1 Department of Psychiatry and 2 Department of Obstetrics and Gynecology, Taipei Veterans General Hospital 3 National Yang-Ming University School of Medicine, Taipei, Taiwan and 4 Department of Psychiatry, Tri-Service, Geneva Hospital, Taipei, Taiwan
5 To whom correspondence should be addressed at: Department of Psychiatry, Taipei Veterans General Hospital, Taipei, 11217 Taiwan. Email: kd.juang{at}msa.hinet.net
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Abstract |
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Key words: assisted reproductive technology/depression/Hospital Anxiety and Depression Scale (HADS)/mental disorder/Mini-International Neuropsychiatric Interview (MINI)
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Introduction |
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The purpose of the current study was to evaluate the prevalence of psychiatric disorders in pre-assisted reproduction treatment women in an assisted reproduction clinic using a structured diagnostic interview performed by a board-certified psychiatrist. It is hoped that clinicians working at assisted reproduction clinics can understand their patients better through an awareness of their psychiatric condition. As a consequence, clinicians may be able to provide more comprehensive care for their assisted reproduction patients.
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Materials and methods |
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Psychiatric diagnosis
After subjects had given informed consent, their demographic data were collected. A board-certified psychiatrist then conducted a standardized structured diagnostic interview according to the Mini-International Neuropsychiatric Interview (MINI) 5.0.0 edition (Sheehan et al., 1998). The MINI is a standardized diagnostic instrument for the diagnosis of Diagnostic and Statistical Manual, 4th edn (DSM-IV; American Psychiatric Association, 2000
) and International Classification of Diseases (ICD)-10 psychiatric disorders (World Health Organization (1992)
). It consists of standardized, structured, closed-end questions throughout its diagnostic procedure. The DSM-IV and ICD-10 criteria were reframed into standardized questions in MINI. The interviewers read literally these close-ended questions as verbatim as possible to the interviewees. Psychiatric diagnosis was made according to the number of affirmative replies to the specific questions. Studies have shown that the MINI is a valid and reliable diagnostic tool. Inter-rater and testretest reliabilities were high among the majority of disorders. Validities with other lengthy structured diagnostic interviews, including the Composite International Diagnostic interview CIDI and Structured Clinical Interview for DSM-IIIR SCID, were also high (Lecrubier et al., 1997
; Sheehan et al., 1997
). Research has also shown that the MINI can be used successfully as a gold standard of psychiatric diagnosis in multi-centre clinical trials and epidemiology studies (Gabarron et al., 2002
; Wojnar et al., 2003
). To reduce the time of the interview, we excluded alcohol abuse and dependence, substance use disorders, psychotic disorders, and antisocial personality disorder, because these disorders are beyond the scope of the present study and are considered to be of negligible frequency in our sample. Only current diagnoses were made.
Psychological assessments
The participants also filled out the Hospital Anxiety and Depression Scale (HADS). The HADS is a self-administered rating scale composed of 14 questions, seven for anxiety and seven for depression, yielding a total score, an anxiety score, and a depression score, respectively. By focusing on psychological symptoms of anxiety and depression, the HADS avoids the confounding effect of physical symptoms in detecting anxiety and depression among subjects with somatic illness (Zigmond and Snaith, 1983). The HADS has been successfully used to screen emotional disorders in subjects with a variety of diseases, including infertile women (Herrmann, 1997
; Juang et al., 1999
; Matsubayashi et al., 2001
). Similar to the study of Matsubayashi et al. (2001)
, we adopted a total HADS score of >12 as a threshold value. In both the anxiety score and depression score, we used a threshold value of >9 to identify participants with high anxiety and high depression respectively.
Statistical analysis
The Statistical Package for Social Sciences for Windows program was used for statistical analysis. Descriptive statistics of frequency, the Student's t-test, 2-test, and linear regression were used for comparisons when appropriate. P<0.05 was considered statistically significant.
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Results |
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When comparing demographic characteristics between participants with a psychiatric disorder and those without, we could not find any significant difference in age, education, income, or any other feature. The comparison of demographic data between the two groups is shown in Table III. When comparing the HADS scores between participants with and without a psychiatric disorder, the differences were significant. The mean total HADS score was 14.2±6.2 for our participants with any psychiatric diagnosis, 15.3±5.8 for participants with any mood disorder, and 14.5±6.5 for participants with any anxiety disorder, which were all significantly different from the mean for 9.4±5.3 of participants without any psychiatric disorder (all P<0.01).
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Discussion |
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The extraordinarily high prevalence of GAD (23.2%) in our assisted reproduction clinic is noteworthy. Anderson et al. (2003), using the HADS, also found that about a quarter of the infertile women attending the clinics had a high level of anxiety. According to DSM-IV (American Psychiatric Association, 2000
), the 1 year prevalence of GAD is
3% in the community. In a similar study that also adopted the MINI in a headache clinic, the frequency of GAD was only 5% (Juang et al., 2000
). Recently, Jackson et al. (2001)
showed that the prevalence of anxiety disorders among general medical outpatients was
11%. Therefore, it is unlikely that the sampling bias of a clinical population alone can explain the high prevalence of GAD in our results. The high prevalence of GAD among our participants suggests that a possible link may exist between GAD and participation in assisted reproduction clinics. It is possible that GAD is associated with infertility or with the intention to receive assisted reproduction treatment, either as a cause or as a consequence. More research is needed to determine the role of GAD in the ART process.
The DSM-IV-TR also concludes that the point prevalence of MDD in adult women in the community varies from 5 to 9%, and that the point prevalence of dysthymic disorder is 3% (American Psychiatric Association, 2000
). In Jackson et al.'s clinical sample, the prevalence of major depression was 6%. Studies that adopted MINI in their survey seemed to find slightly higher rates of depression. Dubini et al. (2001)
adopted MINI in a survey of an Italian community and found the prevalence of major depression to be 8%. In a primary care setting in Spain, the prevalence of depressive disorders (major depression plus dysthymia) was 20.2% in all patients and 26.8% in women by MINI (Gabarron et al., 2002
). In comparison with these data from the community or other clinics, our participants at an assisted reproduction clinic before assisted reproduction treatment did show a high prevalence for major depression (17.0%) and dysthymia (9.8%). The presence of such a high rate of depression among women in an assisted reproduction clinic should arouse much clinical attention and awareness.
The HADS scores of our participants may provide information in addition to the results of diagnosis. The HADS scores may help in the comparison with different research results. Our findings based on the HADS scores were comparable to other studies that also adopted the HADS (Matsubayashi et al., 2001; Anderson et al., 2003
). Since the HADS is filled out by the participants, the results may be less biased by the psychiatrist. Furthermore, the HADS has excluded the physical symptoms of anxiety and depression in order to avoid their confounding effects in subjects with somatic illness. Therefore, the HADS scores may be used to examine whether some physical symptoms confound the relationship between infertility and psychiatric conditions.
Table V summarizes studies of pre-assisted reproduction treatment psychiatric morbidity that have adopted rating scales or other verified instruments. Our finding of a high prevalence of depressive disorder lies within the higher range of these estimations from questionnaire-based studies. Anxiety was explored much less frequently in previous studies. The prevalence of anxiety disorder in the present study was similar to, although slightly higher than, that found by Anderson et al. (2003).
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Some patients with anxiety and depression may lack insight into their psychiatric condition. Consequently, it is possible that estimation based on the subjects' self-assessment of whether or not they are depressed may underestimate these psychiatric disorders. Furthermore, participants in assisted reproduction treatment may try to impress the clinicians at the assisted reproduction clinic as good patients (Wilson and Kopitzke, 2002). The effort to be a good patient, although a proper way to cope with the stress of an assisted reproduction treatment, may prevent participants from revealing psychological distress to their clinicians. Since we provided confidentiality to our subjects, it is possible that our participants may have been more willing to disclose their emotional distress. Further research is needed to determine whether these methodological variables lead to different results.
Cultural factors may play some role in the mood of infertile women. In traditional Eastern culture, the family is usually valued more than the individual. The meaning of an individual's life often includes the extension of the family by giving birth to offspring. Infertile women in the East may suffer from more stress than those in the West. Further research is needed to determine whether the prevalence of anxiety and depression is also high in the assisted reproduction clinics of the West.
Only three (6.7%) of our participants who had a psychiatric disorder had consulted a psychiatrist for their emotional distress before they came to the assisted reproduction clinic. In comparison with the high frequency of participants who had a psychiatric disorder in our sample, disproportionately few of them utilized mental health care services. We do not offer counselling services or self-help groups to the clients of assisted reproduction treatment at our hospital. However, even in those centres that offer a counselling service, the utilization rate has been low (Boivin et al., 1999). Moreover, a counselling service is unnecessary for most of the women undergoing assisted reproduction treatment (Boivin et al., 1999
). Clinicians need to find a way to identify who is at risk of a psychiatric disorder and who needs mental health services. Psychiatric referral based on the assisted reproduction clinicians' judgement may be insufficient. One study found that among the assisted reproduction patients not referred to psychiatrists, 24% had a psychiatric disorder and 33% had psychological dysfunction (Guerra et al., 1998
). More research is needed to establish methods to screen the smaller proportion of subjects who have psychiatric disorders in order to establish a proper referral to the counselling service.
The present study is limited by the low number of cases included. Caution should be taken in interpreting some data from such a small number of participants. We were also limited by our recruiting period. We did not recruit subjects during an entire year, so we do not know whether there is a seasonal variation of mood among the participants attending the assisted reproduction clinic. However, the changes in weather and the amount of sunshine in Taiwan are mild. There are few reports of seasonal affective disorders in Taipei, Taiwan. The study is also limited by the lack of data on the husbands of these women and their families. The spouses may have influenced the mood of the women who were about to undergo assisted reproduction treatment. A previous study showed that psychological reaction response was similar in both husbands and wives during IVF (Boivin et al., 1998), although the husbands were less depressed (Beutel et al., 1999
). The interaction between the couple deserves further investigation. We are also limited by the fact that we do not have data of the MINI diagnosis in community or primary care settings in Taiwan for comparison. Although MINI is a validated and standardized diagnostic instrument, it is still possible that MINI tends to result in slightly higher rates of depression than previous diagnostic tools. We do not know to what extent our results were biased by MINI. We also failed to include a re-confirmed diagnosis by a second psychiatrist. However, due to the high inter-rater and testretest reliabilities of the MINI (Sheehan et al., 1998
), the lack of a second interview should be acceptable.
In conclusion, we found in the present study that the frequencies of depressive and anxiety disorders were high in women who were preparing to undergo a new course of assisted reproduction treatment. Nonetheless, very few women had visited psychiatric clinics for help. The most conspicuous finding is the high frequency of GAD in our participants. Whether GAD plays some role in infertility or in the suffering during the assisted reproduction process deserves more attention in the future. In addition, we also found that psychiatric morbidity was not affected by the woman's age, education level, husband's age, husband's education level, income, years of marriage, years of infertility, or a history of previous assisted reproduction treatment. Based on these findings, we suggest that clinicians offering assisted reproduction treatment to their patients should be aware of the high prevalence of psychiatric morbidity among this group.
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Submitted on February 9, 2004; resubmitted on March 19, 2004; accepted on June 22, 2004.