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Am Fam Physician. 2003;68(2):359-361

Urinary incontinence affects up to 80 percent of older women and is associated with several comorbidities, including depression. Most studies of incontinence have focused on elderly women. Nygaard and colleagues used data from a large, prospective, national study of aging to examine the relationship between depression and urinary incontinence in women 50 to 69 years of age.

They used data from the Health and Retirement Study, which has interviewed a representative sample of the U.S. population about a range of health, economic, and sociologic issues approximately every two years since 1991.The more recent interviews have included questions about urinary incontinence. Women who were interviewed were classified as continent, mildly to moderately incontinent (incontinence on up to 15 days per month), or severely incontinent (incontinence on more than 15 days per month). The interviews also assessed depression with the eight-item Center for Epidemiologic Studies Depression Scale (CES-D) and the short form of the Composite International Diagnostic Interview (CIDI). Other data obtained during the interviews included extensive demographic, health, exercise, and behavior information.

The study involved 5,701 women 50 to 69 years of age. Severe incontinence was reported by 249 women (4.4. percent), and mild to moderate incontinence was reported by 591 women (10.5 percent). Based on six positive replies on the CES-D questionnaire, 9.8 percent were diagnosed as depressed. Based on the CIDI questionnaire, 9.4 percent of the women were depressed. However, only 3.8 percent were diagnosed as depressed by both criteria. Slightly more than 4 percent of women reported taking an antidepressant medication at the time of the interview. In univariate analysis, depression diagnosed by both scales was significantly associated with severe incontinence. Other variables associated with severe incontinence included age, parity, body mass index, smoking, functional limitation, and comorbidity. Severe incontinence was negatively associated with black or Hispanic race, lower educational level, and regular strenuous exercise. Mild to moderate incontinence was associated with similar variables except for parity, smoking, and education level.

In multivariate analysis, depression as assessed by the CIDI questionnaire was associated with severe and mild to moderate incontinence. Depression diagnosed by the CES-D scale was not associated with incontinence after adjustment for confounders. After adjustment for morbidity, functional status, and relevant demographic variables, women with severe incontinence were 80 percent more likely than continent women to meet the criteria for depression in the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Women with mild to moderate incontinence were 40 percent more likely than continent women to be depressed.

The authors attribute the difference between the two diagnostic scales to the influence of medical comorbidity on the CES-D scale. In addition, this scale is based on symptoms present during the week before the interview, whereas the CIDI scale considers symptoms present during the previous year. The authors conclude that depression is significantly associated with urinary incontinence in middle-aged women. Although it is not possible to determine if incontinence causes or exacerbates depression (or vice-versa) or if both conditions result from a common pathology, the authors stress the importance of screening for and treating depression in all women with symptoms of urinary incontinence.

editor's note: Fully 15 percent of “healthy” middle-aged women were found to be incontinent, and about 10 percent of them were significantly depressed! This study validates the effort of taking an extra minute to ask all middle-aged women about these conditions. Patients may hesitate to disclose symptoms of depression or incontinence, but both conditions are treatable. In addition to improving quality of life, boosting health and vigor in women of this age group frequently has a positive effect on the health of others. Many of these women are caregivers for young or elderly dependents, most are employed outside the home, and many have important roles in their families, professions, and communities. Family physicians can certainly multiply their effectiveness by paying special attention to “ladies of an interesting age.”—A.D.W.

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