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ORIGINAL RESEARCH |
From the Department of Obstetrics & Gynecology, University of Texas Medical Branch, Galveston, Texas.
Address reprint requests to: Abbey B. Berenson, MD, 301 University Boulevard, Galveston, TX 77555-0587; E-mail: abberens{at}utmb.edu.
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ABSTRACT |
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METHODS: A retrospective, self-reported, paper-and-pencil survey designed to assess health and risk behaviors was administered to 4726 low-income suburban women, aged 12 and 40 years, attending a family planning clinic in southeast Texas. The survey contained a background and demographic section in addition to six sections addressing health risk behaviors. Women also completed the 13-item Beck Depression Inventory to assess depressive symptoms.
RESULTS: A total of 11.8% exhibited mild symptoms of depression, 14.0% had moderate symptoms, and 4.8% had severe symptoms. Women were at increased risk of moderate to severe symptoms of depression if they were Hispanic, had not graduated high school, were unemployed, or currently smoked cigarettes. Sexual or reproductive characteristics associated with moderate to severe symptoms included two or more lifetime sexual partners, having used hormonal contraception before age 13, not using any birth control at last intercourse, having had a sexually transmitted disease, not having had sexual intercourse in the last 3 months or having had it under the influence of alcohol or drugs, and having heard a family member worry about contracting a sexually transmitted disease or discuss use of alcohol or drugs before sex.
CONCLUSION: A large percentage of women experience moderate to severe depressive symptoms during their reproductive years. These symptoms are associated with numerous risk behaviors, including inconsistent use of birth control. Women’s health care providers have the opportunity to provide a valuable service by screening for depressive symptoms.
National community studies have established that women are more likely than men to suffer from depression.1–3 The lifetime prevalence of depression in women is 21%, compared with 13% in men.3 This sex-based difference is most prominent during the reproductive years. Studies of nonpregnant female subjects conducted in primary care settings demonstrate that 20% to 30% of women exhibit depressive symptoms at the time of their visit.4–6 Thus, using conservative estimates, one in five women of reproductive age visiting a primary care physician is at risk of depression.
A large percentage of women with depression are never diagnosed and consequently are not offered treatment. Reports by the US Preventive Services Task Force7–9 indicate that approximately 50% of cases of depression are not recognized by the provider or the patient. This is especially unfortunate given the highly effective and safe medications now available in the United States to treat this condition. To help address this problem among women, the American College of Obstetricians and Gynecologists released a statement in 2002 recommending that clinicians be alert for symptoms of depression.10 However, increasing the detection rate of mood disorders by obstetricians and gynecologists remains a challenge because less than 25% of these specialists11–15 report confidence in detecting these illnesses.
To help obstetricians and gynecologists more easily recognize depressive symptoms in reproductive-aged women, we conducted a wide-scale survey of ethnically diverse women attending family planning clinics across southeast Texas. The current study was designed to estimate the prevalence of depressive symptoms in this population as well as demographic and reproductive characteristics associated with these symptoms.
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MATERIALS AND METHODS |
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ABSTRACTMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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The survey, available in English or Spanish, contained a background and demographic section in addition to six sections addressing health status and health risk behaviors. A total of 6250 women were offered a survey. Approximately 11% (n = 667) of women refused; thus, 5583 surveys were received during the study period. On average, women who refused to participate were older (29 versus 25 years old, P < .01) and more likely to be Hispanic (53% versus 26%, P < .01), as compared with women who agreed to participate.
Given our interest in reproductive, contraceptive, and sexual behaviors, we excluded women beyond reproductive age (more than 40 years old, n = 307), women who stated they had never had sexual intercourse (n = 64), and women who failed to report sexual activity status (n = 3). Of the remaining 5209 surveys, 483 contained missing data on the 13-item Beck Depression Inventory and could not be analyzed. Thus, the final sample consisted of 4726 women.
Age, race/ethnicity, current marital/partner status, education, employment status, home ownership, and size of community were assessed to characterize the demographics of the sample. The 13-item short form of the Beck Depression Inventory (BDI-SF) was used to assess depressive symptoms.16–18 The short form assesses sadness, pessimism, sense of failure, dissatisfaction, guilt, self-dislike, self-harm, social withdrawal, indecisiveness, self-image change, work difficulty, fatigability, and anorexia with a 0 to 3 rating scale to characterize current feelings. Multiple responses to a single item were scored as the highest value indicated, as recommended.17 Consistent with previous use of the scale, we categorized depressive symptoms using the following ranges: 0 to 4 (none), 5 to 7 (mild), 8 to 15 (moderate), and 16 or more (severe). We created a dichotomous outcome (none and mild compared with moderate and severe) for the purpose of analysis.6,19,20
This instrument is highly correlated (r = 0.90) with the original, 21-item (long) version17,21 and demonstrates strong psychometric properties.22 The sensitivity (83%), specificity (73%), and positive (81%) and negative (75%) predictive values of the short form have been established.23 The concurrent validity has been supported in studies demonstrating associations between short form scores and clinician ratings of depression18,24 and behavioral measures of depression.25 The short form continues to be used extensively among young female patient populations,6 adolescents,26,27 college students,28 and older women.29 The instrument is written at a sixth-grade reading level.30
All surveys were reviewed before the woman left the clinic to assess if she reported suicidal plans. Women who responded positively to the question "I would kill myself if I had the chance" (n = 19) were offered an opportunity to speak with a social worker before leaving the clinic. Seven women chose to speak with a social worker; the remaining 12 declined.
Participants were asked to indicate the lifetime number of sexual partners (1, 2, 3, 4, 5, or 6 or more); age at which she first had sexual intercourse; used condoms; used spermicidal jelly/foam/cream; used hormonal contraception; or became pregnant. These data were recorded using the following response categories: "I have never done this," "10 years old or less," "11," "12," "13," "14," "15," "16," "17," or "18 years or older." Women were presented with a list of birth control methods (no method, withdrawal, condoms, foam/jelly/cream, birth control pills, depot medroxyprogesterone acetate, levonorgestrel implants, intrauterine device, and diaphragm) and asked to indicate which method or methods she used at her first and most recent occurrence of sexual intercourse. In the analysis, birth control use was dichotomized as use of no method compared with use of one or more methods. For women who reported having sexual intercourse during the past 3 months, we assessed whether or how often they had sex "under the influence" as well as their condom use patterns. Specifically, we asked how often they drank alcoholic beverages or used drugs before having sex and how often they used a condom when they had sexual intercourse using a 5-point scale for the following categories: "always," "more than half the time," "half the time," "less than half the time," and "never." Sex under the influence was represented by the categories "did not have sex in the past 3 months," "had sex under the influence," and "had sex, but not under the influence." Condom use was represented by the categories "never," "less than half the time," "half the time," "more than half the time," and "always." Women were also asked to report whether or not they had ever had a sexually transmitted disease and the number of times they have been pregnant (gravidity).
Smoking behavior was described as "never," "regularly in the past," "occasionally now," and "regularly now." The ages at which women first smoked cigarettes and drank enough to feel drunk or very high were recorded. Finally, we assessed the number of days during the past month women consumed at least one alcoholic drink (0, 1–2, 3–5, 6–9, 10–14, 20–29, or all 30 days).
Family exposure to health risk behaviors was assessed using a tabular format in which a checkmark was indicative of a "yes" response for a given exposure. Specifically, women were to indicate whether they had seen or heard of a family member do any of the following: smoke a cigarette, drink alcohol, worry about getting pregnant, worry about catching a sexually transmitted disease (STD) or acquired immunodeficiency syndrome (AIDS), kiss deeply or French kiss, touch breasts or genitals, have sexual intercourse, use birth control, use condoms, use alcohol or drugs before sex, talk about using condoms, talk about having sex, or talk about using birth control.
The prevalence of depressive symptoms, as measured by the BDI-SF, was reported. In initial bivariate analyses, percentages of risk factors (including demographics, sexual behaviors, risk behaviors, and family exposure) were estimated at the two levels of depressive symptoms (none and mild compared with moderate and severe). The statistical significance of each association with depressive symptoms was estimated with a 
2 test using an 
level of .05. Multivariable analysis was performed using logistic regression. All factors significant at = .05 in the bivariate analyses were entered into the regression model using forward selection. A final logistic model containing only significant predictors was estimated to predict the presence of moderate and severe depressive symptoms. Odds ratios, 95% confidence intervals, and levels of significance are reported.
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RESULTS |
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). One-third of the sample had not completed high school, and half were not employed outside the home. Nearly one-third of the women were married. An additional 52% reported having a current partner, but were not married. Approximately half of the women reported that their home was rented (compared with owned), and 62% reported that it was located in a small city or town (less than 50,000 people).
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Almost half of the women reported four or more sexual partners in their lifetime, and 71% reported at least one previous pregnancy (Table 2). Thirty-seven percent reported that they first had sexual intercourse between 13 and 15 years of age, and 30% reported that they were between 13 and 15 years old at first condom use. Depressive symptoms were associated with a greater number of sexual partners; a younger age at first sexual intercourse; a younger age at first use of condoms, hormonal contraception, and spermicides (foam/cream/ jelly); nonuse of birth control at first and most recent sexual intercourse; ever having a sexually transmitted disease; having three or more pregnancies; and having a first pregnancy before age 18. In addition, depressive symptoms were associated with having sex after drinking alcohol or using drugs, or having no sex during the past 3 months. We noted no association between depressive symptoms and condom use patterns in the last 3 months (P = .13).
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).
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). Approximately 46% had heard a family member talk about or saw a family member using birth control, and 40% had heard a family member discuss using condoms. Approximately one fourth of the women reported that they had witnessed or heard a family member worry about getting pregnant or contracting a sexually transmitted disease. Sixteen percent had seen or heard a family member discuss the use of alcohol or drugs before sex. Moderate to severe depressive symptoms were associated with exposure within the family to tobacco use, alcohol use, worry about getting pregnant or contracting a sexually transmitted disease, deep kissing, fondling, having or talking about sexual intercourse, talking about using condoms, and use of alcohol or drugs before sex. No association was noted between depressive symptoms and exposure to witnessing (P = .09) or hearing conversations about birth control usage (P = .05).
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). Hispanic women were 1.4 times more likely to have short-form scores greater than 8 (at least moderate symptoms) compared with white women. Compared with women who reported having sex in the last 3 months but not under the influence of alcohol or drugs, those who reported substance use before sex and those who had not had sex at all in the previous 3 months were more likely to have short-form scores in the moderate to severe category. Compared with women who first used hormonal contraception at or beyond age 18, women who reported first use before 13 years of age were two times more likely to have elevated scores. Additional risk factors for moderate or severe depressive symptoms included being unemployed, not completing high school, having two or more sexual partners, not using birth control at most recent intercourse, having had an STD, smoking, and having heard of a family member worry about catching an STD or AIDS, or discuss using alcohol or drugs before having sex.
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DISCUSSION |
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In addition to a correlation between the number of sexual partners and depressive symptoms, we also observed in this study an association between depressive symptoms and other high-risk sexual behaviors, such as history of an STD and having had sexual intercourse recently under the influence of drugs or alcohol. A correlation between risky sexual behavior and depressive symptoms has been observed in other studies as well. For example, in a study of 21-year-olds from New Zealand, Ramrakha et al31 observed a significant relationship between depression (defined as a major depressive disorder or dysthymia) and risky sexual intercourse. Furthermore, those with depressive disorders were 1.6 times more likely to have a history of an STD. Data from 3391 girls interviewed as part of the National Longitudinal Study of Adolescent Health demonstrated that depressive symptoms were associated with a history of an STD.32 Moreover, Orr et al33 determined in a study of 173 primarily black women that those with higher levels of depressive symptoms were significantly more likely to report having had more than one sexual partner in the past year, having had a partner who was an intravenous drug user, or having had a partner whom they believed had an STD. The authors point out that most traditional STD and AIDS prevention programs focus on behavior change and encourage the individual to take more responsibility in decreasing high-risk behaviors. However, women with high levels of depressive symptoms may lack the energy or initiative to change their behavior. Thus, women who exhibit both depressive symptoms and high-risk sexual behavior may require treatment for their psychological symptoms before they can successfully undertake behavior change.
Moreover, we observed that women with depressive symptoms were more likely to engage in unprotected intercourse the most recent time they had sex. This has been previously demonstrated in adolescent populations34–36 and can lead to disastrous results, especially for adolescents. For example, a longitudinal study of black female adolescents observed that those with significant psychologic distress at baseline were 1.5 times more likely than their peers to not use any form of birth control and twice as likely to become pregnant during the next 6 months.34 As noted by Hankoff and Darney,37 women with depression often pose a serious management problem when providing effective birth control, which must be considered by the provider. This difficulty can be compounded if the woman also abuses drugs to self-treat her depression. To address this problem, they recommend prescribing oral contraceptives for depressed women when compliance can be assured and injectable contraception when it cannot. The newly marketed weekly patch form of birth control may also be a good option for these women.
Finally, we observed that women who overheard or participated in discussions with family members about STDs or substance use before having sex were more likely to report depressive symptoms. The link between substance use and depression has been well established, so it is possible that family members discussing these behaviors may have been suffering from depression. If so, the association between exposure and depressive symptoms that we observed could simply indicate a familial predisposition to mood disorders. Alternatively, it could result from the entire family residing in adverse conditions. This study, however, was not able to evaluate these relationships to a sufficient degree to allow more than speculation regarding this relationship.
This study has several limitations that bear mentioning. First, the cross-sectional design did not allow us to make causal inferences. Second, we used a single instrument to estimate depressive symptoms and did not attempt to diagnose major depression. This most likely resulted in a higher prevalence of depressive symptoms than if we had used diagnostic interviews.38,39 Furthermore, a high score on the Beck Depression Inventory may indicate psychosocial problems or physical symptoms, such as pain, rather than a mood disorder. We did attempt to minimize this problem by using the 13-item Beck Depression Inventory, which was developed to avoid this problem and was the least somatic measure of depressive symptoms available at the time.17
This study demonstrated that a large percentage of women experience moderate to severe depressive symptoms during their reproductive years. These symptoms are associated with numerous risk behaviors, including inconsistent use of birth control. Women’s health care providers have the opportunity to provide a valuable service by screening for this disorder. Patients at risk for depression can be identified by asking them to complete a short self-report form while waiting to see the provider or by adding one or two questions on depressive symptoms to the medical history. Women at risk can then be monitored closely or referred to mental health professionals for further evaluation or treatment. In addition, women could be informed about resources that are available in their community. Finally, the presence of depressive symptoms should alert the clinician that this woman may have difficulty with contraceptive compliance.
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Footnotes |
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Received May 21, 2003. Received in revised form July 9, 2003. Accepted August 14, 2003.
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REFERENCES |
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8) by Multivariate Logistic Regression Analysis