Psychosomatics 47:147-151, April 2006
doi: 10.1176/appi.psy.47.2.147
© 2006 Academy of Psychosomatic Medicine
Major Depression in Female Urinary Incontinence
Simone N. Vigod, M.D., and
Donna E. Stewart, M.D., FRCPC
Received March 16, 2005; accepted June 10, 2005. From the University of Toronto and the Women's Health Program, University Health Network, Toronto, Ontario, Canada. Address correspondence and reprint requests to Dr. Stewart, Toronto General Hospital, 200 Elizabeth St., Rm. EN7-229, Toronto, Ontario, Canada M5G 2C4. e-mail: donna.stewart{at}uhn.on.ca
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ABSTRACT
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The authors explored the relationship between urinary incontinence and major depression through data from the Canadian Community Health Survey. The prevalence of depression was 15.5% in women with urinary incontinence (30% in women ages 18–44) and only 9.2% in women without urinary incontinence. Women with comorbid illness reported increased physician use, subjective distress, and work absence. These conditions frequently occur together in Canadian women, and the combined impact of urinary incontinence and major depression exceeds the impact of either condition alone. Physicians need to be attentive to these findings.
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INTRODUCTION
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Both major depression and urinary incontinence disproportionately affect women and are known, individually, to have significant impact on quality of life.1,2 Because of recent pharmacological research demonstrating the efficacy of serotonin-norepinephrine reuptake inhibitors in stress urinary incontinence, there has been an impetus for increased attention to the tendency for these disorders to co-occur and to their combined impact on patients' quality of life.3
Urinary incontinence will affect 10%–50% of women over their lifetime, and clinical studies report an increased prevalence of major depression in women who suffer from urinary incontinence.5 However, the epidemiology of depression in female urinary incontinence varies widely, depending on the sample and the depression measure used. Prevalence estimates range from 10% to 50%, and odds ratios (ORs) for the likelihood of having depression, given the presence of urinary incontinence, range from 1.41 to 5.23.1 Unfortunately, many of the studies describe clinic-based samples that have inherent selection bias.4–7 Other studies focus primarily on older women.8–10 In general, the prevalence of major depression is lower in older women, so estimates of depressive illness in these samples may not reflect the true scope of the issue.
The Canadian Community Health Survey (CCHS) presents the opportunity to study the association between urinary incontinence and major depression on a population level. CCHS is a large, population-based survey that contains a reliable measurement of depression, and its rich data allow consideration of almost all potential and important confounders of the relationship between depression and urinary incontinence, including the effect of having other chronic conditions. It allows a detailed description of the characteristics and quality of life of women who suffer from urinary incontinence and comorbid depressive illness.
The specific objectives of this study were to 1) evaluate whether an association between urinary incontinence and major depression exists in Canadian women; 2) help identify women with urinary incontinence who are at risk for depression; and 3) highlight the impact that such comorbid illness has on their quality of life.
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METHOD
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Study Sample
The CCHS is a cross-sectional survey that collects information related to health status, healthcare utilization, and health determinants for a representative sample of the Canadian population. CCHS Cycle 1.1 was conducted between September 2000 and November 2001, for 136 health regions, covering all provinces and territories. Using computer-assisted interviewing, responses were collected from individuals age 12 and older, living in privately-occupied dwellings. Individuals living on Indian Reserves and on Crown Lands, institutional residents, full-time members of the Canadian Armed Forces, and residents of certain remote regions were excluded from the sampling frame. The overall household-level response rate was 91.4% (N=125,159). Among these responding households, an overall person-level response rate of 91.9% (N=130,827) was obtained for CCHS Cycle 1.1 (www.statscan.com). For the purposes of the present investigation, we included only individuals who were female, not pregnant, and age 18 years or older.
Identification of Urinary Incontinence Cases
In the variable category "Chronic Conditions," participants were asked about long-term conditions that had lasted or were expected to last 6 months or more and had been diagnosed by a health professional. Participants who answered "Yes" to "Do you suffer from urinary incontinence?" were coded as positive. To obtain an estimate of the minimum prevalence in this sample, all other responses (No, Do Not Know, Not Applicable, Not Stated, or refusal to answer question) were coded as not suffering from urinary incontinence.
Assessment of Depression
The Composite International Diagnostic Interview: Short Form (CIDI-SF) for depression was used to screen for major depression (www.who.int/msa/cidi/index.htm). The CIDI-SF was developed to diagnose a major depressive episode according to the definitions and criteria of the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV). Note that no distinction is made between respondents with major depressive disorder, major depressive episodes that occur as part of a bipolar disorder, or major depressive episodes that occur in the course of psychotic disorders. For this survey, interviewers were trained, through didactic sessions and supervised interviewing, by Statistics Canada before the data collection. Supervision continued on an ongoing basis during data collection (www.statscan.com).
Evidence indicates that 75%–90% of people endorsing a score of 5 or higher on the CIDI-SF for depression experienced an episode of major depression in the preceding 12 months.11 Therefore, participants who received scores of 5 or greater on the CIDI-SF were coded as having had a major depression in the preceding 12 months. Participants who received a score of less than 5 or who did not endorse the screening questions were coded as not having had a major depression in the preceding 12 months. Respondents who refused to answer the questions were excluded from the analysis.
Impact
The CCHS included valid and reliable methods for assessing the impact of chronic disease. The Health Utilities Index, Mark III (HUI3) is a summary measure that incorporates functional and social preferences of health states. This third version of the Health Utilities Index has been adapted for use in population health surveys. Specifically, it has been used to analyze the impact of chronic conditions on quality of life in Canadian populations.12 It provides a quantitative measure of the health-related quality of life associated with an individual's health status, where 1.000 represents perfect health, and 0.000 represents death. Research suggests that differences in HUI3 scores  0.03 represent a minimal clinically important impact, whereas differences in HUI3 scores 0.09 represent severe impact.13,14 Also, the survey includes direct and indirect disability indicators, including a general-health description index, information on healthcare utilization, and self-reported activity-reduction in multiple environments.
Analysis
The CCHS 1.1 database was analyzed with SPSS 11.0 for Windows software. To compare women with urinary incontinence and those without urinary incontinence, we used chi-square tests of association (for categorical variables) and independent-sample t-tests (for continuous variables). We performed the same statistical tests to compare women with and without comorbid depression. Logistic regression was used to determine the likelihood of having depression in the presence of urinary incontinence, controlling for potential confounding factors. All estimates were weighted to represent the population at the time of the survey. Furthermore, to account for the complex cluster-sampling design of the survey, we used a weighted boot-strapping resampling procedure to calculate the coefficients of variations for the estimates.
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RESULTS
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After excluding men, pregnant women, and individuals under the age of 18 from the sample, we performed the analysis on 69,003 respondents.
Urinary Incontinence
Data on the epidemiology of urinary incontinence in Canada is currently being reviewed elsewhere. In summary, the weighted prevalence of urinary incontinence was 3.23% (95% confidence interval [CI]: 3.04–3.41). The mean and median ages of onset of urinary incontinence were 52.1 (95% CI: 49.7–52.2) and 52.0 years, respectively. More than 80% of cases of urinary incontinence were in women over the age of 44 (prevalence: 5.36%; 95% CI: 5.04–5.69).
Major Depression
The prevalence of major depression in the preceding 12 months was 9.40% (95% CI: 9.07–9.73) in our sample of women. The prevalence of depression was higher in younger (18- to 44-year-old) women (11.65%; 95% CI: 11.15–12.14) than in women age 45 and older (7.07%; 95% CI: 6.65–7.49).
Major Depression and Urinary Incontinence
The prevalence of major depression in women who suffered from urinary incontinence (15.5%) was significantly greater than in women who did not suffer from urinary incontinence (9.2%). This increased depression prevalence was most substantial in younger age-groups but persisted in older women as well. Analysis of women who reported any chronic condition (e.g., asthma, arthritis, back problems, chronic headaches, multiple sclerosis) was also included. All comparisons were significant at the level of p<0.001 (see Figure 1).
Women With Urinary Incontinence Who Are at Risk for Depression
Women with urinary incontinence and depression were generally younger (average age: 52.4 [SD: 16.2]) than women with urinary incontinence without depression (mean age: 65.1 [SD: 16.9] years; t = –161.8; p<0.001) and slightly heavier (body mass index: 28.5 [SD: 7.5] versus 27.6 [SD: 6.3]; t=23.31; p<0.001). Women with urinary incontinence and comorbid depression were less likely to be married (44.4% versus 55.6%;  2=658.76; p<0.001) and more likely to be middle- or high-income (83.1% versus 79.0%; 2=494.9; p<0.001). There was no difference in education level between the two groups.
Association Between Urinary Incontinence and Depression
We used logistic-regression analysis to determine the likelihood of depression in the presence of urinary incontinence, inserting an interaction term of age x urinary incontinence to account for the substantially higher prevalence rates of depression seen in younger women with urinary incontinence. The overall odds ratio for urinary incontinence was 5.73 (95% CI: 3.11–10.54), controlling for the effects of age, marital status, suffering from any chronic condition, having had a hysterectomy, and the interaction of age and urinary incontinence (Table 1). The OR for the interaction between age and urinary incontinence was 0.983, indicating that the strength of urinary incontinence as a predictor of depression is greater for younger women.
Physician Use
The majority of women with urinary incontinence (95.7%) had a regular physician, as did women with depression (90.1%). However, women with comorbid urinary incontinence and depression reported almost three times as many consultations with a medical doctor in the preceding 12 months as women without comorbid depression (15.35 [SD: 20.28] versus 5.15 [SD: 8.69]; t=118.2; p<0.001). Overall, women with depression reported an average of 10.78 [SD: 17.88] consultations in the same time period.
Quality of Life
Health Utility Index scores illustrate that comorbid depression has a significant impact on quality of life for women with urinary incontinence (see Figure 2). Overall, 39.5% of women with depression reported Excellent or Very Good health on the Health Description Index, as did 22.9% of women with urinary incontinence. Although 59.2% of the non-depressed women with urinary incontinence reported a subjective state of Excellent or Very Good general health, only 15.1% of women with comorbid depression did so (2=182,486.9; p<0.001).
Reported life stress differed between groups, as well. Overall, 31.2% of women with urinary incontinence reported being "quite a bit" or "extremely" stressed. Significantly, 61.6% of women with comorbid urinary incontinence and depression fell into this group (versus 26.6% of women with urinary incontinence who were not depressed). For women with depression overall, 55.3% reported being "quite a bit" or "extremely" stressed.
Of women with comorbid urinary incontinence and depression, 26.5% had worked in the preceding week, whereas 21.6% were permanently unable to work. Over half of the women without comorbid depression (58.0%) had worked in the preceding week, and only 2.7% were permanently unable to work (2=76,415.2.8; p<0.001). Over half of women reporting depression overall (54.6%) were working, and 31.0% of women with urinary incontinence were working.
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DISCUSSION
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The results of the data from the CCHS 1.1 clearly show that comorbid urinary incontinence and major depression are prevalent in Canadian women. A significant finding is that younger women with urinary incontinence appear to be at increased risk for depressive illness. Women with urinary incontinence who were age 18–44 had the highest prevalence of depression, almost three times that of women age 45 or older. It is difficult to speculate on the reasons for this, as there was no information collected in the CCHS on subtype (stress, urge, mixed) or severity of urinary incontinence. Traditionally, researchers have hypothesized that the disturbance to women's lives created by urinary incontinence would differentially affect younger women, thus leading to more depressive illness. However, young women with urinary incontinence had much higher rates of depression than young women with other chronic conditions, leading us to question whether there are other factors unique to urinary incontinence that increase the risk of depression. It would be desirable to obtain population-based information on urinary incontinence by subtype and specific effects on quality of life by age for further investigation.
Regardless of how the two disorders are related, the combined impact of urinary incontinence and major depression exceeds the impact of either condition alone. There is increased subjective distress, increased physician use, and permanent absence from the workforce. This result has broad implications for urology, urogynecology, psychiatry, and, especially, primary care. It is imperative that women with either condition be screened for the other, no matter what their age-group might be. Leaving either of these disorders undiagnosed and thus untreated will clearly have a significant impact on the health and quality of life of individual patients and the population as a whole.
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REFERENCES
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ABSTRACT
INTRODUCTION
