1. INTRODUCTION
Menopause represents a significant transitional phase in a woman’s life, marked by both physical and emotional changes that can profoundly impact well-being. Among the various challenges faced during this period, depression and anxiety emerge as prevalent psychological concerns affecting menopausal women [1], [2]. The ramifications of these mental health issues extend beyond the individual, influencing overall quality of life, social interactions, productivity, and self-esteem. Recognizing the prevalence and identifying risk factors associated with depression and anxiety in menopausal women in Iraq is crucial [1], [3]. Depression and anxiety, as highlighted in previous research [2], emerge as prevalent challenges during menopause, impacting various facets of women’s lives. The ramifications of these mental health issues extend beyond the individual, influencing overall quality of life, social interactions, productivity, and self-esteem. Recognizing the prevalence and identifying risk factors associated with depression and anxiety in menopausal women in Iraq is crucial [1], [3]. The etiology of depression and anxiety during menopause encompasses hormonal fluctuations, stressors, and socio-cultural influences [4]. Therefore, a comprehensive understanding of their prevalence and associated risks is essential for providing effective healthcare to women in Iraq during this life stage. Menopause entails various consequences, including vasomotor symptoms, atrophy in the general and urinary tracts, osteoporosis, cardiovascular risks, cognitive decline, and psychological changes such as depression and anxiety [5], [6]. The interplay of biological, social, and psychological factors during this stage contributes to the vulnerability of women, with studies indicating a substantial prevalence of depression (18–41.8%) and anxiety (7–25%) in pre- and post-menopausal women[7], [8].
Depression, ranging from transient negative mood states to clinically defined disorders causing significant distress, and anxiety-related disorders manifesting as panic attacks or generalized worry pose significant challenges to women’s mental health [9], [10]. These conditions, as highlighted by researchers, not only lead to risky behaviors but are also strongly correlated with diminished quality of life [11]. In addition, menopausal symptoms are factors that contribute to anxiety and depression [12].
This study centers on the Ali Kamal Health Center in Sulaymaniyah City, a pivotal healthcare institution serving women in the region. Focusing on this center allows for a nuanced examination of depression and anxiety prevalence among menopausal women attending this facility. Different instruments were used to assess mood during menopause in previous studies, such as the depression and anxiety stress scale [13]. The Patient Hospital Questionnaire-9 [14]. However, in this study, we used the Hospital Anxiety and Depression Scale. This scale is used to detect the emotional symptoms of anxiety and depression and was used in previous studies [12], [15].
The study aims to assess depression and anxiety and explore their association with socio-demographic characteristics in menopausal women in Sulaymaniyah City, Kurdistan, Iraq. The outcomes of this research are poised to offer valuable insights into the mental health landscape of menopausal women, guiding the development of targeted interventions to enhance their well-being in Iraq.
2. MATERIAL AND METHODS
2.1. Design
The qualitative, cross-sectional study was conducted at the Ali Kamal consultation center, a facility of the general teaching hospital in Sulaymaniyah City, Iraq, Kurdistan, and the period of data collection started from November 2022 until February 2023.
2.2. Study Sample
Non-probability: a purposive sample size of 126 menopausal women attending Ali Kamal Health Center for the check-up.
2.3. Inclusion and Exclusion Criteria
Women had to meet certain criteria to be included in the study: being between the ages of 50 and 60, reaching menopause naturally (as opposed to undergoing hysterectomy and surgery), having gone more than a year without having their period, and agreeing to participate in the study. Women under 50 who suffer from psychological conditions and cannot participate in interviews were excluded.
2.4. Data Tools
A questionnaire was developed for data collection and composed of three sections. The first section related to sociodemographic characteristics included age, age at marriage, educational level, occupation, marital status, residential area, height and weight, and age at menarche. The second section is related to menopause symptoms, which include forgetfulness, vaginal dryness, no sexual desire, lethargy, hot flashes, hair loss, shortsightedness, weight gain, sweating, skin dryness, urine leakage, and sleep disturbance. The third section, measured through the hospital anxiety scale by Zigmond and Snaith [16], which is a standard tool used for detecting anxiety and depression in non-psychiatric individuals, has been used in many pieces of research with good reliability and validity [7], [12]. Its 14 items were rated on a 4-point ranging from 0 to 3.
The scale comprised seven items to assess depression, five of which are marks for anhedonia (an inability to experience pleasure), and two concern appearance and feelings of slowing down. Seven items assess anxiety; two assess automatic anxiety (panic and butterflies in the stomach); and the other five assess tension and restlessness. The questionnaire was translated into the Kurdish language through a forward-backward procedure.
2.5. Validity and Reliability of the Study Instrument
The validity of the questionnaire is determined through a panel of experts in related fields. For the reliability of the questionnaire, a pilot study was carried out at the Ali-Kamal Health Center on a sample of ten women selected from the October 8–20, 2022, interviewed by the researcher to determine the reliability and clarity of the questionnaire and to estimate the average time required for data collection. The result of a pilot study showed that the items were clear and understood, and the time required was from 30 to 60 min for each respondent. The internal consistency of the instrument was determined through the computation of the interclass correlation coefficient, and the result of the reliability was (r = 0.84, P < 0.01), which was a statistically adequate level of internal consistency. The sample of the pilot study was not included in the original sample of the study.
2.6. Data Collection
The data were collected through a face-to-face interview method conducted with each participant to fill out the questionnaire.
2.7. Data Analysis
The data were analyzed using a Statistical Package for the Social Science, SPSS version 25 software. The descriptive statistics include frequencies, percentages, mean, and forecast standard deviation. The inferential statistics, including the Chi-square (2X) test and Fisher’s exact test, were used to analyze the data; a P-value of 0.05 was used as the cut-off for statistical significance and 0.001 for high statistical significance.
3. RESULTS
As seen in Table 1, women between the ages of 44 and 53 comprised the majority of participants in this study (69.1%), and most were married. In this study, 47.4% of the study samples were overweight according to body mass index (BMI). Regarding education level, more participants (32.5%) were only primary school educated. In this study, 51.7% of the women worked as stay-at-home mothers. Finally, almost all participants were from the city center.
TABLE 1: Demographic characteristics of the participants
Overall data on signs and symptoms of pregnancy reveals that the majority of participants have menopausal signs and symptoms, as shown in the Table 2.
TABLE 2: Signs and symptoms of the patients
The table delineates the frequency and percentage distribution of various signs and symptoms reported by the patients. The most prevalent symptom is forgetfulness, with 86.7% of patients experiencing it. Vaginal dryness is reported by 84.2% of patients, followed by a lack of sexual desire in 82.5% of cases. The table provides a comprehensive overview of the occurrence of diverse symptoms among the surveyed patients.
Table 3 provides an assessment of anxiety among the patients based on various statements. The majority of respondents reported feeling tense or wound up most of the time (72.5%). In addition, a significant proportion experienced worrying thoughts a great deal of the time (62.5%) and reported feeling quite badly or very definitely that something awful was about to happen (60%). The table comprehensively outlines the frequency and percentage distribution of anxiety levels across different statements, offering insights into the prevalence of anxiety symptoms among the surveyed patients.
TABLE 3: Anxiety profile of the patients
Table 5 presents the association between anxiety-related questions and various sociodemographic variables, indicated by the corresponding p-values. The p-values signify the level of significance for each relationship. Lower P-values generally suggest a more significant association. For instance, in the context of age and question 4 (“I can sit at ease and feel relaxed”), a P-value of 0.0 indicates a statistically significant association. This table serves as a valuable reference for understanding the relationships between anxiety symptoms and sociodemographic factors within the studied population.
TABLE 4: Depression scale of the patients by frequency and percentage
TABLE 5: Association between a demographic characteristic of the patients and anxiety
Table 6 illustrates the association between depression-related questions and various sociodemographic variables, denoted by the corresponding P-values. The P-values indicate the level of significance for each association. Lower P-values generally signify a more significant association. For instance, in the context of age and question 2 (“I can laugh and see the funny side of things”), a P-value of 0.022 indicates a statistically significant association. This table provides valuable insights into the relationships between depression symptoms and sociodemographic factors within the studied population.
TABLE 6: Association between a demographic characteristic of the patients and depression
In Table 4 the data shows how depressed the participants were; the majority (74.2%) of the women appeared unhappy. More than half (62.5) of the study samples did not have any ability to laugh or find humor in situations. 49.2% of the participants said they did not feel happy at all. Nearly all of the respondents (58.3%) felt slowed down most of the time. More than half of the female population (69.2%) firmly believes that their interest in women’s looks has diminished. More than half of the women (55.8%) very rarely enjoy listening to or watching an excellent book or radio show.
4. DISCUSSION OF THE RESULTS
The temporal intricacies of a woman’s reproductive phase, marked by the decline in ovarian function, render it challenging to pinpoint a definitive age for menopause initiation. Consistent with the study by Ahlawat et al. (2019), our research focused on women aged 50 to 54, constituting 69.1% of the participants. Our findings indicate that 47.4% of the study sample was classified as overweight, potentially attributed to age-related changes, reduced physical activity, and a sedentary lifestyle. While consistent with [17], discrepancies with [18] are discussed, considering regional variations in race, ethnicity, and biological characteristics.
The prevalence of menopausal symptoms and indications in our study aligns with the hormonal changes inherent in the menopausal transition, affecting diverse biological systems. Notably, despite most participants having completed only primary school, education emerges as a potential modifier, contradicting [19] findings on the positive correlation between education and the quality of life of menopausal women. Our study resonates with [20], [21], reporting prevalent menopausal symptoms among participants aged 50–54. Discrepancies with [22] are acknowledged, considering potential regional variations in cultural and biological characteristics.
The prevalence of nervousness reported by 72.5% of participants during menopause suggests potential anxiety symptoms accompanying or preceding depression. Contrary to Kravitz et al. (2014) [23], our findings emphasize the impact of environmental stressors during the midlife transition. The vulnerability to depression during the menopause transition is underscored by a recent study, indicating a high percentage (74.2%) of women reporting dissatisfaction or depression. This vulnerability, heightened during perimenopause, necessitates attention to potentially reversible psychological conditions, given the increased risks for osteoporosis and cardiovascular disease in post-menopausal women.
Risk factors for depressive mood during the menopause transition, such as poor sleep, stressful life events, unemployment, and a higher BMI, align with existing literature, emphasizing the multifactorial nature of depression during this period. Educational attainment and non-white-collar occupations are highlighted as sociodemographic risk factors, consistent with previous studies. Anxiety, another prevalent symptom during the menopause transition, demonstrates associations with sociodemographic characteristics, except for occupation status. This finding diverges from studies among teachers and healthcare workers, emphasizing the nuanced role of occupation-related stress in exacerbating menopausal symptoms.
5. CONCLUSION
Our study aims to assess depression and anxiety symptoms among menopausal women, with age and age at marriage, BMI, and marital status emerging as significant sociodemographic factors influencing the likelihood of developing these symptoms. The absence of associations with occupation and place of residence underscores the complexity of these psychological manifestations. The study recommends the implementation of counseling and nursing management to mitigate the prevalence of anxiety and depression among menopausal women.
6. ACKNOWLEDGMENT
Gratitude is extended to all study participants for their involvement. Special recognition is given to the administration of the Ali Kamal Health Center for their invaluable support and cooperation in facilitating the collection of research data.
7. ETHICAL CONSIDERATIONS
The research adhered to ethical standards, with a clear articulation of its purpose and the requisite permissions secured. Approval was obtained from the Scientific Committee of the Psychiatric Mental Health Nursing Department at the College of Nursing and the Ethical Committee at the College of Medicine at the University of Sulaymaniyah. Further authorization from the General Health Director was acquired to conduct the study at Ali Kamal Health Centre. Prior to their participation, participants were fully informed about the research objectives, and verbal informed consent was obtained.
8. CONFLICTS OF INTERESTS
The authors declare the absence of any conflicts of interest.
9. FUNDING
The study was financially supported through author fees.
REFERENCES
[1] P. Ahlawat, M. M. Singh, S. Garg and Y. M. Mala. ”Prevalence of depression and its association with sociodemographic factors in post-menopausal women in an urban resettlement colony of Delhi“. Journal of Mid-life Health,vol. 10, no. 1, 33, 2019.
[2] M. Nobahar, Z. Hydarinia-Naieni and R. Ghorbani. ”The prevalence of depression, anxiety, and stress and their association with vitamin D and estrogen levels in postmenopausal women in Semnan“. Middle East Journal of Rehabilitation and Health Studies, vol. 6, no. 4, e91953, 2019.
[3] W. A. Rocca, L. G. Rocca, C. Y. Smith, E. Kapoor, S. S. Faubion and E. A. Stewart, ”Frequency and type of premature or early menopause in a geographically defined American population“. Maturitas, vol. 170, pp. 22-30, 2023.
[4] F. A. Yılmaz and D. Avci. ”The relationship between personality traits, menopausal symptoms, and marital adjustment“. Health Care for Women International, vol. 43, no. 10-11, pp. 1142-1157, 2020.
[5] D. H. Barlow. ”Continuing progress on vasomotor symptoms“. Menopause, vol. 30, no. 3, pp. 235-236, 2023.
[6] R. A. Andrews, B. John and D. Lancastle. ”Symptom monitoring improves physical and emotional outcomes during menopause:A randomized controlled trial“. Menopause, vol. 30, no. 3, pp. 267-274, 2023.
[7] T. Tangen and T. Mykletun. ”Depression and anxiety through the climacteric period:An epidemiological study (HUNT-II)“. Journal of Psychosomatic Obstetrics &Gynecology, vol. 29, no. 2, pp. 125-131, 2019.
[8] C. Zhang, Y. Xue, H. Zhao, X. Zheng, R. Zhu, Y. Du, J. Zheng and T. Yang. ”Prevalence and related influencing factors of depressive symptoms among empty-nest elderly in Shanxi, China“. Journal of Affective Disorders, vol. 245, pp. 750-756, 2019.
[9] C. Schiweck, D. Piette, D. Berckmans, S. Claes and E. Vrieze. ”Heart rate and high frequency heart rate variability during stress as biomarker for clinical depression:A systematic review“. Psychological Medicine, vol. 49, no. 2, pp. 200-211, 2019.
[10] D. H. Barlow and K. K. Ellard. “Anxiety and related disorders”. General Psychology, vol. FA18, no. 178, 179-240, 2018.
[11] C. J. Gibson, Y. Li, A. J. Huang, T. Rife and K. H. Seal. “Menopausal symptoms and higher risk opioid prescribing in a national sample of women veterans with chronic pain”. Journal of General Internal Medicine, vol. 34, pp. 2159-2166, 2019.
[12] A. Nawaz, S. F. Iqbal, A. Fatima and A. Ahmad. “Anxiety and depression and its risk factors among post-menopausal women-hospitals based study”. Pakistan Journal of Medical Research, vol. 59, no. 4, pp. 130-134, 2020.
[13] A. Bener, D. Saleh, N. M. Bakir and A. Bhugra. “Depression, anxiety, and stress symptoms in menopausal Arab women:Shedding more light on a complex relationship”. Annals of Medical and Health Sciences Research, vol. 6, no. 4, pp. 224-231, 2016.
[14] J. Ford, F. Thomas, R. Byng and R. McCabe. “Use of the patient health questionnaire (PHQ-9) in practice:Interactions between patients and physicians”. Qualitative Health Research, vol. 30, no. 13, pp. 2146-2159, 2020.
[15] N. Barghandan, N. Dolatkhah, F. Eslamian, N. Ghafarifar and M. Hashemian. “Association of depression, anxiety and menopausal-related symptoms with demographic, anthropometric and body composition indices in healthy postmenopausal women”. BMC Womens Health, vol. 21, no. 1, 192, 2021.
[16] A. S. Zigmond and R. P. Snaith. “The hospital anxiety and depression scale”. Acta Psychiatrica Scandinavica, vol. 67, no. 6, pp. 361-370, 1983.
[17] J. T. T. Gonçalves, M. F. F. Silveira, M. C. C. Campos and L. H. R. Costa. “Overweight and obesity and factors associated with menopause”. Ciência and Saúde Coletiva, vol. 21, pp. 1145-1156, 2016.
[18] S. Koo, Y. Ahn, J. Y. Lim, J. Cho and H. Y. Park. “Obesity associates with vasomotor symptoms in postmenopause but with physical symptoms in perimenopause:A cross-sectional study”. BMC Womens Health, vol. 17, no. 1, pp. 126, 2017.
[19] J. E. Blumel, C. Castelo-Branco, L. Binfa, G. Gramegna, X. Tacla, B. Aracena, M. A. Cumsille and A. Sanjuan. “Quality of life after menopause:A population study”. Maturitas, vol. 34, no. 1, pp. 17-23, 2000.
[20] P. Monteleone, G. Mascagni, A. Giannini, A. R. Genazzani and T. Simoncini. “Symptoms of menopause-global prevalence, physiology and implications”. Nature Reviews Endocrinology, vol. 14, no. 4, pp. 199-215, 2018.
[21] E. Yisma, N. Eshetu, S. Ly and B. Dessalegn, “Prevalence and severity of menopause symptoms among perimenopausal and post-menopausal women aged 30-49 years in Gulele sub-city of Addis Ababa, Ethiopia”. BMC Womens Health, vol. 17, pp. 24, 2017.
[22] P. Nkwo and H. Onah. “Positive attitude to menopause and improved quality of life among Igbo women in Nigeria”. International Journal of Gynecology and Obstetrics, vol. 103, no. 1, pp. 71-72, 2008.
[23] H. M. Kravitz, L. L. Schott, H. Joffe, J. M. Cyranowski and J. T. Bromberger, “Do anxiety symptoms predict major depressive disorder in midlife women?The Study of Women's Health Across the Nation (SWAN) Mental Health Study (MHS)”. Psychological Medicine, vol. 44, no. 12, pp. 2593-2602, 2014.
[24] P. K. Srikanteswara, J. D. Cheluvaiah, J. B. Agadi and K. Nagaraj. “The relationship between nerve conduction study and clinical grading of carpal tunnel syndrome”. vol. 10, pp. 13-18, 2016.