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ORIGINAL ARTICLE
Year : 2022 | Volume
: 13
| Issue : 3 | Page : 233-240
Depression among Peri- and Post-Menopausal women during COVID-19 pandemic in Chandigarh, North India: A study from community
Sukriti Khatak1, Madhu Gupta1, Sandeep Grover2, Neelam Aggarwal3
1 Department of Community Medicine, School of Public Health, Postgraduate Institute of Medical Education and Research, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
3 Department of Obstetrics and Gynaecology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
Correspondence Address:
Madhu Gupta
Department of Community Medicine, School of Public Health, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh - 160 012
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/jmh.jmh_92_22
Abstract
Background: Peri- and post-menopausal women are vulnerable to suffer from mental health problems including depression, anxiety, and stress, which might have increased during the COVID-19 pandemic. Objective: To estimate the prevalence of depression and associated factors among peri- and post-menopausal women during the COVID-19 pandemic in Chandigarh. Materials and Methods: A community-based cross-sectional study was conducted among 200 urban peri- and post-menopausal women of age 40–60 years in Chandigarh, from May to June 2021. Patient Health Questionnaire-9, Generalized Anxiety Disorder 7, and EuroQol-5D validated tools were used to screen depression, anxiety, and quality of life (QOL). Fear of COVID-19 scale was developed as part of this study was used to assess the fear related to COVID-19 infection. Data analysis was done using the Statistical Package for the Social Sciences (SPSS) software version 26.0. Binary multivariate logistic regression model was used to identify the predictors. Results: The prevalence of depression was 39% and anxiety 29.5% among peri-and post-menopausal women. The fear of COVID-19 infection (adjusted odds ratio [aOR] 8.43, confidence interval [CI]: 1.99–35.64; aOR 10.54, CI: 2.76–40.24) and sleeplessness (aOR 13.29, CI: 3.22–54.82) were the significant (P < 0.005) predictors of depression and anxiety, respectively. Fearful peri- and post-menopausal women (aOR 5.94, CI: 2.68–13.13) and widow status (aOR 7.08, CI: 1.10–45.28) were the significant (P < 0.005) predictors of poor QOL. Conclusions: The prevalence of depression was high among peri- and post-menopausal women during the COVID-19 pandemic. Fear of getting COVID-19 infection was significantly associated with depression, anxiety, and poor QOL.
Keywords: Anxiety, COVID-19, depression, mental health problems, peri- and post-menopausal women, quality of life
Introduction 
The coronavirus 2019 (COVID-19) pandemic emerged in Wuhan, China and had spread globally between December 2019 and early 2020. It had triggered a variety of psychological problems such as panic disorders, sleep disturbances, anger, anxiety, and depression.[1] In addition, to represent a major threat to the population’s physical health, the COVID-19 pandemic also affected the population’s mental health due to increased feelings of fear and uncertainty; disruption of social and economic systems; separation and grief. Another threat to the population’s mental health was the implementation of nationwide quarantine measures to prevent the spread of COVID-19.[2] Quarantine was associated with fear related to health, fear of getting COVID-19 infection, misinformation about the pandemic, fear of travel bans, government orders, inadequate demand and supplies of essential items and financial losses that have an impact on health, particularly for women in the menopausal transition period who are more vulnerable to suffer from mental health issues.[3] Cagnacci et al. have reported the prevalence of depression to be 35.6% among Italian peri- and post-menopausal women during the pandemic period.[4]
There have been many studies focusing on the peri- and post-menopausal vasomotor symptoms but fewer on peri- and post-menopausal depression.[5],[6] There are very few studies from India which have assessed the burden and associated factors of depression among peri-and post-menopausal women during the COVID-19 pandemic. This study aimed to estimate the prevalence and ascertain the various factors associated with depression among peri-and post-menopausal women during the COVID-19 pandemic in Chandigarh, North India. This study also intended to report the increase or decrease in peri- and post-menopausal depression among peri-and post-menopausal women during the COVID-19 pandemic by comparing it with the prevalence reported in the pre-pandemic period.
Materials and Methods Ethical consideration
This study was approved by the Institute’s Ethical Committee at Postgraduate Institute of Medical Education and Research, in Chandigarh (NK/7174/ MPH/215, May 11, 2021). A written informed consent was obtained from the participants after sharing the participant information sheet in the language the participants could understand. The personal information of the participants was kept confidential, and breach of this confidentiality was not done.
Study design, population, and sampling procedures
A cross-sectional study was conducted in the field practice area of the Department of Community Medicine and School of Public Health, May to June 2021. There was a demographic health surveillance system set up in the area by the department. The population of the study area was about 17,000, as per the annual health survey 2019–2020. Women in the age group of 40–60 years were 2207. Residents belonging to all socioeconomic groups (high-, middle-and lower-income groups) reside in this area.
The study population included peri-and post-menopausal women of age 40–60 years. Menopause is documented as a complete cessation of menstruation for a period of 1 year. Perimenopause duration is variable, and it is defined as the time of irregular periods until menopause.[7] Peri- and post-menopause is the span of time dating from the final menstrual period, regardless of whether the menopause was spontaneous or iatrogenic.[8] Inclusion criteria included all married/unmarried/separated/divorced/widow peri-and post-menopausal women, who were residents of the study area for the past 6 months and consented to be part of the study. The exclusion criteria included menopausal women who were having a history of mental illness or were diagnosed with suffering from mental illness, or with any physical disability, illiterate women, or who had a hysterectomy, or women on medication that caused menopause.
The sample size (n) was calculated according to the formula: N = z2 × p × (1 − p)/e2,[9] where: Z = 1.96 for a confidence level (a) of 95%, p = proportion (expressed as a decimal) and assumed to be 40%,[10],[11] e = margin of error and assumed to be 10%. Assuming prevalence of depression among peri-and post-menopausal women to be 40%,[10],[11] sample size was estimated at 92. Considering the nonresponse rate of 20%, the minimum sample size came out to be 110. A total of 200 women meeting the eligibility criteria were enrolled in the study.
A list of all the women of age 40–60 years of age was obtained from the auxiliary nurse midwives peri-and post-ed in HWC 49, field practice area of Department of Community Medicine and School of Public Health, PGIMER from the demographic health surveillance system. There were about 2207 peri-and post-menopausal women in the age group of 40–60 years in the study area as per the annual health survey 2019–2020. These women were numbered, and study participants were selected by simple random sampling technique till desired sample size was achieved. Simple random sampling ensured that women of all the socioeconomic groups were represented in the study.
Data collection methods
Total four questionnaires in Hindi and English language were used to collect the data.
Questionnaire 1: Background Information and Fear of COVID-19 Scale
A structured tool was developed and pretested to record the background socio-demographic information including age, educational status, type of family, socioeconomic status, marital status, and other information like sexually activity, living with husband, decision making of household issues, fear of COVID-19 pandemic.[12]Fear of COVID-19 scale was developed as part of this study was used to assess the fear related to COVID-19 infection.
Questionnaire 2: A standardised validated Patient Health Questionnaire-9[13]
The Patient Health Questionnaire (PHQ-9) questions were based on the diagnostic criteria of depression and asked about the patient’s experience in the last 2 weeks. Questions were about the level of interest in doing things, feeling down or depressed, difficulty with sleeping, energy levels, eating habits, self-perception, ability to concentrate, speed of functioning, and thoughts of suicide. Responses ranged from “0” (Not at all) to “3” (nearly every day). The total sum of the responses suggests varying levels of depression. Scores ranged from 0 to 27. Depression Severity: 0–4 none, 5–9 mild, 10–14 moderate, 15–19 moderately severe, 20–27 severe was used to ascertain the depression levels. This tool is validated in Indian settings.[14]
Questionnaire 3: Generalized Anxiety Disorder 7[15]
Generalized anxiety disorder 7 (GAD-7) is a self-reported questionnaire for screening and severity measuring of a GAD. It is validated in Indian settings.[16] GAD-7 has seven items, The GAD-7 score was calculated by assigning scores of 0, 1, 2, and 3 to the response categories of “not at all,” “several days,” “more than half the days,” and “nearly every day,” respectively, and adding together the scores for the seven questions scores of 5, 10, and 15 were taken as the cut-off points for mild, moderate, and severe anxiety.
Questionnaire 4: EuroQol-5D[17]
It is a standardized instrument used to measure five dimensions: Mobility, self-care, usual activities pain/discomfort and anxiety/depression. Each dimension has 5 levels: No problem, slight problem, moderate problem, severe problem, and extreme problem. The peri- and post-menopausal women were asked to indicate their health state by ticking the box next to the most appropriate statement in each of the five dimensions. This tool is validated in Indian settings.[18]
An online Google form having all the questionnaires was made in Hindi and English language to collect the information from the women online and telephonically due to COVID pandemic restrictions.
Statistical analysis
Data analysis was done using Statistical Package for the Social Sciences (SPSS) version 26.0. IBM Corp. Released 2019. IBM SPSS Statistics for Windows, Version 26.0. Armonk, NY: IBM Corp. The prevalence of depression and anxiety among peri- and post-menopausal women was estimated as proportion. A Chi-square test was done to compare the differences in proportions. A binary multivariate logistic regression model was applied to identify the significant predictors of depression, anxiety, and quality of life (QOL) among the peri-and post-menopausal women in the study area. The difference between the proportions was considered significant at a 95% level confidence interval. For conducting the multivariate binary logistic regression analysis, the following variables were considered:
Independent variables
Age, marital status, living with husband, sexually active, type of family, educational qualification, socioeconomic status, decision making at home, fear of COVID-19.
Dependent variables
Prevalence of depression, the prevalence of anxiety, and QOL. The overall scores for depression, anxiety, and QOL were calculated. A cutoff of 10 was taken to classify depression and anxiety into two categories. A score <10 was considered category 1 suggesting mild depression or anxiety, and a score ≥10 was taken as category 2 i.e., moderate and severe depression or anxiety. For the QOL, the cutoff 9 was taken, i.e., a score of <9 was considered as category 1 suggesting the good QOL, and a score ≥9 was taken as poor QOL.
Results The background characteristics of peri- and post-menopausal women are given in [Table 1]. Of the 200 peri- and post-menopausal women, 70% were between the age group of 51–60 years, 46% studied till graduation, 72.5% were homemakers, 45% belonged to lower middle class, 90% were married, 82.5% were living with their husbands, and 63.5% were currently sexually active (for the last 6 months).
Table 1: Background characteristics of peri- and post-menopausal women in Chandigarh, 2021 (n=200)Perceptions regarding fear of COVID-19 pandemic among peri-and post-menopausal women are given in [Table 2]. Around 49% peri-and post-menopausal women agreed that they were afraid of getting COVID-19 infection, 28% agreed that thinking about COVID-19 infection makes them uncomfortable, and 51.5% agreed that they became nervous or anxious on watching the news about COVID-19 on social media.
Table 2: Fear of coronavirus-2019 among peri- and post-menopausal women in Chandigarh, 2021The prevalence of minimal depression was 61%, mild depression 38.5%, and moderate depression was 0.5%. Feeling bad about herself or that she was a failure or have let herself or her family down was reported by 54.5% women on several days and 10% women on more than half the days. According to the anxiety rating scale, 69.5% of peri-and post-menopausal women had no anxiety symptoms, 29.5% had mild anxiety symptoms, and 1% had moderate anxiety symptoms [Table 3].
Table 3: Prevalence of depression and anxiety among the peri- and post-menopausal women in Chandigarh, 2021 (n=200)Regarding quality-of-life peri-and post-menopausal women reported slight problems in mobility (37.5%), self-care (18%), usual activities (34.5%), pain discomfort (42.5%), anxiety/depression (59%), about 15.5% had moderate anxiety/depression [Table 4].
Table 4: Quality of life among the peri- and post-menopausal women in Chandigarh, 2021As per the multivariate binary logistic regression analysis, a significant association was observed between depression and being uncomfortable to think about COVID-19 infection (adjusted odds ratio [aOR] 8.43; 95% confidence interval [CI]: 1.99–35.64; P < 0.005), being afraid of losing life (aOR 13.67; 95% CI: 1.65–25.70; P < 0.005), clammy hands (aOR 13.67; 95% CI: 1.48–125.8; P < 0.005), become nervous or anxious while watching COVID-19 news on social media (aOR 10.84; 95% CI: 1.27–92.58; P < 0.005), sleeplessness (aOR 13.29; 95% CI: 3.22–54.82; P < 0.005), restlessness (aOR 6.12; 95% CI: 1.30–28.66; P < 0.005) during COVID-19.
A significant association was also observed between anxiety and afraid of getting COVID-19 infection (aOR 3.92; 95% CI: 1.00–15.28; P < 0.005), feeling uncomfortable (aOR 10.54; 95% CI: 2.76–40.24; P < 0.005), become nervous or anxious while watching COVID-19 news on social media (aOR 4.91; 95% CI: 1.17–20.64; P < 0.005), sleeplessness (aOR 13.29; 95% CI: 3.22–54.82; P < 0.005) during COVID-19.
Furthermore, a significant association was found between QoL and marital status (aOR: 7.08; 95% CI: 1.10–45.28; P < 0.005). Similarly, a significant association was seen between QOL and being afraid of getting COVID-19 infection (aOR 5.94; 95% CI: 2.68–13.13; P < 0.005), feeling uncomfortable (aOR 3.35; 95% CI: 1.61–6.98; P < 0.005), increased heart rate (aOR 3.73; 95% CI: 1.45–9.60; P < 0.005), and afraid of losing life (aOR 2.97; 95% CI: 1.20–7.32; P < 0.005) during COVID-19 [Table 5].
Table 5: Results of multivariate logistic regression for depression, anxiety and quality of life among peri- and post-menopausal women during the coronavirus-2019 pandemic Discussion This study reports the high prevalence of depression and moderately high prevalence of anxiety among peri-and post-menopausal women during the COVID-19 pandemic. The depression and anxiety were higher among the peri-and post-menopausal women who were afraid of the COVID-19 pandemic. About 1 in 10 peri-and post-menopausal women were afraid of losing their life due to COVID-19 infection. This study highlighted a statistically significant association of depression, anxiety, and QOL with the fear of getting COVID-19 infection.
The depression among peri-and post-menopausal women in this study was comparatively higher (39%) than that reported in studies before the COVID-19 pandemic (before March 2020). Studies done before COVID-19 pandemic have estimated the prevalence to vary from 11.4% to 20.7%.[19],[20],[21] However, the prevalence was lower than other studies which have estimated the prevalence of depression to range from 41.6% to 76%.[11],[12] The difference between the various study findings can be explained by the different selection of study tools. In the present study we used the PHQ-9 scale to screen for depression while other studies have relied upon Hamilton Depression,[11] or Inventory for Depressive Symptomatology-Self Report scale.[20] A previous study, which relied upon PHQ-9 reported a lower (26.1%) prevalence of depression among peri-and post-menopausal women.[22] This difference can be due to differences in the population characteristics or occurrence of the COVID-19 pandemic in this study. The studies conducted after COVID-19 pandemic (after March 2020) have reported the prevalence of depression to range from 35.6% to 56.34%[4],[23],[24],[25] among the peri-and post-menopausal women, which is similar to this study. This could be attributed to fear of getting affected by COVID-19 infection in these studies.
The prevalence of anxiety in the pre-pandemic period [before March 2020] was significantly lower (7.4%) among peri- and post-menopausal Chinese women as compared to the findings of present study (29.5%).[19] However, anxiety prevalence (29.5%) was lower than reported by Dewangan et al. study in Bhubaneswar[23] and Kalhan et al. study in Haryana (80%)[24] in the post pandemic period. This difference can be explained by the different selection of study tools used in these studies. This study used the GAD-7 scale to screen for anxiety while Kalhan et al. study (2020)[24] had used the Zung-Self-Rating scale, and Dewangan et al. study had used the Menopause Rating Scale.[23] Another reason could be the different socio-cultural backgrounds of the study population. Hyland et al. study conducted in Ireland reported a lower (20%) prevalence of anxiety among peri-and post-menopausal women using the same scale as used in this study.[2] They reported a strong association of marital status and sexual activity with anxiety among peri-and post-menopausal women. The QOL among postmenopausal women was found to be better (77%) in West Bengal[21] and poorer (50%) in Bhubaneshwar[26] in the pre-pandemic period, as compared to this study, probably due to use of different tools, sociocultural differences and covid-19 pandemic. Fear of getting Covid-19 infection and disease was found to be the significant determinant of depression, anxiety and poor QOL in this study.
The strength of the study is that the tools used to screen depression and QOL were standardized and validated as per the Indian setting. Questionnaire was made in both English and Hindi language. Limitation of the study is that the results of this study are generalized to the urban study area only (Health and Wellness centre, sector 49, Chandigarh). As respondents were supposed to send their responses through WhatsApp and E-mail it was a concern of privacy for some respondents. However, their responses were deleted afterwards, and strict confidentiality maintained. Since this was an observational study hence temporality between covid-19 pandemic and depression could not be ascertained. However, conducting analytical studies (case control or cohort study) in pandemic situations is challenging as it will be difficult to find unexposed groups. Hence we could at the best compare the situation pre (existing literature) and post COVID-19 pandemic.
Conclusion Mental health problems including depression, anxiety among peri-and post-menopausal women is important public health problem, which is being highlighted in this study, especially during the COVID-19 pandemic. A significant factor leading to increased symptoms of depression and anxiety was fear of getting affected with COVID-19 among the peri-and post-menopausal women. This indicated an urgent need to have counsellors available in person or online (teleconsultation) to alleviate the underlying fear factor and promote preventive strategies including COVID appropriate behaviour and vaccination to deal with the situation and allay fear. The results of this study can guide the policymakers to also consider having sustainable tele-counselling services with a special focus on the peri-and post-menopausal women as one of the strategies to be included in the COVID-19 management in the community settings to have increased accessibility during restrictions.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References 
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