The Relationship between Premenstrual Syndrome and Depression of Female College Students in Korea

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1 Indian Journal of Science and Technology, Vol 9 (S1), DOI: /ijst/2016/v9iS1/109837, December 2016 ISSN (Print) : ISSN (Online) : The Relationship between Premenstrual Syndrome and Depression of Female College Students in Korea Junghyun Choi* Department of Nursing, Namseoul University, 91 Daehakro, Seonghwan-eup, Seobuk-gu, Chonan-Si, Chungnam, South Korea, 31020; Jhc@nsu.ac.kr Abstract Background/Objectives: The purpose of this study is to investigate the factors that influence Premenstrual Syndrome (PMS) of female college students in Korea. Methods/Statistical analysis: This research is a descriptive correlation study designed to examine the factor influencing premenstrual female college students. The data was collected from September till December The data was collected via structural questionnaires gathered by 270students who agreed to participate in this study, and 245 of them were analyzed except for 25 incomplete questionnaires and male nurses. Descriptive statistics for all study variables as well as the reliability assessment of the study instruments were computed. To analyze the correlation in the independent and dependent variables, correlation analysis was used. Findings: The mean age of the participants was 21.04years. The level of PMS is 28.75±9.92 point and the level of depression is 16.69±10.41 point. PMS includes 3 subscales. The level of emotional disturbance is 2.97±1.28 point, and the level of water retention was 2.30± The level of pain was 3.32± There were positive correlations among PMS, depression, emotional disturbance, water retention, and pain. But there was not a statistically significant correlation between PMS and body weight. In multiple regression depression (t=6.691, p<.001) and perception of PMS (t=2.052, p=.042) were found to be factors significantly associated with PMS. The model explained 22.9% of the variables. Improvements/Applications: This study found that PMS is influenced by the psychological factors such as depression. Therefore, the education program including PMS and depression is needed to promote health for female university students. Keywords: College Students, Depression, Female, Korea, Premenstrual Syndrome 1. Introduction Premenstrual Syndrome (PMS) means various symptoms in which physical and mental discomfort continue for seven to ten days before menstruation starts to the extent that the discomfort disturbs daily life, and then they are eased with the start of menstruation. The differences of PMS level vary, depending on individuals 1.Many scholars have defined physical and mental discomfort before menstruation, and PMS defined by Green et al is universally used 1,2. In a previous study on high school girls premenstrual syndrome, dietary behaviors and daily life habits, 40% of the subjects were surveyed not to know whether they underwent PMS, although they suffered from PMS. From this, it is understood that there are many students who cannot even perceive PMS properly. This implies that the surrounding s attention and the efforts of schools, not to mention those of the subjects experiencing PMS, seem to be needed 2. In a previous study that targeted Korean high school girls, 75% of a group feeling premenstrual dysphoric disorder and 55% of a group with PMS showed change in dietary habits before menstruation started. They said they wanted sweet or salty foods mainly. In Korea, some students eat only what they want and skip *Author for correspondence

2 The Relationship between Premenstrual Syndrome and Depression of Female College Students in Korea meals, because they choose and implement a wrong diet method, irrelevant of their body type and situation, due to the lack of exercise deriving from lots of study amount, and distorted body image though mass media. The characteristics of such dietary and daily life habits seem to affect the occurrence and level of PMS 2. Depressive symptom is a mental health problem, and also affects physical, cognitive and emotional socialization process. Especially, a study result that women s prevalence rate of depressive disorder is higher than men s was confirmed 3. Depressive disorder includes growth symptom in addition to depressive symptom, and is accompanied by various body symptoms such as pain, fatigue and weakness 4. A phenomenon that a person with depressive symptom complains body symptoms frequently occurs, irrelevant of race, culture, and educational level 5. The college student period is an early adulthood period in the growth development process. In such a period, the interactions of physical, mental and social relations are easily formed. An expert suggested that the habits of health developed in the early adulthood period become the foundation for actions of health and healthy life in the mid and late parts of adulthood 6. Therefore, the control of wrongly formed habits of health, improper social support and depression shaped in the period can have effects on health status and health level in the future adulthood 7. In this regard, it is very important to correct undesirable actions, and establish good actions of health in the college student period for health care 8. Most Korean college students not only drink or smoke freely due to suddenly increased interpersonal relationship after entering university, but the amount of drinking and smoking is on the rise. The college student period, however, is the healthiest period in one s life, and therefore college students may conduct risky behaviors due to their active and strong curious characteristics, confidence in their own health and social attention. Since the period is also a dynamic period in which no clear symptom threatening health is developed, they are seldom engaged in health promotion actions for disease prevention 9. Although the college student period is the period when the desire of individualization to be independent from their parents is high, the independence period within family is delayed due mainly to the repetitive leave of absence from school and returning to school, and increase in young people s unemployment 10. Family function has a material effect on adaptation to college life and individual growth and development, and it helps the growth and development of the college students preparing for the future 8. In the previous studies, the lack of perception on PMS of high school girls was confirmed. In relation with the confirmation, this study is conducted to find out the effects of female college students general characteristics, depression on PMS. 2. Methods 2.1 Design This research is a descriptive correlation study designed to examine the factor influencing premenstrual female college students. 2.2 Participants The data was collected from September till December The data was collected via structural questionnaires gathered by 270 students who participated in this study, and 245 of them were analyzed except for 25 incomplete questionnaires and male nurses. 2.3 Measurements Premenstrual Syndrome PMS means various physical and mental symptoms which are showed after the ovulation and continue before the beginning of menstruation in a menstrual period which defines the first day of menstruation as day first. We used Shortened Premenstrual Assessment Form (SPAF) translated by 11. This scale was abbreviated from the 95 items of Premenstrual Assessment Form (PAF) 12. The composition of these tools are consisted of 10 items which reflects 3 areas, these items are based on a 6-point Likert scale (1 = no change, 6 =very severe change). The sum of 10 items is varied from minimum 10 points to maximum 60 points, and high scores indicate greater premenstrual syndrome. In the current study, Cronbach s α of internal reliability was.87, and in subscale, Cronbach s α of internal reliability of 4 items measuring of emotional disturbance was.89, Cronbach s α of internal reliability of 3 items measuring pain.55, and Cronbach s α of internal reliability of 3 items measuring water retention was Depression The Center for Epidemiological Studies-Depression Scale (CES-D) is a tool developed by NIMH in 1971 to carry out 2 Vol 9 (S1) December Indian Journal of Science and Technology

3 Junghyun Choi epidemiological research of depressive Symptomatology for a general population group 13. It is composed of 20 short questions, and they are self-report type to record a frequency of symptoms experienced last week. We used CES-D translated by 14. Response options of each item range from 0 to 3 (0 = Rarely or None of the Time, 1 = Some or Little of the Time, 2 = Moderately or Much of the time, 3 = Most or Almost All the Time). Scores range from 0 to 60, with high scores indicating greater depressive symptoms. Cronbach s alpha for depression in this study was Method of Data Analysis. SPSS18.0 statistical program was used to analyze the collected data. Descriptive statistics for all study variables as well as the reliability assessment of the study instruments were computed. To analyze the correlation in the independent and dependent variables, correlation analysis was used. 2.5 Ethical Consideration Before collecting the data, the decision regarding consent for participation was made by university students after they received information on this study including purpose, benefits, potential risks of the study and the data collection procedures. Any participant who was reluctant to participate in the study could refuse participation at any time. 3. Results 3.1 Demographic Characteristics The baseline characteristics of the participants are shown in Table 1.The mean age of the participants was 21.04years. Body Mass Index (BMI) was as followers: low weight, 60 students (24.5%); normal weight, 162 students (66.1%); overweight, 17students (6.9%); and obesity, 6 students (2.4%). Of the 245 participants, 61 students (24.9%) had family history of premenstrual syndrome. Regarding smoking, 13 students (5.3%) of the participants were smoker and 232 students (94.7%) were nonsmoker. Most students are using alcohol (77.6%) and caffeine (85.3%). Half of the subjects (56.3%) had experience of PMS. 3.2 Descriptive Statistics Descriptive statistics for PMS, depression, emotional disturbance, water retention, and pain are shown in Table 2. The level of PMS is 28.75±9.92 point (ranging 10~60) and the level of depression is 16.69±10.41 point (ranging 0~60). PMS includes 3 subscales. The level of emotional disturbance is 2.97±1.28point (ranging 1-6). The level of water retention was2.30±1.25 (ranging 1-6). The level of pain was3.32±1.05 (ranging 1-6). 3.3 PMS and Depression According to General Characteristics Table 3 shows PMS and depression according to general characteristics. The research participants showed a Table 1. General characteristics (N=245) Variable Category n(%),mean± SD Age BMI Family history Smoking Alcohol drink Experience of PMS Perception of PMS Table 2. 18~19 20~21 22~ ± (22.4) 90(36.7) 85 (34.7) 24 15(6.1) Low weight Normal Over weight Obesity No Unknown No No No Unknown 60 (24.5) 162 (66.1) 17(6.9) 6(2.4) 61(24.9) 44(26.2) 140 (28.4) 13 (5.3) 232 (94.7) 190(77.6) 55 (22.4) 138(56.3) 25(10.2) 82(33.5) Very low 21(12.5) low 43(25.6) Normal 80(47.6) Well 22(13.1) Very Well 2(1.2) Descriptive statistics for variables (N=245) Variable Category Mean±SD PMS subscale PMS (10~60) 28.75±9.92 Depression (0-60) 16.69±10.41 Emotional disturbance(1~6) 2.97±1.28 Water retention(1~6) 2.30±1.25 Pain(1~6) 3.32±1.05 Vol 9 (S1) December Indian Journal of Science and Technology 3

4 The Relationship between Premenstrual Syndrome and Depression of Female College Students in Korea Table 3. PMS and depression according to general characteristics (N=245) Variables * Categories PMS F,χ 2 (p) Depression F,χ 2 (p) Age BMI Family History Smoking Alcohol drink Perception of PMS * Post hoc Scheffe s test 18~ (8.30) 18.18(10.64) 20~ (9.58) 16.63(10.38) 2.252(.083) 22~ (10.77) 16.67(10.58) (11.06) 11.73(7.78) Low weight 28.45(10.89) 18.40(9.80) Normal 28.81(9.24) 15.93(10.30).147(.932) Over weight 28.35(9.65) 15.94(7.02) Obesity 31.17(18.54) 22.33(22.01) 31.43(10.96)a 17.36(12.60) No 26.23(9.10)b 3.835(.023) a>b * 13.84(10.45) Unknown 28.37(9.48) 17.30(9.21) 34.00(8.73) 30.23(10.61) 1.974(.049) No 28.45(9.91) (9.89) 28.77(9.90) 16.69(10.24).063(.950) No 28.67(10.07) 16.69(11.09) Very low 25.71(8.80) 15.90(10.47) Low 27.44(8.92) 14.26(8.832) Normal 30.03(10.67) 1.499(.205) 16.45(11.78) Well 29.55(10.36) 16.09(10.10) Very Well 38.50(12.02) 11.50(14.85) 1.521(.210) 1.451(.229) 2.032(.133) 5.055(p<.001).002(.998).378(.824) statistically significant difference in PMS according to family history (F=3.835, p=.023), smoking (t=1.974, p=.049). The participants with family history got more PMS than the subjects without family history. Also the smoking subjects had high degree of PMS than nonsmoking subjects. The research participants showed a statistically difference in depression according to smoking (t=5.055, p<.001). The smoking subjects were in high depressive level than non-smoking subjects. 3.4 Emotional Disturbance, Water Retention, and Pain According to General Characteristics Table 4 shows emotional disturbance, water retention, and pain according to general characteristics. The water retention symptom showed a statistically significant difference according to age (F=5.285, p=.002) and family history (F=3.467, p=.033). The participants with family history of PMS got more water retention symptom than the subjects without family history. Also the pain symptom showed a statistically significant difference according to family history (F=3.467, p=.033). The participants with family history of PMS got more pain symptom than the subjects without family history. The emotional disturbance showed a statistically difference according to smoking (t=2.401, p=.017). The smoking subject had more emotional disturbance than non-smoking subjects. 3.5 Correlation Coefficients for Major Study Variables Correlations are shown in Table 5. There were positive correlations among PMS, depression, emotional disturbance, water retention, and pain. But there was not a statistically significant correlation between PMS and body weight. 4 Vol 9 (S1) December Indian Journal of Science and Technology

5 Junghyun Choi Table 4. Emotional disturbance, water retention, and pain according to general characteristics (N=245) Variables Age BMI Family History Smoking Alcohol drink Perception of PMS * Post hoc Scheffe s test Table 5. Correlation among main variables (N=245) Premenstrual syndrome Premenstrual syndrome 1 Depression Depression.41 ** 1 Emotional disturbance Emotional disturbance.85 ***.40 *** 1 Water retention Water retention.81 ***.31 ***.45 *** 1 Pain.81 ***.27 ***.50 ***.63 *** 1 Body weight * p<.05, ** p<.01, *** p<.001 Categories Emotional disturbance 18~ (1.25) F,χ 2 (p) Water retention F,χ 2 (p) Pain F,χ 2 (p) 1.81(.78) a 3.16(.94) 20~ (1.28) 2.29(1.17) 5.285(.002) 3.29(1.06).923(.430) 22~ (1.30) 2.65(1.48) b a<b * 3.48(1.09) (1.20) 2.20(1.16) 3.24(1.16) Low weight 2.95(1.40) 2.19(1.37) 3.35(1.07) Normal 2.96(1.19) 2.36(1.21) 3.30(1.02).084(.969).849(.468) Over weight 3.11(1.24) 1.98(.89) 3.31(1.08) Obesity 2.91(1.28) 2.72(1.84) 3.78(1.68) 3.21(1.38) 2.57(1.35) a 3.62(1.11)a No 2.81(1.23) 1.607(.203) 1.92(1.07) b 3.467(.033) a>b * 3.08(.96) b Unknown 2.91(1.28) 2.30(1.23) 3.27(1.03) 3.79(1.14) 2.74(1.18) 3.54(.74) 2.401(.017) 1.391(.187) No 2.92(1.27) 2.27(1.25) 3.31(1.07) 2.95(1.27) 2.33(1.26) 3.33(1.04).531(.596).751(.454) No 3.05(1.32) 2.19(1.23) 3.30(1.10) Very low 2.60(1.34) 1.94(.93) 3.17(.95) Low 2.77(1.10) 2.27(1.22) 3.19(.91) Normal 3.20(1.34) 1.801(.131) 2.34(1.27).586(.673) 3.40(1.07) Well 2.89(1.20) 2.44(1.25) 3.56(1.26) Very Well 4.13(1.94) 2.00(1.41) 5.33(.00) 1.100(.350).414(.743) 3.956(.020) a>b *.755(.451).166(.868) 2.506(.044) Pain 3.6 Factors Influencing in Premenstrual Syndrome Multiple regressions were conducted to investigate the effects of risk factors on the PMS in Table 6. Depression (t=6.691, p<.001) and perception of PMS (t=2.052, p=.042) were found to be factors significantly associated with PMS. The model explained 22.9% of the variables. 4. Discussion This study aims to obtain basic data from structured questionnaires to examine the factors influencing PMS of female college students. PMS is diagnosed via the presence of physical, behavioral, and mood symptoms that arise in the luteal phase of the menstrual cycle and disappear after menstruation 15. The overall frequency of Vol 9 (S1) December Indian Journal of Science and Technology 5

6 The Relationship between Premenstrual Syndrome and Depression of Female College Students in Korea Table 6. Factors influencing on PMS (N=245) Variables B S. E. Beta t p Age Height Body weight Religion Smoking Perception of PMS Depression Adj. R2 =.229, F(p)=8.078 (p<.001) PMS among subjects was 56.3%, which was similar to the results reported by adolescents study 16. A study reported that approximately half of the girls had PMS 17.It was determined that PMS was associated with premenstrual and menstrual pain, having a mother with PMS, and menstrual problems present after coming to university in Ordu 17. The ratio of female workers and housewives in their thirties in Korea who repeatedly experience PMS every month was 60.8% and 58.3% respectively when a frequency had been researched, and the frequency in that research is similar to the frequency of this study 18. On the other hand, in the study that participated Turkey university student, PMS frequency was 84.5%, which was higher prevalence than our study 19. In Korea, middle school girl s research reported that the proportion of mild PMS was 83.4%, moderate to severe PMS was 12.9% 20.The large variation in the prevalence rate of PMS is due to the usage of various diagnostic criteria for PMS and to differences in study populations, age, and cultural and social norms 19.The degree of PMS in university students was points, and it was similar to the degree of points which was resulted in another research 21. It was also similar to the degree of 29.9 points which was resulted in a survey of general nurses in a general hospital 22.The degree of points in this study was a medium level when it is considered that the range of score is from 10 to 60 points. The scores of emotional disturbance, water retention, and pain were 2.97 points, 2.30 points, and 3.32 points respectively in the subscale of PMS by a realm, and the score in the realm of pain is higher than other realms. It was similar to the result of advanced research 21 conducted for nurses, and the result of the advanced research was that each score of emotional disturbance, water retention, and pain was 2.80 points, 2.70 points, and 3.50 points in turn and the score in the realm of pain is also higher than other realms. However, we can know a difference, that is, the score in the realm of water retention is higher than others in another research for female production workers and housewives in their thirties. So, we can see that the score in the realm of pain is higher than other realms in unmarried women and the score in the realm of water retention is higher than other realms in married women. The research participants showed a statistically significant difference in PMS according to family history (F=3.835, p=.023), smoking (t=1.974, p=.049). The participant with family history got more PMS than the subject without family history. Also the smoking subjects had high degree of PMS than non-smoking subject. This result is partly consistent with the prior research which argued that family history and BMI of PMS were found to be the most important risk factors. A study suggested that smokers demonstrated more severe symptomatology than nonsmokers during the menstrual and premenstrual phases 23. Among smokers, premenstrual symptom was significantly more severe than menstrual symptom 23. In the current study, the level of emotional disturbance showed a statistically difference according to smoking (t=2.401, p=.017). The smoking subject had more emotional disturbance than non-smoking subject. This result is partly consistent with the prior study 24, indicating that premenstrual symptom groups with pain and water retention were significantly higher in smokers than in nonsmokers. A researcher argued that cigarette smoking itself also increased the risk of developing premenstrual syndrome, especially during adolescence and young adulthood 24. In this study, there was positive correlation between PMS and depression. Depression is psychosocial variable which is studied the most recently in connection with menstrual cycle. In multiple regression, depression (t=6.691, p<.001) and perception of PMS (t=2.052, p=.042) were found to be factors significantly associated with PMS, which parallels the results of study 25. It was shown that women with menstrual problems were significantly more likely to report depression according to a U.S. populationbased study 26. In 25 reported that the prevalence of major depression was 11.3% in women screening positive for moderate PMS and 24.6%in women screening positive for severe PMS. The study suggests that treatment might be particularly important for the group of women who suffer from both major depression and PMS. Up to now, it is difficult to explain clearly whether depression 27 causes 6 Vol 9 (S1) December Indian Journal of Science and Technology

7 Junghyun Choi PMS or symptom experience of PMS causes psychological problems such as depression. Therefore, it is needed to enlarge the number of research subject and to conduct prospective research to verify causality Conclusion The purpose of this study is to investigate the factors that influence PMS of female college students in Korea. The data was collected from September till December The data was collected via structural questionnaires gathered by 270 students who agreed to participate in the study, and 245 of them were analyzed except for 25 incomplete questionnaires and male nurses. There were positive correlations among PMS, depression, emotional disturbance, water retention, and pain. But there was not a statistically significant correlation between PMS and body weight. This study found that PMS is influenced by the psychological factors such as depression. Therefore, the education program including PMS and depression is needed to promote health for female university students. 6. Acknowledgments Funding for this paper was provided by Namseoul university. 7. References 1. Green R, Dalton K. The premenstrual syndrome. British Journal of Medicine. 1953; 1: Kim SM. A study on premenstrual syndrome, dietary behavior and life habits among high school girls [Master thesis]. Korea, Dong Guk University; Hankin BL, Abramson L, Moffitt TE, McGee R, Silvia PA, Angell KE. Development of depression from preadolescence to young adulthood: Emerging gender differences in a 10-year longitudinal study. Journal of Abnormal Psychology. 1998; 107: Lee SJ. The mediating effects of cognitive facts on the relationships between female adolescent s depression symptom and somatization symptom [Master thesis]. Korea, Sook Myung University; Sartorius N. Physical symptoms of depression as a public health concern. Journal of Clinical Psychiatry. 2003; 64(7): Choi JH. A study on the relationship between health promoting activities and self-efficacy a female university students [Master thesis]. Korea, ChungAng University; Han KS. Self-efficacy, health promoting behaviors, and symptoms of stress among university students. Journal of Korean Academy of Nursing. 2005; 35(2): Ryu EJ. The influence of university students family function and self-efficacy on their health promotion behavior [Master thesis]. Korea, Nambu University; Kim BK, Jung MS, Han CH. Health promotion behavior of university students and related factors. Journal of Korean Society for Health Education and Promotion. 2002; 19(1): Lee YH, Lee JY, Chung HJ. Relationships among family functioning, self-differentiation, and career attitude maturity perceived by college students. Korean Association of Family Relations. 2011; 18(1): Kang HJ, Son CN. The effects of cognitive behavioral therapy and relaxation training on reduction of premenstrual syndrome. Korean Psychological Association. 1998; 3(1): Halbreich U, Endicott J, Schacht S, Nee J. The diversity of premenstrual changes as reflected in the premenstrual assessment form. Acta Psychiatrica Scandinavica. 1982; 65(1): Radloff LS. The CES-D scale: A self report depression scale for research in the general population. Applied Psychological Measurements. 1977; 1: Cho MJ, Kim KH. The diagnostic validity of the CES-D (Korean Version) in the assessment of DSM-III-R major depression. Journal of Korean Neuropsychiatric Association. 1993; 32(3): The American Congress of Obstetricians and Gynecologists (ACOG). Practice bulletin: premenstrual syndrome. International Journal of Gynecology and Obstetrics. 2001; 73: Derman O, Kanbur NO, Tokur T, Kutluk T. Premenstrual syndrome and associated symptoms in adolescent girls. European Journal of Obstetrics and Gynecology and Reproductive Biology. 2004; 116: Erbil N, Karaca A, Kiris T. Investigation of premenstrual syndrome and contributing factors among university students. Turkish Journal of Medical Science. 2010; 40(4): Kim YR, Nam M, Meng KH. A comparative study on premenstrual syndrome between women workers and house wives. Korean Journal of Occupational Medicine. 1997; 9(3): Isik H, Ergol S, Aynioglu O, Sahbaz A, Kuzu A, Uzun M. Premenstrual syndrome and life quality in Turkish health science students. Turkish Journal of Medical Science. 2016; 46: Kan BS, Gin NH, Kim YW, Ahn SB, Yang JE, Lee KE, Choi GE, Choi SG, Choi HJ. A descriptive study on premenstrual Vol 9 (S1) December Indian Journal of Science and Technology 7

8 The Relationship between Premenstrual Syndrome and Depression of Female College Students in Korea syndrome in middle school girls. Journal of the Nursing Academic Association of Ewha Womans University. 2015; 49: Lee SH. The effect of emotional labor and stress on premenstrual syndrome and menstrual pain in nurses [Master thesis]. Korea, Eulji University; Ahn AK. Job stress and premenstrual syndrome of staff nurse in a general hospital [Master thesis]. Korea, Yonsei University; Sakai H, Kawamura C, Cardenas X, Ohashi K. Premenstrual and menstrual symptomatology in young adult Japanese females who smoke tobacco. The Journal of Obstetrics and Gynecology Research. 2011; 37(4): Bertone-Johnson ER, Hankinson SE, Johnson AR, Manson JE. Cigarette smoking and the development of premenstrual syndrome. American Journal of Epidemiology (AJE). 2008; 168: Forrester- Knauss C, Stutz EZ, Weiss C, Tschudin S. The interrelation between premenstrual syndrome and major depression: Results from a population based sample. BMC Public Health. 2011; 11(795): Strine TW, Chapman DP, Ahluwalia IB. Menstrual-related problems and psychological distress among women in the United States. Journal of Womens Health. 2005; 14(4): Choi JH, Ju SJ, Kin KS, Kim MO, Kim HJ, Yu M. A study on Korean university students depression and anxiety. Indian Journal of Science and Technology Apr; 8(S8): Moon WH, Kwon MJ, Chung KS. Influence of academic resilience, self efficacy and depression in college life adjustment in Korea s nursing college students. Indian Journal of Science and Technology. 2015; 8(19): Vol 9 (S1) December Indian Journal of Science and Technology