CLIMACTERIC 2014;17:660–665
Comparison of depression, anxiety, quality of life, vitality and mental health between premenopausal and postmenopausal women F. Jafari, M. H. Hadizadeh*, R. Zabihi and K. Ganji†
Climacteric Downloaded from informahealthcare.com by University of Ulster at Jordanstown on 11/30/14 For personal use only.
Department of Psychology, Islamshahr Branch, Islamic Azad University, Islamshahr; *Department of Psychology, Science and Research Branch, Islamic Azad University, Islamshahr; †Department of Psychology, Malayer Branch, Islamic Azad University, Malayer, Iran Key words: MENOPAUSE, DEPRESSION, ANXIETY, QUALITY OF LIFE, VITALITY, MENTAL HEALTH
ABSTRACT Objective The purpose of this research was to investigate and compare the rates of depression, anxiety, quality of life, vitality and mental health between premenopausal and postmenopausal women. Method The sample included 218 women selected randomly from the cultural center of Tehran in November and December 2013 and was divided into two groups. The first group included 110 postmenopausal women (45–55 years old). One year had passed since their last monthly period and they had not used any hormones. The second group included 108 premenopausal women (35–45 years old) who had not yet experienced menopause. In order to assess data, three tests were used: the Zung Anxiety Self-Report scale, the Beck Depression Inventory and the Quality of Life questionnaire (SF-36). The gathered data were analyzed with the T-test for independent groups. Results The results indicated that all five hypotheses were confirmed. There were significant differences between the scores of anxiety, depression, quality of life, vitality and mental health between the two groups. Conclusion Since menopausal women spend almost one-third of their long life in this situation, it can be useful to recognize the causes of these disorders in women and their influences on their families. We can also increase their motivation and self-efficacy in order to improve their quality of life.
INTRODUCTION Menopause is the time in a woman’s life when her period stops. It usually occurs naturally, after the age of 45 years. Menopause happens because the woman’s ovaries stop producing the hormones estrogen and progesterone. Changes and symptoms can start several years earlier. They include: change in periods – shorter or longer, lighter or heavier, with more or less time in between, hot flushes and/or night sweats, trouble sleeping, vaginal dryness, mood swings, trouble focusing and losing hair on their head, but growing more hair on their face1. The menopausal transition may also be a source of psychological distress or instability, despite the fact that certain subgroups of women may be more vulnerable to such adverse outcomes than others2. Collectively, these adverse physical and mental health changes may negatively impact on quality of life
as women transit through menopause. Whether quality of life is impacted during menopause, however, depends on multiple factors including its symptoms and other physical health, psychosocial, lifestyle, and contextual variables3. Menopause has been found to have the most dramatic effect on quality of life during the pre- and early postmenopausal stages (especially in symptomatic women), although it has been suggested that this effect depends on the quality-of-life measure used4. While many women going through menopause experience depression and anxiety, the reasons for these mood disorders cannot be attributed to menopause status alone. The influence of psychological factors, lifestyle, body image, interpersonal relationships, social roles, and sociocultural factors in predicting levels of depression and anxiety in the menopausal patient cannot be ignored5. At the same time, there are often many other changes occurring in the lives of women who experience
Correspondence: Assistant Professor F. Jafari, Department of Psychology, Islamshahr Branch, Islamic Azad University, Islamshahr, Iran; Email: forugh_ [email protected] ORIGINAL ARTICLE © 2014 International Menopause Society DOI: 10.3109/13697137.2014.905528
Received 19-01-2014 Revised 01-03-2014 Accepted 07-03-2014
Climacteric Downloaded from informahealthcare.com by University of Ulster at Jordanstown on 11/30/14 For personal use only.
Comparison of quality of life in pre/postmenopausal women menopause such as a partner’s retirement, children becoming more independent, parents’ death or requiring constant care, and reassessment of a woman’s career or role. These changes can result in positive attitudes for some women and despair and depression for others. Menopause often marks the beginning of a new life stage and some women may make changes to their interpersonal relationships and roles6. Menopause occurs at a time of life when women are facing many threats and challenges, and it is important not to identify the menopause erroneously as the sole reason for reductions in the quality of life of such individuals. Most women attending a menopause clinic complain of psychological symptoms such as mood swings, rather than purely physical symptoms, and it is likely that the physiological correlations of such psychological symptoms have been underestimated. Much of the distress experienced by menopausal women is also linked to their beliefs and perceptions related to the processes that they are experiencing, and to misinformation and myths with which they may be burdened. An awareness of this complex scenario, by clinicians, helps them to treat their patients more effectively7. The results suggest that cultural factors may influence the experience of menopause for women. These findings may improve health professionals’ understanding of cultural beliefs relating to menopause so that culturally appropriate care can be provided8. In many societies, menopause may affect women’s social positions because of the loss of reproductive ability. In contrast, in some ethnic cultures, such as Chinese and Indian, age is respected and has a higher status and a certain prestige that increases as a person ages. In these Asian cultures, menopause is seen as a transition to a higher status9. Some have described the experiences of women and the positive aspects of menopause as having more freedom, personal growth, achievements, and gaining competency. Iranian culture bestows special value and importance on the elderly. The traditions and religion of Islam have placed great emphasis on respecting and valuing the elderly and their presence at all ceremonies and traditional activities and participation in making grand decisions is of great importance. In this respect, older women have a significant place in the culture because of their extensive experience as mothers and wives. On the other hand, some of the values women hold in Iran might be at risk due to mood fluctuations and other changes during menopause. Emotional challenges might occur related to a wide range of concerns, such as the loss of fertility, the discipline of young children, and personal contentment. Z˙ołnierczuk-Kieliszek and his colleagues10 showed that the quality of a woman’s life was significantly affected by the place of her permanent residency. City and town inhabitants revealed a considerably higher level of quality of life. A permanent place of residency in the country was an independent predictor of a poorer quality of life. Jafary and colleagues11, in their research about quality of life and menopause, showed that meaning in life not only affects quality of life directly, but it also indirectly affects the quality of life through evaluations of health, self-efficacy and body area satisfaction. In addition, health, self-efficacy, and
Climacteric
Jafari et al. body area satisfaction might affect the quality of life separately and each might predict some parts of quality of life. Bloch, in a cross-sectional survey of 51 women between 43 and 63 years of age, showed that those with a negative attitude toward menopause were more distressed by their symptoms12. Menopausal symptoms have been widely studied in women from western societies, but less information is available for women of non-western ethnic groups. There is evidence of differences in the prevalence of symptoms in Asian versus Western women13. There are no studies from this region of the subcontinent regarding the quality of life of menopausal women. This study compares the differences in quality of life, depression, anxiety, mental health and vitality between premenopausal and postmenopausal women.
METHOD This research was carried out in the last 3 months of 2013 in Iran. The participants in this study were divided into two groups: postmenopausal and premenopausal women. The postmenopausal women were 45–55 years old and the premenopausal women were 35–45 years old. Both groups had, at least, a high school education. Women who became menopausal as a result of disease or surgery and menopausal women with serious gynecological diseases at the time of recruitment were not included in this study. The sample groups were selected as follows: six cultural centers in Tehran were chosen, at random, and women who were participating in sports, cultural, educational, and religious classes or were members of women’s clubs at the cultural centers were considered for the study. A total of 240 women (120 postmenopause and 120 premenopause) at each cultural center were selected at random from the list of names of women who qualified for the study and who consented to participate. The total number of individuals who received research questionnaires was 240; however, 22 of the questionnaires were considered as incomplete or were unreturned. Since the subject of research was the comparison of the differences in quality of life, depression, anxiety, mental health and vitality between premenopausal and postmenopausal women, the causal-comparative research method was used. The gathered data were analyzed with descriptive statistical methods and the T-test for independent groups. This research follows five hypotheses: (1) There are significant differences in depression premenopausal and postmenopausal women; (2) There are significant differences in anxiety premenopausal and postmenopausal women; (3) There are significant differences in quality of life premenopausal and postmenopausal women; (4) There are significant differences in vitality premenopausal and postmenopausal women; (5) There are significant differences in mental health premenopausal and postmenopausal women.
between between between between between
661
Comparison of quality of life in pre/postmenopausal women
Research tools
Jafari et al.
Questionnaire for the Quality of Life Assessment (SF-36)
Climacteric Downloaded from informahealthcare.com by University of Ulster at Jordanstown on 11/30/14 For personal use only.
Zung Anxiety Scale Survey This scale was designed in 1970 by William Zung similar to a customer service survey questionnaire14. It is a 20-item, self-report assessment device built to measure anxiety levels, based on scoring in four groups of manifestations: cognitive, autonomic, motor and central nervous system symptoms. Answering the statements, a person should indicate how much each statement applies to him or her. Each question is scored on a Likert-type scale of 1 to 4 (based on the replies: ‘a little of the time’, ‘some of the time’, ‘a good part of the time’, ‘most of the time’). The overall assessment is made from the total score. The total raw scores range from 20 to 80. The raw score is then converted into an ‘Anxiety Index’ score using the chart on the paper version of the test14. The ‘Anxiety Index’ score can then be used on the scale to determine the clinical interpretation of one’s level of anxiety: a score of 20–44 reflects the normal range, 45–59 reflects mild to moderate anxiety levels, 60–74 reflects marked to severe anxiety levels and 75–80 reflects extreme anxiety levels. The Anxiety Scale for calculating the reliability of the method of Zung correlations, within the coherence or congruence questions to consider is to use statistical analysis conducted about 0.84, indicating the high reliability of this scale. Gilani calculated that Cronbach’s α, the coefficient of reliability, of the questionnaire is about 0.78 in Iran15.
The SF-36 is a 36-item questionnaire which was devised by Ware and Sherbourne20 for measuring quality of life. Montazeri and colleagues translated the questionnaire and performed the necessary psychometric studies to prepare this assessment tool for use in Iran21. The reliability of the questionnaire using the statistical analysis of the internal consistency coefficient and the methods of comparing identified group and convergent validity were analyzed. Cronbach’s α, as reported for the eight dimensions of this tool, is in the range of 65–90%. The scale in this questionnaire includes eight dimensions of physical functioning (ten items), role limitation due to physical health (four items), bodily pain (two items), general health (five items), vitality (four items), social functioning (two items), role limitation due to emotional problems (three items), and mental health (five items). The reported α efficiencies for these dimensions were 0.90, 0.85, 0.83, 0.71, 0.65, 0.77, 0.84, and 0.77, respectively; these indicated the internal consistency of the questionnaire. Other psychological analysis such as validation has also been conducted by Montazeri and colleagues21, which indicates that the tools used were appropriate. The scoring of the questionnaire was based on the RAND scoring system from 0 to 100 and the total of the scores in each dimension was divided by the number of questions in the same dimension. The attained score indicated the desired quality of life.
Beck Depression Inventory RESULTS The Beck Depression Inventory scale was devised by Aaron Beck in 196116. The purpose of this questionnaire is to reveal the severity of symptoms of depression and its cognitive content is more emphasized. It includes 21 items; each item, based on the intensity and weakness of the symptoms, is scored from 0 to 3, and the range of the scores is between 0 to a maximum of 63. The reliability of the test was reported to be around 93% in 1972, based on the Spearman–Brown method. In a high level of analysis, after making different efforts to determine the internal differential, Beck and colleagues achieved an internal consistency coefficient of 73% with a mean of 86%16. The evaluations of content, construct, discriminant validity and also factor analysis have generally had good results. Gharaii reported Cronbach’s a for this questionnaire to be 0.78 and the test–retest reliability to be 0.73 within 2 weeks in Iran17. Tashakori and colleagues have reported on the efficiency of the Beck Depression test in non-western students and have reported its reliability consistency to be around 78%18. The reliability of the split-half method scale using the Spearman– Brown correction formula was 80%. In Iran, Posht-Mashhadi studied the Beck Depression Inventory in a pool of 116 people and the correlation efficiencies of the scores in each section in the entire test were 23–68% and the internal consistency coefficient of the scale was 85%19.
662
Table 1 shows the number, mean scores and standard deviations in the premenopausal and postmenopausal groups. The mean scores of postmenopausal women (n 110) for the components of depression, anxiety, quality of life, vitality and mental health were 22.04, 54.36, 39.22, 8.33
Table 1 Number, mean scores and standard deviation in premenopausal (n 108) and postmenopausal women (n 110) Components
Mean
Standard deviation
Postmenopausal Depression Anxiety Quality of life Vitality Mental health
22.04 54.36 39.22 8.33 15.64
10.48 8.79 10.99 3.45 6.78
Premenopausal Depression Anxiety Quality of life Vitality Mental health
12.44 44.68 59.62 13.74 21.54
8.446 10.765 14.866 5.86 9.37
Climacteric
Climacteric Downloaded from informahealthcare.com by University of Ulster at Jordanstown on 11/30/14 For personal use only.
Comparison of quality of life in pre/postmenopausal women
Jafari et al.
and 15.64, and the standard deviations were 10.48, 8.79, 10.99, 3.45 and 6.78, respectively; in the group of premenopausal women (n 108), the mean scores of the components were 12.44, 44.68, 59.62, 13.74 and 21.54 and the standard deviations were 8.44, 10.76, 14.86, 5.86 and 9.3, respectively. The test for equality of variances for using the t-test was conducted and the results indicated the significance values of the F-test to be equal. The t-tests for comparing the mean scores of depression, anxiety, quality of life, vitality and mental health in premenopausal and postmenopausal women indicate the significant differences in all the scores (at p 0.001). The result is that the scores for depression and anxiety in postmenopausal women, with a probability of 0.99, are higher and the scores for quality of life, vitality and mental health in postmenopausal women, with a probability of 0.99, are lower than in premenopausal women. The results of the five hypotheses and the related tables are given below.
Hypothesis two The results from the second question (whether there are significant differences in anxiety between premenopausal and postmenopausal women) are shown in Table 2 and indicate that, from the statistical point of view, there was a significant difference between premenopausal and postmenopausal women (t 3.48, p 0.001). This suggests that postmenopausal women experience higher levels of anxiety than premenopausal women.
Hypothesis three The results from the third question (whether there are significant differences in quality of life between premenopausal and postmenopausal women) are shown in Table 2, and indicated that, from the statistical point of view, there was a significant difference between premenopausal and postmenopausal women (t 5.517, p 0.001). This suggests that postmenopausal women experience lower levels of quality of life than premenopausal women
Hypothesis one Results from the first question (whether there are significant differences in depression between premenopausal and postmenopausal women) are shown in Table 2, and indicate that, from the statistical point of view, there was a significant difference between premenopausal and postmenopausal women (t 3.56, p 0.001). This suggests that postmenopausal women experience higher levels of depression than premenopausal women.
Hypothesis four The results from the fourth question (whether there are significant differences in vitality between premenopausal and postmenopausal women) are shown in Table 2, and indicated that, from the statistical point of view, there was a significant difference between premenopausal and postmenopausal women (t 2.92, p 0.001). This suggests that
Table 2 Comparison of depression, anxiety, quality of life, vitality and mental health in premenopausal (n 108) and postmenopausal (n 110) women Levene’s test for equality of variances
t-test for equality of means Component Depression Premenopause Postmenopause Anxiety Premenopause Postmenopause Quality of life Premenopause Postmenopause Vitality Premenopause Postmenopause Mental health Premenopause Postmenopause
Climacteric
Mean
Mean difference
Significance
d.f.
t
Significance
F
12.44 22.04
9.60
0.001
216
3.56
0.457
0.562
44.68 54.36
9.68
0.001
216
3.48
0.094
2.91
59.62 39.22
20.40
0.001
216
5.517
0.058
3.76
13.74 8.33
8.42
0.001
216
2.92
0.423
0.612
21.54 15.64
10.35
0.001
216
4.12
0.476
0.623
663
Comparison of quality of life in pre/postmenopausal women postmenopausal women experience lower levels of vitality than premenopausal women.
Hypothesis five
Climacteric Downloaded from informahealthcare.com by University of Ulster at Jordanstown on 11/30/14 For personal use only.
The results from the fifth question (whether there are significant differences in mental health between premenopausal and postmenopausal women) are shown in Table 2, and indicated that, from the statistical point of view, there was a significant difference between premenopausal and postmenopausal women (t 4.12, p 0.001). This suggests that postmenopausal women experience lower levels of mental health than premenopausal women
CONCLUSION AND DISCUSSION The results indicated that all five hypotheses were confirmed, meaning that postmenopausal women experience higher levels of anxiety and depression and lower levels of quality of life, mental health and vitality. The results of research by Z˙ołnierczuk-Kieliszek10, Short7, Deeks5, Genazzani22 and their colleagues are similar to our results. In a series of longitudinal studies23, 24, depression during middle age was predicted by psychosocial variables, physical distress, and history of depression rather than by menopause status, except, perhaps, for a subset of women. Neugarten and Kraines25 reported that women complaining of psychological distress around the menopausal period are those who have manifested low self-esteem and low rates of satisfaction throughout their lives. Psychological symptoms such as anxiety, depression and insomnia are most common just before the onset of menopause; vasomotor symptoms with night sweats often lead to chronic fatigue, sleep deprivation and hence indirectly to psychological symptoms such as depression. The results of the analysis of answers given by premenopausal and postmenopausal women about their daily experiences in this sample suggest that postmenopausal women compared to premenopausal women claim lower levels of quality of life. Taking into account the fact that Iran is considered to be a developing country, the status of women is not so favorable. A woman in Iran as wife, mother and child has to do her best to perform the tasks of being responsible for having an appropriate relationship with her husband and her family’s husbands, rearing her children and helping them to resolve their educational and relationship problems, taking care of her and her husband’s old parents and, in addition, handling her own job and social activities. Studying, employment and the fulfillment of individual needs are some of the activities that cannot be ignored in order to enter the modern world. As a result of all these activities plus the fact that there is not enough time for leisure and rest and for attaining desir-
664
Jafari et al. able standards of health by exercising, eating correctly and desirable social interaction, when these women reach the stage of menopause, they will consider the first symptoms of menopause as serious alarms for the reduction in their physical and mental abilities. Since there are not any planned programs to inform women of the mental and physiological changes that happen simultaneously as they reach menopause, during this relatively long period of their lives, they do not get a chance to use the experiences gained in accordance with their capabilities. Practitioners will benefit from an understanding and exploration of the previous history of mood disturbance, prior thoughts and behavior patterns in their menopausal patients. With the physiological changes at menopause often mimicking the symptoms of depression and anxiety, it is important to differentiate between what is true depression and anxiety, and what can be related to menopause6. Two types of psychotherapy are highly recommended for depression related to menopause. Interpersonal therapy focuses on understanding how changing human relationships may contribute to, or relieve, depression. Cognitivebehavioral therapy focuses on identifying and changing the pessimistic thoughts and beliefs that accompany depression. When used alone, psychotherapy usually works more gradually than medication, taking 2 months or more to show its full effects. However, the benefits may be long lasting. Psychotherapy is usually combined with medication in major depression26. The effects of self-statements and positive thoughts in changing their attitudes toward menopause and life satisfaction can be helpful. Exercises were provided to find meaning in life as well as goals and values in life in accordance with the new conditions of menopause. Promotion of self-efficacy by recognizing successful past experiences, considering models of similar successful individuals or seeking past social confirmations were included in the sessions. Coping with physical and body changes, accepting them, and dealing with exaggeration and excessive aggrandizement or feelings of happiness and life satisfaction due to physical attractiveness can also be useful27. Ultimately, all these variables are beliefs or feelings that relate to each other and can produce peace, happiness, a feeling of well-being, self-efficacy, capability, goal orientation, value, and, in general, a good quality of life in menopausal women11. Considering the obtained results from this research and the deficiencies felt by the researchers during this research, the following important points for the current conditions and future studies are recommended. • Educating the husbands of women going through menopause to make them aware of changes in this period and give them more understanding of their wives; • Educating women about menopause and its common symptoms before they reach the age of menopause;
Climacteric
Comparison of quality of life in pre/postmenopausal women • Holding and coordinating individual or group exercise classes for women with menopause (for the purpose of helping to elevate women’s social, emotional and physical conditions); • Broadcasting appropriate programs about menopause through the mass media.
Jafari et al. Conflict of interest The authors report no confl ict of interest. The authors alone are responsible for the content and writing of this paper. Source of funding
Nil.
Climacteric Downloaded from informahealthcare.com by University of Ulster at Jordanstown on 11/30/14 For personal use only.
References 1. Zoler YF, Acquadro C, Schaefer M. Literature review of instruments to assess health-related quality of life during and after menopause. Qual Life Res 2005;14:309–27 2. Schilling C, Gallicchio L, Miller SR, Langenberg P, Zacur H, Flaws JA. Relation of body mass and sex steroid hormone levels to hot flushes in a sample of midlife women. Climacteric 2007;10:27–37 3. Avis NE, Ory MG, Mathews KA, Shocken M, Bromberger J, Colvin A. Health-related quality of life in a multiethnic sample of middle-aged women. Med Care 2003;41:1262–76 4. Utian WH. Quality of life (QOL) in menopause. Maturitas 2007;57:100–2 5. Deeks AA. Psychological aspects of menopause management. Clin Endocrinol Metab 2003;17:17–31 6. Deeks AA. Sexual desire: menopause and its psychological impact. Aust Fam Physician 2002;31:433–9 7. Short M. Menopause, mood and management. Climacteric 2003;6:33–6 8. Fu SY, Anderson D, Courtney M. Cross-cultural menopausal experience: comparison of Australian and Taiwanese women. Nurs Health Sci 2003;5:77–84 9. Li S, Carlson ES, Snyder D, et al. Perspectives on menopause. Clin Nurse Specialist 1995;9:145–7 10. Z˙ ołnierczuk-Kieliszek D, Kulik TB, Jarosz MJ, et al. Quality of life in pre- and post-menopausal Polish women living in Lublin Province – differences between urban and rural dwellers. Ann Agric Environ Med 2012;19:129–33 11. Jafary F, Farahbakhsh K, Shafiabadi A, Delavar A. Quality of life and menopause: developing a theoretical model based on meaning in life, self-efficacy beliefs, and body image. J Aging Mental Health 2011;15:630–7 12. Bloch A. Self-awareness during the menopause. Maturitas 2002;41:61–8 13. Pan HA, Wu MH, Hsu CC, Yao BL, Huong KE. The perception of menopause among women in Taiwan. Maturitas 2002;41: 269–74
Climacteric
14. Karami A. Zung Anxiety Self-report Scale. Tehran, Iran: Sina Psychometric Institution, 2004 15. Gilani B. Anxiety after war. J Psychol Res 1991;1:6–11 16. Beck AT, Steer RA, Garbun MG. Psychometric properties of the Beck Depression Inventory: twenty-five years of evaluation. Clin Psychol Rev 1988;8:77–100 17. Gharaii B. Determining identification states and their relation to identification styles and depression in adolescents. PhD thesis in clinical psychology, University of Medical Sciences of Iran, Psychiatric Institution [in Persian] 18. Tashakori A. The analysis of women’s attitude and action in the city of Mashhad about menopause. MA thesis in midwifery from the University of Medical Science in Mashhad, 1995 19. Posht-Mashhadi M. The study of effect of cognitive-behaviour treatment in pain disorder. MS Thesis, Tehran, 2001 [Persian] 20. Ware JE, Sherbourne CD. The MOS 36-item Short Form Health Survey (SF-36). I. Conceptual framework and item selection. Med Care 1992;30:473–83 21. Montazeri A, Goshtasbi A, Vahdani-Niam. Translation, validity and reliability of Iranian version of SF-36 questionnaire. Q J Payesh 2005;49–50 22. Genazzani AR, Gambacciani M, Simoncini T. Menopause and aging, quality of life and sexuality. Climacteric 2007;10:88–96 23. Dennerstein L, Lehert P, Burger H, Dudley E. Mood and the menopausal transition. J Nerv Ment Dis 1999;187:685–91 24. Kaufert PA, Gilbert P, Tate R. The Manitoba Project: re-examination of the link between menopause and depression. Maturitas 1992;14:143–55 25. Neugarten BL, Kraines RJ. Menopausal symptoms in women of various ages. Psychosom Med 1965;27:266–73 26. Kahn DA, Moline ML, Ross RW, Altshuler LL, Cohen LS. Depression during the transition to menopause: A Guide for Patients and Families. www.womensmentalhealth.org 27. Jafary F, Afzali L. Comparison of the effectiveness of four group therapies in improving the quality of life in menopausal women. Przegl d Menopauzalny 2013;3:194–201
665
Comparison of depression, anxiety, quality of life, vitality and mental health between premenopausal and postmenopausal women F. Jafari, M. H. Hadizadeh*, R. Zabihi and K. Ganji†
Climacteric Downloaded from informahealthcare.com by University of Ulster at Jordanstown on 11/30/14 For personal use only.
Department of Psychology, Islamshahr Branch, Islamic Azad University, Islamshahr; *Department of Psychology, Science and Research Branch, Islamic Azad University, Islamshahr; †Department of Psychology, Malayer Branch, Islamic Azad University, Malayer, Iran Key words: MENOPAUSE, DEPRESSION, ANXIETY, QUALITY OF LIFE, VITALITY, MENTAL HEALTH
ABSTRACT Objective The purpose of this research was to investigate and compare the rates of depression, anxiety, quality of life, vitality and mental health between premenopausal and postmenopausal women. Method The sample included 218 women selected randomly from the cultural center of Tehran in November and December 2013 and was divided into two groups. The first group included 110 postmenopausal women (45–55 years old). One year had passed since their last monthly period and they had not used any hormones. The second group included 108 premenopausal women (35–45 years old) who had not yet experienced menopause. In order to assess data, three tests were used: the Zung Anxiety Self-Report scale, the Beck Depression Inventory and the Quality of Life questionnaire (SF-36). The gathered data were analyzed with the T-test for independent groups. Results The results indicated that all five hypotheses were confirmed. There were significant differences between the scores of anxiety, depression, quality of life, vitality and mental health between the two groups. Conclusion Since menopausal women spend almost one-third of their long life in this situation, it can be useful to recognize the causes of these disorders in women and their influences on their families. We can also increase their motivation and self-efficacy in order to improve their quality of life.
INTRODUCTION Menopause is the time in a woman’s life when her period stops. It usually occurs naturally, after the age of 45 years. Menopause happens because the woman’s ovaries stop producing the hormones estrogen and progesterone. Changes and symptoms can start several years earlier. They include: change in periods – shorter or longer, lighter or heavier, with more or less time in between, hot flushes and/or night sweats, trouble sleeping, vaginal dryness, mood swings, trouble focusing and losing hair on their head, but growing more hair on their face1. The menopausal transition may also be a source of psychological distress or instability, despite the fact that certain subgroups of women may be more vulnerable to such adverse outcomes than others2. Collectively, these adverse physical and mental health changes may negatively impact on quality of life
as women transit through menopause. Whether quality of life is impacted during menopause, however, depends on multiple factors including its symptoms and other physical health, psychosocial, lifestyle, and contextual variables3. Menopause has been found to have the most dramatic effect on quality of life during the pre- and early postmenopausal stages (especially in symptomatic women), although it has been suggested that this effect depends on the quality-of-life measure used4. While many women going through menopause experience depression and anxiety, the reasons for these mood disorders cannot be attributed to menopause status alone. The influence of psychological factors, lifestyle, body image, interpersonal relationships, social roles, and sociocultural factors in predicting levels of depression and anxiety in the menopausal patient cannot be ignored5. At the same time, there are often many other changes occurring in the lives of women who experience
Correspondence: Assistant Professor F. Jafari, Department of Psychology, Islamshahr Branch, Islamic Azad University, Islamshahr, Iran; Email: forugh_ [email protected] ORIGINAL ARTICLE © 2014 International Menopause Society DOI: 10.3109/13697137.2014.905528
Received 19-01-2014 Revised 01-03-2014 Accepted 07-03-2014
Climacteric Downloaded from informahealthcare.com by University of Ulster at Jordanstown on 11/30/14 For personal use only.
Comparison of quality of life in pre/postmenopausal women menopause such as a partner’s retirement, children becoming more independent, parents’ death or requiring constant care, and reassessment of a woman’s career or role. These changes can result in positive attitudes for some women and despair and depression for others. Menopause often marks the beginning of a new life stage and some women may make changes to their interpersonal relationships and roles6. Menopause occurs at a time of life when women are facing many threats and challenges, and it is important not to identify the menopause erroneously as the sole reason for reductions in the quality of life of such individuals. Most women attending a menopause clinic complain of psychological symptoms such as mood swings, rather than purely physical symptoms, and it is likely that the physiological correlations of such psychological symptoms have been underestimated. Much of the distress experienced by menopausal women is also linked to their beliefs and perceptions related to the processes that they are experiencing, and to misinformation and myths with which they may be burdened. An awareness of this complex scenario, by clinicians, helps them to treat their patients more effectively7. The results suggest that cultural factors may influence the experience of menopause for women. These findings may improve health professionals’ understanding of cultural beliefs relating to menopause so that culturally appropriate care can be provided8. In many societies, menopause may affect women’s social positions because of the loss of reproductive ability. In contrast, in some ethnic cultures, such as Chinese and Indian, age is respected and has a higher status and a certain prestige that increases as a person ages. In these Asian cultures, menopause is seen as a transition to a higher status9. Some have described the experiences of women and the positive aspects of menopause as having more freedom, personal growth, achievements, and gaining competency. Iranian culture bestows special value and importance on the elderly. The traditions and religion of Islam have placed great emphasis on respecting and valuing the elderly and their presence at all ceremonies and traditional activities and participation in making grand decisions is of great importance. In this respect, older women have a significant place in the culture because of their extensive experience as mothers and wives. On the other hand, some of the values women hold in Iran might be at risk due to mood fluctuations and other changes during menopause. Emotional challenges might occur related to a wide range of concerns, such as the loss of fertility, the discipline of young children, and personal contentment. Z˙ołnierczuk-Kieliszek and his colleagues10 showed that the quality of a woman’s life was significantly affected by the place of her permanent residency. City and town inhabitants revealed a considerably higher level of quality of life. A permanent place of residency in the country was an independent predictor of a poorer quality of life. Jafary and colleagues11, in their research about quality of life and menopause, showed that meaning in life not only affects quality of life directly, but it also indirectly affects the quality of life through evaluations of health, self-efficacy and body area satisfaction. In addition, health, self-efficacy, and
Climacteric
Jafari et al. body area satisfaction might affect the quality of life separately and each might predict some parts of quality of life. Bloch, in a cross-sectional survey of 51 women between 43 and 63 years of age, showed that those with a negative attitude toward menopause were more distressed by their symptoms12. Menopausal symptoms have been widely studied in women from western societies, but less information is available for women of non-western ethnic groups. There is evidence of differences in the prevalence of symptoms in Asian versus Western women13. There are no studies from this region of the subcontinent regarding the quality of life of menopausal women. This study compares the differences in quality of life, depression, anxiety, mental health and vitality between premenopausal and postmenopausal women.
METHOD This research was carried out in the last 3 months of 2013 in Iran. The participants in this study were divided into two groups: postmenopausal and premenopausal women. The postmenopausal women were 45–55 years old and the premenopausal women were 35–45 years old. Both groups had, at least, a high school education. Women who became menopausal as a result of disease or surgery and menopausal women with serious gynecological diseases at the time of recruitment were not included in this study. The sample groups were selected as follows: six cultural centers in Tehran were chosen, at random, and women who were participating in sports, cultural, educational, and religious classes or were members of women’s clubs at the cultural centers were considered for the study. A total of 240 women (120 postmenopause and 120 premenopause) at each cultural center were selected at random from the list of names of women who qualified for the study and who consented to participate. The total number of individuals who received research questionnaires was 240; however, 22 of the questionnaires were considered as incomplete or were unreturned. Since the subject of research was the comparison of the differences in quality of life, depression, anxiety, mental health and vitality between premenopausal and postmenopausal women, the causal-comparative research method was used. The gathered data were analyzed with descriptive statistical methods and the T-test for independent groups. This research follows five hypotheses: (1) There are significant differences in depression premenopausal and postmenopausal women; (2) There are significant differences in anxiety premenopausal and postmenopausal women; (3) There are significant differences in quality of life premenopausal and postmenopausal women; (4) There are significant differences in vitality premenopausal and postmenopausal women; (5) There are significant differences in mental health premenopausal and postmenopausal women.
between between between between between
661
Comparison of quality of life in pre/postmenopausal women
Research tools
Jafari et al.
Questionnaire for the Quality of Life Assessment (SF-36)
Climacteric Downloaded from informahealthcare.com by University of Ulster at Jordanstown on 11/30/14 For personal use only.
Zung Anxiety Scale Survey This scale was designed in 1970 by William Zung similar to a customer service survey questionnaire14. It is a 20-item, self-report assessment device built to measure anxiety levels, based on scoring in four groups of manifestations: cognitive, autonomic, motor and central nervous system symptoms. Answering the statements, a person should indicate how much each statement applies to him or her. Each question is scored on a Likert-type scale of 1 to 4 (based on the replies: ‘a little of the time’, ‘some of the time’, ‘a good part of the time’, ‘most of the time’). The overall assessment is made from the total score. The total raw scores range from 20 to 80. The raw score is then converted into an ‘Anxiety Index’ score using the chart on the paper version of the test14. The ‘Anxiety Index’ score can then be used on the scale to determine the clinical interpretation of one’s level of anxiety: a score of 20–44 reflects the normal range, 45–59 reflects mild to moderate anxiety levels, 60–74 reflects marked to severe anxiety levels and 75–80 reflects extreme anxiety levels. The Anxiety Scale for calculating the reliability of the method of Zung correlations, within the coherence or congruence questions to consider is to use statistical analysis conducted about 0.84, indicating the high reliability of this scale. Gilani calculated that Cronbach’s α, the coefficient of reliability, of the questionnaire is about 0.78 in Iran15.
The SF-36 is a 36-item questionnaire which was devised by Ware and Sherbourne20 for measuring quality of life. Montazeri and colleagues translated the questionnaire and performed the necessary psychometric studies to prepare this assessment tool for use in Iran21. The reliability of the questionnaire using the statistical analysis of the internal consistency coefficient and the methods of comparing identified group and convergent validity were analyzed. Cronbach’s α, as reported for the eight dimensions of this tool, is in the range of 65–90%. The scale in this questionnaire includes eight dimensions of physical functioning (ten items), role limitation due to physical health (four items), bodily pain (two items), general health (five items), vitality (four items), social functioning (two items), role limitation due to emotional problems (three items), and mental health (five items). The reported α efficiencies for these dimensions were 0.90, 0.85, 0.83, 0.71, 0.65, 0.77, 0.84, and 0.77, respectively; these indicated the internal consistency of the questionnaire. Other psychological analysis such as validation has also been conducted by Montazeri and colleagues21, which indicates that the tools used were appropriate. The scoring of the questionnaire was based on the RAND scoring system from 0 to 100 and the total of the scores in each dimension was divided by the number of questions in the same dimension. The attained score indicated the desired quality of life.
Beck Depression Inventory RESULTS The Beck Depression Inventory scale was devised by Aaron Beck in 196116. The purpose of this questionnaire is to reveal the severity of symptoms of depression and its cognitive content is more emphasized. It includes 21 items; each item, based on the intensity and weakness of the symptoms, is scored from 0 to 3, and the range of the scores is between 0 to a maximum of 63. The reliability of the test was reported to be around 93% in 1972, based on the Spearman–Brown method. In a high level of analysis, after making different efforts to determine the internal differential, Beck and colleagues achieved an internal consistency coefficient of 73% with a mean of 86%16. The evaluations of content, construct, discriminant validity and also factor analysis have generally had good results. Gharaii reported Cronbach’s a for this questionnaire to be 0.78 and the test–retest reliability to be 0.73 within 2 weeks in Iran17. Tashakori and colleagues have reported on the efficiency of the Beck Depression test in non-western students and have reported its reliability consistency to be around 78%18. The reliability of the split-half method scale using the Spearman– Brown correction formula was 80%. In Iran, Posht-Mashhadi studied the Beck Depression Inventory in a pool of 116 people and the correlation efficiencies of the scores in each section in the entire test were 23–68% and the internal consistency coefficient of the scale was 85%19.
662
Table 1 shows the number, mean scores and standard deviations in the premenopausal and postmenopausal groups. The mean scores of postmenopausal women (n 110) for the components of depression, anxiety, quality of life, vitality and mental health were 22.04, 54.36, 39.22, 8.33
Table 1 Number, mean scores and standard deviation in premenopausal (n 108) and postmenopausal women (n 110) Components
Mean
Standard deviation
Postmenopausal Depression Anxiety Quality of life Vitality Mental health
22.04 54.36 39.22 8.33 15.64
10.48 8.79 10.99 3.45 6.78
Premenopausal Depression Anxiety Quality of life Vitality Mental health
12.44 44.68 59.62 13.74 21.54
8.446 10.765 14.866 5.86 9.37
Climacteric
Climacteric Downloaded from informahealthcare.com by University of Ulster at Jordanstown on 11/30/14 For personal use only.
Comparison of quality of life in pre/postmenopausal women
Jafari et al.
and 15.64, and the standard deviations were 10.48, 8.79, 10.99, 3.45 and 6.78, respectively; in the group of premenopausal women (n 108), the mean scores of the components were 12.44, 44.68, 59.62, 13.74 and 21.54 and the standard deviations were 8.44, 10.76, 14.86, 5.86 and 9.3, respectively. The test for equality of variances for using the t-test was conducted and the results indicated the significance values of the F-test to be equal. The t-tests for comparing the mean scores of depression, anxiety, quality of life, vitality and mental health in premenopausal and postmenopausal women indicate the significant differences in all the scores (at p 0.001). The result is that the scores for depression and anxiety in postmenopausal women, with a probability of 0.99, are higher and the scores for quality of life, vitality and mental health in postmenopausal women, with a probability of 0.99, are lower than in premenopausal women. The results of the five hypotheses and the related tables are given below.
Hypothesis two The results from the second question (whether there are significant differences in anxiety between premenopausal and postmenopausal women) are shown in Table 2 and indicate that, from the statistical point of view, there was a significant difference between premenopausal and postmenopausal women (t 3.48, p 0.001). This suggests that postmenopausal women experience higher levels of anxiety than premenopausal women.
Hypothesis three The results from the third question (whether there are significant differences in quality of life between premenopausal and postmenopausal women) are shown in Table 2, and indicated that, from the statistical point of view, there was a significant difference between premenopausal and postmenopausal women (t 5.517, p 0.001). This suggests that postmenopausal women experience lower levels of quality of life than premenopausal women
Hypothesis one Results from the first question (whether there are significant differences in depression between premenopausal and postmenopausal women) are shown in Table 2, and indicate that, from the statistical point of view, there was a significant difference between premenopausal and postmenopausal women (t 3.56, p 0.001). This suggests that postmenopausal women experience higher levels of depression than premenopausal women.
Hypothesis four The results from the fourth question (whether there are significant differences in vitality between premenopausal and postmenopausal women) are shown in Table 2, and indicated that, from the statistical point of view, there was a significant difference between premenopausal and postmenopausal women (t 2.92, p 0.001). This suggests that
Table 2 Comparison of depression, anxiety, quality of life, vitality and mental health in premenopausal (n 108) and postmenopausal (n 110) women Levene’s test for equality of variances
t-test for equality of means Component Depression Premenopause Postmenopause Anxiety Premenopause Postmenopause Quality of life Premenopause Postmenopause Vitality Premenopause Postmenopause Mental health Premenopause Postmenopause
Climacteric
Mean
Mean difference
Significance
d.f.
t
Significance
F
12.44 22.04
9.60
0.001
216
3.56
0.457
0.562
44.68 54.36
9.68
0.001
216
3.48
0.094
2.91
59.62 39.22
20.40
0.001
216
5.517
0.058
3.76
13.74 8.33
8.42
0.001
216
2.92
0.423
0.612
21.54 15.64
10.35
0.001
216
4.12
0.476
0.623
663
Comparison of quality of life in pre/postmenopausal women postmenopausal women experience lower levels of vitality than premenopausal women.
Hypothesis five
Climacteric Downloaded from informahealthcare.com by University of Ulster at Jordanstown on 11/30/14 For personal use only.
The results from the fifth question (whether there are significant differences in mental health between premenopausal and postmenopausal women) are shown in Table 2, and indicated that, from the statistical point of view, there was a significant difference between premenopausal and postmenopausal women (t 4.12, p 0.001). This suggests that postmenopausal women experience lower levels of mental health than premenopausal women
CONCLUSION AND DISCUSSION The results indicated that all five hypotheses were confirmed, meaning that postmenopausal women experience higher levels of anxiety and depression and lower levels of quality of life, mental health and vitality. The results of research by Z˙ołnierczuk-Kieliszek10, Short7, Deeks5, Genazzani22 and their colleagues are similar to our results. In a series of longitudinal studies23, 24, depression during middle age was predicted by psychosocial variables, physical distress, and history of depression rather than by menopause status, except, perhaps, for a subset of women. Neugarten and Kraines25 reported that women complaining of psychological distress around the menopausal period are those who have manifested low self-esteem and low rates of satisfaction throughout their lives. Psychological symptoms such as anxiety, depression and insomnia are most common just before the onset of menopause; vasomotor symptoms with night sweats often lead to chronic fatigue, sleep deprivation and hence indirectly to psychological symptoms such as depression. The results of the analysis of answers given by premenopausal and postmenopausal women about their daily experiences in this sample suggest that postmenopausal women compared to premenopausal women claim lower levels of quality of life. Taking into account the fact that Iran is considered to be a developing country, the status of women is not so favorable. A woman in Iran as wife, mother and child has to do her best to perform the tasks of being responsible for having an appropriate relationship with her husband and her family’s husbands, rearing her children and helping them to resolve their educational and relationship problems, taking care of her and her husband’s old parents and, in addition, handling her own job and social activities. Studying, employment and the fulfillment of individual needs are some of the activities that cannot be ignored in order to enter the modern world. As a result of all these activities plus the fact that there is not enough time for leisure and rest and for attaining desir-
664
Jafari et al. able standards of health by exercising, eating correctly and desirable social interaction, when these women reach the stage of menopause, they will consider the first symptoms of menopause as serious alarms for the reduction in their physical and mental abilities. Since there are not any planned programs to inform women of the mental and physiological changes that happen simultaneously as they reach menopause, during this relatively long period of their lives, they do not get a chance to use the experiences gained in accordance with their capabilities. Practitioners will benefit from an understanding and exploration of the previous history of mood disturbance, prior thoughts and behavior patterns in their menopausal patients. With the physiological changes at menopause often mimicking the symptoms of depression and anxiety, it is important to differentiate between what is true depression and anxiety, and what can be related to menopause6. Two types of psychotherapy are highly recommended for depression related to menopause. Interpersonal therapy focuses on understanding how changing human relationships may contribute to, or relieve, depression. Cognitivebehavioral therapy focuses on identifying and changing the pessimistic thoughts and beliefs that accompany depression. When used alone, psychotherapy usually works more gradually than medication, taking 2 months or more to show its full effects. However, the benefits may be long lasting. Psychotherapy is usually combined with medication in major depression26. The effects of self-statements and positive thoughts in changing their attitudes toward menopause and life satisfaction can be helpful. Exercises were provided to find meaning in life as well as goals and values in life in accordance with the new conditions of menopause. Promotion of self-efficacy by recognizing successful past experiences, considering models of similar successful individuals or seeking past social confirmations were included in the sessions. Coping with physical and body changes, accepting them, and dealing with exaggeration and excessive aggrandizement or feelings of happiness and life satisfaction due to physical attractiveness can also be useful27. Ultimately, all these variables are beliefs or feelings that relate to each other and can produce peace, happiness, a feeling of well-being, self-efficacy, capability, goal orientation, value, and, in general, a good quality of life in menopausal women11. Considering the obtained results from this research and the deficiencies felt by the researchers during this research, the following important points for the current conditions and future studies are recommended. • Educating the husbands of women going through menopause to make them aware of changes in this period and give them more understanding of their wives; • Educating women about menopause and its common symptoms before they reach the age of menopause;
Climacteric
Comparison of quality of life in pre/postmenopausal women • Holding and coordinating individual or group exercise classes for women with menopause (for the purpose of helping to elevate women’s social, emotional and physical conditions); • Broadcasting appropriate programs about menopause through the mass media.
Jafari et al. Conflict of interest The authors report no confl ict of interest. The authors alone are responsible for the content and writing of this paper. Source of funding
Nil.
Climacteric Downloaded from informahealthcare.com by University of Ulster at Jordanstown on 11/30/14 For personal use only.
References 1. Zoler YF, Acquadro C, Schaefer M. Literature review of instruments to assess health-related quality of life during and after menopause. Qual Life Res 2005;14:309–27 2. Schilling C, Gallicchio L, Miller SR, Langenberg P, Zacur H, Flaws JA. Relation of body mass and sex steroid hormone levels to hot flushes in a sample of midlife women. Climacteric 2007;10:27–37 3. Avis NE, Ory MG, Mathews KA, Shocken M, Bromberger J, Colvin A. Health-related quality of life in a multiethnic sample of middle-aged women. Med Care 2003;41:1262–76 4. Utian WH. Quality of life (QOL) in menopause. Maturitas 2007;57:100–2 5. Deeks AA. Psychological aspects of menopause management. Clin Endocrinol Metab 2003;17:17–31 6. Deeks AA. Sexual desire: menopause and its psychological impact. Aust Fam Physician 2002;31:433–9 7. Short M. Menopause, mood and management. Climacteric 2003;6:33–6 8. Fu SY, Anderson D, Courtney M. Cross-cultural menopausal experience: comparison of Australian and Taiwanese women. Nurs Health Sci 2003;5:77–84 9. Li S, Carlson ES, Snyder D, et al. Perspectives on menopause. Clin Nurse Specialist 1995;9:145–7 10. Z˙ ołnierczuk-Kieliszek D, Kulik TB, Jarosz MJ, et al. Quality of life in pre- and post-menopausal Polish women living in Lublin Province – differences between urban and rural dwellers. Ann Agric Environ Med 2012;19:129–33 11. Jafary F, Farahbakhsh K, Shafiabadi A, Delavar A. Quality of life and menopause: developing a theoretical model based on meaning in life, self-efficacy beliefs, and body image. J Aging Mental Health 2011;15:630–7 12. Bloch A. Self-awareness during the menopause. Maturitas 2002;41:61–8 13. Pan HA, Wu MH, Hsu CC, Yao BL, Huong KE. The perception of menopause among women in Taiwan. Maturitas 2002;41: 269–74
Climacteric
14. Karami A. Zung Anxiety Self-report Scale. Tehran, Iran: Sina Psychometric Institution, 2004 15. Gilani B. Anxiety after war. J Psychol Res 1991;1:6–11 16. Beck AT, Steer RA, Garbun MG. Psychometric properties of the Beck Depression Inventory: twenty-five years of evaluation. Clin Psychol Rev 1988;8:77–100 17. Gharaii B. Determining identification states and their relation to identification styles and depression in adolescents. PhD thesis in clinical psychology, University of Medical Sciences of Iran, Psychiatric Institution [in Persian] 18. Tashakori A. The analysis of women’s attitude and action in the city of Mashhad about menopause. MA thesis in midwifery from the University of Medical Science in Mashhad, 1995 19. Posht-Mashhadi M. The study of effect of cognitive-behaviour treatment in pain disorder. MS Thesis, Tehran, 2001 [Persian] 20. Ware JE, Sherbourne CD. The MOS 36-item Short Form Health Survey (SF-36). I. Conceptual framework and item selection. Med Care 1992;30:473–83 21. Montazeri A, Goshtasbi A, Vahdani-Niam. Translation, validity and reliability of Iranian version of SF-36 questionnaire. Q J Payesh 2005;49–50 22. Genazzani AR, Gambacciani M, Simoncini T. Menopause and aging, quality of life and sexuality. Climacteric 2007;10:88–96 23. Dennerstein L, Lehert P, Burger H, Dudley E. Mood and the menopausal transition. J Nerv Ment Dis 1999;187:685–91 24. Kaufert PA, Gilbert P, Tate R. The Manitoba Project: re-examination of the link between menopause and depression. Maturitas 1992;14:143–55 25. Neugarten BL, Kraines RJ. Menopausal symptoms in women of various ages. Psychosom Med 1965;27:266–73 26. Kahn DA, Moline ML, Ross RW, Altshuler LL, Cohen LS. Depression during the transition to menopause: A Guide for Patients and Families. www.womensmentalhealth.org 27. Jafary F, Afzali L. Comparison of the effectiveness of four group therapies in improving the quality of life in menopausal women. Przegl d Menopauzalny 2013;3:194–201
665
