Research Article, J Sleep Disor Treat Care Vol: 7 Issue: 1
Prevalence of Depression and Sleep in Women with Voiding Complaints in Brazil
Mário Maciel de Lima Junior*, Paloma Moraes de Souza and Adrya Midiã de Lima Oliveira
Cathedral College Boa Vista, Brazil
*Corresponding Author : Mario Maciel De Lima Junior, PhD
Cathedral College Boa Vista, Brazil, Rua Levindo Inacio De Oliveira, 1547, Bairro Paraviana, Boa Vista - Roraima – Brazil, Zip Code: 69307-272
E-mail: [email protected]
Received: August 23, 2017 Accepted: February 20, 2018 Published: March 04, 2018
Citation: Junior MML, Souza PM, Oliveira AML (2018) Prevalence of Depression and Sleep in Women with Voiding Complaints in Brazil. J Sleep Disor: Treat Care 7:1. doi: 10.4172/2325-9639.1000209
Objective: The purpose of the study is to investigate the association of depression, anxiety and excessive sleepiness in UI women and to assess the influence of these comorbid diseases on the severity of incontinence.
Methods: One hundred and twenty women with primary complaint of voiding problem participated in this prospective study at Brazil. All the participants completed a questionnaire which comprised of three different instruments. The instruments were Kings Health Questionnaire (KHQ) to assess impact of UI on QoL, Hospital Anxiety and Depression Scale (HADS) to assess anxiety and depression and Epworth Sleepiness Scale (ESS) to measure daytime sleepiness. Logistic regression model was applied to predict the odds of developing severe UI among women having depression, anxiety and excessive sleepiness.
Results: Of the total, 70.8% had mild to moderate incontinence while 29.2% had severe incontinence. The quality of life (QoL) was greatly reduced in severe incontinent group. No difference in the mean age and health was observed between the groups. Excessive daytime sleepiness (EDS) was not associated with symptom severity, QoL and health, while depression and anxiety was significantly associated with reduced QoL and health and increased symptom severity. When combined with depression or anxiety, EDS leads to increased symptom severity in incontinent women.
Conclusion: Excessive sleepiness and depression but not anxiety is associated with severity of UI in women. This new association should be taken into consideration by the physicians while managing the patients.
Keywords: Urinary incontinence; Depression; Anxiety; Excessive daytime sleepiness; Incontinence severity; Quality of life; Stress urinary incontinence
Urinary incontinence (UI), and psychological disorders such as depression, anxiety and excessive daytime sleepiness (EDS) are common in women of all ages [1,2]. Urinary incontinence (UI) is defined by International Continence Society (ICS) as “the complaint of any involuntary leakage of urine” and is divided into a) stress urinary incontinence, b) urge incontinence, and c) mixed urinary incontinence . The general prevalence rate of UI ranges from 10% to 58%, while prevalence of moderate and severe incontinence ranges from about 3% to 17% . Severe incontinence has a low prevalence in young women but rapidly increases at ages 70 through 80. Excessive daytime sleepiness (EDS) is defined as the difficulty in maintaining the desired level of wakefulness . The severity of sleepiness is based on frequency and degree of impairment of daily activities . The prevalence rate for EDS ranges from 9% to 17% in female . Depression affects about 10% - 50% of women during their lifetime . Similarly, the lifetime prevalence rate for anxiety disorders in women is about 30.5% .
Plethoras of cross-sectional studies have established that depression and UI are often comorbid in women [7,9-13]. Women with both disorders experience a greater decline in QoL and functional status and increased incontinence symptom severity compared to women with UI alone [10,11,13,14]. The mechanism for the association between depression and UI is explained by the common neurologic or biochemical pathways underlying both conditions [15,16]. On the other hand, chronic embarrassment, social isolation, and symptom burden associated with UI could also lead to depression over time . Besides, few studies have also reported anxiety as a risk factor for UI . Anxiety is associated with urge incontinence and incontinence related function loss.
A strong association between EDS and depression is established by many studies [5,18]. Depression is an important risk factor for EDS . Approximately 25% of patients with EDS reported depression scores suggestive of moderate-to-severe depression . Nevertheless, till date no studies have examined either the lone or the combined effect of depression and sleep on the severity of the UI in women.
We therefore, hypothesized that both depression and excessive daytime sleepiness might aggravate the severity of UI in women of all age groups.
This prospective and descriptive study was conducted in a Women's health reference center in Boa Vista, Brazil. One hundred and twenty patients visiting the Department of Urology with original complaints of voiding problem were included in the study. Inclusion criteria were the presence of symptoms of urinary incontinence, the absence of other associated diseases, ability to read, write and speak and agreeing to cooperate. An exclusion criterion was patients with a record of surgical treatment for incontinence. Informed consent was obtained from all the participants, and the study protocol was approved by the local ethics committee of the institution.
The questionnaire comprised of three different instruments along with patients name and age to assess the UI, EDS, depression, and anxiety in the participants. In total 120 questionnaires were distributed.
Kings health questionnaire (KHQ)
KHQ is a self-reported questionnaire which evaluates the global and specific impact of UI on health-related QoL . KHQ consists of 21 items distributed into nine domains, general health perception, incontinence impact, role limitations, physical limitations, social limitations, personal relationships, emotions and sleep/energy, and severity measures. The responses in KHQ are rated on four point scale and scored from 0 to 100. An additional independent scale with ten questions was designed to evaluate symptom severity perception and is scored from 0 to 30. Higher scores indicate a more impaired QoL. Urinary incontinence was deemed as severe if severity measures and symptom severity scores were above 75th centile (upper quartile). UI was classified according to the ICS as urge incontinence; stress incontinence; and mixed UI (presence of both urge and stress incontinence). In the present study, the Cronbach’s alpha coefficient of the total scale was 0.90.
Epworth sleepiness scale (ESS)
EDS was assessed using the Epworth Sleepiness Scale (ESS). It is a simple and self-administered questionnaire which evaluates the subjective sleepiness . It consists of 8 items measuring the susceptibility of patients to doze off or fall asleep in any of the eight situations. Each question has four possible responses and is scored on a scale of 0–3. All the scores were summed to obtain the final score which ranges from 0 to 24. A final score between 0 and 9 indicates the normal level of sleepiness while scores≥10 indicates pathologic levels of sleepiness. In the current study, the Cronbach’s alpha coefficient of the total scale was 0.74.
Hospital anxiety and depressions scale
Hospital Anxiety and Depression Scale (HADS) is a selfevaluation questionnaire comprising two subscales, one measuring anxiety, with seven items, and another measuring depression, with seven items, which are scored separately . Each question has four possible responses and scored on a scale of 0–3 for each question. All the components of either scale were added to obtain the final score ranging from 0-21. A score ≤ 7 is considered healthy while score ≥ 8 indicates psychological morbidity. In the present study, Cronbach’s alpha was .79 for anxiety and .76 for depression.
All the data were analyzed using the SPSS for Windows version 21 (SPSS Inc., Chicago, IL, USA). Descriptive statistics such as frequency, quartiles, percentage, mean and standard deviations were used to describe the data. Urinary incontinence was defined as severe if the Symptom severity score of KHQ were above 75th centile (upper quartile). All quantitative measures were treated with parametric test such as Student's t-test and 1-way ANOVA with Bonferroni post-hoc test. Cross-tabulation along with Chi-square test and odds ratio analysis was performed for categorical data. Logistic regression analyses along with Fischer’s exact test were applied to investigate the associations between EDS and UI as well as anxiety and depression and UI. In the regression model, we adjusted for age which was used as a continuous variable. Associations are shown as odds ratios (ORs) with significance level. P value less than 0.05 was considered statistically significant.
This prospective study included 120 women diagnosed with UI. The response rate of the survey was 100%. The age of the participants ranged from 15 to 78 years (mean 49.7 ± 11.6 years). Of the total, 85 (70.8%) had mild to moderate incontinence (Symptom severity score < 15) while 35 (29.2%) had severe incontinence (Symptom severity score ≥ 15 i.e. above 75th centile) (Figure 1). No difference in the mean age (49.36 ± 12.31 vs. 50.48 ± 9.79, p=0.63) was observed between both the groups. The mean QoL was remarkably high in severely incontinent women compared to mild-moderate incontinent women (83.80 ± 23.39 vs. 56.86 ± 35.93), indicating reduced QoL in severely incontinent women. However, overall health was comparable in both the groups (Figure 2). In relation to the type of UI, prevalence of stress UI was 78.3%, urge UI was 76.7%, and of mixed UI was 84.2%.
UI and sleep
The patients were classified into two groups based on the ESS scores: a) normal daytime sleepiness (NDS, overall ESS score ≤ 9), and b) excessive daytime sleepiness (EDS, overall ESS score ≥ 10). According to this classification, 83 (69.2%) had NDS while 37 (30.8%) had EDS. The mean age was not different among the groups (NDS: 50.02 ± 11.84 years; EDS: 48.65 ± 10.96 years; p=0.58). The incontinence features in both the groups was analyzed using studentst- test (Table 1). Although no statistically significant difference was observed in all the domains of KHQ between both the groups, increased mean Symptom severity score and mean score for role limitation was observed in EDS group indicating that EDS has a tendency for increasing severity of incontinence and negatively affects the daily activities (role limitation) in UI women. To further analyze if EDS in UI women is due to disturbed or fragmented sleep we assessed the nocturia component and sleep component of KHQ. Chi-square analysis revealed that the frequency of nocturia (χ2=3.849, df=3, p=0.278) as well as of disturbed sleep (χ2=0.790, df=3, p=0.852) was comparable between EDS and normal sleep group. In EDS group, 30 (81%) had urge incontinence, and 29 (78.37%) had stress incontinence. No differences were found between the two groups in terms of severity of urge incontinence (χ2=0.360, df=1, OR= 0.765, p=0.657) or stress incontinence (χ2=0.496, df=1, OR = 1.374, p=0.510) indicating EDS does not affect the severity of any particular type of UI in women.
|KHQ domains||Without EDS
(mean score ± SD)
(mean score ± SD)
|Overall health||45.32 ± 26.06||48.27 ± 26.66||0.59|
|QoL||65.46 ± 35.85||63.06 ± 33.13||0.73|
|Role limitation||34.53 ± 32.38||47.29 ± 35.46||0.05|
|Physical limitation||43.37 ± 33.42||50.90 ± 34.90||0.26|
|Social limitation||18.74 ± 21.73||21.92 ± 21.83||0.46|
|Personal limitation||32.73 ± 33.47||29.27 ± 34.33||0.60|
|Emotion||42.03 ± 32.88||45.88 ± 40.12||0.60|
|Sleep/energy||37.34 ± 33.29||36.03 ± 28.19||0.84|
|Severity measures||40.26 ± 28.95||46.39 ± 27.53||0.28|
|Symptom severity||11.36 ± 5.43||13.35 ± 5.51||0.07|
Table 1: Urinary incontinence features in EDS group.
UI and depression
Based on overall score for depression on HADS scale, patients were stratified as normal or depressed. Of the total, 67 (55.8%) were normal while 53 (44.2%) were depressed. The mean age was not different among the groups (49.46 ± 11.92 years vs. 49.98 ± 11.29 years; p=0.80). The mean score for health in KHQ was considerably lowered in depressed subjects while the mean score for all the remaining domains increased significantly except for QoL, indicating detrimental effect of depression on UI (Table 2). Although not significant, increased mean QoL score in depressed subjects indicates a tendency for decreased QoL in depressed women (p=0.07). In depressed group, 47 (88.7%) had urge, and 47 (88.7%) had stress incontinence. Depression increased the severity of stress incontinence (χ2=10.938, df=1, OR= 4.167, p<0.01), but not for urge incontinence (χ2=2.162, df=1, OR= 1.857, p=0.141).
(mean score ± SD)
(mean score ± SD)
|Overall health||50.37 ± 25.18||40.56 ± 26.50||< 0.05|
|QoL||59.70 ± 36.94||71.06 ± 31.37||0.07|
|Role limitation||28.35 ± 32.69||51.25 ± 30.80||< 0.001|
|Physical limitation||38.05 ± 30.95||55.34 ± 35.32||< 0.01|
|Social limitation||14.26 ± 17.91||26.62 ± 24.20||< 0.01|
|Personal limitation||25.87 ± 30.19||38.99 ± 36.53||< 0.05|
|Emotion||36.65 ± 34.76||51.36 ± 34.19||< 0.05|
|Sleep/energy||24.87 ± 26.80||52.20 ± 31.01||< 0.001|
|Severity measures||32.58 ± 22.83||54.24 ± 30.60||< 0.001|
|Symptom severity||9.95 ± 4.97||14.52 ± 5.13||< 0.001|
Table 2: Characteristic of urinary incontinence features in depressive women.
UI and anxiety
Of the total participants, 62 (51.7%) had anxiety while 58 (48.3%) were normal. The mean age was not different among the groups (50.41 ± 11.71 years vs. 48.91 ± 11.54 years; p=0.48). The mean score of all the domains of KHQ was increased in women having anxiety except for personal limitation, indicating negative effect of anxiety on UI (Table 3). Among anxiety women, 53 (85.5%) had urge incontinence, and 51 (82.3%) had stress incontinence. No remarkable differences were found between the two groups in terms of severity of urge incontinence (χ2=2.379, df=1, OR=1.933 p=0.123) or stress incontinence (χ2=2.581, df=1, OR=1.958, p=0.108).
(mean score ± SD)
(mean score ± SD)
|Overall health||55.17 ± 24.22||37.50 ± 25.10||<0.001|
|QoL||54.02 ± 37.89||74.73 ± 28.74||<0.01|
|Role limitation||23.27 ± 26.47||52.68 ± 33.76||<0.001|
|Physical limitation||36.78 ± 31.64||54.03 ± 34.10||<0.01|
|Social limitation||13.98 ± 19.25||25.08 ± 22.66||<0.01|
|Personal limitation||26.43 ± 30.91||36.55 ± 35.55||0.10|
|Emotion||29.11 ± 30.07||56.27 ± 34.66||<0.001|
|Sleep/energy||27.58 ± 26.40||45.69 ± 33.86||<0.01|
|Severity measures||35.77 ± 25.45||48.11 ± 30.15||<0.05|
|Symptom severity||10.12 ± 4.63||13.70 ± 5.73||<0.001|
Table 3: Urinary incontinence characteristics in women having anxiety.
Association of sleep, anxiety and depression with UI
Women were classified into four groups: with UI, UI and EDS, UI and depression/anxiety and UI and depression/anxiety and EDS. The mean score for health, QoL and symptom severity were compared between these groups (Figure 3). Significant difference existed in the symptom severity between UI with EDS and Depression/ anxiety group and UI only (p<0.001), EDS only (p<0.05), while with depression/anxiety there was a strong tendency to increase the symptom severity (p=0.092). Nevertheless, the overall health perception and QoL was comparable between all the groups (Figure 3). Logistic regression analysis revealed a significant association of EDS (OR=2.725, p<0.05) and depression (OR=5.271, p<0.01) with the severity for UI but not for anxiety (OR=1.236, p=0.675) when adjusted for age, suggesting sleep and depression aggravates severity symptom in women with UI.
Urinary incontinence, excessive daytime sleepiness, depression and anxiety are predominantly observed in women and are often present as comorbid conditions [1,2]. Comorbid diseases increase the symptom burden and distress . Depression and in few studies anxiety also augments the severity of the UI . In our study we found that EDS and depression but not anxiety were significantly associated with severity of the UI in women. Depression was strongly associated with the stress incontinence, while EDS and anxiety affected equally to the severity of urge and stress incontinence.
Major cause of EDS are insufficient sleep duration, fragmented sleep or poor sleep quality and sleep disorders which significantly affects the QoL, especially those relating to daytime activities . Our study demonstrates that EDS in incontinent women has a tendency towards negatively affecting their daily activities without having any effect on QoL. In UI patients, increased incidence of nocturia is one of the primary reasons for poor sleep quality. Increased incidence of nocturia is associated with the severity of incontinence . We observed a considerable effect of EDS on severity of UI however this was not associated with disturbed night sleep due to increased nocturia suggesting an insignificant relationship between nighttime sleep and excessive daytime sleep .
Sleepiness is more common in those reporting symptoms of depression or anxiety disorders . Depression and anxiety increases the incidence and severity of UI in a dose dependent manner and significantly impacts their health-related quality of life . Presence of depression as well as anxiety in incontinent women remarkably worsen their overall health and QoL as well as augmented the severity of incontinence by negatively affecting different domains of life indicated in KHQ in the present study. Taken together, effect of EDS on UI severity is dependent on either depression or anxiety or both.
The UI incidence, depression, anxiety as well as EDS are more prevalent in elderly women . Therefore, it is assumed that these comorbidities would increase the severity of UI more so in women belonging to higher age groups. Even though these comorbid diseases had a severe impact on incontinence, mean age was always comparable between them in the present study. This contradictory effect suggests that EDS, depression and anxiety affects the QoL, health and UI in an age-independent manner. Our findings are in line with study by Felde et al. . They showed that both depression and anxiety was associated with UI in women from 20 years of age.
Stress and urge incontinences are more prevalent types in women . Association of depression and anxiety with any particular type of UI is debatable. While many studies have shown a relationship of depression and anxiety with urge or mixed incontinence, few studies have associated it with stress UI [10,14]. Moreover, most of the studies haven’t analyzed the effect with respect to the severity of UI type. Only the study by Melville et al.  had only shown that major or severe depression was associated with urge incontinence. Our results exhibit a significant association of stress incontinence with major depression. Anxiety and EDS, although affected the general UI severity, was not associated with the severity of either stress or urge incontinence, suggesting these comorbid conditions affect both the UI types equally in women.
Logistic regression assessment of factors contributing to severity of UI in women showed that depression and EDS, but not anxiety, were significantly associated with UI severity when adjusted for age. Failure of anxiety to have any effect on UI severity when controlled for age implies that more number of anxious women might cluster with either younger or older age groups in this study (data not shown). High mean scores of UI symptom severity in women with both depression or anxiety and EDS support our hypothesis.
The relationship between depression and UI is explained by two important mechanisms. First is by serotonergic pathway where reduced levels of serotonin, causes depression and negatively regulates voiding function . Second, is by increased activity of hypothalamic- pituitary axis and the sympathetic nervous system in many depressed individuals, resulting in increased release of cortisol and catecholamines which affects bladder function . However, mechanisms describing the association of EDS with depression are rare. Lessov-Schlager and colleagues have reported EDS and depression to be genetically associated in elders . Variations in the orexin/hypocretin gene OC2R and catechol-O-methyltransferase (COMT) gene necessary for degradation of dopamine have been associated with EDS [25,26]. However, further research is warranted in this area.
One of the major limitations of the study is small sample size. UI in women is affected by many factors such as parity, childbirth, menopause, hysterectomy, urinary tract infections which are not accounted for in our study. This might lead to biasing of our results and forms the second major limitation of our study.
In conclusion, psychological disorders such as depression and excessive sleepiness aggravate UI in women primarily by increasing the burden of disease symptom. Interestingly, no effect on overall health and QoL was observed. Therefore, it is important to be aware of the association as it would aid physicians in their management of such patients.
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