Author's Accepted Manuscript
Gender differences on functioning in depressive patients Margarita Gili, Adoración Castro, Capilla Navarro, Rosa Molina, Rosa Magallón, Mauro García-Toro, Miquel Roca
www.elsevier.com/locate/jad
PII: DOI: Reference:
S0165-0327(14)00325-5 http://dx.doi.org/10.1016/j.jad.2014.05.030 JAD6775
To appear in:
Journal of Affective Disorders
Received date: 17 December 2013 Revised date: 20 May 2014 Accepted date: 21 May 2014 Cite this article as: Margarita Gili, Adoración Castro, Capilla Navarro, Rosa Molina, Rosa Magallón, Mauro García-Toro, Miquel Roca, Gender differences on functioning in depressive patients, Journal of Affective Disorders, http://dx.doi. org/10.1016/j.jad.2014.05.030 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
GENDERDIFFERENCESONFUNCTIONINGINDEPRESSIVEPATIENTS MargaritaGilia,b*,AdoraciónCastroa,b,CapillaNavarroc,RosaMolinab,d,Rosa Magallónb,e,MauroGarcíaToroa,b,MiquelRocaa,b a
InstitutUniversitarid’InvestigacióenCiènciesdelaSalut(UniversityInstituteof
HealthScienceResearch,IUNICS),UniversityoftheBalearicIslands,Palmade Mallorca,Spain b
ReddeActividadesPreventivasyPromocióndelaSaludenAtenciónPrimaria
(NetworkofPrimaryCarePreventiveActivities&HealthcarePromotion,RediAPP), Spain c
DepartmentofPsychology.UniversityoftheBalearicIslands.Spain
d
ManacorHospital,IBSalut.BalearicIslands.Spain
e
FamilyMedicineDepartment,ArrabalHealthCentre,ZaragozaUniversity.Instituto
AragonésdeCienciasdelaSalud(AragónInstituteofHealthSciences,IACS),Zaragoza, Spain *Correspondingauthor:MargalidaGili.InstitutUniversitarid’InvestigacióenCiències delaSalut(UniversityInstituteofHealthScienceResearch,IUNICS),Universityofthe BalearicIslands,07122Palma,Ctra.Valldemossa,km7.5,Spain.Tel.:+34971173081; fax:+34971259935.Emailaddress:[email protected]
ABSTRACT Background Depression is one of the most common disorders in primary care and the fourth most disabling medical condition worldwide. Although gender differences in the prevalence of depression are well established, the little available data on genderrelated differences in disabilities among depression patients gives controversial results. This study aims to analyse whether there are gender differences in the disabilities experienced by patients withdepression. Methods Acrosssectional,multicentre,nationwideepidemiologicalstudywasconducted,with1226 patients.ACaseReportFormwasusedtocollectsociodemographicdataandthe12item version of the World Health Organization Disability Assessment Schedule II (WHODASII) wasusedtoassessfunctioning.DepressionseveritywasassessedusingtheQuickInventory ofDepressiveSymptomatology(QIDS). Results Nonstatistically significant differences in functioning were found between males and females. An itembyitem analysis of the WHODASII shows significant differences between both sexes in specific areas. Women obtained higher scores than men for standingforlongperiodsandwalkingalongdistance.Malesscoredhigherthanwomenin dealingwithpeopleyoudidnotknowwellandmaintainingafriendship. Limitations
Given the descriptive and crosssectional nature of the study, the results are limited, highlighting the need for further research. Also, other variables that might influence disability,suchasmedicalillnesses,werenotconsidered. Conclusions Theeffectofdepressionondisabilityissimilarforbothsexesbutnotuniforminterms of the impact on different aspects of the quality of life. These findings could be an importantfactorintheassessmentoffunctioningandmanagementofdepression. Keywords Depression,genderdifferences,disability.
INTRODUCTION DepressionisoneofthemostcommondisordersinPsychiatricandPrimaryCaresettings (Roca et al., 2009) and it is often associated with decreased physical, social and role functioning (Hardeveld et al., 2013). According to WHO terminology, a disability is “an umbrellaterm,coveringimpairments,activitylimitations,andparticipationrestrictions.An impairmentisaprobleminbodyfunctionorstructure;anactivitylimitationisadifficulty encounteredbyanindividualinexecutingataskoraction;whileaparticipationrestriction isaproblemexperiencedbyanindividualininvolvementinlifesituations”(WHO,2014). Previousstudieshaveshowndailylimitationsindepressivepatientsintermsofselfreport care, disability days, productivity lossrelated costs, physical and emotional health and increaseduseofhealthservices(Ormeletal.,1998;Drussetal.,2000;Plaisieretal.,2010 Gilietal.,2013). It is a wellestablished finding that women experience major depression about twice as often as men (Kessler et al., 2003; Roca et al., 2009; Seedat et al., 2009; Parker and Brotchie, 2010; Silverstein et al., 2012). Previous studies have also reported gender differences in the severity of depression, although the findings are inconsistent. Several studies describe the severity of depression symptoms as being slightly greater in women thaninmen(vanNoordenetal.,2010;Johanssonetal.,2013),althoughoppositefindings
havealsobeenreported(Rocaetal.,2009).Additionally,thedegreeofdisabilityisdirectly relatedtotheseverityofdepression(Chungetal.,2009; Saizetal.,2009;Lai,2011,)andto thepresenceofsomaticsymptoms(Saiz,etal.,2009). There is limited data on gender differences in disability among depressive patients and previous research has led to controversial results. The lack of terminological exactitude mentionedpreviouslycouldpartiallyexplaintheseambiguousresults.Severalstudieshave suggestedthatmenwitheithermoodoranxietydisordersaresignificantlymorelikelyto reportdisabilitiesinrole,socialandcognitiveimpairmentthanwomenwiththesametype of diagnosis (Scott and Collings, 2010). This result is in line with a recent study of adolescents, which showed that the effect of symptoms of anxiety and depression on psychosocialfunctioningwasstrongerinboysthangirls(DerdikmanEironetal.,2012).In contrast, other studies show that depressed women report higher disability levels than depressed men (van Noorden et al., 2010, Lai, 2011, Cook, 2003; Kornstein et al., 1995; Lyness et al., 1993) and a poorer quality of life (Kornstein et al., 2000). Nevertheless, a studybyCroninStubbsetal.(2000)supportsthehypothesisthattherearenodifferences in disability between the sexes, suggesting that symptoms of depression in older people areassociatedwithanincreasedlikelihoodofbecomingdisabledandadecreasedchance of recovery, regardless of the person’s sex and other factors that contribute to physical disability. Gender differences in specific areas of daily life functioning affected by depressive disorders have also been studied. Rafful et al. (2012) reported that for household activities, women aged 30 to 44 were significantly more impaired than men of the same age. In contrast, other studies found no gender differences in household or work
limitationsbutdepressedmenreportedmoredisabilityinleisureactivitiesthandepressed women (Breslin et al, 2006). Other authors find substantial gender differences in overall impairment, although females are described as suffering from more disability in their maritalrole(Weissmanetal.,1981;Bauwensetal.,1991)andfamilyunitrole(Weissman etal.,1978). Previousresearchhasbeenconstrainednotjustbythediversemeasuresofdisabilitythat were used, but also because the different studies did not take into account some parameterslikeageorbiologicalaspects,suchashormonalchangesinfemales. Theaimofthisstudyistoanalysewhethertherearegenderdifferencesinthedisabilities experiencedbypatientssufferingfromdepressionaccordingtoagegroupsanddepression severity. As far as we know, this investigation is the first of its kind to examine these variableswithinasinglesamplegroup.Thesubjectisespeciallyrelevantbecauseabetter understandingoftheassociationbetweentheabilitytofunctionandgenderindepression canhelptoidentifydifferentfactorstobeincludedintreatmentstrategies. METHOD Design,participantsandsetting Acrosssectional,multicentre,nationwideepidemiologicalstudywasconductedwith1242 depressivepatientsinSpain,lastingfromMarch2011toJuly2011.Theparticipantswere recruited from outpatient psychiatric services. A total of 245 psychiatrists, proportionally selectedfromamongthe17Spanishautonomouscommunities,participatedinthepatient recruitment process. Each psychiatrist was asked to recruit five consecutive eligible patients. In the event of the patient’s refusal or exclusion, the psychiatrist’s next patient
meeting the inclusion criteria was enrolled until each psychiatrist obtained a total of 5 subjects.16datasetswereexcludedduetoincompleteormissingdata.Intheend,1226 patientswereincluded.Patientswereincludedinthestudyiftheywere18yearsofageor older,iftheycouldbediagnosedwithMajorDepressiveDisorder(MDD)accordingtoDSM IVcriteria(AmericanPsychiatricAssociation,2000)andiftheywereundergoinganyusual treatment with antidepressants. Patients with any medical or psychological disorder that would limit their ability to understand and/or answer the questions, complete the questionnairesorcollaboratesufficientlywereexcluded.Thestudyprotocolwasapproved bythelocalEthicsCommittee. Measures The patients’ sociodemographic and clinical characteristics were gathered using a Case Report Form (CRF). These included their sex, marital status, rural or urban place of residence, whether they lived alone or accompanied, their level of education and work status, use of alcohol, caffeine or tobacco, and physical activity. Depressionrelated variableswerealsoassessedforalltheparticipants:theageofonset,numberofepisodes (singleorrecurrentepisodes),andpharmacologicalandnonpharmacologicaltreatment.
Clinical Global Impression Improvement (CGII). (Guy, 1976) The Clinical Global – Improvement scale (CGII) is a 7point scale that the clinician uses to assess the severityofdepressioninrelationtothebeginningofpharmacologicaltreatment. World Health Organization Disability Assessment Schedule II (WHODASII). A 12item version of the WHODASII was used to assess activity limitations and participation restrictions(Lucianoetal.,2010).Foreachitem,thesubjectsmustestimatethemagnitude
of the disability during the previous 30 days, with ratings ranging from none= 1 to extreme/cannotdo=5.Thetotalscoremayvaryfrom0to100withhigherscoresreflecting agreaterdisability.
Quick Inventory of Depressive Symptomatology (QIDS). To assess the severity of the depressive symptoms, we used the QIDSSR16 Spanish version, from the official QIDS website (http://www.idsqids.org/). The QIDS covers only the nine diagnostic symptom domainsusedtocharacterizeaMDD,withoutitemsforassessingatypical,melancholic,or theircommonlyassociatedsymptoms.Depressionseveritywascategorizedinto5classes basedontheQIDSscore:Nodepression(from0to5points),milddepression(from6to10 points), moderate depression (from 11 to 15 points); severe depression (from 16 to 20 points)andveryseveredepression(from21to27points).Cronbach’salphawas0.90for theentiresample.
Statisticalanalysis All the data was processed using SPSS 21 for Windows. The descriptive analysis was calculated in terms of the mean, standard deviation and ranges for the continuous variables, while the frequency was computed in percentages for ordinal and nominal variables.DiscretevariableswerecomparedusingtheChiSquaretest(2).Thecontinuous variables were normally distributed (ShapiroWilk p>0.05) and therefore the Student’s t testwasusedfortheircomparisons.AnANOVAanalysiswasconductedwithdisabilityas the dependent variable, using different age and severity of depression categories. Statistically significant genderrelated sociodemographic and clinical variables were included in the multivariate analysis as potential confounders. For all statistical analyses, p
Gender differences on functioning in depressive patients Margarita Gili, Adoración Castro, Capilla Navarro, Rosa Molina, Rosa Magallón, Mauro García-Toro, Miquel Roca
www.elsevier.com/locate/jad
PII: DOI: Reference:
S0165-0327(14)00325-5 http://dx.doi.org/10.1016/j.jad.2014.05.030 JAD6775
To appear in:
Journal of Affective Disorders
Received date: 17 December 2013 Revised date: 20 May 2014 Accepted date: 21 May 2014 Cite this article as: Margarita Gili, Adoración Castro, Capilla Navarro, Rosa Molina, Rosa Magallón, Mauro García-Toro, Miquel Roca, Gender differences on functioning in depressive patients, Journal of Affective Disorders, http://dx.doi. org/10.1016/j.jad.2014.05.030 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
GENDERDIFFERENCESONFUNCTIONINGINDEPRESSIVEPATIENTS MargaritaGilia,b*,AdoraciónCastroa,b,CapillaNavarroc,RosaMolinab,d,Rosa Magallónb,e,MauroGarcíaToroa,b,MiquelRocaa,b a
InstitutUniversitarid’InvestigacióenCiènciesdelaSalut(UniversityInstituteof
HealthScienceResearch,IUNICS),UniversityoftheBalearicIslands,Palmade Mallorca,Spain b
ReddeActividadesPreventivasyPromocióndelaSaludenAtenciónPrimaria
(NetworkofPrimaryCarePreventiveActivities&HealthcarePromotion,RediAPP), Spain c
DepartmentofPsychology.UniversityoftheBalearicIslands.Spain
d
ManacorHospital,IBSalut.BalearicIslands.Spain
e
FamilyMedicineDepartment,ArrabalHealthCentre,ZaragozaUniversity.Instituto
AragonésdeCienciasdelaSalud(AragónInstituteofHealthSciences,IACS),Zaragoza, Spain *Correspondingauthor:MargalidaGili.InstitutUniversitarid’InvestigacióenCiències delaSalut(UniversityInstituteofHealthScienceResearch,IUNICS),Universityofthe BalearicIslands,07122Palma,Ctra.Valldemossa,km7.5,Spain.Tel.:+34971173081; fax:+34971259935.Emailaddress:[email protected]
ABSTRACT Background Depression is one of the most common disorders in primary care and the fourth most disabling medical condition worldwide. Although gender differences in the prevalence of depression are well established, the little available data on genderrelated differences in disabilities among depression patients gives controversial results. This study aims to analyse whether there are gender differences in the disabilities experienced by patients withdepression. Methods Acrosssectional,multicentre,nationwideepidemiologicalstudywasconducted,with1226 patients.ACaseReportFormwasusedtocollectsociodemographicdataandthe12item version of the World Health Organization Disability Assessment Schedule II (WHODASII) wasusedtoassessfunctioning.DepressionseveritywasassessedusingtheQuickInventory ofDepressiveSymptomatology(QIDS). Results Nonstatistically significant differences in functioning were found between males and females. An itembyitem analysis of the WHODASII shows significant differences between both sexes in specific areas. Women obtained higher scores than men for standingforlongperiodsandwalkingalongdistance.Malesscoredhigherthanwomenin dealingwithpeopleyoudidnotknowwellandmaintainingafriendship. Limitations
Given the descriptive and crosssectional nature of the study, the results are limited, highlighting the need for further research. Also, other variables that might influence disability,suchasmedicalillnesses,werenotconsidered. Conclusions Theeffectofdepressionondisabilityissimilarforbothsexesbutnotuniforminterms of the impact on different aspects of the quality of life. These findings could be an importantfactorintheassessmentoffunctioningandmanagementofdepression. Keywords Depression,genderdifferences,disability.
INTRODUCTION DepressionisoneofthemostcommondisordersinPsychiatricandPrimaryCaresettings (Roca et al., 2009) and it is often associated with decreased physical, social and role functioning (Hardeveld et al., 2013). According to WHO terminology, a disability is “an umbrellaterm,coveringimpairments,activitylimitations,andparticipationrestrictions.An impairmentisaprobleminbodyfunctionorstructure;anactivitylimitationisadifficulty encounteredbyanindividualinexecutingataskoraction;whileaparticipationrestriction isaproblemexperiencedbyanindividualininvolvementinlifesituations”(WHO,2014). Previousstudieshaveshowndailylimitationsindepressivepatientsintermsofselfreport care, disability days, productivity lossrelated costs, physical and emotional health and increaseduseofhealthservices(Ormeletal.,1998;Drussetal.,2000;Plaisieretal.,2010 Gilietal.,2013). It is a wellestablished finding that women experience major depression about twice as often as men (Kessler et al., 2003; Roca et al., 2009; Seedat et al., 2009; Parker and Brotchie, 2010; Silverstein et al., 2012). Previous studies have also reported gender differences in the severity of depression, although the findings are inconsistent. Several studies describe the severity of depression symptoms as being slightly greater in women thaninmen(vanNoordenetal.,2010;Johanssonetal.,2013),althoughoppositefindings
havealsobeenreported(Rocaetal.,2009).Additionally,thedegreeofdisabilityisdirectly relatedtotheseverityofdepression(Chungetal.,2009; Saizetal.,2009;Lai,2011,)andto thepresenceofsomaticsymptoms(Saiz,etal.,2009). There is limited data on gender differences in disability among depressive patients and previous research has led to controversial results. The lack of terminological exactitude mentionedpreviouslycouldpartiallyexplaintheseambiguousresults.Severalstudieshave suggestedthatmenwitheithermoodoranxietydisordersaresignificantlymorelikelyto reportdisabilitiesinrole,socialandcognitiveimpairmentthanwomenwiththesametype of diagnosis (Scott and Collings, 2010). This result is in line with a recent study of adolescents, which showed that the effect of symptoms of anxiety and depression on psychosocialfunctioningwasstrongerinboysthangirls(DerdikmanEironetal.,2012).In contrast, other studies show that depressed women report higher disability levels than depressed men (van Noorden et al., 2010, Lai, 2011, Cook, 2003; Kornstein et al., 1995; Lyness et al., 1993) and a poorer quality of life (Kornstein et al., 2000). Nevertheless, a studybyCroninStubbsetal.(2000)supportsthehypothesisthattherearenodifferences in disability between the sexes, suggesting that symptoms of depression in older people areassociatedwithanincreasedlikelihoodofbecomingdisabledandadecreasedchance of recovery, regardless of the person’s sex and other factors that contribute to physical disability. Gender differences in specific areas of daily life functioning affected by depressive disorders have also been studied. Rafful et al. (2012) reported that for household activities, women aged 30 to 44 were significantly more impaired than men of the same age. In contrast, other studies found no gender differences in household or work
limitationsbutdepressedmenreportedmoredisabilityinleisureactivitiesthandepressed women (Breslin et al, 2006). Other authors find substantial gender differences in overall impairment, although females are described as suffering from more disability in their maritalrole(Weissmanetal.,1981;Bauwensetal.,1991)andfamilyunitrole(Weissman etal.,1978). Previousresearchhasbeenconstrainednotjustbythediversemeasuresofdisabilitythat were used, but also because the different studies did not take into account some parameterslikeageorbiologicalaspects,suchashormonalchangesinfemales. Theaimofthisstudyistoanalysewhethertherearegenderdifferencesinthedisabilities experiencedbypatientssufferingfromdepressionaccordingtoagegroupsanddepression severity. As far as we know, this investigation is the first of its kind to examine these variableswithinasinglesamplegroup.Thesubjectisespeciallyrelevantbecauseabetter understandingoftheassociationbetweentheabilitytofunctionandgenderindepression canhelptoidentifydifferentfactorstobeincludedintreatmentstrategies. METHOD Design,participantsandsetting Acrosssectional,multicentre,nationwideepidemiologicalstudywasconductedwith1242 depressivepatientsinSpain,lastingfromMarch2011toJuly2011.Theparticipantswere recruited from outpatient psychiatric services. A total of 245 psychiatrists, proportionally selectedfromamongthe17Spanishautonomouscommunities,participatedinthepatient recruitment process. Each psychiatrist was asked to recruit five consecutive eligible patients. In the event of the patient’s refusal or exclusion, the psychiatrist’s next patient
meeting the inclusion criteria was enrolled until each psychiatrist obtained a total of 5 subjects.16datasetswereexcludedduetoincompleteormissingdata.Intheend,1226 patientswereincluded.Patientswereincludedinthestudyiftheywere18yearsofageor older,iftheycouldbediagnosedwithMajorDepressiveDisorder(MDD)accordingtoDSM IVcriteria(AmericanPsychiatricAssociation,2000)andiftheywereundergoinganyusual treatment with antidepressants. Patients with any medical or psychological disorder that would limit their ability to understand and/or answer the questions, complete the questionnairesorcollaboratesufficientlywereexcluded.Thestudyprotocolwasapproved bythelocalEthicsCommittee. Measures The patients’ sociodemographic and clinical characteristics were gathered using a Case Report Form (CRF). These included their sex, marital status, rural or urban place of residence, whether they lived alone or accompanied, their level of education and work status, use of alcohol, caffeine or tobacco, and physical activity. Depressionrelated variableswerealsoassessedforalltheparticipants:theageofonset,numberofepisodes (singleorrecurrentepisodes),andpharmacologicalandnonpharmacologicaltreatment.
Clinical Global Impression Improvement (CGII). (Guy, 1976) The Clinical Global – Improvement scale (CGII) is a 7point scale that the clinician uses to assess the severityofdepressioninrelationtothebeginningofpharmacologicaltreatment. World Health Organization Disability Assessment Schedule II (WHODASII). A 12item version of the WHODASII was used to assess activity limitations and participation restrictions(Lucianoetal.,2010).Foreachitem,thesubjectsmustestimatethemagnitude
of the disability during the previous 30 days, with ratings ranging from none= 1 to extreme/cannotdo=5.Thetotalscoremayvaryfrom0to100withhigherscoresreflecting agreaterdisability.
Quick Inventory of Depressive Symptomatology (QIDS). To assess the severity of the depressive symptoms, we used the QIDSSR16 Spanish version, from the official QIDS website (http://www.idsqids.org/). The QIDS covers only the nine diagnostic symptom domainsusedtocharacterizeaMDD,withoutitemsforassessingatypical,melancholic,or theircommonlyassociatedsymptoms.Depressionseveritywascategorizedinto5classes basedontheQIDSscore:Nodepression(from0to5points),milddepression(from6to10 points), moderate depression (from 11 to 15 points); severe depression (from 16 to 20 points)andveryseveredepression(from21to27points).Cronbach’salphawas0.90for theentiresample.
Statisticalanalysis All the data was processed using SPSS 21 for Windows. The descriptive analysis was calculated in terms of the mean, standard deviation and ranges for the continuous variables, while the frequency was computed in percentages for ordinal and nominal variables.DiscretevariableswerecomparedusingtheChiSquaretest(2).Thecontinuous variables were normally distributed (ShapiroWilk p>0.05) and therefore the Student’s t testwasusedfortheircomparisons.AnANOVAanalysiswasconductedwithdisabilityas the dependent variable, using different age and severity of depression categories. Statistically significant genderrelated sociodemographic and clinical variables were included in the multivariate analysis as potential confounders. For all statistical analyses, p
