Severe depression
Pa
502 74 ± 7.0 26.7 ± 10.1 6 (5, 6) 7 06 49 34 1,468 ± 465 33
133 74 ± 7.1 28.4 ± 10.4 5 (3, 6) 5 03 23 50 1,628 ± 480 43
.84 .11 65 years of age participated, reflecting postmenopausal women. Results showed that a high proportion, 21%, of them reported severe depressive symptoms.
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Other Depressive Symptoms Determinants The educational level of participants varied between the two categories of depressive symptoms status, similar to other studies (Dohrenwend et al., 1992; Miech & Shanahan, 2000). We found that women with higher educational levels were protected against depressive symptoms similarly to the Nord-Trøndelag Health (HUNT) Study (n = 50,918) in which lower educational levels were significantly associated with anxiety and depressive symptoms (Bjelland et al., 2008). This finding was further enhanced by the observation that the association between depressive symptoms and education strengthened with older age (Miech & Shanahan, 2000). Lower depressive symptom scores were usually observed in those that had more than 16 years of education, and this difference was observed among different ages (Miech & Shanahan, 2000). In one study performed in postmenopausal women, a statistically significant inverse relationship was confirmed between depressive symptoms and educational level (Lee, 2003). Furthermore, educated women have been reported to have a more positive reaction to menopause (Chen, Voda, & Mansfield, 1998). Smoking is among the factors known to have the strongest correlations with depressive symptoms (Lee, 2003; Wilhelm et al., 2003). In our study current smoking was also positively related with the likelihood of having severe depressive symptoms. Godin et al. (2012) in an elderly population followed for 10 years found that participants with a high BMI had an increased adjusted risk for developing depression compared to those with a normal BMI. In the Timur and Sahin (2010) study in perimenopausal and postmenopausal women, an increased BMI was significantly related to the development of depression. Also, in the present study obesity had an OR = 1.34 for its association with depressive symptoms. Other socioeconomic factors, such as annual income were also inversely associated with depressive symptoms in a number of studies, similar to our findings (Rajala et al., 1994; Woo et al., 1994). More specifically, in a study of postmenopausal women, significant differences in depressive symptoms were observed in relation to economic levels (Lee, 2003). Older adults living alone in our study often suffered from severe depressive symptoms. Social support and the importance of friends have been underlined in the literature (Potts, 1997). One in ten people older than 65 years had at least one mental disorder, often with somatic complaints and depression (Bland, 2012). In our study menopause, had a strong association with depressive symptoms, even when
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adjusted for age. Also, people with type 2 diabetes have a 24% increased risk of developing depression (Nouwen et al., 2010). Similarly, we found a strong positive association between severe depressive symptoms and diabetes.
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A Focus on the Association Between Menopause and Depressive Symptoms Climacteric symptoms, presence of a spouse, smoking and lack of exercise accounted for 45% of the variance in postmenopausal women’s depression in one study (Lee, 2003). The severity of menopausal symptoms and depressive symptoms in those women who exercised more than three times a week were significantly lower than in those who did not exercise (Lee & Kim, 2008). We also found significantly increased severity of depressive symptoms in women with low levels of exercise. The association of depressive symptoms with the menopausal transition has been extensively underlined in the literature; however, data on the postmenopausal period are limited (Reed et al, 2007; Soares & Maki, 2010). In the present study, the association of depressive symptoms with time since the final menstrual period was so important that even a one-year increase in time since menopause was associated with a significantly increased reporting of severe depressive symptoms by 3%. A positive association between depressive symptoms and time being postmenopausal has been reported in other studies as well (Lee, 2003; Lee & Kim, 2008; Miller et al., 2004). Miller et al. (2004) reported that depressive symptoms as measured with the Center of Epidemiological Studies Depression Scale (CES-D) scores were worse in postmenopausal women compared with peri- or premenopausal women. In this study, although depressive symptoms increased with age, no significant association between age and depressive symptoms or with different menopause stages (i.e, pre/postmenopause was observed; Miller et al, 2004). However, results reported in the literature have been conflicting. In a study of postmenopausal women, no clinically meaningful depression was found (Lee et al., 2010). In contrast, Lee et al. examined the degree of depressive symptoms in 325 postmenopausal women between the ages of 40 and 65 years and found that that a sizeable proportion, 64%, had elevated depressive symptom scores (Lee, 2003).
Strengths and Limitations This study included a significant number of participants from several Mediterranean islands. However, it was a cross-sectional study, and as with every cross-sectional study, temporal relations and causality could not be adequately assessed. Depressive symptoms have been identified by using screening questionnaires, and we are not certain to what extent this fact
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accounted for a potential overestimation of the true prevalence of depressive symptoms and to what extent it had an effect on the main study findings. Further, we did not include in the analyses other potentially important confounding variables, such as a prior major depression event or other stressful events, such as death or illness of family members, or marital status (Lorant et al., 2003; Potts, 1997; Timur & Sahin, 2010) so that our results may have reflected uncontrolled confounding.
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IMPLICATIONS OF THIS STUDY The results from this observational study have several clear implications for the clinical practice setting and for primary health care practitioners themselves. Specifically, the findings could be beneficial when practical guidelines and recommendations for early recognition of depressive symptoms in postmenopausal women. Primary health care practitioners can be also assisted in carefully interpreting the physical complaints of women after menopause in their decision making either on diagnosis or on effective management.
CONCLUSIONS This study adds to the body of literature that time since the final menstrual period is associated with depressive symptoms and addresses the finding that menopause was still independently associated with depressive symptoms even after years from the occurrence of menopause. Early menopause can be significantly related to depressive symptoms (Freeman et al., 2004). After adjusting for several other factors (age, living alone, financial income, diabetes, and obesity), years since menopause was still significantly associated with depressive symptoms. Further larger scale studies that include prospective data will assist researchers to confirm this finding longitudinally and provide special attention to depression in postmenopausal women.
ACKNOWLEDGMENTS We are, particularly, grateful to the men and women from the islands of Cyprus, Mitilini, Samothraki, Crete, Corfu, Zakynthos, and Cephalonia, who participated in and collaborated on this research. We also wish to express our gratitude to: M. Tornaritis, A. Polystipioti, M. Economou, N. Papairakleous (field investigators from Cyprus), A. Zeimbekis, K. Gelastopoulou, I. Vlachou (field investigator from Mitilini), C. Lionis, N. Tsakoundakis, E. Ladoudaki, M. Antonopoulou (field investigators from Crete), E. Niforatou, V. Alpentzou,
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M. Voutsadaki, M. Galiatsatos (field investigators from Cephalonia), G. Metallinos, E. Lioliou, K. Voutsa (field investigator from Corfu), S. Tyrovolas, G. Pounis, E. Papavenetiou, E. Apostolidou, G. Papavassiliou, P. Stravopodis (field investigators from Zakynthos), K. Kaldaridou, E. Tourloukis, B.E. Qira (field investigators from Naxos and Syros) and E; Gotsis (field investigator from Lemnos), for their substantial assistance in the enrolment of the participants.
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FUNDING The study was funded by research grants from the Hellenic Heart Foundation.
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Depressive Symptoms in Postmenopausal Women: Results from the MEDIS Study ab
cd
Ioanna G. Tsiligianni MD, MPH, PhD , Stefanos Tyrovolas PhD , c
e
Vassiliki Bountziouka PhD , Akis Zeimbekis MD , Efthimios Gotsis c
c
c
MSc , George Metallinos MD , Dimitra Tyrovola MD , Evangelos c
a
Polychronopoulos MD, PhD , Christos Lionis MD, PhD & Demosthenes Panagiotakos PhD
c
a
Clinic of Social and Family Medicine, School of Medicine, University of Crete, Heraklion, Greece b
Agia Barbara Health Care Centre, Heraklion, Crete, Greece
c
Department of Nutrition and Dietetics, Harokopio University, Athens, Greece d
Parc Sanitari Sant Joan de Déu, Fundació Sant Joan de Déu, CIBERSAM, Universitat de Barcelona, Sant Boi de Llobregat, Barcelona, Spain e
Health Center of Kalloni, General Hospital of Mitilini, Mitilini, Greece Accepted author version posted online: 02 May 2014.Published online: 07 Jul 2014.
To cite this article: Ioanna G. Tsiligianni MD, MPH, PhD, Stefanos Tyrovolas PhD, Vassiliki Bountziouka PhD, Akis Zeimbekis MD, Efthimios Gotsis MSc, George Metallinos MD, Dimitra Tyrovola MD, Evangelos Polychronopoulos MD, PhD, Christos Lionis MD, PhD & Demosthenes Panagiotakos PhD (2014) Depressive Symptoms in Postmenopausal Women: Results from the MEDIS Study, Women & Health, 54:5, 389-401, DOI: 10.1080/03630242.2014.897678 To link to this article: http://dx.doi.org/10.1080/03630242.2014.897678
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Women & Health, 54:389–401, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 0363-0242 print/1541-0331 online DOI: 10.1080/03630242.2014.897678
Depressive Symptoms in Postmenopausal Women: Results from the MEDIS Study IOANNA G. TSILIGIANNI, MD, MPH, PhD Downloaded by [Mount St Vincent University] at 21:46 05 October 2014
Clinic of Social and Family Medicine, School of Medicine, University of Crete, Heraklion, Greece; and Agia Barbara Health Care Centre, Heraklion, Crete, Greece
STEFANOS TYROVOLAS, PhD Department of Nutrition and Dietetics, Harokopio University, Athens, Greece; and Parc Sanitari Sant Joan de Déu, Fundació Sant Joan de Déu, CIBERSAM, Universitat de Barcelona, Sant Boi de Llobregat, Barcelona, Spain
VASSILIKI BOUNTZIOUKA, PhD Department of Nutrition and Dietetics, Harokopio University, Athens, Greece
AKIS ZEIMBEKIS, MD Health Center of Kalloni, General Hospital of Mitilini, Mitilini, Greece
EFTHIMIOS GOTSIS, MSc, GEORGE METALLINOS, MD, DIMITRA TYROVOLA, MD, and EVANGELOS POLYCHRONOPOULOS, MD, PhD Department of Nutrition and Dietetics, Harokopio University, Athens, Greece
CHRISTOS LIONIS, MD, PhD Clinic of Social and Family Medicine, School of Medicine, University of Crete, Heraklion, Greece
DEMOSTHENES PANAGIOTAKOS, PhD Department of Nutrition and Dietetics, Harokopio University, Athens, Greece
Data regarding the factors associated with depressive symptoms are limited, especially in postmenopausal women. The aim of this study was to investigate to what extent depressive symptoms were present in postmenopausal women, to explore characteristics associated with depressive symptoms and to determine if time since
Received August 6, 2013; revised February 6, 2014; accepted February 14, 2014. Address correspondence to Ioanna G. Tsiligianni, MD, MPH, PhD, Clinic of Social and Family Medicine, School of Medicine, University of Crete, Voutes, P.O. Box 2208, 71003, Heraklion, Crete, Greece. E-mail: [email protected] 389
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menopause was independently associated with depressive symptoms. Data collected within the Mediterranean Islands (MEDIS) Study, a health and nutrition survey of elderly people living on Mediterranean islands was used. A total of 851 postmenopausal women living in various Greek islands, Cyprus, and Malta participated in the study. Depressive symptoms were evaluated using the Geriatric Depression Scale (GDS). Age-adjusted logistic regression analysis showed that a year’s increase in the time since menopause increased the likelihood of postmenopausal women having severe depressive symptoms by 3% (odds ratio [OR] per 1 year = 1.03, 95% CI 1.001–1.05). This positive association was also evident when other potential confounding factors (i.e, living conditions, financial status, physical activity, adherence to the Mediterranean diet, smoking habits, and several clinical conditions) were also taken into account in multivariable analyses. Primary health care practitioners and public health care authorities could use the findings of this study to identify depressive symptoms early in postmenopausal women. KEYWORDS MEDIS
depressive
symptoms,
postmenopausal
women,
INTRODUCTION Depression is one of the most common mental diseases related to increased morbidity and mortality that impairs quality of life, especially in the elderly (D’Alisa et al, 2006; Sartorius et al, 1996). Symptoms usually include depressed mood, hopelessness, loss of interest and pleasure, sadness, worthlessness, and, often, sleep and appetite disorders (American Psychiatric Association (APA), 2000). According to the World Health Organization (WHO; n.d.), 350 million people suffer worldwide from depression, which is considered to be one of the leading causes of disability. A high prevalence of mild to severe depressive symptoms has also been observed in Greece, as reported in the ATTICA study (Pitsavos et al, 2003). Similarly, 25% of men and 35% of women were classified in the highest score category of the Geriatric Depression Scale (GDS; Fountoulakis et al., 1999), indicating intense depressive symptoms, as shown in another published Mediterranean Islands (MEDIS) Study (Mamplekou et al, 2010). In other studies, women were twice as likely as men to suffer from depressive symptoms (Bromberger & Kravitz, 2011). In an attempt to limit the consequences of depression, the WHO Mental Health Gap Action Programme (www.who.int/mental_health/ mhgap/en/) has been developed to increase services for mental health in low income countries.
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Menopause is an important phase in a woman’s life and is associated with a plethora of hormonal changes. It is a natural life-stage transition reflecting the end of reproductive capability. Women usually report hot flashes, night sweats and trouble sleeping during the perimenopausal period, which have been reported to be associated with depression (Avis et al., 2001; Freeman, 2010). Depressive symptoms have been reported to increase in women during early to late perimenopause and to decrease after menopause (Freeman et al., 2004). However, most studies have been focused on the perimenopausal period, while studies focused on depressive symptoms during the postmenopausal period and their determinants are still limited (Clayton & Ninan, 2010; Cohen et al., 2006; Lee, 2003; Schmidt, Haq, & Rubinow, 2004; Timur & Sahin, 2010). Determinants such as socioeconomic factors, educational level, smoking, living alone, body mass index (BMI), and diabetes have been mentioned to be associated with depressive symptoms; however, their role in depressive symptoms during the postmenopausal period needs further study (Godin, Elbejjani & Kaufman, 2012; Lorant et al., 2003; Miech & Shanahan, 2000; Nouwen et al., 2010; Potts, 1997; Wilhelm et al., 2003; Woo et al., 1994). A health and nutrition survey which aimed to evaluate bio-clinical., lifestyle, behavioral and dietary characteristics of elderly people living on certain Mediterranean islands, entitled the MEDIS Study, has been designed and implemented during the past years. Thus, studying depressive symptoms in this population was possible as was exploration of the extent to which depressive symptoms were associated with years since the final menstrual period. This observational study was used to determine rates of depressive symptoms among a sample of postmenopausal women and explored factors related to these symptoms.
METHODOLOGY Participants The MEDIS Study used a random, population-based, multistage sampling method with three age groups (65–75, 75–85, and >85 years) and two gender levels to select men (Mean = 75 ± 7 years) and women (Mean = 74 ± 7 years), from the Republic of Cyprus (Cyprus Island), Malta (West Mediterranean islands), and the islands of Mitilini, Lemnos, Samothraki, Ikaria, Syros, Naxos, Kassos (Aegean Islands), Crete (Crete island), Corfu, Zakynthos, Cephalonia (Ionian Islands), and Salamina (Saronikos Gulf) in Greece. The catchment area was all major towns in an Island (with the exception of Crete where villages from the Heraklion area were recruited), as well as some smaller villages to represent the referent population better. No population registry was used. The Cretan sample was based on people that visited medical practices involved in the Cretan practice-based research network.
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This sample was selected to be representative of those patients registered in each practice. This sample may not have been representative of the Cretan population, however, because it was derived from rural areas and a nonrandom sample of primary care practices across the Prefecture of Heraklion. For sample collection, individuals residing in assisted-living centers and those with a clinical history of cardiovascular disease (CVD) or cancer were not included. The target sample size was 300 people from Cyprus and Malta, and 150 from each of the other islands. Of the 2,400 people initially selected, 2,011 (83.8%) agreed to participate. Of these participants, 34% were living in rural areas on the islands. The participation rate varied according to island, from 75% to 89%. From these participants, 851 women were postmenopausal. The age at menopause was determined by self-report. A group of health scientists including physicians, dietitians, and nurses with experience in field investigation collected all the required information, using a quantitative questionnaire and standard procedures. The collected data were confidential., and the study followed the ethical considerations provided by the World Medical Association (52nd WMA General Assembly, Edinburgh, Scotland, October 2000). The Institutional Review Board approved the design, procedures and aims of the study. Before the interviews, participants were informed about the aims and procedures of the study and provided their written and signed consent.
Evaluation of Clinical Characteristics All the measurements taken in the different study centers were standardized. Weight and height were measured. Overweight was defined as body mass index (BMI; kg/m2 ) between 25 and 29.9 kg/m2 , while obesity was defined as BMI > 29.9 kg/m2 . Diabetes mellitus (type 2) was determined in accordance with the American Diabetes Association diagnostic criteria (American Diabetes Association, 2012). Participants who had blood pressure levels ≥140/90 mmHg or used antihypertensive medications were classified as hypertensive. Fasting blood lipids levels were also recorded, and hypercholesterolemia was defined as total serum cholesterol levels >200 mg/dL or the use of lipid-lowering agents according to the NCEP ATPIII guidelines (Grundy et al., 2005). Furthermore, female participants were asked whether they were postmenopausal., and time since menopause was recorded.
Evaluation of Dietary Habits, Sociodemographic, Other Lifestyle Characteristics To assess dietary habits, we used a valid semi-quantitative food-frequency questionnaire (Tyrovolas et al., 2010). To evaluate the level of adherence to the Mediterranean diet, we used the MedDietScore (possible range 0–55;
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Panagiotakos, Pitsavos, & Stefanadis, 2006). Higher values for this diet score indicate greater adherence to the Mediterranean diet. We also collected basic sociodemographic characteristics, such as age, gender, annual income (basic annual income was defined as 8,000 C per person according to the Greek Ministry of Economics), and lifestyle characteristics, such as smoking habits and physical activity status. To evaluate physical activity we used the shortened version of the self-reported International Physical Activity Questionnaire (IPA; Craig, Marshall, & Sjostrom, 2003). The frequency (times per week), duration (minutes per day) and intensity of physical activity during sports, occupation and/or leisure activities was also recorded. Then, participants were classified as inactive, minimally active, and health enhancing physical activity (HEPA active), a highly active category.
Assessment of Depressive Symptoms To assess depressive symptoms during the past month we used the shortened, self-reported GDS (translated and validated to Greek) with a total score ranging from 0–15 (GDS) (Fountoulakis et al., 1999). Higher values indicate more severe depressive symptomatology. We classified participants with GDS score >11 in the group of severe depressive symptoms, while those with GDS 8,000 euro (%) Current Smoker (%) Minimally or HEPA active (%) Obesity (%) Energy intake, kcal (Mean ± SD) Living alone (%)
Mild and low depression
Severe depression
Pa
502 74 ± 7.0 26.7 ± 10.1 6 (5, 6) 7 06 49 34 1,468 ± 465 33
133 74 ± 7.1 28.4 ± 10.4 5 (3, 6) 5 03 23 50 1,628 ± 480 43
.84 .11 65 years of age participated, reflecting postmenopausal women. Results showed that a high proportion, 21%, of them reported severe depressive symptoms.
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Other Depressive Symptoms Determinants The educational level of participants varied between the two categories of depressive symptoms status, similar to other studies (Dohrenwend et al., 1992; Miech & Shanahan, 2000). We found that women with higher educational levels were protected against depressive symptoms similarly to the Nord-Trøndelag Health (HUNT) Study (n = 50,918) in which lower educational levels were significantly associated with anxiety and depressive symptoms (Bjelland et al., 2008). This finding was further enhanced by the observation that the association between depressive symptoms and education strengthened with older age (Miech & Shanahan, 2000). Lower depressive symptom scores were usually observed in those that had more than 16 years of education, and this difference was observed among different ages (Miech & Shanahan, 2000). In one study performed in postmenopausal women, a statistically significant inverse relationship was confirmed between depressive symptoms and educational level (Lee, 2003). Furthermore, educated women have been reported to have a more positive reaction to menopause (Chen, Voda, & Mansfield, 1998). Smoking is among the factors known to have the strongest correlations with depressive symptoms (Lee, 2003; Wilhelm et al., 2003). In our study current smoking was also positively related with the likelihood of having severe depressive symptoms. Godin et al. (2012) in an elderly population followed for 10 years found that participants with a high BMI had an increased adjusted risk for developing depression compared to those with a normal BMI. In the Timur and Sahin (2010) study in perimenopausal and postmenopausal women, an increased BMI was significantly related to the development of depression. Also, in the present study obesity had an OR = 1.34 for its association with depressive symptoms. Other socioeconomic factors, such as annual income were also inversely associated with depressive symptoms in a number of studies, similar to our findings (Rajala et al., 1994; Woo et al., 1994). More specifically, in a study of postmenopausal women, significant differences in depressive symptoms were observed in relation to economic levels (Lee, 2003). Older adults living alone in our study often suffered from severe depressive symptoms. Social support and the importance of friends have been underlined in the literature (Potts, 1997). One in ten people older than 65 years had at least one mental disorder, often with somatic complaints and depression (Bland, 2012). In our study menopause, had a strong association with depressive symptoms, even when
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adjusted for age. Also, people with type 2 diabetes have a 24% increased risk of developing depression (Nouwen et al., 2010). Similarly, we found a strong positive association between severe depressive symptoms and diabetes.
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A Focus on the Association Between Menopause and Depressive Symptoms Climacteric symptoms, presence of a spouse, smoking and lack of exercise accounted for 45% of the variance in postmenopausal women’s depression in one study (Lee, 2003). The severity of menopausal symptoms and depressive symptoms in those women who exercised more than three times a week were significantly lower than in those who did not exercise (Lee & Kim, 2008). We also found significantly increased severity of depressive symptoms in women with low levels of exercise. The association of depressive symptoms with the menopausal transition has been extensively underlined in the literature; however, data on the postmenopausal period are limited (Reed et al, 2007; Soares & Maki, 2010). In the present study, the association of depressive symptoms with time since the final menstrual period was so important that even a one-year increase in time since menopause was associated with a significantly increased reporting of severe depressive symptoms by 3%. A positive association between depressive symptoms and time being postmenopausal has been reported in other studies as well (Lee, 2003; Lee & Kim, 2008; Miller et al., 2004). Miller et al. (2004) reported that depressive symptoms as measured with the Center of Epidemiological Studies Depression Scale (CES-D) scores were worse in postmenopausal women compared with peri- or premenopausal women. In this study, although depressive symptoms increased with age, no significant association between age and depressive symptoms or with different menopause stages (i.e, pre/postmenopause was observed; Miller et al, 2004). However, results reported in the literature have been conflicting. In a study of postmenopausal women, no clinically meaningful depression was found (Lee et al., 2010). In contrast, Lee et al. examined the degree of depressive symptoms in 325 postmenopausal women between the ages of 40 and 65 years and found that that a sizeable proportion, 64%, had elevated depressive symptom scores (Lee, 2003).
Strengths and Limitations This study included a significant number of participants from several Mediterranean islands. However, it was a cross-sectional study, and as with every cross-sectional study, temporal relations and causality could not be adequately assessed. Depressive symptoms have been identified by using screening questionnaires, and we are not certain to what extent this fact
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accounted for a potential overestimation of the true prevalence of depressive symptoms and to what extent it had an effect on the main study findings. Further, we did not include in the analyses other potentially important confounding variables, such as a prior major depression event or other stressful events, such as death or illness of family members, or marital status (Lorant et al., 2003; Potts, 1997; Timur & Sahin, 2010) so that our results may have reflected uncontrolled confounding.
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IMPLICATIONS OF THIS STUDY The results from this observational study have several clear implications for the clinical practice setting and for primary health care practitioners themselves. Specifically, the findings could be beneficial when practical guidelines and recommendations for early recognition of depressive symptoms in postmenopausal women. Primary health care practitioners can be also assisted in carefully interpreting the physical complaints of women after menopause in their decision making either on diagnosis or on effective management.
CONCLUSIONS This study adds to the body of literature that time since the final menstrual period is associated with depressive symptoms and addresses the finding that menopause was still independently associated with depressive symptoms even after years from the occurrence of menopause. Early menopause can be significantly related to depressive symptoms (Freeman et al., 2004). After adjusting for several other factors (age, living alone, financial income, diabetes, and obesity), years since menopause was still significantly associated with depressive symptoms. Further larger scale studies that include prospective data will assist researchers to confirm this finding longitudinally and provide special attention to depression in postmenopausal women.
ACKNOWLEDGMENTS We are, particularly, grateful to the men and women from the islands of Cyprus, Mitilini, Samothraki, Crete, Corfu, Zakynthos, and Cephalonia, who participated in and collaborated on this research. We also wish to express our gratitude to: M. Tornaritis, A. Polystipioti, M. Economou, N. Papairakleous (field investigators from Cyprus), A. Zeimbekis, K. Gelastopoulou, I. Vlachou (field investigator from Mitilini), C. Lionis, N. Tsakoundakis, E. Ladoudaki, M. Antonopoulou (field investigators from Crete), E. Niforatou, V. Alpentzou,
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M. Voutsadaki, M. Galiatsatos (field investigators from Cephalonia), G. Metallinos, E. Lioliou, K. Voutsa (field investigator from Corfu), S. Tyrovolas, G. Pounis, E. Papavenetiou, E. Apostolidou, G. Papavassiliou, P. Stravopodis (field investigators from Zakynthos), K. Kaldaridou, E. Tourloukis, B.E. Qira (field investigators from Naxos and Syros) and E; Gotsis (field investigator from Lemnos), for their substantial assistance in the enrolment of the participants.
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FUNDING The study was funded by research grants from the Hellenic Heart Foundation.
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