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Contents lists available at ScienceDirect
Maturitas journal homepage: www.elsevier.com/locate/maturitas
Self-compassion weakens the association between hot flushes and night sweats and daily life functioning and depression
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Lydia Brown a,∗ , Christina Bryant a,b , Valerie M. Brown a , Bei Bei a,b,c,d , Fiona K. Judd b,d a
Melbourne School of Psychological Sciences, Redmond Barry Building, University of Melbourne, VIC 3010, Australia Centre for Women’s Mental Health, Royal Women’s Hospital, Locked Bag 300, Grattan St & Flemington Rd, Parkville, VIC 3052, Australia School of Psychological Sciences, Monash University, Building 17, Clayton Campus, Wellington Road, VIC 3800, Australia d Department of Psychiatry, University of Melbourne, Level 1 North, Main Block, Royal Melbourne Hospital, VIC 3050, Australia b c
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Article history: Received 28 March 2014 Received in revised form 14 May 2014 Accepted 19 May 2014 Available online xxx
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Keywords: Menopause Self-compassion Hot flushes Night sweats Midlife Well-being
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1. Introduction
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Objectives: Some women find hot flushes and night sweats (HFNS) to interfere more in daily life and mood than others. Psychological resources may help to explain these individual differences. The aim of this study was to investigate the role of self-compassion, defined as healthy way of relating toward the self when dealing with difficult experiences, as a potential moderator of the relationship between HFNS and daily life activities, which in turn influences symptoms of depression. Study design: This was a cross-sectional study using questionnaire data from 206 women aged 40–60 who were currently experiencing hot flushes and/or night sweats. Path analysis was used to model relationships among menopausal factors (HFNS frequency and daily interference ratings), self-compassion and mood. Main outcome measure: Hot flush interference in daily activities and depressive symptoms. Results: On average, women experienced 4.02 HFNS per day, and HFNS frequency was moderately correlated with interference ratings (r = 0.38). In the path analytic model, self-compassion made significant direct contribution to hot flush interference ratings (ˇ = −0.37) and symptoms of depression (ˇ = −0.42), and higher self-compassion was associated with lower interference and depressive symptoms. Selfcompassion also moderated the relationship between HFNS frequency and hot flush interference. Higher self-compassion was associated with weaker effects of HFNS frequency on daily interference. Conclusions: Self-compassion may weaken the association between HFNS and daily life functioning, which in turn, could lead to less HFNS-related mood problems. These findings imply that self-compassion may be a resilience factor to help women manage hot flushes and night sweats. © 2014 Published by Elsevier Ireland Ltd.
Hot flushes and night sweats (HFNS) are common during the menopausal transition and early postmenopause, affecting up to 75% of midlife women [1]. HFNS cause substantial burden on quality of life [2], sleep [3], work [1] and mood [4], and they are one of the leading reasons why women seek medical help at midlife [5].
Abbreviations: HFNS, hot flushes and night sweats; HFI, Hot Flush Related Daily Interference Scale; CES-D, Centre for Epidemiologic Studies Depression Scale; BMI, body mass index. ∗ Corresponding author at: Melbourne School of Psychological Sciences, Redmond Barry Building, University of Melbourne, VIC 3010, Australia. Tel.: +61 437 552 208. E-mail addresses: [email protected], [email protected] (L. Brown).
Women’s experience of HFNS is heterogeneous, influenced by physiological, symptom detection and appraisal components [6]. Physiological studies have shown that women underestimate up to 75% of objective hot flushes in their self-reported frequency ratings [7]. Self-reported HFNS have at least some direct influence on well-being outcomes, such as depressive symptoms [4] and also contribute to subjective appraisals of distress, bothersomeness and interference with daily life functioning. It is these subjective appraisals that most strongly relate to well-being outcomes [6]. Interestingly, self-reported frequency is only moderately associated with daily interference, with published bivariate correlations in the range of 0.15 [7] to 0.45 [8]. For a given level of perceived symptoms, therefore, there is a large degree of individual difference in the level of interference experienced in daily life. Why do hot flushes interfere with daily activities more for some women than others? The answer to this question is still poorly understood. Cognitive factors including attitudes and beliefs about the
http://dx.doi.org/10.1016/j.maturitas.2014.05.012 0378-5122/© 2014 Published by Elsevier Ireland Ltd.
Please cite this article in press as: Brown L, et al. Self-compassion weakens the association between hot flushes and night sweats and daily life functioning and depression. Maturitas (2014), http://dx.doi.org/10.1016/j.maturitas.2014.05.012
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2. Materials and methods
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2.1. Participants
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Participants were selected from a larger sample of men and women aged between 18 and 101 (N = 7615) randomly recruited from the electoral roll who had participated in an earlier study of mental health and wellbeing [19]. Women in the original study who were aged between 40 and 60 at the time of data collection, and who had indicated their willingness to be involved in further research (n = 1450) were invited to participate in this study. 2.2. Measures Fig. 1. Hypothesized conceptual model of the roles of self-compassion, HFNS frequency, and hot flush interference in predicting depressive symptoms. Note: HFNS, hot flushes and night sweats; CES-D, Center for Epidemiologic Studies Depression Scale.
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menopause [9], and the perception of symptoms as having high life consequences [10] are known to contribute to the burden of symptoms. However, prior studies have only examined the independent contributions of these factors to problem ratings. To our knowledge no psychological moderator of the relationship between reported HFNS frequency and interference with daily life functioning has been identified to date. Previously, relatively fixed factors such as health diagnosis and personality have been identified as moderators in the menopause literature [11,12]. Carpenter et al., for instance, found that perceived control plays a more important role in how much HFNS interfere in daily life for breast cancer survivors relative to healthy midlife women [11]. This finding demonstrates HFNS interference might vary as a function of a woman’s health status, and opens the possibility that other personal characteristics might be relevant as well. While diagnosis and personality are reasonably fixed factors, we were interested in uncovering a more readily modifiable psychological moderator of the relationship between HFNS frequency and interference with daily life functioning. Self-compassion is defined as a healthy way of relating toward the self when dealing with difficult experiences [13]. It incorporates three interrelated dichotomies: self-kindness (as opposed to selfjudgment), a sense of common humanity (rather than a sense of isolation), and mindfulness (rather than over-identification) when considering personal weaknesses or imperfections. Unlike selfesteem, which can be undermined by personal difficulties including menopause symptoms [14], self-compassion is especially relevant when times get tough. Self-compassion is a strong predictor of psychological health among younger and older adults [15,16], and is also known to attenuate the impact of experiences involving embarrassment, failure and rejection [17]. Given that some midlife women find HFNS to be embarrassing, uncomfortable and disruptive [6], it is plausible that self-compassion may similarly lighten the impact that HFNS have on daily activities and subsequently well-being. Self-compassion is a skill that can be taught [18] so if supported, this hypothesis could have clinical implications for the psychological management of HFNS. The purpose of the current study is to examine the relationships between HFNS symptom frequency, HFNS interference in daily functioning, self-compassion and symptoms of depression using a path analysis framework. In particular, the possibility that selfcompassion moderates the relationship between HFNS frequency and daily interference will be explored, such that for a given level of symptomatology, those with high self-compassion will experience less interference in daily functioning relative to those with low self-compassion. The hypothesized conceptual model illustrated in Fig. 1.
2.2.1. Frequency of hot flushes and night sweats Participants were asked to indicate on average how many hot flushes and night sweats they currently experienced. They were given the option of reporting their average number of HFNS per day, per week or per month. All scores were then converted into an average daily frequency for comparison. 2.2.2. Hot Flush Related Daily Interference Scale (HFI) The HFI is a 10-item scale measuring the degree to which hot flushes interfere with nine daily activities including work, socializing, leisure, sleep, mood, concentration, relaxation, sex and enjoyment of life [20]. The remaining item assesses overall interference with quality of life. Participants rate the degree of interference on a scale ranging from 0 (do not interfere) to 10 (completely interfere). A total score is computed by summing items, with a higher score indicating a greater impact of hot flushes on quality of life. The HFI has good published reliability and validity [20], and Cronbach’s ˛ was 0.95 in this study. 2.2.3. Menopausal status The Stages of Reproductive Ageing Workshop + 10 criteria (STRAW + 10) were used to assess menopausal status [21]. Women were classified into four reproductive stages based on the regularity of their menses, which is the principal STRAW criterion. Women were classified as being premenopausal (regular menstrual cycles or subtle changes in length/flow), early perimenopausal (variable cycle length, with a persistent change of ≥7 days in consecutive cycles), late perimenopausal (interval of amenorrhea of at least 60 days) or postmenopausal (at least 12 months of amenorrhea). The STRAW + 10 criteria are validated for use regardless of a women’s age, ethnicity, body size or lifestyle characteristics [21]. 2.2.4. Self-Compassion Scale (SCS) The SCS is a 26-item scale measuring six facets of selfcompassion: self-kindness, self-judgment, common humanity, isolation, mindfulness and over-identification [13]. Participants indicated agreement to statements describing responses to challenging experiences (for example “when I see aspects of my personality that I don’t like, I get down on myself”) on a 5-point Likert scale ranging from 1 “Almost never” to 5 “Almost always.” Subscale scores were created by averaging across subscale items. A total score was generated through obtaining a grand mean, after reverse-scoring self-judgment, isolation and over-identification items. Research demonstrates the SCS has good test–retest reliability (˛ = 0.93; Neff [13]) and has convergent validity (e.g. self ratings correlate with therapist ratings), concurrent validity (e.g. correlates with social connectedness) and discriminate validity (e.g. no correlation with social desirability or narcissism). In this study Cronbach’s ˛ was acceptable for all subscales: self-kindness ˛ = 0.86, self-judgment ˛ = 0.85, common humanity ˛ = 0.77,
Please cite this article in press as: Brown L, et al. Self-compassion weakens the association between hot flushes and night sweats and daily life functioning and depression. Maturitas (2014), http://dx.doi.org/10.1016/j.maturitas.2014.05.012
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isolation ˛ = 0.82, mindfulness ˛ = 0.78 and over-identification ˛ = 0.81. For the full scale, Cronbach’s ˛ was 0.94.
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2.2.5. Centre for Epidemiological Studies Depression Scale (CES-D) This is a widely used 20-item scale assessing symptoms of depression during the previous week on a 4-point scale from 0 (“rarely”) to 3 (“most or all of the time”). A score 16 or greater indicates moderate symptoms of depression [22]. The CES-D has good internal consistency and validity for use among midlife women [23], and in this study Cronbach’s ˛ was 0.94.
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Data were collected between March and August 2013. Participants (n = 1450) were mailed a questionnaire booklet, a plain language statement, a consent form, and a prepaid envelope. To enhance the response rate, a second copy of the questionnaire and consent form was sent to participants who did not respond within two months. Ethics approval for the study was sought and obtained from the University of Melbourne’s Human Ethics Committee (HERC#1136819.1).
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2.4.1. Raw data handling Scales that had more than two items missing (or 10%, whichever was lower) were considered incomplete and were therefore removed from relevant analyses. As a result, 3 (1.5%) responses from the HFI, 3 (1.5%) responses from the self-compassion questionnaire and 4 (1.9%) responses from the CES-D were removed from the analysis. This cut-off allowed for the inclusion of cases with 1 (i.e. 10 on the SCS, 6 on the CES-D and 1 on the HFI) or 2 (i.e. 3 on the SCS and 1 on the CES-D) items missing, thus reducing bias toward complete responses without compromising the validity of the data. Valid mean substitution [24] was used to impute remaining missing values. Valid mean substitution involves replacing a missing item with the case mean for the relevant subscale and is known to offer a good representation of original data when the rate of missing data is less than 20% [25]. Valid mean substitution has the advantage over grand mean substitution in that it controls for individual differences, such that imputed values are not unduly affected by scores of the rest of the sample [24]. Given the low numbers of women in the early perimenopausal (n = 6) and late perimenopausal stages (n = 20), these categories were collapsed to form the perimenopausal group. A logarithmic transformation was performed on HFNS frequency and body mass index (BMI) to adjust for significant positive skew. All independent variables were standardized prior to conducting the analysis. Questionnaires were scored using standard scoring methods. 2.4.2. Statistical analyses To assess the feasibility of the model, bivariate associations between menopausal factors, self-compassion, depressive symptoms and demographics were tested with one-way analysis of variance (ANOVA) and Pearson’s r correlation. The conceptual model in Fig. 1 was estimated using path analysis, and missing data was handled using full information maximum likelihood. The moderating role of self-compassion in the relationship between HFNS frequency and HFI was tested by including an interaction term between HFNS frequency and self-compassion. Overall model fit was assessed through multiple fit statistics, with p > 0.05 for likelihood-ratio 2 , comparative fit index (CFI) ≥ 95, the root means square error of approximation (RMSEA) ≤ 06, and the standardized root mean square residual (SRMR) ≤ 08, indicating good fit [26,27]. Data were processed with
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IBM SPSS Version 21.0, and path analysis was conducted using Mplus version 6.0 [28].
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Valid consent and questionnaire responses were received from 517 participants, resulting in a response rate of 35.7%. Of these respondents 206 reported current hot flushes and/or night sweats. This subset of respondents constitutes the sample for this study. The mean age of the sample (n = 206) was 53.64 years (SD = 4.00). The majority of subjects were postmenopausal (71.8%), of which 23 (11.2%) had had surgical menopause. Eight women (3.9%) were currently using hormone replacement therapy (HRT). Most subjects were of an Australian background (92.7%), married (77.7%) and were living with their spouse either with (34.5%) or without (47.1%) children. The women were mostly working either full-time (35.9%) or part-time (44.2%). Table 1 includes detailed information on the characteristics of the sample.
Table 1 Demographic characteristics of the sample. Variable
Description
Age Menopause status Premenopausal Perimenopausal Postmenopausal (total) Natural menopause Surgical menopause Current HRT use Education Up to year 10 Up to year 12 Apprenticeship Undergraduate degree Postgraduate degree Other Missing Ethnicity Australian Indigenous Australian British Other Missing Employment status Disability/sickness benefit Unemployed Full time house duties Retired Working part-time Working full-time Missing Relationship status Married Separated/divorced Widowed Single/never married Other Missing Living situation Living with spouse/partner Living with spouse/partner and children Lone parent Living alone Living with parent(s) Other Missing BMI
M = 53.64; SD = 5.49 30 (14.6%) 26 (12.6%) 148 (71.8%) 124 (60.2%) 23 (11.2%) 8 (3.9%) 66 (32.0%) 25 (12.1%) 64 (30.0%) 29 (14.1%) 16 (7.8%) 4 (1.9%) 2 (1%) 191 (92.7%) 5 (2.4%) 3 (1.5%) 6 (2.9%) 1 (0.5%) 10 (4.9%) 5 (2.4%) 16 (7.8%) 10 (4.9%) 91 (44.2%) 74 (35.9%) 0 160 (77.7%) 27 (13.1%) 11 (5.3%) 4 (1.9%) 4 (1.9%) 0 97 (47.1%) 71 (34.5%) 14 (6.8%) 20 (9.7%) 3 (1.5%) 1 (0.5%) 0 M = 28.47, SD = 6.49
Note: HRT, hormone replacement therapy; BMI, body mass index.
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Table 4 Standardized parameter estimates (standard errors) of paths predicting HFI and CES-D.
Variable
Mean (SD)
HFNS daily frequency Hot flush interference – total Work Socializing Leisure Sleep Mood Concentration Relaxation Sex Joy Quality of life Self-Compassion CES-D
4.02 (5.70) 2.96 (2.39) 2.13 (0.94) 1.77 (0.17) 1.80 (0.17) 5.91 (0.20) 3.45 (0.22) 3.45 (0.21) 2.35 (0.19) 3.49 (0.24) 2.64 (0.21) 2.54 (0.21) 3.25 (0.64) 12.98 (11.14)
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3.2. Bivariate analyses The women reported an average of 4.02 HFNS per day, and a mean interference rating on the HFI of 2.96/10. Consistent with normative data [20], hot flushes interfered most with sleep (5.91/10). Sex (3.49/10), concentration (3.45/10) and mood (3.45/10) were also moderately affected. Means and standard deviations of these study variables as well as self-compassion and self-reported depressive symptoms are shown in Table 2. Preliminary one-way ANOVA indicated that menopausal status, menopausal type (surgical versus natural) and ethnicity were independent of all study variables, and were therefore not included in the model. Higher depressive symptoms were associated with younger age (r = −0.22, p = 0.001), not having a partner (r = 0.17, p = 0.02) and being unemployed (r = 0.31, p < 0.001), but not with HRT use (r = 0.01, p = 0.85) or BMI (r = 0.15, p = 0.53). HFI was associated with current HRT use (r = 0.13, p = 0.048), higher BMI (r = 0.17, p = 0.02) and being unemployed (r = 0.19, p = −0.006), but not with education (r = −0.11, p = 0.12), age (r = −0.14, p = 0.05) or relationship status (r = −0.09, p = 0.21). Intercorrelations between key study variables are summarized in Table 3. CES-D and HFI were significantly associated with all study variables, with effect sizes ranging from 0.19 to 0.60 and 0.36 to 0.55, respectively. 3.2.1. Path analysis The hypothesized path model offered a very good fit for the data (2 (1) = 0.52, p = 0.47, CFI = 1.00, RMSEA < 0.001, SRMR = 0.004). The HFNS × self-compassion interaction term was significant in predicting HFI (ˇ = −0.21, p < 0.001), demonstrating the moderating role of self-compassion in the model. There was no significant direct effect of HFNS frequency on depressive symptoms (ˇ = −0.031, p = 0.57). However, by including HFI as a mediator, HFNS frequency had a significant indirect effect on mood (ˇ = 0.095, p = 0.001). Significant covariates in the model included current use of HRT predicting higher HFI (ˇ = 0.17, p = −0.001), and being without a Table 3 Intercorrelation matrix of study variables. Variable 1. CES-D 2. Hot flush interference 3. HFNS frequency 4. Self-compassion
1 1
2
3 **
0.55 1
4 **
0.19 0.38** 1
HFI
CES-D
Self-compassion HFNS frequency SC × HFNS frequency BMI HRT use Age Unemployment Relationship HFI
−0.37 (0.06)** 0.34 (0.06)** −0.21(0.06)** 0.099 (0.06) 0.17 (0.06)** −0.094 (0.06) 0.067 (0.06) −0.055 (0.06) NA
−0.42 (0.06)** −0.031 (0.06) NA −0.21 (0.06) 0.018 (0.05) −0.17 (0.05)** 0.17 (0.05)* −0.106 (0.05)** 0.28 (0.06)**
Note: HFNS, Hot flushes and night sweats; CES-D, Center for Epidemiologic Studies Depression Scale. * p < 0.05. ** p < 0.01.
Note: HFNS, hot flushes and night sweats; CES-D, Center for Epidemiologic Studies Depression Scale.
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Variable
−0.60 −0.49** −0.23** 1 **
Note: HFNS, hot flushes and night sweats; CES-D, Center for Epidemiologic Studies Depression Scale. ** p < 0.01.
partner (ˇ = −0.17, p = 0.038), unemployed (ˇ = 0.17, p = 0.001) and of younger age (ˇ = −0.17, p = 0.001) predicting greater depressive symptoms. Details of parameter estimates (standard errors) and statistical significance are shown in Table 4. The model explained approximately 51% of the variance in depressive symptoms, and 41% of the variance in HFI. Significant paths of the model are illustrated in Fig. 2. To determine the amount of unique variance contributed by the moderation effect, a nested model that constrained the SC × HFNS frequency interaction term to zero was constructed. The constrained model caused a drop in HFI r2 of 0.04–0.37. Therefore, the moderating effect of self-compassion served to explain 4% of unique variance in HFI over and above the contribution of direct effects. A plot of the relationship between HFNS frequency and HFI for women with low (1 SD below the mean), medium (mean) and high (1 SD above the mean) self-compassion is shown in Fig. 3. The relatively steeper slope for women with low self-compassion indicates that a given frequency of HFNS will cause more daily interference for this subgroup. 4. Discussion The primary objective of this study was to investigate the potential protective role of self-compassion in weakening the association between HFNS and daily life functioning, which in turn influences depression. We assessed the hypothesized model with preliminary bivariate tests followed by path analysis, with HFNS interference and depressive symptoms included as endogenous outcome variables. Our results indicated that self-compassion was both a direct predictor of HFNS interference and depressive symptoms, and also a powerful moderator of the relationship between HFNS frequency and the degree to which HFNS symptoms interfere with daily life. Consistent with prior work [6–8], HFNS interference rating was a significant predictor of depressive symptoms, and a stronger predictor than HFNS frequency. HFNS frequency was significantly correlated with depression in bivariate analyses (r = 0.19, p < 0.01), which is compatible with a recent review [4]. The direct relationship failed to reach significance in the final model, however, when demographic factors and HFNS interference were also taken into account. Instead, there was an indirect effect of HFNS frequency on depressive symptoms via HFNS interference. This demonstrates that a key mechanism by which self-reported HFNS influence mood is the degree to which symptoms interfere with daily activities. Self-compassion was the strongest direct predictor of HFNS interference (ˇ = −0.37), followed by HFNS frequency (ˇ = 0.34). Consistent with prior work, this finding adds weight to the argument that emotional and cognitive factors are central contributors to HFNS appraisals. In a cognitive model of hot flushes, Hunter and
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Fig. 2. Path analysis testing the interaction of self-compassion and HFNS in contributing to HFI and depressive symptoms. Path coefficients are standardized. Note: HFNS, hot flushes and night sweats; CES-D, Center for Epidemiologic Studies Depression Scale.
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Chilcot identified social, control and sleep beliefs as being central predictors of HFNS problem ratings [6]. While these factors are predominantly cognitive in nature, here we identify an emotional factor, with cognitive components (self-compassion) that is likewise important. Self-compassion was also the strongest direct predictor of depressive symptoms in the model, followed closely by HFNS interference. This demonstrates that a combination of psychological and menopause-specific factors contribute to mood at midlife, and these should be considered in tandem when conceptualizing mood and depression among midlife women. As hypothesized, self-compassion significantly moderated the relationship between HFNS frequency and HFNS interference, such that for a given frequency of HFNS, those women with high selfcompassion experienced less symptom interference in daily life. This finding helps to explain why some women find symptoms more interfering than others. Given that HFNS can be disruptive and embarrassing; self-compassion may provide a psychological resource to help women deal with the challenge through selfkindness, a sense of common humanity and mindfulness. Those
Fig. 3. Interaction effect between HFNS frequency and self-compassion in predicting hot flush interference in daily functioning. All variables are standardized Z scores. Note: HFNS, hot flushes and night sweats.
women low on self-compassion, on the other hand, may reinforce difficulties related to their symptoms through self-criticism (e.g. ‘I am stupid for feeling this way’), a sense of isolation (e.g. ‘I am the only one suffering from hot flushes’) and over-identification (e.g. ‘these symptoms define who I am’). These maladaptive reactions, in turn, exacerbate the degree to which symptoms interfere with women’s lives. A recent randomized controlled trial has demonstrated that the 8 week Mindful Self-Compassion group programme significantly reduces symptoms of depression relative to waitlist controls, with gains maintained at 6 month and 1 year follow ups [18]. This demonstrates that self-compassion is modifiable, and that changes in self-compassion can have a direct influence on well-being. Given that the current study has demonstrated the relevance of selfcompassion to menopausal factors in a cross-sectional design, it is plausible that attempts to bolster self-compassion may serve the dual purpose of influencing mood and menopause related issues simultaneously, a hypothesis to be tested in future experimental research. A limitation of the study is the cross-sectional nature of the findings, meaning that directions of causality cannot be confirmed. As such, while we have found that self-compassion acts as a moderator, weakening the association between HFNS and daily interference, a future experimental study design is needed to clarify directions of causality. Secondly, the study had a relatively modest response rate of 35.7%. While the study was cross-sectional, data collection resembled that of a longitudinal design due to participants’ prior participation in the larger project. The lowerthan-desired response rate was comparable with other longitudinal studies [29], where attrition is a common problem. Our sample size was nonetheless large enough to permit robust statistical analyses, but was arguably skewed toward better functioning individuals. An interesting extension, therefore, could be to consider self-compassion as a mediator of HFNS and other climacteric symptoms in a clinical setting such as a menopause clinic, where women are seeking help for more acute symptoms. This study examined depressive symptoms as the sole well-being outcome variable. Since a growing body of evidence is linking anxiety with HFNS [6,30], exploring self-compassion in the context of anxiety and menopausal factors would be worthy of investigation. In summary, this study explores the role of self-compassion in attenuating the impact of HFNS on daily activities and
Please cite this article in press as: Brown L, et al. Self-compassion weakens the association between hot flushes and night sweats and daily life functioning and depression. Maturitas (2014), http://dx.doi.org/10.1016/j.maturitas.2014.05.012
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depressive symptoms. Prior work has identified cognitive factors that help explain why some women but not others are troubled by HFNS [6]. This study extends our understanding of these individual differences through identifying that a woman’s relationship toward herself, specifically how compassionate she is toward herself, is also worthy of note. Since self-compassion is a skill that responds well to training [18], this finding has clinically relevant implications for the management of HFNS. Given that the Mindful Self-Compassion group programme is an evidence-based approach to bolstering self-compassion [18], women experiencing menopause related disturbances to well-being may benefit from taking part in a programme of this type. Finally, this study provides the impetus for an experimental study to assess self-compassion training as an alternative or adjunct to CBT and pharmacological treatments for hot flushes and night sweats. Contributors Ms. L. Brown, Ms. V. Brown, Dr. Bryant and Professor Judd formulated the research question and designed the study. Ms. L. Brown, Ms. V. Brown and Dr. Bryant carried out data collection. Ms. L. Brown and Dr. Bei were responsible for carrying out the statistical analysis. Ms. Brown wrote the paper, and all authors contributed to its revision. Competing interest
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None.
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Funding
The cost of printing and mailing the questionnaire where all study data was obtained was covered by a small grant available to 397 Q3 PhD students in the School of Psychological Sciences, University of 398 Q4 399 Melbourne. 396
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Acknowledgement We thank the participants for their time and ongoing interest in this study. References [1] Utian WH. Psychosocial and socioeconomic burden of vasomotor symptoms in menopause: a comprehensive review. Health Qual Life Out 2005;3(1):47. [2] Avis NE, Colvin A, Bromberger JT, et al. Change in health-related quality of life over the menopausal transition in a multiethnic cohort of middle-aged women: study of Women’s Health Across the Nation (SWAN). Menopause 2009;16(5):860. [3] Brown JP, Gallicchio L, Flaws JA, Tracy JK. Relations among menopausal symptoms, sleep disturbance and depressive symptoms in midlife. Maturitas 2009;62(2):184–90.
[4] Worsley R, Bell R, Kulkarni J, Davis SR. The association between vasomotor symptoms and depression during perimenopause: a systematic review. Matu- Q5 ritas 2014. [5] Freeman EW, Sammel MD, Lin H, Liu Z, Gracia CR. Duration of menopausal hot flushes and associated risk factors. Obstet Gynecol 2011;117(5):1095. [6] Hunter MS, Chilcot J. Testing a cognitive model of menopausal hot flushes and night sweats. J Psychosom Res 2013;74(4):307–12. [7] Carpenter JS, Rand KL. Modeling the hot flash experience in breast cancer survivors. Menopause 2008;15(3):469–75. [8] Rand KL, Otte JL, Flockhart D, et al. Modeling hot flushes and quality of life in breast cancer survivors. Climacteric 2011;14(1):171–80. [9] Hunter MS, Mann E. A cognitive model of menopausal hot flushes and night sweats. J Psychosom Res 2010;69(5):491–501. [10] Duffy OK, Iversen L, Aucott L, Hannaford PC. Factors associated with resilience or vulnerability to hot flushes and night sweats during the menopausal transition. Menopause 2013;20(4):383–92. [11] Carpenter JS, Wu MJ, Burns DS, Yu M. Perceived control and hot flashes in treatment-seeking breast cancer survivors and menopausal women. Cancer Nurs 2012;35(3):195. [12] Lin M-F, Ko H-C, Wu JYW, Chang F-M. The impact of extroversion or menopause status on depressive symptoms among climacteric women in Taiwan: neuroticism as moderator or mediator? Menopause 2008;15(1):138–43. [13] Neff KD. The development and validation of a scale to measure self-compassion. Self Identity 2003;2(3):223–50. [14] Elavsky S, McAuley E. Physical activity, symptoms, esteem, and life satisfaction during menopause. Maturitas 2005;52(3–4):374–85. [15] Barnard LK, Curry JF. Self-compassion: 1. Conceptualizations, correlates, & interventions. Rev Gen Psychol 2010;15(4):289. [16] Phillips WJ, Ferguson SJ. Self-compassion: 1. A resource for positive aging. J Gerontol B: Psychol Sci Soc Sci 2013;68(4):529–39. [17] Leary MR, Tate EB, Adams CE, Batts Allen A, Hancock J. Self-compassion and reactions to unpleasant self-relevant events: the implications of treating oneself kindly. J Pers Soc Psychol 2007;92(5):887. [18] Neff KD, Germer CK. A pilot study and randomized controlled trial of the mindful self-compassion program. J Clin Psychol 2013;69(1):28–44. [19] Murray G, Judd F, Jackson H, et al. Rurality and mental health: the role of accessibility. Aust N Z J Psychiatry 2004;38(8):629–34. [20] Carpenter JS. The Hot Flash Related Daily Interference Scale: a tool for assessing the impact of hot flashes on quality of life following breast cancer. J Pain Symptom Manage 2001;22(6):979–89. [21] Harlow S, Gass M, Hall JE, et al. Executive summary of the Stages of Reproductive Aging Workshop + 10 addressing the unfinished agenda of staging reproductive aging. Climacteric 2012;15(2):105–14. [22] Hertzog C, Van Alstine J, Usala PD, Hultsch DF, Dixon R. Measurement properties of the Center for Epidemiological Studies Depression Scale (CES-D) in older populations. Psychol Assess 1990;2(1):64. [23] Knight RG, Williams S, McGee R, Olaman S. Psychometric properties of the Centre for Epidemiologic Studies Depression Scale (CES-D) in a sample of women in middle life. Behav Res Ther 1997;35(4):373–80. [24] Raymond MR. Missing data in evaluation research. Eval Health Prof 1986;9(4):395–420. [25] Downey RG, King CV. Missing data in Likert ratings: a comparison of replacement methods. J Gen Psychol 1998;125(2):175–91. [26] Hu Lt, Bentler PM. Cutoff criteria for fit indexes in covariance structure analysis: conventional criteria versus new alternatives. Struct Equat Model 1999;6(1):1–55. [27] Schreiber JB. Core reporting practices in structural equation modeling. Res Soc Admin Pharm 2008;4(2):83–97. [28] Muthén L, Muthén B. Mplus software version 6.0. Los Angeles, CA: Muthén & Muthén; 2010. [29] Martin M, Grünendahl M, Martin P. Age differences in stress, social resources, and well-being in middle and older age. J Gerontol B: Psychol Sci Soc Sci 2001;56(4):214–22. [30] Bryant C, Judd FK, Hickey M. Anxiety during the menopausal transition: a systematic review. J Affect Disord 2012;139(2):141–8.
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Contents lists available at ScienceDirect
Maturitas journal homepage: www.elsevier.com/locate/maturitas
Self-compassion weakens the association between hot flushes and night sweats and daily life functioning and depression
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Lydia Brown a,∗ , Christina Bryant a,b , Valerie M. Brown a , Bei Bei a,b,c,d , Fiona K. Judd b,d a
Melbourne School of Psychological Sciences, Redmond Barry Building, University of Melbourne, VIC 3010, Australia Centre for Women’s Mental Health, Royal Women’s Hospital, Locked Bag 300, Grattan St & Flemington Rd, Parkville, VIC 3052, Australia School of Psychological Sciences, Monash University, Building 17, Clayton Campus, Wellington Road, VIC 3800, Australia d Department of Psychiatry, University of Melbourne, Level 1 North, Main Block, Royal Melbourne Hospital, VIC 3050, Australia b c
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Article history: Received 28 March 2014 Received in revised form 14 May 2014 Accepted 19 May 2014 Available online xxx
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Keywords: Menopause Self-compassion Hot flushes Night sweats Midlife Well-being
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1. Introduction
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Objectives: Some women find hot flushes and night sweats (HFNS) to interfere more in daily life and mood than others. Psychological resources may help to explain these individual differences. The aim of this study was to investigate the role of self-compassion, defined as healthy way of relating toward the self when dealing with difficult experiences, as a potential moderator of the relationship between HFNS and daily life activities, which in turn influences symptoms of depression. Study design: This was a cross-sectional study using questionnaire data from 206 women aged 40–60 who were currently experiencing hot flushes and/or night sweats. Path analysis was used to model relationships among menopausal factors (HFNS frequency and daily interference ratings), self-compassion and mood. Main outcome measure: Hot flush interference in daily activities and depressive symptoms. Results: On average, women experienced 4.02 HFNS per day, and HFNS frequency was moderately correlated with interference ratings (r = 0.38). In the path analytic model, self-compassion made significant direct contribution to hot flush interference ratings (ˇ = −0.37) and symptoms of depression (ˇ = −0.42), and higher self-compassion was associated with lower interference and depressive symptoms. Selfcompassion also moderated the relationship between HFNS frequency and hot flush interference. Higher self-compassion was associated with weaker effects of HFNS frequency on daily interference. Conclusions: Self-compassion may weaken the association between HFNS and daily life functioning, which in turn, could lead to less HFNS-related mood problems. These findings imply that self-compassion may be a resilience factor to help women manage hot flushes and night sweats. © 2014 Published by Elsevier Ireland Ltd.
Hot flushes and night sweats (HFNS) are common during the menopausal transition and early postmenopause, affecting up to 75% of midlife women [1]. HFNS cause substantial burden on quality of life [2], sleep [3], work [1] and mood [4], and they are one of the leading reasons why women seek medical help at midlife [5].
Abbreviations: HFNS, hot flushes and night sweats; HFI, Hot Flush Related Daily Interference Scale; CES-D, Centre for Epidemiologic Studies Depression Scale; BMI, body mass index. ∗ Corresponding author at: Melbourne School of Psychological Sciences, Redmond Barry Building, University of Melbourne, VIC 3010, Australia. Tel.: +61 437 552 208. E-mail addresses: [email protected], [email protected] (L. Brown).
Women’s experience of HFNS is heterogeneous, influenced by physiological, symptom detection and appraisal components [6]. Physiological studies have shown that women underestimate up to 75% of objective hot flushes in their self-reported frequency ratings [7]. Self-reported HFNS have at least some direct influence on well-being outcomes, such as depressive symptoms [4] and also contribute to subjective appraisals of distress, bothersomeness and interference with daily life functioning. It is these subjective appraisals that most strongly relate to well-being outcomes [6]. Interestingly, self-reported frequency is only moderately associated with daily interference, with published bivariate correlations in the range of 0.15 [7] to 0.45 [8]. For a given level of perceived symptoms, therefore, there is a large degree of individual difference in the level of interference experienced in daily life. Why do hot flushes interfere with daily activities more for some women than others? The answer to this question is still poorly understood. Cognitive factors including attitudes and beliefs about the
http://dx.doi.org/10.1016/j.maturitas.2014.05.012 0378-5122/© 2014 Published by Elsevier Ireland Ltd.
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2. Materials and methods
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2.1. Participants
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Participants were selected from a larger sample of men and women aged between 18 and 101 (N = 7615) randomly recruited from the electoral roll who had participated in an earlier study of mental health and wellbeing [19]. Women in the original study who were aged between 40 and 60 at the time of data collection, and who had indicated their willingness to be involved in further research (n = 1450) were invited to participate in this study. 2.2. Measures Fig. 1. Hypothesized conceptual model of the roles of self-compassion, HFNS frequency, and hot flush interference in predicting depressive symptoms. Note: HFNS, hot flushes and night sweats; CES-D, Center for Epidemiologic Studies Depression Scale.
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menopause [9], and the perception of symptoms as having high life consequences [10] are known to contribute to the burden of symptoms. However, prior studies have only examined the independent contributions of these factors to problem ratings. To our knowledge no psychological moderator of the relationship between reported HFNS frequency and interference with daily life functioning has been identified to date. Previously, relatively fixed factors such as health diagnosis and personality have been identified as moderators in the menopause literature [11,12]. Carpenter et al., for instance, found that perceived control plays a more important role in how much HFNS interfere in daily life for breast cancer survivors relative to healthy midlife women [11]. This finding demonstrates HFNS interference might vary as a function of a woman’s health status, and opens the possibility that other personal characteristics might be relevant as well. While diagnosis and personality are reasonably fixed factors, we were interested in uncovering a more readily modifiable psychological moderator of the relationship between HFNS frequency and interference with daily life functioning. Self-compassion is defined as a healthy way of relating toward the self when dealing with difficult experiences [13]. It incorporates three interrelated dichotomies: self-kindness (as opposed to selfjudgment), a sense of common humanity (rather than a sense of isolation), and mindfulness (rather than over-identification) when considering personal weaknesses or imperfections. Unlike selfesteem, which can be undermined by personal difficulties including menopause symptoms [14], self-compassion is especially relevant when times get tough. Self-compassion is a strong predictor of psychological health among younger and older adults [15,16], and is also known to attenuate the impact of experiences involving embarrassment, failure and rejection [17]. Given that some midlife women find HFNS to be embarrassing, uncomfortable and disruptive [6], it is plausible that self-compassion may similarly lighten the impact that HFNS have on daily activities and subsequently well-being. Self-compassion is a skill that can be taught [18] so if supported, this hypothesis could have clinical implications for the psychological management of HFNS. The purpose of the current study is to examine the relationships between HFNS symptom frequency, HFNS interference in daily functioning, self-compassion and symptoms of depression using a path analysis framework. In particular, the possibility that selfcompassion moderates the relationship between HFNS frequency and daily interference will be explored, such that for a given level of symptomatology, those with high self-compassion will experience less interference in daily functioning relative to those with low self-compassion. The hypothesized conceptual model illustrated in Fig. 1.
2.2.1. Frequency of hot flushes and night sweats Participants were asked to indicate on average how many hot flushes and night sweats they currently experienced. They were given the option of reporting their average number of HFNS per day, per week or per month. All scores were then converted into an average daily frequency for comparison. 2.2.2. Hot Flush Related Daily Interference Scale (HFI) The HFI is a 10-item scale measuring the degree to which hot flushes interfere with nine daily activities including work, socializing, leisure, sleep, mood, concentration, relaxation, sex and enjoyment of life [20]. The remaining item assesses overall interference with quality of life. Participants rate the degree of interference on a scale ranging from 0 (do not interfere) to 10 (completely interfere). A total score is computed by summing items, with a higher score indicating a greater impact of hot flushes on quality of life. The HFI has good published reliability and validity [20], and Cronbach’s ˛ was 0.95 in this study. 2.2.3. Menopausal status The Stages of Reproductive Ageing Workshop + 10 criteria (STRAW + 10) were used to assess menopausal status [21]. Women were classified into four reproductive stages based on the regularity of their menses, which is the principal STRAW criterion. Women were classified as being premenopausal (regular menstrual cycles or subtle changes in length/flow), early perimenopausal (variable cycle length, with a persistent change of ≥7 days in consecutive cycles), late perimenopausal (interval of amenorrhea of at least 60 days) or postmenopausal (at least 12 months of amenorrhea). The STRAW + 10 criteria are validated for use regardless of a women’s age, ethnicity, body size or lifestyle characteristics [21]. 2.2.4. Self-Compassion Scale (SCS) The SCS is a 26-item scale measuring six facets of selfcompassion: self-kindness, self-judgment, common humanity, isolation, mindfulness and over-identification [13]. Participants indicated agreement to statements describing responses to challenging experiences (for example “when I see aspects of my personality that I don’t like, I get down on myself”) on a 5-point Likert scale ranging from 1 “Almost never” to 5 “Almost always.” Subscale scores were created by averaging across subscale items. A total score was generated through obtaining a grand mean, after reverse-scoring self-judgment, isolation and over-identification items. Research demonstrates the SCS has good test–retest reliability (˛ = 0.93; Neff [13]) and has convergent validity (e.g. self ratings correlate with therapist ratings), concurrent validity (e.g. correlates with social connectedness) and discriminate validity (e.g. no correlation with social desirability or narcissism). In this study Cronbach’s ˛ was acceptable for all subscales: self-kindness ˛ = 0.86, self-judgment ˛ = 0.85, common humanity ˛ = 0.77,
Please cite this article in press as: Brown L, et al. Self-compassion weakens the association between hot flushes and night sweats and daily life functioning and depression. Maturitas (2014), http://dx.doi.org/10.1016/j.maturitas.2014.05.012
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isolation ˛ = 0.82, mindfulness ˛ = 0.78 and over-identification ˛ = 0.81. For the full scale, Cronbach’s ˛ was 0.94.
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2.2.5. Centre for Epidemiological Studies Depression Scale (CES-D) This is a widely used 20-item scale assessing symptoms of depression during the previous week on a 4-point scale from 0 (“rarely”) to 3 (“most or all of the time”). A score 16 or greater indicates moderate symptoms of depression [22]. The CES-D has good internal consistency and validity for use among midlife women [23], and in this study Cronbach’s ˛ was 0.94.
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Data were collected between March and August 2013. Participants (n = 1450) were mailed a questionnaire booklet, a plain language statement, a consent form, and a prepaid envelope. To enhance the response rate, a second copy of the questionnaire and consent form was sent to participants who did not respond within two months. Ethics approval for the study was sought and obtained from the University of Melbourne’s Human Ethics Committee (HERC#1136819.1).
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2.4.1. Raw data handling Scales that had more than two items missing (or 10%, whichever was lower) were considered incomplete and were therefore removed from relevant analyses. As a result, 3 (1.5%) responses from the HFI, 3 (1.5%) responses from the self-compassion questionnaire and 4 (1.9%) responses from the CES-D were removed from the analysis. This cut-off allowed for the inclusion of cases with 1 (i.e. 10 on the SCS, 6 on the CES-D and 1 on the HFI) or 2 (i.e. 3 on the SCS and 1 on the CES-D) items missing, thus reducing bias toward complete responses without compromising the validity of the data. Valid mean substitution [24] was used to impute remaining missing values. Valid mean substitution involves replacing a missing item with the case mean for the relevant subscale and is known to offer a good representation of original data when the rate of missing data is less than 20% [25]. Valid mean substitution has the advantage over grand mean substitution in that it controls for individual differences, such that imputed values are not unduly affected by scores of the rest of the sample [24]. Given the low numbers of women in the early perimenopausal (n = 6) and late perimenopausal stages (n = 20), these categories were collapsed to form the perimenopausal group. A logarithmic transformation was performed on HFNS frequency and body mass index (BMI) to adjust for significant positive skew. All independent variables were standardized prior to conducting the analysis. Questionnaires were scored using standard scoring methods. 2.4.2. Statistical analyses To assess the feasibility of the model, bivariate associations between menopausal factors, self-compassion, depressive symptoms and demographics were tested with one-way analysis of variance (ANOVA) and Pearson’s r correlation. The conceptual model in Fig. 1 was estimated using path analysis, and missing data was handled using full information maximum likelihood. The moderating role of self-compassion in the relationship between HFNS frequency and HFI was tested by including an interaction term between HFNS frequency and self-compassion. Overall model fit was assessed through multiple fit statistics, with p > 0.05 for likelihood-ratio 2 , comparative fit index (CFI) ≥ 95, the root means square error of approximation (RMSEA) ≤ 06, and the standardized root mean square residual (SRMR) ≤ 08, indicating good fit [26,27]. Data were processed with
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IBM SPSS Version 21.0, and path analysis was conducted using Mplus version 6.0 [28].
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3.1. Descriptive results
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Valid consent and questionnaire responses were received from 517 participants, resulting in a response rate of 35.7%. Of these respondents 206 reported current hot flushes and/or night sweats. This subset of respondents constitutes the sample for this study. The mean age of the sample (n = 206) was 53.64 years (SD = 4.00). The majority of subjects were postmenopausal (71.8%), of which 23 (11.2%) had had surgical menopause. Eight women (3.9%) were currently using hormone replacement therapy (HRT). Most subjects were of an Australian background (92.7%), married (77.7%) and were living with their spouse either with (34.5%) or without (47.1%) children. The women were mostly working either full-time (35.9%) or part-time (44.2%). Table 1 includes detailed information on the characteristics of the sample.
Table 1 Demographic characteristics of the sample. Variable
Description
Age Menopause status Premenopausal Perimenopausal Postmenopausal (total) Natural menopause Surgical menopause Current HRT use Education Up to year 10 Up to year 12 Apprenticeship Undergraduate degree Postgraduate degree Other Missing Ethnicity Australian Indigenous Australian British Other Missing Employment status Disability/sickness benefit Unemployed Full time house duties Retired Working part-time Working full-time Missing Relationship status Married Separated/divorced Widowed Single/never married Other Missing Living situation Living with spouse/partner Living with spouse/partner and children Lone parent Living alone Living with parent(s) Other Missing BMI
M = 53.64; SD = 5.49 30 (14.6%) 26 (12.6%) 148 (71.8%) 124 (60.2%) 23 (11.2%) 8 (3.9%) 66 (32.0%) 25 (12.1%) 64 (30.0%) 29 (14.1%) 16 (7.8%) 4 (1.9%) 2 (1%) 191 (92.7%) 5 (2.4%) 3 (1.5%) 6 (2.9%) 1 (0.5%) 10 (4.9%) 5 (2.4%) 16 (7.8%) 10 (4.9%) 91 (44.2%) 74 (35.9%) 0 160 (77.7%) 27 (13.1%) 11 (5.3%) 4 (1.9%) 4 (1.9%) 0 97 (47.1%) 71 (34.5%) 14 (6.8%) 20 (9.7%) 3 (1.5%) 1 (0.5%) 0 M = 28.47, SD = 6.49
Note: HRT, hormone replacement therapy; BMI, body mass index.
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4 Table 2 Means and standard deviations of study variables.
Table 4 Standardized parameter estimates (standard errors) of paths predicting HFI and CES-D.
Variable
Mean (SD)
HFNS daily frequency Hot flush interference – total Work Socializing Leisure Sleep Mood Concentration Relaxation Sex Joy Quality of life Self-Compassion CES-D
4.02 (5.70) 2.96 (2.39) 2.13 (0.94) 1.77 (0.17) 1.80 (0.17) 5.91 (0.20) 3.45 (0.22) 3.45 (0.21) 2.35 (0.19) 3.49 (0.24) 2.64 (0.21) 2.54 (0.21) 3.25 (0.64) 12.98 (11.14)
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3.2. Bivariate analyses The women reported an average of 4.02 HFNS per day, and a mean interference rating on the HFI of 2.96/10. Consistent with normative data [20], hot flushes interfered most with sleep (5.91/10). Sex (3.49/10), concentration (3.45/10) and mood (3.45/10) were also moderately affected. Means and standard deviations of these study variables as well as self-compassion and self-reported depressive symptoms are shown in Table 2. Preliminary one-way ANOVA indicated that menopausal status, menopausal type (surgical versus natural) and ethnicity were independent of all study variables, and were therefore not included in the model. Higher depressive symptoms were associated with younger age (r = −0.22, p = 0.001), not having a partner (r = 0.17, p = 0.02) and being unemployed (r = 0.31, p < 0.001), but not with HRT use (r = 0.01, p = 0.85) or BMI (r = 0.15, p = 0.53). HFI was associated with current HRT use (r = 0.13, p = 0.048), higher BMI (r = 0.17, p = 0.02) and being unemployed (r = 0.19, p = −0.006), but not with education (r = −0.11, p = 0.12), age (r = −0.14, p = 0.05) or relationship status (r = −0.09, p = 0.21). Intercorrelations between key study variables are summarized in Table 3. CES-D and HFI were significantly associated with all study variables, with effect sizes ranging from 0.19 to 0.60 and 0.36 to 0.55, respectively. 3.2.1. Path analysis The hypothesized path model offered a very good fit for the data (2 (1) = 0.52, p = 0.47, CFI = 1.00, RMSEA < 0.001, SRMR = 0.004). The HFNS × self-compassion interaction term was significant in predicting HFI (ˇ = −0.21, p < 0.001), demonstrating the moderating role of self-compassion in the model. There was no significant direct effect of HFNS frequency on depressive symptoms (ˇ = −0.031, p = 0.57). However, by including HFI as a mediator, HFNS frequency had a significant indirect effect on mood (ˇ = 0.095, p = 0.001). Significant covariates in the model included current use of HRT predicting higher HFI (ˇ = 0.17, p = −0.001), and being without a Table 3 Intercorrelation matrix of study variables. Variable 1. CES-D 2. Hot flush interference 3. HFNS frequency 4. Self-compassion
1 1
2
3 **
0.55 1
4 **
0.19 0.38** 1
HFI
CES-D
Self-compassion HFNS frequency SC × HFNS frequency BMI HRT use Age Unemployment Relationship HFI
−0.37 (0.06)** 0.34 (0.06)** −0.21(0.06)** 0.099 (0.06) 0.17 (0.06)** −0.094 (0.06) 0.067 (0.06) −0.055 (0.06) NA
−0.42 (0.06)** −0.031 (0.06) NA −0.21 (0.06) 0.018 (0.05) −0.17 (0.05)** 0.17 (0.05)* −0.106 (0.05)** 0.28 (0.06)**
Note: HFNS, Hot flushes and night sweats; CES-D, Center for Epidemiologic Studies Depression Scale. * p < 0.05. ** p < 0.01.
Note: HFNS, hot flushes and night sweats; CES-D, Center for Epidemiologic Studies Depression Scale.
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Variable
−0.60 −0.49** −0.23** 1 **
Note: HFNS, hot flushes and night sweats; CES-D, Center for Epidemiologic Studies Depression Scale. ** p < 0.01.
partner (ˇ = −0.17, p = 0.038), unemployed (ˇ = 0.17, p = 0.001) and of younger age (ˇ = −0.17, p = 0.001) predicting greater depressive symptoms. Details of parameter estimates (standard errors) and statistical significance are shown in Table 4. The model explained approximately 51% of the variance in depressive symptoms, and 41% of the variance in HFI. Significant paths of the model are illustrated in Fig. 2. To determine the amount of unique variance contributed by the moderation effect, a nested model that constrained the SC × HFNS frequency interaction term to zero was constructed. The constrained model caused a drop in HFI r2 of 0.04–0.37. Therefore, the moderating effect of self-compassion served to explain 4% of unique variance in HFI over and above the contribution of direct effects. A plot of the relationship between HFNS frequency and HFI for women with low (1 SD below the mean), medium (mean) and high (1 SD above the mean) self-compassion is shown in Fig. 3. The relatively steeper slope for women with low self-compassion indicates that a given frequency of HFNS will cause more daily interference for this subgroup. 4. Discussion The primary objective of this study was to investigate the potential protective role of self-compassion in weakening the association between HFNS and daily life functioning, which in turn influences depression. We assessed the hypothesized model with preliminary bivariate tests followed by path analysis, with HFNS interference and depressive symptoms included as endogenous outcome variables. Our results indicated that self-compassion was both a direct predictor of HFNS interference and depressive symptoms, and also a powerful moderator of the relationship between HFNS frequency and the degree to which HFNS symptoms interfere with daily life. Consistent with prior work [6–8], HFNS interference rating was a significant predictor of depressive symptoms, and a stronger predictor than HFNS frequency. HFNS frequency was significantly correlated with depression in bivariate analyses (r = 0.19, p < 0.01), which is compatible with a recent review [4]. The direct relationship failed to reach significance in the final model, however, when demographic factors and HFNS interference were also taken into account. Instead, there was an indirect effect of HFNS frequency on depressive symptoms via HFNS interference. This demonstrates that a key mechanism by which self-reported HFNS influence mood is the degree to which symptoms interfere with daily activities. Self-compassion was the strongest direct predictor of HFNS interference (ˇ = −0.37), followed by HFNS frequency (ˇ = 0.34). Consistent with prior work, this finding adds weight to the argument that emotional and cognitive factors are central contributors to HFNS appraisals. In a cognitive model of hot flushes, Hunter and
Please cite this article in press as: Brown L, et al. Self-compassion weakens the association between hot flushes and night sweats and daily life functioning and depression. Maturitas (2014), http://dx.doi.org/10.1016/j.maturitas.2014.05.012
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Fig. 2. Path analysis testing the interaction of self-compassion and HFNS in contributing to HFI and depressive symptoms. Path coefficients are standardized. Note: HFNS, hot flushes and night sweats; CES-D, Center for Epidemiologic Studies Depression Scale.
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Chilcot identified social, control and sleep beliefs as being central predictors of HFNS problem ratings [6]. While these factors are predominantly cognitive in nature, here we identify an emotional factor, with cognitive components (self-compassion) that is likewise important. Self-compassion was also the strongest direct predictor of depressive symptoms in the model, followed closely by HFNS interference. This demonstrates that a combination of psychological and menopause-specific factors contribute to mood at midlife, and these should be considered in tandem when conceptualizing mood and depression among midlife women. As hypothesized, self-compassion significantly moderated the relationship between HFNS frequency and HFNS interference, such that for a given frequency of HFNS, those women with high selfcompassion experienced less symptom interference in daily life. This finding helps to explain why some women find symptoms more interfering than others. Given that HFNS can be disruptive and embarrassing; self-compassion may provide a psychological resource to help women deal with the challenge through selfkindness, a sense of common humanity and mindfulness. Those
Fig. 3. Interaction effect between HFNS frequency and self-compassion in predicting hot flush interference in daily functioning. All variables are standardized Z scores. Note: HFNS, hot flushes and night sweats.
women low on self-compassion, on the other hand, may reinforce difficulties related to their symptoms through self-criticism (e.g. ‘I am stupid for feeling this way’), a sense of isolation (e.g. ‘I am the only one suffering from hot flushes’) and over-identification (e.g. ‘these symptoms define who I am’). These maladaptive reactions, in turn, exacerbate the degree to which symptoms interfere with women’s lives. A recent randomized controlled trial has demonstrated that the 8 week Mindful Self-Compassion group programme significantly reduces symptoms of depression relative to waitlist controls, with gains maintained at 6 month and 1 year follow ups [18]. This demonstrates that self-compassion is modifiable, and that changes in self-compassion can have a direct influence on well-being. Given that the current study has demonstrated the relevance of selfcompassion to menopausal factors in a cross-sectional design, it is plausible that attempts to bolster self-compassion may serve the dual purpose of influencing mood and menopause related issues simultaneously, a hypothesis to be tested in future experimental research. A limitation of the study is the cross-sectional nature of the findings, meaning that directions of causality cannot be confirmed. As such, while we have found that self-compassion acts as a moderator, weakening the association between HFNS and daily interference, a future experimental study design is needed to clarify directions of causality. Secondly, the study had a relatively modest response rate of 35.7%. While the study was cross-sectional, data collection resembled that of a longitudinal design due to participants’ prior participation in the larger project. The lowerthan-desired response rate was comparable with other longitudinal studies [29], where attrition is a common problem. Our sample size was nonetheless large enough to permit robust statistical analyses, but was arguably skewed toward better functioning individuals. An interesting extension, therefore, could be to consider self-compassion as a mediator of HFNS and other climacteric symptoms in a clinical setting such as a menopause clinic, where women are seeking help for more acute symptoms. This study examined depressive symptoms as the sole well-being outcome variable. Since a growing body of evidence is linking anxiety with HFNS [6,30], exploring self-compassion in the context of anxiety and menopausal factors would be worthy of investigation. In summary, this study explores the role of self-compassion in attenuating the impact of HFNS on daily activities and
Please cite this article in press as: Brown L, et al. Self-compassion weakens the association between hot flushes and night sweats and daily life functioning and depression. Maturitas (2014), http://dx.doi.org/10.1016/j.maturitas.2014.05.012
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depressive symptoms. Prior work has identified cognitive factors that help explain why some women but not others are troubled by HFNS [6]. This study extends our understanding of these individual differences through identifying that a woman’s relationship toward herself, specifically how compassionate she is toward herself, is also worthy of note. Since self-compassion is a skill that responds well to training [18], this finding has clinically relevant implications for the management of HFNS. Given that the Mindful Self-Compassion group programme is an evidence-based approach to bolstering self-compassion [18], women experiencing menopause related disturbances to well-being may benefit from taking part in a programme of this type. Finally, this study provides the impetus for an experimental study to assess self-compassion training as an alternative or adjunct to CBT and pharmacological treatments for hot flushes and night sweats. Contributors Ms. L. Brown, Ms. V. Brown, Dr. Bryant and Professor Judd formulated the research question and designed the study. Ms. L. Brown, Ms. V. Brown and Dr. Bryant carried out data collection. Ms. L. Brown and Dr. Bei were responsible for carrying out the statistical analysis. Ms. Brown wrote the paper, and all authors contributed to its revision. Competing interest
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The cost of printing and mailing the questionnaire where all study data was obtained was covered by a small grant available to 397 Q3 PhD students in the School of Psychological Sciences, University of 398 Q4 399 Melbourne. 396
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Please cite this article in press as: Brown L, et al. Self-compassion weakens the association between hot flushes and night sweats and daily life functioning and depression. Maturitas (2014), http://dx.doi.org/10.1016/j.maturitas.2014.05.012
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