Scholarly article on topic 'The prevalence of anxiety and depression among people with infertility referring to Royan Institute in Tehran, Iran: A cross-sectional questionnaire study'

The prevalence of anxiety and depression among people with infertility referring to Royan Institute in Tehran, Iran: A cross-sectional questionnaire study Academic research paper on "Health sciences"

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Abstract of research paper on Health sciences, author of scientific article — Saman Maroufizadeh, Azadeh Ghaheri, Amir Almasi-Hashiani, Maryam Mohammadi, Behnaz Navid, et al.

Abstract Background and objective Infertility is a global public health issue and is a low control stressor often leading to increased level of anxiety and depression. The objective of this study was to determine the prevalence of anxiety and depression and their related factors among Iranian infertile patients. Materials and methods This cross-sectional study included 1128 infertile patients (479men and 649 women) in a referral fertility center in Tehran, Iran from January 2014 to March 2015. The Hospital Anxiety and Depression Scale (HADS) were administrated to all participants. Results The prevalence rates of anxiety and depression were 49.6% and 33.0%, respectively. Based on adjusted analysis, females were 2.26 times more likely to have anxiety symptoms than males (OR=2.26, 95% CI: 1.75–2.90), while depression rate was not related to sex (OR=1.09, 95% CI: 0.84–1.42). Patients with≥5years infertility duration were 1.51-fold and 1.30-fold more likely than others to have anxiety and depressive symptoms, respectively. Conclusion We found that the anxiety and depression rates were very high among infertile patients. Thus, there may be a need for infertile patients to receive ongoing psychological interventions and support that matches their backgroundduring ART in order to reduce level of anxiety and depression.

Academic research paper on topic "The prevalence of anxiety and depression among people with infertility referring to Royan Institute in Tehran, Iran: A cross-sectional questionnaire study"

Middle East Fertility Society Journal xxx (2017) xxx-xxx

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Middle East Fertility Society Journal

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Original Article

The prevalence of anxiety and depression among people with infertility referring to Royan Institute in Tehran, Iran: A cross-sectional questionnaire study

Saman Maroufizadeh, Azadeh Ghaheri, Amir Almasi-Hashiani, Maryam Mohammadi, Behnaz Navid, Zahra Ezabadi, Reza Omani Samani *

Department of Epidemiology and Reproductive Health, Reproductive Epidemiology Research Center, Royan Institute for Reproductive Biomedicine, ACECR, Tehran, Iran

ARTICLE INFO

ABSTRACT

Article history: Received 3 May 2017 Revised 25 July 2017 Accepted 6 September 2017 Available online xxxx

Keywords:

Anxiety

Depression

Prevalence

Fertility

Background and objective: Infertility is a global public health issue and is a low control stressor often leading to increased level of anxiety and depression. The objective of this study was to determine the prevalence of anxiety and depression and their related factors among Iranian infertile patients. Materials and methods: This cross-sectional study included 1128 infertile patients (479 men and 649 women) in a referral fertility center in Tehran, Iran from January 2014 to March 2015. The Hospital Anxiety and Depression Scale (HADS) were administrated to all participants.

Results: The prevalence rates of anxiety and depression were 49.6% and 33.0%, respectively. Based on adjusted analysis, females were 2.26 times more likely to have anxiety symptoms than males (OR = 2.26, 95% CI: 1.75-2.90), while depression rate was not related to sex (OR= 1.09, 95% CI: 0.841.42). Patients with > 5 years infertility duration were 1.51-fold and 1.30-fold more likely than others to have anxiety and depressive symptoms, respectively.

Conclusion: We found that the anxiety and depression rates were very high among infertile patients. Thus, there may be a need for infertile patients to receive ongoing psychological interventions and support that matches their background during ART in order to reduce level of anxiety and depression. © 2017 Middle East Fertility Society. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction

Infertility was defined by the World Health Organization (WHO) as ''a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse" [1] and affects approximately 10-15% of couples throughout the world [2]. Besides being a medical condition in itself, infertility can have a significant impact on well-being and quality of life [3-6]. It has been ranked as one of the great stressors in life with psychological, social and cultural consequences. Infertile patients, for example, experience more anxiety, depression and stress in their life and many authors have

Peer review under responsibility of Middle East Fertility Society.

* Corresponding author.

E-mail addresses: saman.maroufizadeh@gmail.com (S. Maroufizadeh), ghaheri@ royaninstitute.org (A. Ghaheri), amiralmasi2007@gmail.com (A. Almasi-Hashiani), maryammohammadi8766@gmail.com (M. Mohammadi), behnaz_navid@yahoo. com (B. Navid), z_ezabadi@yahoo.com (Z. Ezabadi), samani@royaninstitute.org (R. Omani Samani).

highlighted the negative impact of infertility and its treatments on these disorders [3-7].

Anxiety and depression are the most common mental disorders in both patients and general populations, which frequently coexist [8]. People experiencing fertility problem are almost twice as likely to suffer from anxiety and depression as the general population. Anxiety and depression significantly affect the quality of life of infertile couples and consequently, these disorders deserve more clinical attention [9,10]. Most of previous studies indicated that the following factors are independently associated with anxiety and depressive disorder in infertile patients: age, sex, educational level, duration of infertility, cause of infertility, number of previous infertility treatment failures [11-15].

Despite the importance of psychiatric disorders in infertile couples, there has been little research of anxiety prevalence on Iranian infertile couples in recent years and most of the studies have been carried out with relatively small sample size. In the present study the authors decided to determine the prevalence of both anxiety and depression with larger sample size among people experiencing fertility problem in a referral fertility clinic in Iran. Moreover, some

http://dx.doi.org/10.1016/j.mefs.2017.09.003

1110-5690/® 2017 Middle East Fertility Society. Production and hosting by Elsevier B.V.

This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

S. Maroufizadeh et al./Middle East Fertility Society Journal xxx (2017) xxx-xxx

associated factors (age, sex, duration of infertility, cause of infertility and history of abortion) with symptoms of anxiety and depression were examined.

2. Materials and methods

2.1. Participants and study design

This cross sectional study was conducted in Infertility Clinic of Royan Institute, Tehran, Iran between October 2014 and March 2015. This center is a referral center for infertility treatment in Tehran, Iran [16]. The inclusion criteria were as follows: (a) male and female 18 years and older; (b) suffering from infertility; (c) ability to read, write, and comprehend Persian. The exclusion criteria were incomplete questionnaires and patients' unwillingness to participate in the study

The questionnaires were administered to infertile patients. In total, 1128 people with infertility agreed to participate and filled out the questionnaires completely.

2.2. Ethical considerations

Table 1

Demographic and fertility characteristics of the participants (n = 1128).

Mean ± SD or n (%)

Age (years) 31.37 ±5.69 Sex

Male 479 (42.5)

Female 649 (57.5) Duration of infertility (years) 5.62 ± 4.03 Cause of infertility

Male factor 473 (41.9)

Female factor 276 (24.5)

Both 137 (12.1)

Unexplained 242 (21.5) History of abortion

No 950 (84.2)

Yes 178 (15.8)

SD: standard deviation.

mean infertility duration was 5.62 ± 4.03 years (rang: 1-30 years). Of the participants, 41.9% had male factor infertility and 15.8% had history of abortion.

This research was approved by the Ethics Committee of Royan Institute, and written informed consent was obtained from all participants before data collection.

2.3. Instruments

2.3.1. Demographic and fertility characteristics

Some demographic and fertility information of participants included: age, gender, infertility duration, cause of infertility and history of abortion.

2.3.2. Hospital Anxiety and Depression Scale (HADS)

The HADS is a widely used 14-item self-report instrument composed of two subscales: Anxiety (7 Items) and Depression (7 Items) [17]. Items are scored on a 4-point Likert scale ranging from 0 (no symptoms) to 3 (severe symptoms). Both subscales scores can range 0-21, with higher scores indicating greater levels of anxiety and depression. Subscale scores of more than 8 indicated the presence of anxiety and depressive symptoms [17]. The Persian version of the HADS has shown adequate reliability and validity among Iranian infertile patients [18]. The Cronbach's alpha coefficient for Anxiety and Depression subscales in the present study were 0.863 and 0.744, respectively.

2.4. Statistical analysis

In this study, continuous variables were expressed as mean ± standard deviation (SD) and categorical variables as numbers (percentage). Univariate and multivariate logistic regression analysis were used to explore the association between HADS sub-scales scores and demographic/fertility variables. Statistical analysis was performed using IBM SPSS Statistics for Windows, Version 22.0 (IBM Crop., Armonk, NY, USA). All statistical tests were 2-tailed and a p-value < 0.05 was considered statistically significant.

3. Results

3.1. Participant characteristics

3.2. Prevalence of anxiety and depression disorders

The percentage of participants meeting the HADS cut-offs of eight was 49.6% (n = 559) for anxiety and 33.0% (n = 372) for depression. Adopting Snaith and Zigmond's higher threshold for sensitivity of Anxiety and Depression scores of 11 or over, 302 participants (26.8%) demonstrated probable clinically relevant levels of anxiety and 147 participants (13.00%) probable clinically relevant levels of depression. Moreover, the mean score of Anxiety was 7.85 ±4.49 (range 0-21) and the mean score of Depression was 5.99 ± 3.76 (range 0-21).

3.3. Factor associated with anxiety

The relationships between some demographic/fertility information and anxiety using univariate and multivariate logistic regression analysis are shown in Table 2. According to adjusted analysis, females were 2.26 times more likely to have anxiety symptoms than males (OR = 2.26, 95% CI: 1.75-2.90). Having more than 5 years of infertility duration increased the likelihood of having anxiety symptoms by 51.0 percent (OR= 1.51, 95% CI: 1.18-1.94). In both unadjusted and adjusted analyses, anxiety was not significantly related to age, cause of infertility and history of abortion.

3.4. Factor associated with depression

Univariate and multivariate logistic regression analysis were used to examine the association between depression and some demographic/fertility variables (Table 3). Based on adjusted analysis, participants with >5 years duration of infertility were 1.30 times more likely to have depression symptoms than participants with <5 years duration of infertility (OR = 1.30, 95% CI: 1.011.69). Participants who had both cause of infertility were more likely to have depressive symptoms than those who had male factor infertility, although this difference was not statistically significant after adjusted for other variables (OR = 1.47, 95% CI: 0.992.19). In both unadjusted and adjusted analyses, depression was not significantly related to age, sex, and history of abortion.

Table 1 shows the demographic/fertility characteristics of the participants. In total, 1128 people suffering from infertility (479 men and 649 women) were included in this study. The mean age of participants was 31.37 ± 5.69 years (rang: 18-63 years) and

4. Discussion

To our knowledge, this is one of the first studies investigating both anxiety and depressive symptoms in men and women suffer-

S. Maroufizadeh et al./Middle East Fertility Society Journal xxx (2017) xxx-xxx

Table 2

Association between anxiety and some demographic/clinical variables among people with infertility.

Anxiety Univariate analysis Multivariate analysis

<8 >8 ORcrude (95% CI) P-Value ORAdj(95% CI) P-Value

Age (years)

<35 409 (49.9) 411 (50.1) 1 - 1 -

>35 160 (51.9) 148 (48.1) 0.92 (0.71-1.20) 0.536 0.97 (0.73-1.30) 0.859

Male 297 (62.0) 182 (38.0) 1 - 1 -

Female 272 (41.9) 377 (58.1) 2.26 (1.78-2.88) <0.001 2.26 (1.75-2.90) <0.001

Infertility duration (years)

<5 311 (55.8) 246 (44.2) 1 - 1 -

>5 258 (45.2) 313 (54.8) 1.53 (1.21-1.94) <0.001 1.51 (1.18-1.94) 0.001

Cause of infertility

Male factor 234 (49.5) 239 (50.5) 1 - 1 -

Female factor 148 (53.6) 128 (46.4) 0.85 (0.63-1.14) 0.273 0.77 (0.57-1.05) 0.102

Both 59 (43.1) 78 (56.9) 1.29 (0.88-1.90) 0.187 1.17 (0.79-1.73) 0.436

Unexplained 128 (52.9) 114(47.1) 0.87 (0.64-1.19) 0.387 0.92 (0.67-1.27) 0.629

History of abortion

No 484 (50.9) 466 (49.1) 1 - 1 -

Yes 85 (47.8) 93 (52.2) 1.14(0.82-1.57) 0.434 1.02 (0.73-1.43) 0.899

OR: odds ratio, CI: confidence interval.

Table 3

Association between depression and some demographic/clinical variables among people with infertility.

Depression Univariate analysis Multivariate analysis

<8 >8 ORcrude (95% CI) P-Value ORAdj(95% CI) P-Value

Age (years)

<35 554 (67.6) 266 (32.4) 1 - 1 -

>35 202 (65.6) 106 (34.4) 1.09 (0.83-1.44) 0.529 1.04 (0.78-1.40) 0.778

Male 327 (68.3) 152 (31.7) 1 - 1 -

Female 429 (66.1) 220 (33.9) 1.10 (0.86-1.42) 0.445 1.09 (0.84-1.42) 0.501

Infertility duration (years)

<5 391 (70.2) 166 (29.8) 1 - 1 -

>5 365 (63.9) 206 (36.1) 1.33 (1.04-1.71) 0.025 1.30(1.01-1.69) 0.046

Cause of infertility

Male factor 323 (68.3) 150 (31.7) 1 - 1 -

Female factor 182 (65.9) 94 (34.1) 1.11 (0.81-1.52) 0.509 1.13 (0.82-1.55) 0.458

Both 81 (59.1) 56 (40.9) 1.49 (1.01-2.20) 0.047 1.47 (0.99-2.19) 0.055

Unexplained 170(70.2) 72 (29.8) 0.91 (0.65-1.28) 0.592 0.95 (0.68-1.34) 0.790

History of abortion

No 630 (66.3) 320 (33.7) 1 - 1 -

Yes 126 (70.8) 52 (29.2) 0.81 (0.57-1.15) 0.245 0.77 (0.54-1.09) 0.143

OR: odds ratio, CI: confidence interval

ing from infertility in Iran. We found that people attending a referral fertility clinic for treatment have a higher prevalence of anxiety and depressive symptoms compared to general population using the General Health Questionnaire (GHQ-28) (21% for depressive symptoms and 20.8% for anxiety symptoms) [19]. This difference could be due to the uncertainty about the treatment duration and cause of infertility as well as the social stigma experienced by infertile couples [14]. To the majority of Iranian infertile couples the infertility procedures appear ambiguous and this uncertainty about the procedures and unawareness about the details of costs also increases the psychological consequences [20,21]. In the present study, the prevalence of depression was 33.0% (Females: 33.9%, Males: 31.7%), which is lower than what was reported by Masoumi et al. (Females: 46%, Males: 47%) [22], Farzadi et al. (Females: 72.54%) [23], Al-Homaidan (Females: 53.8%) [13], Ramezanzadeh et al. (Females: 40.8%) [11], Alhassan et al. (Females: 62.0%) [24] and Domar et al. (Females: 36.7%) [25], but consistent whit what was reported by Drosdzol et al. (Females: 35.4%) [12] and Abbasi et al. (Female: 31.0%) [26]. The prevalence of anxiety was 49.6% in this study, which is lower than what was reported by Ramezanzadeh et al. (Females: 86.8%) [11], but higher than what was reported by Aarts et al. (Total: 23.2%) [27]. The

relative variation in literature reports on anxiety and depression prevalence could be due to different tools or due to different demo-graphical characteristics.

Anxiety and depression caused by infertility may be related to several factors, including uncertainty of the cause of infertility, uncertain treatment duration and procedure, financial stress, and social pressure. In the present study both anxiety and depression were positively associated with duration of infertility. This association might be explained by the fact that the longer the infertility crisis continues, the more people in families and neighbors will know about it and hence the more social pressure one will feel; Another possible explanation is that longer infertility duration and repeated referrals would gradually change infertility to a chronic problem [28]. A great deal of the previous work in this field have shown an association between infertility duration and both anxiety and depression [11,12,29]. However, Ogawa et al. [14] and Maroufizadeh et al. [15] showed that these disorders were not correlated with infertility duration among infertile patients. Our findings indicated that anxiety occurs more frequently than depression among infertile patients, which is consistent with previous studies [11,15,26]. We found that anxiety is more common in infertile women compared to infertile men; an explanation for this

S. Maroufizadeh et al./Middle East Fertility Society Journal xxx (2017) xxx-xxx

might be that in Iran women are often considered responsible when a couple is infertile and infertility results in social stigmati-zation for women; therefore women are more vulnerable than men to the negative psychological effects of infertility. However depressive symptoms showed no difference between the male and female groups.

Organizing support groups and open forums for infertile couples and also providing some psychological interventions emphasizing on coping-skills training, cognitive-behavioral therapy and stress management can have positive effects on infertile couples [30-32].

Our study has several strengths that should be considered, including (a) the relatively large sample size, (b) evaluating both anxiety and depressive symptoms, (c) include both men and women experiencing fertility problem (d) conducted in one of the largest referral fertility clinic in Iran. There are also a few limitations that should be mentioned in evaluating these results. First, we did not examine the prevalence of anxiety and depression according to some demographic and clinical characteristics such as level of education, urban and rural, socioeconomic status, and type of infertility (primary-secondary). Second, the cross-sectional design of the present study does not allow us to establish causal inferences between study variables. Third, using questionnaires and self-rating, although a useful for assessing the severity of symptoms, are not the best way of identifying the existence of major depression as a disorder or differentiating between specific anxiety disorders [33]. More studies utilizing structured interviews are needed to determine the prevalence rate of anxiety and depression among infertile couples.

5. Conclusion

In summary, the prevalence rate of anxiety and depression as measured with the HADS in infertile patients is considerably higher than in general population samples. These data serve as a benchmark for the prevalence rate of anxiety and depression in Iranian infertile patients. In addition, there may be a need for infertile patients to receive ongoing psychological interventions and support that matches their background in order to reduce level of anxiety and depression. Establishing a community based intervention strategy to educate couples about infertility treatment procedures and cost might be helpful as well.

Acknowledgements

This study was founded by Royan Institute for Reproductive Biomedicine, ACECR, Tehran, Iran. The authors wish to thank the infertile patients for their participation in this research and the staff at the fertility clinic of Royan Institute for their contribution to this research.

Conflict of interest

The authors declare that they have no conflict of interest. References

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