Wu CM, Li CH, Fang YY, Wu H, Ji DM, Zhou P, Cao YX, He Y, Wei ZL. Analysis of risk factors for postoperative anxiety and depression in endometriosis patients with reproductive intention. World J Psychiatry 2024; 14(9): 1364-1374 [PMID: 39319230 DOI: 10.5498/wjp.v14.i9.1364]
Corresponding Author of This Article
Zhao-Lian Wei, MD, Chief Physician, Department of Obstetrics and Gynecology, The First Affiliated Hospital of Anhui Medical University, No. 218 Jixi Road, Shushan District, Hefei 230000, Anhui Province, China. weizhaolian_1@126.com
Research Domain of This Article
Obstetrics & Gynecology
Article-Type of This Article
Observational Study
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Chun-Mei Wu, Cai-Hua Li, You-Yan Fang, Huan Wu, Dong-Mei Ji, Ping Zhou, Yun-Xia Cao, Ye He, Zhao-Lian Wei, Department of Obstetrics and Gynecology, the First Affiliated Hospital of Anhui Medical University, Hefei 230000, Anhui Province, China
Chun-Mei Wu, Department of Obstetrics and Gynecology, Huaibei People's Hospital of Anhui Province, Huaibei 235000, Anhui Province, China
Co-corresponding authors: Ye He and Zhao-Lian Wei.
Author contributions: He Y and Wei ZL contribute equally to this study as co-corresponding authors. Wu CM was responsible for writing of original draft, collect information, conceptualization, formal analysis; Li CH, Fang YY and Wu H were responsible for resources, supervision, methodology; Ji DM, Zhou P and He Y were responsible for formal analysis, investigation, and validation; Cao YX was responsible for software and data curation; Wei ZL was responsible for writing, review and editing.
Supported byResearch Funds of Center for Big Data and Population Health of IHM, No. JKS2022009; Huaibei Science and Technology Plan Project, No. 2021HK016.
Institutional review board statement: The study was reviewed and approved by the First Affiliated Hospital of Anhui Medical University Institutional Review Board.
Informed consent statement: All study participants provided informed written consent before study enrollment.
Conflict-of-interest statement: The authors have no conflicts of interest to declare.
Data sharing statement: No additional data are available.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Zhao-Lian Wei, MD, Chief Physician, Department of Obstetrics and Gynecology, The First Affiliated Hospital of Anhui Medical University, No. 218 Jixi Road, Shushan District, Hefei 230000, Anhui Province, China. weizhaolian_1@126.com
Received: July 24, 2024 Revised: August 13, 2024 Accepted: August 15, 2024 Published online: September 19, 2024 Processing time: 48 Days and 19.3 Hours
Abstract
BACKGROUND
The occurrence of postoperative depression and anxiety in patients with endometriosis (EMS) not only causes psychological distress, but may also harm their physical health.
AIM
To explore the postoperative depression status, and its influencing factors, of EMS patients with reproductive intention.
METHODS
A total of 321 EMS patients with reproductive intent were included. Using the self-rating anxiety scale and self-rating depression scale, EMS patients with anxiety or depression were distinguished. A clinical model for predicting anxiety or depression in EMS patients was constructed and evaluated using a nomogram, receiver operating characteristic curve, and calibration curve.
RESULTS
The results of the single factor analysis showed that smoking, coffee, EMS stage, chronic pelvic pain, and sexual discomfort may be related to anxiety. Further, smoking, drinking, spouse, annual household income and EMS stage may be related to depression in EMS patients. Multivariate logistic regression illustrated that smoking, coffee, chronic pelvic pain and sexual discomfort may be independent risk factors for anxiety in EMS patients, while smoking, EMS stage (Phase III and Phase IV), spouse and high annual household income may be independent risk factors for depression in EMS patients. Additionally, the models used to predict the risk of anxiety or depression in EMS patients have good predictive value.
CONCLUSION
The anxiety and depression of EMS patients may be related to many factors. In clinical treatment, additional attention should be paid to the psychological status of EMS patients.
Core Tip: The occurrence of postoperative depression and anxiety in patients with endometriosis (EMS) not only causes psychological distress, but may also harm their physical health. This study included 321 EMS patients with fertility intentions. Evaluate the anxiety or depression of EMS patients using the self-rating anxiety scale and self-rating depression scale. A clinical model for predicting anxiety or depression in EMS patients was constructed based on multiple regression equations, and the results showed that the model for predicting the risk of anxiety or depression in EMS patients has good predictive value.
Citation: Wu CM, Li CH, Fang YY, Wu H, Ji DM, Zhou P, Cao YX, He Y, Wei ZL. Analysis of risk factors for postoperative anxiety and depression in endometriosis patients with reproductive intention. World J Psychiatry 2024; 14(9): 1364-1374
Endometriosis (EMS) is a prevalent gynecological condition characterized by the ectopic growth of endometrial-like tissue in extra-uterine sites, such as the ovaries, fallopian tubes, and pelvic cavity[1]. EMS affects approximately 10% of women of reproductive age worldwide, and there has been a gradual upward trend in recent years[2]. EMS often presents clinically in the form of menstrual cycle disturbances, dysmenorrhea, dyspareunia, pelvic pain, and other symptoms. In severe cases, it can lead to infertility, significantly impacting the patient's physical and mental well-being as well as their quality of life[3]. Due to the influence of female hormones on ectopic endometrial tissue, patients may experience cyclical pain outside of their menstrual periods, with varying degrees of severity[4]. Additionally, some individuals with EMS may wish to conceive, but it is possible that the condition itself and surgical interventions could adversely impact their fertility[4]. As a chronic gynecological condition, EMS not only causes physical suffering for women but also imposes a significant psychological burden due to infertility, making it a pressing social and medical issue that cannot be overlooked[5]. Therefore, it is crucial to investigate postoperative depression and its associated risk factors in order to enhance the prognosis of EMS patients seeking fertility treatment.
Although the medical community has developed a range of treatment modalities, such as pharmacotherapy and surgical interventions, the high recurrence rate following EMS remains a significant factor impeding treatment efficacy and diminishing patient satisfaction and quality of life[6]. The impact of EMS on women extends beyond the physical realm, often leading to psychological disorders such as anxiety and depression due to the pain and infertility problems it causes. While surgical treatment can effectively alleviate patients' pain symptoms, the postoperative recovery period often presents numerous psychological challenges, with depression being one of the most prevalent mental health disorders[7]. Postoperative depression exhibits a higher prevalence among EMS patients, and this manifestation of depressive symptoms not only inflicts psychological distress upon patients, but also has the potential to compromise their physiological well-being, prolong the disease course, and impede social functioning[8]. For patients with fertility intentions, infertility caused by EMS or repeated treatment failures often leads to significant psychological pressure, resulting in the development and exacerbation of depression, thus perpetuating a vicious cycle[9]. Currently, only a small number of studies have investigated the correlation between EMS and postoperative depression, with the research involving a limited sample size. As such, it is imperative to incorporate a substantial number of studies with large samples to further investigate the current situation and risk factors of postoperative depression in EMS patients, so as to establish a scientific foundation for the development of personalized psychological intervention measures.
This project involved the conducting of an investigational study with a large sample to investigate postoperative depression in patients with EMS. The study investigated the correlation which disease-related factors (such as chronic pain, menstruation, and medication situation), psychosocial factors (including marital status, income, and psychological well-being), and personal factors (such as age, education, and occupation) have with patients' depressive symptoms. Through both quantitative and qualitative analysis, a comprehensive examination of the factors influencing postoperative depression in EMS patients was conducted. Furthermore, the study specifically focuses on patients with reproductive intentions, which holds significant clinical and practical value. The findings of this study will offer new insights into comprehending the psychological mechanisms of postoperative depression in patients with EMS, while also aiding the development of targeted prevention and intervention strategies to alleviate depressive symptoms in patients, enhance their fertility success, and improve their overall well-being.
MATERIALS AND METHODS
Patient population
The subjects were selected from a cohort study at the Reproductive Center of the First Affiliated Hospital of Anhui Medical University from October 2021 to September 2022. Initially, 327 EMS patients with reproductive intention after EMS surgery were included, six of whom were excluded due to incomplete data. The data of 321 patients were finally collated and analyzed. These patients were subjected to strict inclusion and exclusion criteria before finally entering this investigative study. All patients voluntarily signed informed consent sheets. The inclusion criteria were as follows: (1) ≥ 20 years old and BMI < 30 kg/m2; (2) patients who meet the diagnostic criteria of the Chinese Medical Association for EMS; (3) patients who had undergone surgical treatment and have reproductive intentions; and (4) no other serious gynecological diseases or cancers. The exclusion criteria were as follows: (1) Untreated hydrosalpinx; (2) uterine malformation, uterine cavity adhesion, multiple uterine fibroids, submucous or intramural fibroids > 3 cm; (3) polycystic ovary syndrome; (4) chromosomal abnormality; (5) thyroid disease; (6) hyperprolactinemia; (7) pancreatic disease and diabetes; and (8) adrenal disease or Cushing's syndrome.
Study design
Medical records or structured questionnaires were utilized for the collection of general and clinical data from patients. General information encompassed age, smoking, drinking, coffee, tea, body mass index (BMI), place of birth, place of residence, marital status, education, occupation, income, etc. Clinical data included age at onset of first episode, type of EMS, disease stage, medication treatment history, duration of infertility, chronic pelvic pain assessment, sexual discomfort evaluation, history of blood transfusion, fertility and abortion history, number of existing children, menstrual status, and dysmenorrhea. The patients’ postoperative quality of life was assessed using the Short Form-12 Health Survey (SF-12)[10]. Each item in the SF-12 was assigned a fixed scoring standard, and scores were determined based on individual circumstances. Ultimately, these scores were converted to a scale of 0-100, with higher scores indicating better quality of life[11]. The self-rating anxiety scale (SAS) and self-rating depression scale (SDS) were used to evaluate the patients’ anxiety and depression status[12-14]. The SAS and SDS both contained 20 items, and the scores of each item were added together to obtain a rough total score. To improve the comparability and standardization of the scoring results, the standard score was obtained by multiplying the rough total score by 1.25 and taking an integer. According to the standards commonly used in China, an SAS standard score of ≥ 50 was deemed to indicate anxiety, with 50-59 classified as mild anxiety, 60-69 as moderate anxiety, and more than 70 as severe anxiety. An SDS score of ≥ 53 was deemed to indicate depression, with 53-60 being mild depression, 61-70 being moderate depression, and scores above 70 being severe depression.
Quality control
All survey personnel participating in this study had to undergo training and pass the assessment before they could participate in the research. The questionnaire was filled out by the surveyed patients themselves, reflecting their self-perception in the past week. All data were summarized in double entry mode. In case of disagreement, a third party checked and inputted the data.
Statistical analysis
The continuous variables were described in the form of mean ± SD, and the categorical variables were described in the form of frequency (percentage). The difference between the two groups of continuous variables was analyzed using a t-test or Mann-Whitney U test. Differences between categorical variables were determined via the χ2 test. Univariate and multivariate logistic regression models were used to explain the independent variables’ degree of influence on the dependent variables, while the OR value and its 95%CI were calculated. When the P value of the univariate logistic regression analysis was < 0.05, the variable was included in the multi-factor regression model, and the backward stepwise regression method was used for analysis. All statistical analyses were performed using SPSS. P < 0.05 was considered statistically significant.
Clinical prediction model
The clinical prediction model was developed using multivariate logistic regression analysis. The general and clinical information of the patients was included in that analysis, and the results were included in the production of the nomograph. The area under the curve (AUC) of the receiver operating characteristic was used to evaluate the differentiation of the model. The Hosmer-Lemeshow goodness of fit test was employed to evaluate the calibration degree of the model. If P > 0.05, there was no significant difference between the predicted value and the observed value, and the model had a good fit. Calibration curves were drawn to reflect the model fit. Additionally, accuracy, sensitivity and specificity indexes were also utilized to evaluate the prediction effect of the model. For new patients, the clinical predictive model can calculate EMS patients' risk scores for anxiety or depression based on the nomogram. Participants predicted to be at higher risk would then receive additional psychological support and intervention.
RESULTS
General condition of anxiety and depression in EMS patients
A total of 321 patients with reproductive intention after EMS operations were included in this study. Their SAS score was 43.14 ± 8.44, and 61 (19.00%) of them met the diagnostic criteria for anxiety (Table 1). Among the 61 EMS patients with anxiety, 56 (17.45%) had been diagnosed with mild anxiety, four (1.25%) with moderate anxiety, and one (0.31%) with severe anxiety (Table 1). For depression, the SDS score was 53.97 ± 10.94. Of 220 (68.54%) EMS patients who met the diagnostic criteria for depression, 132 (41.12%) had been diagnosed with mild depression, 85 (26.48%) with moderate depression, and three (0.93%) with severe depression (Table 1).
Table 1 The occurrence and degree of anxiety and depression in patients with endometriosis.
Symptom
Score
Asymptomatic
Symptomatic
Mild
Moderate
Severe
Anxiety
43.14 ± 8.44
260
61
56
4
1
Depressed
53.97 ± 10.94
101
220
132
85
3
Demographic characteristics of EMS patients with anxiety or depression
The mean age of EMS patients with anxiety was 31.74 ± 3.69, which was not significantly different from that of patients without anxiety (Table 2). Significant differences were found between smokers and non-smokers (χ2 = 5.57, P = 0.018) and between coffee and non-coffee groups (χ2 = 5.00, P = 0.025) in patients with EMS anxiety disorders. EMS patients with anxiety did not exhibit significant differences in other demographic characteristics. The mean age of EMS patients with depression was 31.80 ± 4.13, and there was no statistical difference between EMS patients with depression and those without depression (Table 2). EMS patients with depression differed significantly in whether they smoked (χ2 = 6.12, P = 0.013) and whether they drank alcohol (χ2 = 4.26, P = 0.039). Patients with and without depression exhibited significant differences in the presence or absence of spouses (χ2 = 4.63, P= 0.031; Table 2). Additionally, EMS patients with depression and those without depression showed significant differences in annual household income (χ2 = 11.85, P= 0.003; Table 2).
Table 2 Demographic characteristics of endometriosis combined with anxiety or depression.
Variable
Anxiety
Depression
Yes
No
t/χ2
P value
Yes
No
t/χ2
P value
Age
31.74 ± 3.69
31.75 ± 4.41
0.01
0.989
31.80 ± 4.13
31.62 ± 4.60
-0.34
0.732
Smoking
5.57
0.018
6.12
0.013
Yes
10 (16.39)
18 (6.92)
25 (11.36)
3 (2.97)
No
51 (83.61)
242 (93.08)
195 (88.64)
98 (97.03)
Drinking
3.24
0.072
4.26
0.039
Yes
17 (27.87)
46 (17.69)
50 (22.73)
13 (12.87)
No
44 (72.13)
214 (82.31)
170 (77.27)
88 (87.13)
Coffee
5.00
0.025
0.26
0.611
Yes
22 (36.07)
58 (22.31)
53 (24.09)
27 (26.73)
No
39 (63.93)
202 (77.69)
167 (75.91)
74 (73.27)
Tea
0.17
0.681
1.20
0.274
Yes
9 (14.75)
44 (16.92)
34 (15.45)
11 (10.89)
No
52 (85.25)
216 (83.08)
186 (84.55)
90 (89.11)
Place of birth
0.79
0.672
1.49
0.476
City
15 (24.59)
77 (29.62)
61 (27.73)
31 (30.69)
Towns
14 (22.95)
50 (19.23)
41 (18.64)
23 (22.77)
Village
32 (52.46)
133 (51.15)
118 (53.64)
47 (46.53)
Place of Residence
2.58
0.275
2.80
0.246
City
49 (80.33)
186 (71.54)
167 (75.91)
68 (67.33)
Towns
8 (13.11)
39 (15.00)
28 (12.73)
19 (18.81)
Village
4 (6.56)
35 (13.46)
25 (11.36)
14 (13.86)
Spousal
0.19
0.662
4.63
0.031
Yes
57 (93.44)
249 (95.77)
214 (97.27)
92 (91.09)
No
4 (6.56)
11 (4.23)
6 (2.73)
9 (8.91)
Educational level
1.57
0.456
4.43
0.109
Junior high school and below
9 (14.75)
33 (12.69)
23 (10.45)
19 (18.81)
High school to junior college
18 (29.51)
99 (38.08)
81 (36.82)
36 (35.64)
Bachelor degree or above
34 (55.74)
128 (49.23)
116 (52.73)
46 (45.54)
Occupation
0.08
0.777
2.65
0.109
Permanent occupation
38 (62.30)
167 (64.23)
147 (66.82)
58 (57.43)
Freelance work
23 (37.70)
93 (35.77)
73 (33.18)
43 (42.57)
Annual household income
1.14
0.565
11.85
0.003
Low-income
22 (36.07)
89 (34.23)
70 (31.82)
41 (40.59)
Middle-income
19 (31.15)
99 (38.08)
74 (33.64)
44 (43.56)
High-income
20 (32.79)
72 (27.69)
76 (34.55)
16 (15.84)
Clinical characteristics of EMS patients with anxiety or depression
Significant differences were found in different EMS stages groups (χ2 = 8.47, P = 0.037), different chronic pelvic pain groups (χ2 = 7.22, P = 0.007), and different sexual discomfort groups (χ2 = 12.62, P < 0.001) among EMS patients combined with anxiety (Table 3). No significant differences were found in other clinical features. Among patients with EMS combined with depression, the results showed significant differences in different EMS stages groups (χ2 = 78.06, P < 0.001). However, no significant differences were found in other clinical features among EMS patients with depression.
Table 3 Clinical characteristics of endometriosis combined with anxiety or depression.
Variable
Anxiety
Depression
Yes
No
t/χ2
P value
Yes
No
t/χ2
P value
BMI
21.82 ± 3.24
21.80 ± 2.91
-0.05
0.960
21.76 ± 2.88
21.89 ± 3.17
0.35
0.725
History of blood transfusion
0.01
0.911
0.28
0.594
Yes
2 (3.28)
14 (4.36)
11 (5.00)
3 (2.97)
No
59 (96.72)
307 (95.64)
209 (95.00)
98 (97.03)
Knowing the age of EMS
28.15 ± 3.74
27.71 ± 4.28
-0.73
0.464
27.91 ± 4.04
27.54 ± 4.49
-0.73
0.469
EMS type
0.59
0.744
2.92
0.232
Peritoneal type
28 (45.90)
112 (43.08)
103 (46.82)
37 (36.63)
Ovarian type
21 (34.43)
103 (39.62)
80 (36.36)
44 (43.56)
Other types
12 (19.67)
45 (17.31)
37 (16.82)
20 (19.80)
EMS staging
8.47
0.037
78.06
< 0.001
Phase I
6 (9.84)
41 (15.77)
22 (10.00)
25 (24.75)
Phase II
5 (8.20)
54 (20.77)
17 (7.73)
42 (41.58)
Phase III
28 (45.90)
101 (38.85)
110 (50.00)
19 (18.81)
Phase IV
22 (36.07)
64 (24.62)
71 (32.27)
15 (14.85)
EMS medication
0.48
0.487
0.18
0.674
Yes
21 (34.43)
102 (39.23)
134 (60.91)
64 (63.37)
No
40 (65.57)
158 (60.77)
86 (39.09)
37 (36.63)
Chronic pelvic pain
7.22
0.007
Yes
19 (31.15)
42 (16.15)
40 (18.18)
21 (20.79)
No
42 (68.85)
218 (83.85)
180 (81.82)
80 (79.21)
Sexual discomfort
12.62
< 0.001
0.00
0.945
Yes
29 (39.34)
64 (24.62)
64 (29.09)
29 (28.71)
No
32 (52.46)
196 (75.38)
156 (70.91)
72 (71.29)
Infertility years
3.98 ± 3.14
3.57 ± 2.36
-1.12
0.264
3.65 ± 2.58
3.64 ± 2.43
-0.03
0.977
Age of menarche
13.54 ± 1.29
13.43 ± 1.28
-0.58
0.560
13.45 ± 1.21
13.47 ± 1.43
0.10
0.921
Menstrual cycle
30.90 ± 5.91
29.47 ± 4.93
-1.96
0.051
29.98 ± 5.74
29.23 ± 3.48
0.92
0.224
Menstrual period
6.47 ± 1.29
6.14 ± 1.23
-1.87
0.062
6.20 ± 1.22
6.23 ± 1.32
0.41
0.844
Dysmenorrhea
0.56
0.454
0.06
0.802
Yes
40 (65.57)
157 (60.38)
134 (60.91)
63 (62.38)
No
21 (34.43)
103 (39.62)
86 (39.09)
38 (37.62)
Childbearing history
1.46
0.226
1.13
0.288
Yes
11 (18.03)
66 (25.38)
49 (22.27)
28 (27.72)
No
50 (81.97)
194 (74.62)
171 (77.73)
73 (72.28)
History of abortion
0.88
0.349
0.47
0.491
Yes
12 (19.67)
66 (25.38)
51 (23.18)
27 (26.73)
No
49 (80.33)
194 (76.54)
169 (76.82)
74 (73.27)
SF-12 score
32.51 ± 2.84
32.70 ± 4.66
0.31
0.754
32.96 ± 3.25
32.02 ± 6.12
-1.80
0.073
Logistic regression analysis of EMS patients with anxiety
Univariate and multivariate logistic regression analysis showed that smoking, coffee, chronic pelvic pain, and sexual discomfort were associated with an increased risk of anxiety in EMS patients. Multivariate logistic regression illustrated that demographic characteristics such as smoking (OR = 2.54, 95%CI: 1.06-6.11, P = 0.037) and coffee (OR = 1.92, 95%CI: 1.02-3.61, P = 0.042) were associated with an increased risk of anxiety (Table 4). In addition, EMS patients with chronic pelvic pain (OR = 1.97, 95%CI: 1.01-3.85, P = 0.045) or sexual discomfort (OR = 2.60, 95%CI: 1.42-4.76, P = 0.002) were also associated with an increased risk of anxiety (Table 4). For the other features, no significant association was found.
Table 4 Univariate and multifactorial logistic analysis of anxiety in endometriosis patients.
Variable
Univariate logistic analysis
Multivariate logistic analysis
OR (95%CI)
P value
OR (95%CI)
P value
Smoking
Yes
2.64 (1.15-6.05)
0.022
2.54 (1.06-6.11)
0.037
No
Reference
Reference
Coffee
Yes
1.96 (1.08-3.57)
0.027
1.92 (1.02-3.61)
0.042
No
Reference
Reference
Chronic pelvic pain
Yes
2.35 (1.24-4.43)
0.008
1.97 (1.01-3.85)
0.045
No
Reference
Reference
Sexual discomfort
Yes
2.78 (1.56-4.94)
< 0.001
2.60 (1.42-4.76)
0.002
No
Reference
Reference
Logistic regression analysis of EMS patients with depression
Univariate and multivariate logistic regression analysis showed that smoking, EMS stage, spouse and household income were significantly associated with depression. Smoking was significantly associated with a higher risk of depression compared to non-smoking EMS patients (OR = 4.19, 95%CI: 1.10-15.93, P = 0.036; Table 5). Additionally, stage 3 (OR = 7.67, 95%CI: 3.44-17.11, P < 0.001) and stage 4 (OR = 6.12, 95%CI: 2.65-14.15, P < 0.001) EMS patients were associated with a higher risk of developing depression than were stage 1 EMS patients. No statistical association was found between stage 2 and stage 1 in terms of the risk of depression. Compared to EMS patients without spouses, those with spouses exhibited a higher risk of depression (OR = 4.96, 95%CI: 1.48-16.63, P = 0.010). Additionally, low-income (OR = 0.40, 95%CI: 0.19-0.87, P = 0.020) and middle-income (OR = 0.42, 95%CI: 0.20-0.90, P = 0.025) EMS patients exhibited a lower risk of depression than those with higher household incomes.
Table 5 Univariate and multifactorial logistic analysis of depression in endometriosis patients.
Variable
Univariate logistic analysis
Multivariate logistic analysis
OR (95%CI)
P value
OR (95%CI)
P value
Smoking
Yes
4.19 (1.23-14.21)
0.022
4.19 (1.10-15.93)
0.036
No
Reference
Reference
EMS staging
Phase I
Reference
Reference
Phase II
0.46 (0.21-1.03)
0.058
0.50 (0.21-1.16)
0.104
Phase III
6.58 (3.10-13.95)
< 0.001
7.67 (3.44-17.11)
< 0.001
Phase IV
5.38 (2.42-11.96)
< 0.001
6.12 (2.65-14.15)
< 0.001
Spousal
Yes
3.49 (1.21-10.09)
0.021
4.96 (1.48-16.63)
0.010
No
Reference
Reference
Annual household income
Low-income
0.36 (0.19-0.70)
0.002
0.40 (0.19-0.87)
0.020
Middle-income
0.35 (0.18-0.68)
0.002
0.42 (0.20-0.90)
0.025
High-income
Reference
Reference
Construction and evaluation of prediction model
Based on the demographic and clinical information of EMS patients, this study constructed a clinical prediction model for predicting anxiety or depression in EMS patients. In the model that predicted anxiety in EMS patients, the AUC was 0.706 (95%CI: 0.632-0.780; Figure 1A). For the nomogram, the Hosmer-Lemeshow goodness of fit test results showed that the model has a good fit (P= 0.832; Figure 2A). The calibration curve illustrated that the model has a good fit between the predicted value and the observed value (Figure 3A). The accuracy of the model was 0.71 (95%CI: 0.65-0.76). Under the optimal cut-off value, the sensitivity was 0.73 (95%CI: 0.68-0.78) and the specificity was 0.61 (95%CI: 0.88-0.73; Supplementary Table 1). In constructing a model to predict depression in EMS patients, the AUC was 0.814 (95%CI: 0.762-0.867; Figure 1B). The results of the Hosmer-Lemeshow goodness of fit test indicate that the model has a certain degree of calibration (P= 0.937; Figure 2B). Moreover, the predicted value and the actual value of the calibration curve fit well, indicating that the model has a good prediction effect (Figure 3B). Additionally, the model’s accuracy was 0.78 (95%CI: 0.73-0.83), the sensitivity was 0.72 (95%CI: 0.64-0.81), and the specificity was 0.81 (95%CI: 0.76-0.86; Supplementary Table 1).
Figure 3 Calibration curve analysis of endometriosis patients with anxiety or depression.
A: Combined anxiety; B: Combined depression.
DISCUSSION
EMS, as a common female reproductive system disease, can lead to dysmenorrhea, pelvic pain, infertility and other symptoms in women, possibly seriously harming their physical health and mental health, especially for women with reproductive intentions[15]. Moreover, EMS has no obvious specific symptoms in the early stage, and treatment is often delayed because it is mistaken for other gynecological diseases[16]. EMS patients with reproductive intention often not only have to suffer from pain, but also face a great deal of pressure from their family and society, resulting in anxiety, depression and other psychological diseases[17]. This study focuses on the mental health of EMS patients, starting from anxiety and depression states, analyzing the psychological status and influencing factors of EMS patients with reproductive intentions, and exploring new ways to alleviate symptoms, reduce tissue damage, and improve fertility. This study found a high incidence of both anxiety and depression, especially depression, in EMS patients with reproductive intentions. The results of the single factor analysis showed that smoking, coffee, EMS stage, chronic pelvic pain, and sexual discomfort may be related to anxiety. Smoking, drinking, spouse, annual household income and EMS stage may be related to depression in EMS patients. Multivariate logistic regression analysis revealed that smoking, coffee, chronic pelvic pain and sexual discomfort may be independent risk factors for anxiety in EMS patients, while smoking, EMS stage, spouse and annual household income may be independent risk factors for depression in patients with EMS.
The results of this study show that anxiety and depression in EMS patients have an incidence rate which is significantly higher than that of the general population[18]. Firstly, the symptoms of EMS itself are complex and diverse, including dysmenorrhea, chronic pelvic pain, low fertility, etc.; indeed, these symptoms not only inflict physical pain on patients, but may also lead to worry and anxiety about fertility[19]. Moreover, EMS is a chronic disease, and its recurring and intractable characteristics afflict the mental state of patients for a long time, which leads to anxiety and depression[20]. Secondly, EMS is often associated with infertility, and for women who have reproductive wishes, the conflict between those wishes and reality can easily give rise to a strong sense of anxiety among patients[21]. Previous studies have shown that EMS is associated with hormone disorders in the body[22,23]. Fluctuations or misalignments in sex hormones can themselves cause mood swings that increase the risk of anxiety and depression[24]. Finally, some patients may lack adequate psychological support and guidance in the face of disease and fertility pressure, meaning they are unable to cope effectively with negative emotions, which in turn exacerbates symptoms of anxiety and depression.
This study found that smoking, coffee, chronic pelvic pain and sexual discomfort may be independent risk factors for anxiety in EMS patients. Nicotine is the main active ingredient in tobacco, and has strong pharmacological effects, including stimulating the central nervous system[25]. Nguyen et al[26] found that nicotine promotes anxiety by directly activating nicotinic acetylcholine receptors on midbrain dopamine neurons, affecting dopamine neural circuits projected from the ventral tegmental area of the midbrain to the amygdala. In addition, smokers may experience anxiety due to the health risks and social exclusion associated with smoking. Liu et al[27] through a meta-analysis, showed a positive association between caffeine intake and anxiety risk, with caffeine consumption increasing anxiety risk, especially when consumed at doses greater than 400 mg. Chronic pelvic pain is one of the common symptoms experienced by EMS patients, and long-term pain not only affects patients’ quality of life, but may also lead to emotional problems[28]. Studies have shown that chronic pain activates areas of the brain associated with emotional regulation, such as the amygdala and prefrontal cortex, which can trigger anxiety and depression[29]. Moreover, sexual activity is an important part of the relationship between husband and wife, and sexual discomfort not only affects that intimate relationship, but may also lead to patients' fear and avoidance of sexual life, thus causing anxiety[30]. In addition, sexual discomfort may be related to the patient's self-image and self-esteem, and long-term sexual discomfort could weaken the patient's self-confidence while also increasing anxiety.
In terms of depression, the results suggest that smoking, EMS stage, spouse and annual household income may be risk factors for depression. In a study of 57441 Korean men, Park et al[31] found that smoking was associated with an increased risk of depressive symptoms, and that the risk increased in proportion to the amount of daily smoking. This suggests a dose-dependent relationship between smoking and depressive symptoms. A previous cross-sectional study also reported that daily smokers have a higher risk of depression; the longer they quit smoking for, the lower their risk[32]. Nicotine can affect neurotransmitters such as dopamine and serotonin, which play a key role in regulating mood. Long-term smoking may lead to dysfunction of these systems, which increases the risk of depression. However, the specific mechanism of long-term smoking needs to be further explored. In terms of disease staging, with the increase in the severity of EMS, the degree of damage to the body is also increasing. In addition, an increase in the severity of the disease is often accompanied by fear of the consequences of the said disease, a decrease in social activities, an increase in the cost of treatment, etc., which may directly or indirectly affect the emotional state of the patient and increase the risk of depression[33]. Patients with spouses may face more life pressures, such as financial pressure, children's education, and caring for both families. These additional stressors could overwhelm an individual's ability to cope, increasing the risk of depression. Although a spouse is the primary source of emotional support, poor communication, apathy, or frequent conflict can lead to emotional isolation and feelings of loss, which in turn increases the risk of depression[34]. In addition, EMS patients in high-income families may live in a fast-paced, high-intensity environment, which can lead to physical and mental exhaustion, as well as lack of rest and relaxation, which can affect mental health. Second, high income may be accompanied by higher psychological expectations, including expectations in terms of work achievements, social status, family responsibilities, etc., which might translate into great psychological pressure. However, the relevant mechanisms need to be further explored.
This study has certain limitations. First, due to the limited sample source, the extrapolation of the study results may be limited. Second, the number of individual subgroups was small, which may have led to large experimental errors, and so the interpretation of some of this study’s results needs to be cautious. Finally, the psychological assessment method used in this study may have limitations. While the study employed standardized psychological assessment tools to measure anxiety and depression, these tools may have not fully captured the patients' complex mental states. The subjectivity and limitations of psychological assessment tools may have affected the accuracy of the assessment results. Nevertheless, this study still revealed the current situation and influencing factors of anxiety and depression and established a good clinical prediction model for predicting the risk of anxiety or depression in EMS patients with fertility intention. Indeed, this provides certain theoretical support for further implementation of psychological intervention and improvement of patient prognosis.
CONCLUSION
This study conducted a survey analysis of the anxiety and depression status and influencing factors of 321 EMS patients with fertility intentions, finding that anxiety and depression were at a high incidence level among EMS patients. Additionally, smoking, coffee, chronic pelvic pain, and sexual discomfort may be associated with an increased risk of developing anxiety in EMS patients, while smoking, EMS stage (Phase III and Phase IV), spouse and high annual household income may be associated with depression. This study can provide an important theoretical basis for further understanding of the status quo of anxiety and depression in EMS patients and its influencing factors, as well as for identifying high-risk patients with anxiety and depression in advance. The results have certain clinical and practical significance for optimizing psychological treatment and improving patients’ quality of life.
Footnotes
Provenance and peer review: Unsolicited article; Externally peer reviewed.
Peer-review model: Single blind
Specialty type: Psychiatry
Country of origin: China
Peer-review report’s classification
Scientific Quality: Grade B
Novelty: Grade B
Creativity or Innovation: Grade C
Scientific Significance: Grade B
P-Reviewer: Ayata C S-Editor: Lin C L-Editor: A P-Editor: Che XX
Koller D, Pathak GA, Wendt FR, Tylee DS, Levey DF, Overstreet C, Gelernter J, Taylor HS, Polimanti R. Epidemiologic and Genetic Associations of Endometriosis With Depression, Anxiety, and Eating Disorders.JAMA Netw Open. 2023;6:e2251214.
[PubMed] [DOI][Cited in This Article: ][Cited by in F6Publishing: 32][Reference Citation Analysis (0)]
Busija L, Pausenberger E, Haines TP, Haymes S, Buchbinder R, Osborne RH. Adult measures of general health and health-related quality of life: Medical Outcomes Study Short Form 36-Item (SF-36) and Short Form 12-Item (SF-12) Health Surveys, Nottingham Health Profile (NHP), Sickness Impact Profile (SIP), Medical Outcomes Study Short Form 6D (SF-6D), Health Utilities Index Mark 3 (HUI3), Quality of Well-Being Scale (QWB), and Assessment of Quality of Life (AQoL).Arthritis Care Res (Hoboken). 2011;63 Suppl 11:S383-S412.
[PubMed] [DOI][Cited in This Article: ][Cited by in Crossref: 231][Cited by in F6Publishing: 256][Article Influence: 21.3][Reference Citation Analysis (0)]
Nguyen C, Mondoloni S, Le Borgne T, Centeno I, Come M, Jehl J, Solié C, Reynolds LM, Durand-de Cuttoli R, Tolu S, Valverde S, Didienne S, Hannesse B, Fiancette JF, Pons S, Maskos U, Deroche-Gamonet V, Dalkara D, Hardelin JP, Mourot A, Marti F, Faure P. Nicotine inhibits the VTA-to-amygdala dopamine pathway to promote anxiety.Neuron. 2021;109:2604-2615.e9.
[PubMed] [DOI][Cited in This Article: ][Cited by in Crossref: 15][Cited by in F6Publishing: 67][Article Influence: 22.3][Reference Citation Analysis (0)]
Park SK, Oh CM, Kim E, Ryoo JH, Jung JY. The longitudinal analysis for the association between smoking and the risk of depressive symptoms.BMC Psychiatry. 2024;24:364.
[PubMed] [DOI][Cited in This Article: ][Cited by in Crossref: 2][Reference Citation Analysis (0)]
