Anxiety & Depression Associate with Incontinenc in Women
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Anxiety and depression are both associated with urinary incontinence in Norwegian women

Felde G, Bjelland I, Hunskaar S. Anxiety and depression associated with incontinence in middle-aged women: a large Norwegian cross-sectional study.  Int Urogynecol J 2012; 23 (3): 299-306.

Why they did the study

About one fifth of women with urinary incontinence [UI] will have one or more episodes of major depression.  The 12-month prevalence for anxiety disorders in incontinent women varies from 11% to 18%.  Compared with women with UI alone, women with both depression and UI have greater decrements in quality of life and functional status and also increased symptom burden of their UI. There are limited data on the relationship between anxiety or depression and UI and the few studies that had been done are not conclusive.

How they did it

This was a nested study within a large community-based cross-sectional study from Norway, The Hordaland Health Study (HUSK, 1997–1999).  HUSK was a large, population-based survey which covered many topics, for example mental health, cardiovascular diseases, cancer, muscle and skeletal diseases, occupational health, UI and use of drugs. All persons born between 1953 and 1957 and who lived in the county of Hordaland were invited by mail to participate - altogether 29,400 individuals (14,349 women) were invited. A total of 9,976 women (70%) met at a screening station (office or bus) for blood tests and some examinations and received a questionnaire that they filled in at home and returned by mail; 7,039 of these women (71%) received a questionnaire concerning depression, anxiety and UI. Five thousand three hundred twenty-one (76%) of these women answered and the study was designed as a cross-sectional survey of the women in this subgroup.

The section about UI in the HUSK questionnaire was similar to the questionnaire in the EPINCONT study by the same group and started with an entry question about experiencing involuntary loss of urine or not. If the answer was yes, the woman was asked to answer more specific questions: How often do you leak (four levels), how much leakage each time (three levels), do you leak when coughing, sneezing, laughing, lifting heavy items (yes/no), is leakage accompanied by sudden and strong urgency to void (yes/no). She was also asked about duration of urinary leakage (three levels). The Sandvik severity index, a semi-objective and quantitative perception of the leakage that has been validated against a 48-hour pad-weighing test, was used to categorize the severity of incontinence. The index was calculated by multiplying the reported frequency (four levels) by the amount of leakage (three levels).

Anxiety and depression was measured in HUSK by the Hospital Anxiety and Depression Scale (HADS), a questionnaire consisting of 14 items, seven for anxiety (HADS-A) and seven for depression (HADS-D). Each item has four possible answers and is scored on a Likert scale from 0 to 3. The item scores are added, giving subscales from 0 (minimum symptom level) to 21 (maximum symptom level). HADS-A contains questions related to restlessness and worry and one question reflecting panic attacks. The HADS-D focuses mainly on the reduced pleasure response aspect of depression, but also psychomotor retardation and impaired mood. Clinically significant anxiety is usually defined as a HADS-A score of 8 or more. Depression is usually defined as a HADS-D score of 8 or more. A cut-off of 11 or more is a measure of very high level of anxiety and depression.

Prevalence rates of anxiety and depression were calculated among the incontinent and the continent women and in the subgroups of incontinent women according to type and severity of incontinence. Logistic regression analysis was used to adjust for possible confounding factors

What they found

A total of 5,321 of 7,039 (76%) women answered the questionnaire. Mean age was 42 years, the large majority was married and with high educational level. Almost 85% stated their health status as being good or very good, less than 10% were obese and about a third were daily smokers.

The prevalence of UI was 26.2%. More than two thirds of the incontinent women had leakages less than once a week. More than half were experiencing symptoms of stress UI alone. Almost 60% had slight UI according to the Sandvik severity index and most of the women reported a duration of the problem of less than 5 years. Almost one of five had high levels of anxiety defined by a HADS-A score of 8 or more and about 6% had very high levels of anxiety defined by a HADS-A score of 11 or more; 8.5% had high levels of depression defined by a HADS-D score of 8 or more, and about 2% had very high levels of depression defined by a HADS-D score of 11 or more. About 6% had both HADS-A and HADS-D score of8 or more.

About one of four had high levels of anxiety in the incontinent group. This was significantly higher than in the continent group (p<0.001). Almost 12% had high levels of depression in the UI group. This was also significantly higher than in the continent group (p<0.001). There was a significant association between UI and combined high levels of anxiety and depression. Among the different types of UI, the highest rates of anxiety were seen in mixed UI (32.0%) and urgency UI (28.1%). The highest prevalence of depression was also seen in mixed UI (16.9%) and urgency UI (11.7%). After adjustment for age, education, nocturia, parity, body mass index and smoking, UI was still significantly associated with anxiety and depression with the highest odds ratios (>2) for mixed and severe UI.

Why it matters

Depression, anxiety and UI are all associated with social stigma and the conditions are often not recognized by the physicians.  This study shows that UI is associated with high levels of depression and anxiety in women 40–44 years old. For both depression and anxiety, the association was strongest for mixed and urgency incontinence and was stronger with increasing severity of the UI. The associations persisted also after adjusting for established risk factors for UI, like obesity, smoking and parity.

As a cross-sectional study, this study cannot answer the question of whether being incontinent cause women to be depressed or anxious or whether depression and anxiety causes incontinence. Further longitudinal cohort studies regarding causality between depression or anxiety and UI are therefore needed to answer this question.

Next question

For clinical practice, it is important to be aware of the extensive co-occurrence of UI and depression and anxiety. These are all common conditions in primary care, all with adverse effects on function and with quality-of life decrements. Since the symptom burden of UI is greater with a co-morbid illness, the practitioners’ knowledge about this association is of great importance for the patients. More knowledge is needed, however, before routine screening for depression or anxiety among women with UI is recommended in clinical settings.

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