Postpartum women experience many physical symptoms such as fatigue, abdominal/pelvic pain, breast complaints, bowel complaints, and urinary frequency or incontinence. McGovern et al1 conducted telephone interviews with new mothers at 5 weeks postpartum and found that women reported an average of 6.2 physical symptoms, with the most common symptoms being fatigue, breast discomfort, and loss of libido.
In addition to the high prevalence of postpartum physical symptoms, mood disturbances are commonly diagnosed at the postpartum visit. Postpartum depression is common, with a prevalence as high as 15%, and is defined by the development of depressive symptoms within 4 weeks of delivery.2 Risk for postpartum depression is routinely screened for with the Edinburgh Postnatal Depression Scale (EPDS), which is a validated 10-question survey administered at postpartum visits.3
Postpartum depression can have significant impacts on both mother and child and has been linked to difficulties in bonding between mother and infant, increased utilization of health resources, negative impacts on infant development, and long-term behavioral and mental health disorders for the child.2,4 While the exact etiology and pathophysiology of postpartum depression are unknown, the hormonal changes that occur in the immediate postpartum period have been postulated as a possible mechanism.2,5,6
Risk factors for postpartum depression include bothersome physical symptoms, as well as trauma from childbirth. Woolhouse et al7 demonstrated that poor physical health and an increasing number of physical problems were associated with a higher risk of experiencing poor mental health in the postpartum period. Urinary incontinence, a specific physical symptom self-reported via questionnaires in 20.7% of women at 4 months postpartum and 19.9% of women at 24 months after delivery,8 has been shown to negatively affect quality of life and be associated with depressive symptoms in nonpregnant populations.
Two studies have shown a correlation with an increased risk of depression and urinary incontinence in the late postpartum period. An analysis of the EDEN Mother-Child Cohort demonstrated an increased incidence of depressive symptoms or use of antidepressant medication at 12 months postpartum in women with urinary incontinence compared with women without incontinence.9 Brown and Lumley10 found women with urinary incontinence at 6 to 7 months postpartum had increased odds of experiencing depression. Whereas most other studies have examined urinary incontinence and depression in middle-aged to elderly women, Hullfish et al11 recently demonstrated a correlation between urinary incontinence and postpartum depression in the immediate postpartum period. Our study aimed to further examine the link between urinary incontinence and postpartum depression using validated questionnaires, with additional focus on physical symptoms and the impact of concurrent antidepressant medication use.
MATERIALS AND METHODS
Women who received care in The Ohio State University medical system were recruited to participate in this cross-sectional study at the time of their 6-week postpartum visit from January to July 2016. A sample size calculation was not performed prior to the start of the study. The study design was to recruit as many patients as possible during the 7-month study time frame, and study recruitment was ended with a total of 108 patients in July 2016. Exclusion criteria included women younger than 18 years, fetal or neonatal loss, non-English speakers, and incarcerated patients. All information was collected via anonymous surveys completed during the regularly scheduled postpartum visit. This study was approved by the institutional review board at The Ohio State University.
Demographic data including age, race, marital status, education, payor status, perception of overall health, and number of pregnancies and births were collected. Additional data regarding the details of the birth, prior treatment of depression, and antidepressant medication use were collected. Risk for postpartum depression was evaluated by administration of the EPDS, which is routinely administered as part of the postpartum visit. A score of greater than or equal to 10 on the EPDS, which has a maximum score of 30, indicated that a patient was at increased risk of experiencing postpartum depression.3
The impact of urinary incontinence was assessed through the administration of the short forms of the Urinary Distress Inventory (UDI) and Incontinence Impact Questionnaire (IIQ), which are validated tools to assess the impact of urinary incontinence on quality of life.12 The UDI is composed of 6 questions that ask how much a patient is bothered by a specific urinary/pelvic symptom. The IIQ is composed of 7 questions from 4 different domains (physical activity, travel, social activities, and emotional health). Individual analyses for each IIQ domain were also performed.
The presence or absence of bothersome physical symptoms was assessed through the use of a Postpartum Symptom Inventory (PSI), where patients were asked to grade 20 common physical symptoms on degree of bother on a scale ranging from 0 (never) to 4 (always) (Supplemental Digital Content 1, http://links.lww.com/FPMRS/A59). While the construct validity of the PSI has not yet been evaluated, it was used to approximate the overall degree of physical distress women were experiencing at the time of their postpartum visit. Significant distress for a particular symptom was identified by a score of 3 or 4 for that symptom. Physical symptoms assessed included tiredness or fatigue, insomnia, headache, nausea, heartburn/indigestion, urinary incontinence, increased urinary frequency, fecal incontinence, constipation, hemorrhoids, backache/hip pain, abdominal/pelvic pain, breast pain, vaginal pain, change in sexual drive, pain during intercourse, painful veins (varicose veins), abnormal or persistent vaginal bleeding, vaginal discharges, and hot flashes. A composite score ranging between 0 and 80 was calculated to indicate the severity of bother of postpartum symptoms.
Logistic regression was used to estimate the associations between risk of postpartum depression based on the EPDS score and either UDI score or IIQ score while controlling for a history of treatment for depression. Logistic regression was also used to assess the association between delivery type and UDI score and IIQ score while controlling for parity. Finally, logistic regression was also used to estimate the association between either UDI score or IIQ score and the use of depression medication. Linear regression was used to estimate associations between PSI score and either UDI score or IIQ score (with UDI score and IIQ score as a binary predictor collapsed to 0 vs >0), after controlling for level of education, age, and whether a cesarean delivery was performed. All analyses were conducted with STATA version 14.0 (Stata Statistical Software: Release 14, College Station, TX: StataCorp LP; 2015). Significance was set at P < 0.05. All P values and confidence intervals were 2-sided and were unadjusted for multiple comparisons.
Between January 2016 and July 2016, a total of 327 women were seen for a postpartum visit at The Ohio State University obstetrics and gynecology resident clinic in addition to patients seen in the private office. A random representative sampling of these patients was approached for recruitment. Of those approached, 80% agreed to participate, with a total of 108 women enrolled in the study. Three women were excluded secondary to incomplete IIQ or UDI data, and an additional patient was excluded for being younger than 18 years, leaving 104 women included in the analysis. Twelve patients (12%) were classified as at risk of depression based on an EPDS score greater than or equal to 10. The median age in our study population was 29 years, with age range 18 to 45 years, and the vast majority of patients (89%) self-reported excellent or good health. In the study, a total of 23 women (22%) reported a history of depression, although only 7 women (7%) were actively taking an antidepressant. The remainder of the demographic data is summarized in Table 1. No demographic factor was found to have a statistically significant association with risk of depression (Table 2).
The relationship between urinary symptoms and risk of postpartum depression was examined. Because of an abundance of participants with a score of zero on the UDI (48%) and IIQ scales (71%) and the low prevalence of increased risk of depression (12%), it was difficult to fit regression models to the continuous data for each score. Thus, the scores for each questionnaire were dichotomized into those who scored zero and those who scored greater than zero for analysis. The median UDI score was 5.6, with range 0 to 44.4. The median IIQ score was 0, with range 0 to 85.7. Adjusting for parity, mode of delivery did not show a significant relation to either UDI or IIQ scores (Table 3). The dichotomized data from the UDI and IIQ scores were examined for association with positive screens for increased risk of depression, and no statistically significant association was found for UDI score, IIQ score, or the IIQ subscales (Table 4). The most notable association was observed between UDI score and increased risk of postpartum depression based on EPDS score. Patients with a UDI score greater than zero had 2.9 times the adjusted odds of being found to be at risk of postpartum depression compared with those with a UDI score of zero, adjusting for history of depression (95% confidence interval [CI], 0.7–12.5; P = 0.15).
The PSI was analyzed in terms of individual symptoms, and an average score for each symptom was calculated. In addition, we identified the percentage of women who experienced significant distress for each symptom, which was defined as scoring 3 or 4 for an individual symptom. The most common postpartum symptoms experienced by women in our survey were fatigue/tiredness, with an average score of 2.02, and backache/hip pain with an average score of 1.48. This was in contrast to urinary frequency and urinary incontinence complaints, which had average scores of 0.33 and 0.20, respectively. Notably only 2% of patients reported significant distress from urinary incontinence, and only 2% of patients reported significant distress from urinary frequency, whereas 31% and 25% of patients reported significant distress with fatigue/tiredness and backache/hip pain, respectively.
There was a significant relationship between UDI score and PSI score, but not between IIQ score and PSI. Postpartum Symptom Inventory scores for women increased by 5.4 points if a woman had a UDI score that was greater than zero versus a UDI score of zero, controlling for education level, age, and whether the patient had a cesarean delivery (95% CI, 2.2–8.6; P = 0.001). Postpartum Symptom Inventory scores for women increased by 2.9 points if a woman had an IIQ score that was greater than zero versus an IIQ score of zero, controlling for education level, age, and whether the patient had a cesarean delivery (95% CI, −0.9 to 6.8; P = 0.13). There was no statistically significant association found between UDI and IIQ scores and the use of antidepressant medication. Unadjusted for potential confounders, the odds of a mother with a UDI score greater than zero being on depression medication during her postpartum visit were 2.4 times those of a mother with a UDI score of zero (odds ratio [OR], 2.4; 95% CI, 0.5–13.2; P = 0.30), and the odds of a mother with an IIQ score greater than zero being on depression medication during her postpartum visit were 1.9 times the odds of a mother with an IIQ score of zero (OR, 1.9; 95% CI, 0.4–9.3; P = 0.40).
In this study, we did not find a significant relationship between bothersome postpartum urinary incontinence and an increased risk of developing postpartum depression. Research regarding urinary symptoms in the postpartum period is clinically relevant as pregnancy and childbirth are both frequently blamed events for the onset of incontinence.13 The emerging literature suggesting an association between bothersome physical symptoms, including urinary symptoms and postpartum mood disturbances,4,5,7 raises the potential for increased screening and for enacting clinical interventions that may improve multiple aspects of a patient’s care.
Although we did not find a statistically significant association between a positive screen for increased risk of postpartum depression and UDI or IIQ scores, the substantial effect size of the association between UDI score and a positive screen for risk of depression compared with the IIQ score suggests that there may be an actual difference between the questionnaires that was not seen in this study because of the small sample size and lack of power. This difference is interesting in that the UDI and IIQ short forms are both validated questionnaires used to assess for bothersome urinary incontinence and are frequently cited together in the literature. In addition, UDI scores did show a statistically significant association with elevated PSI scores, unlike IIQ scores.
The low prevalence of urinary incontinence in our study population and lack of power may be an explanation for the discordant findings between the UDI and IIQ. However, these discordant findings may also be explained by the different emphases of the questions present in each questionnaire. The UDI asks patients to assess the bother caused by specific symptoms related to urinary incontinence, whereas the overall trend of the IIQ is to focus on the degree of functional impact that urinary incontinence imparts on patients. In this study, our participants were young and generally rated themselves to be in good to excellent health in contrast to older populations, in which urinary incontinence has traditionally been studied. We posit that younger women may be less willing to tolerate incontinence than their older counterparts and thus report greater bother from these symptoms, while experiencing less of a functional impact due to their overall superior performance status at baseline. To further examine these trends, we considered each individual domain for the IIQ. We thought that the IIQ domain of emotional health might show an association with risk of depression as it is the domain with the smallest assessment of functional impact. Although our analysis did not show such an association, this may have been due to the small sample size; additional research with a larger group may support this hypothesis.
With the addition of the PSI, we hoped to assess the overall burden of physical symptoms in the postpartum period and the relation to both mood and urinary symptoms. The PSI was developed and used in this study as it provided a method to quantify the degree of symptom bother experienced by patients and allowed for the standardization of responses between patients. This is in contrast to prior studies that used questionnaires that did not use a rating to determine degree of severity and thus were less useful in creating a numerical score of symptom bother. Not surprisingly, in our cohort of young and generally healthy women, the average score for urinary incontinence/frequency and percentage of patients with significant urinary symptom bother on the PSI were low. The low median UDI score of 5.6 in this sample correlates well with a recent study that demonstrated that a UDI score of 25 or greater was predictive for women to seek care because of symptom bother of urinary incontinence.14 Those with scores lower than 25 would be less motivated to seek care, consistent with our cohort that did not rate their incontinence symptoms as bothersome. It is also not surprising that an association was found between UDI and PSI scores as both the UDI and PSI focus more on degree of bother from symptoms as opposed to the functional impact questions present on the IIQ. Thus, degree of bother from urinary symptoms based on the UDI may be predictive of overall physical symptom bother in the postpartum period. Additional research is needed to clarify the impact that this association has on postpartum mood.
We also hoped to explore the impact of antidepressant use on the symptoms of postpartum depression and urinary incontinence. This is an important area of study as the dysregulation and down-regulation of serotonin are thought to be a crucial element in the development of depression. Estrogen can affect serotonin levels and receptor status through its action on monoamine oxidase A levels, whereas progesterone can affect γ-aminobutyric acid receptors. As these substances have been linked to psychiatric illnesses, it stands to reason that any hormonally driven dysregulation, such as occurs in the postpartum period, may predispose an individual to mood disturbances and provides rationale for antidepressant use in the treatment of postpartum depression.2,5,6 In the prior study by Hullfish et al,11 they postulated that this dysregulation of serotonin symptoms may be responsible for any potential association between urge incontinence and depression as serotonergic activity has been shown to affect bladder function. By collecting data on antidepressant use, which were not collected in the prior study, we hoped to demonstrate evidence to support this theory. Interestingly, in our study, we found no relation between UDI or IIQ scores and the use of antidepressants. However, our ability to draw conclusions from these data is limited as only 7 patients in the study population were taking an antidepressant (6/7 taking selective serotonin reuptake inhibitor, 1/7 taking serotonin-norepinephrine reuptake inhibitor).
Strengths of this study include our use of validated questionnaires for depression and urinary incontinence to explore a clinically prevalent and important issue from a health care perspective in a population with limited previous data. In addition, we tried to broaden the scope of this study with the addition of the PSI to explore the burden of overall physical symptoms in the postpartum period and the questions regarding antidepressant use. However, there are a number of limitations to the current study. First, given our modest sample size, we may have been underpowered to identify an association between bothersome urinary symptoms via the UDI and the odds of screening positive for postpartum depression. The necessity of using dichotomized data in the analysis of our dataset also presents a limitation. This was necessary because of the homogeneity of the UDI and IIQ responses, with an abundance of participants with scores of zero on the UDI and IIQ. This requirement limits the clinical validity of the study as both the UDI and IIQ are scored in a linear fashion. Second, as a cross-sectional study, we are unable to assess for any directionality between physical symptoms, urinary incontinence, and postpartum depression. Larger, multicenter studies with adequate power are needed in the future for further clarification.
In summary, our study did not demonstrate a significant association between urinary dysfunction in the immediate postpartum period and risk of postpartum depression. The low incidence of urinary problems in our population may provide reassurance to women that delivery usually does not have a major impact on urinary function, but made it difficult to assess possible associations for women who do have such problems.
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Incontinence Impact Questionnaire (IIQ); postpartum depression; Urinary Distress Inventory (UDI); urinary incontinence
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