Severe depression and anxiety in women with overactive bladder

Transcription

1 Received: 23 June 2016 Accepted: 4 January 2017 DOI: /nau ORIGINAL CLINICAL ARTICLE Severe depression and anxiety in women with overactive bladder Iane Glauce Ribeiro Melotti 1 Cássia Raquel Teatin Juliato 2 Mariana Tanaka 3 Cassio Luiz Zanettini Riccetto 4 1 Department of Surgery, School of Medicine, University of Campinas (UNICAMP), Campinas, Brazil 2 Departament of Obstetrics and Gynecology, School of Medicine, University of Campinas (UNICAMP), Campinas, Brazil 3 Departament of Surgery, School of Medicine, University of Campinas (UNICAMP) School of Medicine, Campinas, Brazil 4 Department of Surgery, School of Medicine, University of Campinas (UNICAMP) School of Medicine, Campinas, Brazil Correspondence Cassio LZ. Riccetto, MD, Associated Professor of Urology, Department of Surgery, University of Campinas, Unicamp, R. Vital Brasil, 250, Campinas SP, Postal Code; cassioriccetto@gmail.com Funding information Coordenação de Aperfeiçoamento de Pessoal de Nível Superior, Grant number: support a post graduated grant Aim: Depression and anxiety are prevalent psychiatric conditions and are associated with overactive bladder. The objective of this study was to determine prevalence and severity of anxiety and depression associated with overactive bladder (OAB) in women. Methods: 274 women with clinical diagnosis of OAB were recruited from 2012 to They were submitted to the International Consultation on Incontinence Questionnaire-Overactive Bladder (ICIQ-OAB), the Beck Depression Inventory (BDI), and the Beck Anxiety Inventory (BAI). Results: Severe or moderate depression was present in 59.8% of women and severe or moderate anxiety was identified in 62.4%. Higher scores of depression and anxiety were associated with higher scores of ICIQ-OAB (P = and ). Women with severe depression had higher nocturia score than those with mild depression (P = ). Also, women with severe depression had higher urgency incontinence score than those with minimal depression (P = ). Patients with severe anxiety had higher nocturia score than those with minimal anxiety (P = ) and women with moderate anxiety had higher urgency incontinence score than with minimal anxiety (P = ). Conclusions: Moderate or severe depression and anxiety are prevalent in women with OAB. There is a correlation between intensity of OAB symptoms with depression and anxiety. Anxiety and depression levels are mainly related with urgency incontinence and nocturia. KEYWORDS anxiety, depression, overactive bladder, urge, urinary incontinence, women 1 INTRODUCTION Overactive bladder (OAB) is defined as urgency with or without urgency incontinence and is usually accompanied by urinary frequency and nocturia, in the absence of lower urinary tract infection or other diseases. 1,2 The OAB Fred Milani led the peer-review process as the Associate Editor responsible for the paper. symptoms negatively interfere in patient s quality of life (QoL) and can lead to or worsen social, psychological, emotional, physical, and sexual problems. 3 Studies carried out in the United States found OAB is a prevalent condition, affecting up to 16.9% of women in all age groups. 4,5 Irwin et al conducted a population based study conducted in five countries which showed a 11, 8% prevalence of OAB, with similar rates in men and women and increased prevalence in older patients in both sexes. 6 In the study, patients with OAB reported significant impairment Neurourology and Urodynamics. 2018;37: wileyonlinelibrary.com/journal/nau 2017 Wiley Periodicals, Inc. 223

2 224 MELOTTI ET AL. on household chores, physical activities, sleep, and productivity, social, and sexual life. 7 Depressive disorders represent a major public health problem that affects patients and society and anxiety is the most common psychiatric symptom in the United States, with a prevalence of 18%. 8 Moreover, depression and anxiety can occur in a variety of clinical conditions and may develop in response to stressful situations or adverse social or economic conditions and may have a pathophysiological background related to chronic diseases. 9 The deterioration of QoL related to OAB symptoms may lead depression and anxiety. In a systematic review, the relationship between OAB and psychiatric conditions was analyzed. There was sufficient evidence to affirm that these conditions were frequently co-occurent, although causality could not be identified. 10 The aim of this study was to evaluate prevalence and severity of anxiety and depression and their correlation with severity of symptoms in women diagnosed with OAB, using culturally adapted and validated instruments. 2 MATERIALS AND METHODS We conducted a cross-sectional study recruiting 274 women with clinical diagnosis of idiopathic OAB treated at the Female Urology Division and at the Center of Integral Attention of Women s Health (CAISM) at the University of Campinas Unicamp, Brazil, from March 2012 to March The study was registered in the Brazilian Ministry of Health at the National Council of Ethics in Research CONEP and was approved by the Research Ethics Committee of the Faculty of Medical Sciences and Research Committee of the Department of Obstetrics and Gynecology of the University of Campinas Unicamp (CAAE June, ). Inclusion criteria were women over 18 years of age with clinical diagnosis of OAB, based on the criteria of the International Continence Society (ICS). 1 Criteria for exclusion were: known or suspected pregnancy, current lactation, systemic diseases, severe hypertension, cardiopathy, primary psychiatric disorders and other cognitive conditions that could hinder comprehension of the questionnaires. Patients who had previous attempts to treat OAB and those on hormonal therapy for menopause were also excluded from the study. After signing informed consent, patients were assessed for socio-demographic data and answered the International Consultation on Incontinence Questionnaire Overactive Bladder (ICIQ-OAB), the Beck Depression Inventory (BDI), and the Beck Anxiety Inventory (BAI). ICIQ-OAB contains four basic questions that investigate urinary frequency, nocturia, urgency, and urgency incontinence. The corresponding values of the questions are added and the score may range from 0 to 16 points. The greater the sum, the more severe the symptoms. 11 The BDI and BAI are self-reporting scales which consists of 21 items each. The BDI implies in increasing levels of severity for depression, with a score from 0 to 3, ranging from minimal to severe. The BAI measures anxiety symptoms that are minimally shared with depression symptoms. Symptoms should be evaluated by the patients themselves in reference to their own complaints, on a scale of 0-3 points. According to the manual, the scale reflects levels of severity of each symptom, from minimal to severe. The BDI and BAI total scores provide a classification of depression and anxiety intensity levels. The classification of the scores for depression are as follows: minimal (0-11), mild (12-19), moderate (20-35), and severe (36-63). The classification of scores for anxiety are as follows: minimal (0-10), mild (11-19), moderate (20-30), and severe (31-63). 12,13 Each degree of BDI and BAI scores was compared to ICIQ-OAB and sub scores (frequency, nocturia, urgency, and urgency incontinence) separately. Sample power provided 86.2% and 88.9% to test association between BAI scores (anxiety) and BDI scores (depression) and the mean values of ICIQ-OAB, respectively. Unfortunately, we could not find articles that objectively presented data regarding association between anxiety or depression scales with OAB levels, so it was not possible to get a reference to calculate the ideal sample size. Kruskal-Wallis test was used to compare ICIQ-OAB total score and sub-scores regarding frequency, nocturia, urgency, and urgency incontinence with the BDI and BAI scores. Linear regression models were used for multivariate comparisons between the ICIQ-OAB scores and clinical variables (BDI and BAI scores, age, parity, and menopause). 3 RESULTS The study enrolled 274 women with clinical diagnosis of OAB according to ICS criteria. Patients average age was 50.2 (±11.9) years. In the studied population, 70.1% of women were married or had a steady partner, 5% were illiterate and 51.1% achieved no more than middle school grade. One-third of them worked as housewives (no paid work), and more than half had three or more children and were postmenopausal (Table 1). One hundred and sixty four women (59.8%) with OAB were moderately or severely depressed. Patients with severe depression had higher total ICIQ-OAB scores than those with minimal (11.9 ± 3.12 and 9.4 ± 3.04, respectively, P = ) and mild depression (9.0 ± 3.0, P = ) (Table 2). Women with severe depression had higher nocturia scores than those with mild depression (2.7 ± 1.2 and 1.8 ± 1.4,

3 MELOTTI ET AL. 225 TABLE 1 Characteristics of sample (n = 274) Characteristics Frequency % Age (years) (Average) (SD) = Marital status Married/living with a partner Others Schooling Illiterate Middle school ,1 High school graduate University Profession Not paid work Paid work Parity or more No Yes respectively, P = ) and higher scores of urgency incontinence than those women with minimal depression (3 ± 1.27 and 2.4 ± 1.25, respectively, P = ). There was no difference in scores regarding urinary frequency and urgency amongst women with different levels of depression (Table 2). One hundred and seventy one patients (62.4%) had moderate or severe anxiety. Those with severe anxiety showed higher ICIQ-OAB scores compared to women with mild anxiety (10.5 ± 2.8 and 9.08 ± 3, respectively, P = ). Nocturia scores were higher in patients with severe anxiety compared to those with minimal anxiety (2.5 ± 1.25 and 1.89 ± 1.2, respectively, P = ). Higher urgency incontinence scores were identified in patients with moderate anxiety compared to those in women with minimal anxiety (2.91 ± 1.12 and 2.27 ± 1.30, respectively, P = ). There was no difference in urinary frequency and urgency with various degrees of anxiety (Table 3). In the multivariate linear regression analysis, women with most severe symptoms of OAB were older, had greater parity and higher levels of anxiety and depression (Table 4). 4 DISCUSSION This study identified that around two-thirds of women with moderate or severe depression and anxiety had concomitant symptoms of OAB. Recent Brazilian population studies showed a depression range from 5.6% to 16% in Brazilian women. Furthermore, a prevalence of anxiety is 30% in this population. 14 The higher depression and anxiety prevalence showed in this present study could be related to possible OAB impact in affective disorders. Several studies associated OAB with more severe depression levels. 4,15,16 This association shows the importance of addressing this issue during OAB evaluation and follow-up. Psychological factors could impact on OAB management and influence treatment-seeking behavior, adherence to treatment and satisfaction with therapy. 16 This study showed that women with OAB had moderate or severe depression and anxiety. Patients with severe depression had higher ICIQ-OAB scores compared to those with mild depression, which may indicate an association between OAB symptoms and depression. We also found that women with severe anxiety had higher OAB scores, which corroborates the association between OAB and anxiety, as it has been shown by many other groups. 4 6,15 19 TABLE 2 Correlation between ICIQ-OAB general and sub-scores (frequency, nocturia, urgency, and urgency incontinence) with the BDI scales (average ± SD) BDI ICIQ-OAB Frequency Nocturia Urgency Urgency incontinence P-value* a b c Minimal (n = 61) 9.41 ± ± ± ± ± 1.25 Mild (n = 49) 9.0 ± ± ± ± ± 1.10 Moderate (n = 100) ± ± ± ± ± 1.17 Severe (n = 64) ± ± ± ± ± 1.27 SD, standard deviation. All significant values are in bold. a Significant difference between severe versus minimal and severe versus mild. b Significant difference between severe and mild. c Significant difference between severe and minimal. *Kruskal-Wallis Test.

4 226 MELOTTI ET AL. TABLE 3 Correlation between ICIQ-OAB general and sub-scores (frequency, nocturia, urgency, and urgency incontinence) with the BAI scales (average ± SD) BAI ICIQ-OAB Frequency Nocturia Urgency Urgency incontinence P-value* a b c Minimal (n = 44) 9.07 ± ± ± ± ± 1.30 Mild (n = 59) 9.08 ± ± ± ± ± 1.18 Moderate (n = 86) 10.4 ± ± ± ± ± 1.12 Severe (n = 85) 10.5 ± ± ± ± ± 1.22 SD, standard deviation. All significant values are in bold. a Significant difference between severe and mild. b Significant difference between severe and minimal. c Significant difference between moderate and minimal. *Kruskal-Wallis Test. OAB and depression share common biological pathways, which could explain their co-occurrence. Serotonin and norepinephrine, as well as interactions between these two neurotransmitter systems, are thought to have an important role in the etiology of depression. 20 Furthermore, evidence support that the serotonergic system plays a role in anxiety regulation both during development and in adulthood. 21 Serotonin also has a role in bladder function. An experimental study in rats showed that decreased levels of serotonin in the central nervous system (CNS) lead to increased urinary frequency and detrusor overactivity. That decreased serotonin levels could cause depression and have a role in anxiety, could explain the association between these mental disorders and OAB. 22 Other possible explanation is that deregulation on the hypothalamus-hypophysis-adrenal axis, resulting in an increase in corticotropin-releasing factor (CRF), would raise adrenocorticotropic hormone (ACTH) and cortisol, which are linked to anxiety, depression, and hormone dependent pathways in bladder function. 22 The social impact of OAB with decrease in functional capacity (physical and social) of individuals can generate stress, which could lead to anxiety and depression. Regardless of other studies that showed around 40% of women with concomitant OAB and depression, 15,16 the TABLE 4 Clinical variables versus ICIQ-OAB-Linear regression analysis Variable Parameter Estimate P-value Depression score (BDI) Anxiety score (BAI) Age Parity Menopause All significant values are in bold. BDI, beck depression inventory; BAI, beck anxiety inventory. present study, classified almost 60% of the enrolled patients as being moderate or severely depressed. This difference could be explained by the fact that our patients had higher ICIQ-OAB scores indicating severe OAB. Two thirds of women included in this study presented with moderate or severe anxiety. These rates are similar to prevalence assessed by Coyne et al and Perry et al 17,23 although Alves et al showed a smaller percentage of patients with OAB and anxiety. 19 These results could be influenced by the fact that the previously cited study was conducted with only 166 elderly women. In this study, women with severe depression and moderate anxiety had higher levels of urgency incontinence. The risk of incontinence and social embarrassment could be related to lower self-esteem and higher probability of reclusion, predisposing them to affective disorders. 15,24 Patients with severe scores of depression and anxiety also had significant association with nocturia. An epidemiological population-based study showed that nocturia is associated with increased prevalence of depression. 25 Sleep disturbance is one of the most frequent complaints reported by older adults who develop nocturia, 26 which can explain the association between these conditions. While other found an increased urinary frequency and urgency are also related to anxiety and depression, 27 we found no association between anxiety or depression and these OAB symptoms the present study. The main limitation of this study is that its design made it difficult to determine a cause effect relationship between OAB and anxiety or depression symptoms. The positive points of the study are the large sample size and the inclusion of an expressively younger population. To the best of our knowledge, this is the first study that associated the severity of OAB with depression and anxiety in younger patients.

5 MELOTTI ET AL. 227 Women with OAB often have severe anxiety and depression. Even with such high-severity symptom levels, few patients seek treatment. 7,24 The recognition of the co-occurrence of OAB and affective disorders can assist health professionals in increasing clinical suspicion of anxiety and depression in women with OAB and offering better intervention strategies for these women. 5 CONCLUSION This study showed a correlation between intensity of OAB symptoms and depression and anxiety. Around two-thirds of women with OAB were categorized as presenting moderate or severe depression and anxiety. These psychiatric disorders are predominantly associated with urgency incontinence and nocturia. AUTHORS CONTRIBUTIONS Project development, data collection, manuscript writing was contributed by Melotti, IGR; Project development, manuscript writing was contributed by Juliato, CRT and Riccetto CLZ. Tanaka, M contributed with manuscript writing. CONFLICTS OF INTEREST None. REFERENCES 1. 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6 228 MELOTTI ET AL. 24. Nicolson P, Kopp Z, Chapple CR, Kelleher C. Itś just the worry about not being able control it! A qualitative study of living with overactive bladder. Br J Health Psychol. 2008;13: Kupelian V, Wei JT, O Leary MP, Nogaard JP, Rosen RC, McKinlay JB. Nocturia and quality of life: results from the Boston area community health survey. Eur Urol. 2012;61: Asplund R, Aberg HE. Development of nocturia in relation to health age and the menopause. Maturitas. 2005;51: Macaulay AJ, Stern RS, Holmes DM, Stanton SL. Micturition and the Mind: psychological factors in the etiology and treatment of urinary symptoms in women. Brit Med J. 1987; 294: How to cite this article: Melotti IGR, Juliato CRT, Tanaka M, Riccetto CLZ. Severe depression and anxiety in women with overactive bladder. Neurourology and Urodynamics. 2018;37: