Racial/Ethnic Differences in Women's Life Event Exposure Across Midlife.

OBJECTIVE: Stressful life events are associated with poorer physical, cognitive, and mental health. Examining life events trends across midlife illustrates normative experiences of stress in a critical life period for intervention and disease prevention. Further, there is a critical need for research with racially/ethnically diverse samples to identify differences in life event exposure, as they may relate to later health disparities. METHOD: Annual life event reports were analyzed from 3,066 White, Black, Hispanic, Chinese, and Japanese women in the Study of Women's Health Across the Nation. Across ages 43-65, longitudinal trajectories were fit to annual number of life events and 9 subcategories of life events (i.e., work problems, economic problems, partner unemployment, illness/accident of loved one, caregiving, bereavement, relationship problems, family legal/police problems, and violent events that happened to the self or family). Racial/ethnic differences were examined, controlling for education. RESULTS: Number of annual life events declined with age and plateaued in later midlife. This pattern was largely consistent across types of life events, though family health and bereavement-related life events increased in later midlife. Compared to White women, Black women experienced more life events, while Chinese, Hispanic, and Japanese women experienced fewer life events. Racial/ethnic differences were amplified in specific subtypes of life events. DISCUSSION: Racial/ethnic differences in exposure to life events across midlife may contribute to racial/ethnic health disparities in later life.

Risk factors for major depression during midlife among a community sample of women with and without prior major depression: are they the same or different?

BACKGROUND: Women's vulnerability for a first lifetime-onset of major depressive disorder (MDD) during midlife is substantial. It is unclear whether risk factors differ for first lifetime-onset and recurrent MDD. Identifying these risk factors can provide more focused depression screening and earlier intervention. This study aims to evaluate whether lifetime psychiatric and health histories, personality traits, menopausal status and factors that vary over time, e.g. symptoms, are independent risk factors for first-onset or recurrent MDD across 13 annual follow-ups. METHOD: Four hundred and forty-three women, aged 42-52 years, enrolled in the Study of Women's Health Across the Nation in Pittsburgh and participated in the Mental Health Study. Psychiatric interviews obtained information on lifetime psychiatric disorders at baseline and on occurrences of MDD episodes annually. Psychosocial and health-related data were collected annually. Cox multivariable analyses were conducted separately for women with and without a MDD history at baseline. RESULTS: Women without lifetime MDD at baseline had a lower risk of developing MDD during midlife than those with a prior MDD history (28% v. 59%) and their risk profiles differed. Health conditions prior to baseline and during follow-ups perception of functioning (ps < 0.05) and vasomotor symptoms (VMS) (p = 0.08) were risk factors for first lifetime-onset MDD. Being peri- and post-menopausal, psychological symptoms and a prior anxiety disorder were predominant risk factors for MDD recurrence. CONCLUSIONS: The menopausal transition warrants attention as a period of vulnerability to MDD recurrence, while health factors and VMS should be considered important risk factors for first lifetime-onset of MDD during midlife.

Do anxiety symptoms predict major depressive disorder in midlife women? The Study of Women's Health Across the Nation (SWAN) Mental Health Study (MHS).

BACKGROUND: In women, anxiety symptoms are common and increase during midlife, but little is known about whether these symptoms predict onsets of major depressive disorder (MDD) episodes. We examined whether anxiety symptoms are associated with subsequent episodes of MDD in midlife African-American and Caucasian women, and whether they confer a different risk for first versus recurrent MDD episodes. METHOD: A longitudinal analysis was conducted using 12 years of data from the Study of Women's Health Across the Nation (SWAN) Mental Health Study (MHS). The baseline sample comprised 425 Caucasian (n=278) and African American (n=147) community-dwelling women, aged 46.1±2.5 years. Anxiety symptoms measured annually using a self-report questionnaire were examined in relation to MDD episodes in the subsequent year, assessed with the SCID. Multivariable models were estimated with random effects logistic regression. RESULTS: Higher anxiety symptoms scores were associated with a significantly higher adjusted odds of developing an episode of MDD at the subsequent annual visit [odds ratio (OR) 1.47, p=0.01], specifically for a recurrent episode (OR 1.49, p=0.03) but non-significant for a first episode (OR 1.32, p=0.27). There were no significant racial effects in the association between anxiety symptoms and subsequent MDD episodes. CONCLUSIONS: Anxiety symptoms often precede MDD and may increase the vulnerability of midlife women to depressive episodes, particularly recurrences. Women with anxiety symptoms should be monitored clinically during the ensuing year for the development of an MDD episode.

Major depression during and after the menopausal transition: Study of Women's Health Across the Nation (SWAN).

BACKGROUND: It is unclear whether risk for major depression during the menopausal transition or immediately thereafter is increased relative to pre-menopause. We aimed to examine whether the odds of experiencing major depression were greater when women were peri- or post-menopausal compared to when they were pre-menopausal, independent of a history of major depression at study entry and annual measures of vasomotor symptoms (VMS), serum levels of, or changes in, estradiol (E2), follicular stimulating hormone (FSH) or testosterone (T) and relevant confounders. METHOD: Participants included the 221 African American and Caucasian women, aged 42-52 years, who were pre-menopausal at entry into the Pittsburgh site of a community-based study of menopause, the Study of Women's Health Across the Nation (SWAN). We conducted the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID) to assess diagnoses of lifetime, annual and current major depression at baseline and at annual follow-ups. Psychosocial and health factors, and blood samples for assay of reproductive hormones, were obtained annually. RESULTS: Women were two to four times more likely to experience a major depressive episode (MDE) when they were peri-menopausal or early post-menopausal. Repeated-measures logistic regression analyses showed that the effect of menopausal status was independent of history of major depression and annually measured upsetting life events, psychotropic medication use, VMS and serum levels of or changes in reproductive hormones. History of major depression was a strong predictor of major depression throughout the study. CONCLUSIONS: The risk of major depression is greater for women during and immediately after the menopausal transition than when they are pre-menopausal.

Predictors of first lifetime episodes of major depression in midlife women.

BACKGROUND: Little is known about factors that predict first lifetime episodes of major depression in middle-aged women. It is not known whether health-related factors and life stress pose more or less of a risk to the onset of clinical depression than does the menopausal transition. METHOD: The Structured Clinical Interview for DSM-IV Axis I Disorders (SCID) was used to assess diagnoses of lifetime, annual and current major depression in a community-based sample of premenopausal or early perimenopausal African American and White women. Menstrual cycle characteristics, psychosocial and health-related factors, and blood samples for assay of reproductive hormones were obtained annually. Two hundred and sixty-six women without a history of major depression at baseline constituted the cohort for the current analyses. RESULTS: Over 7 years of follow-up, 42 (15.8%) women met criteria for a diagnosis of major depression. Frequent vasomotor symptoms (VMS; hot flashes and/or night sweats) (HR 2.14, p=0.03) were a significant predictor of major depression in univariate analyses. After simultaneous adjustment for multiple predictors in Cox proportional hazards analyses, frequent VMS were no longer significant; lifetime history of an anxiety disorder (HR 2.20, p=0.02) and role limitations due to physical health (HR 1.88, p=0.07) at baseline and a very stressful life event (HR 2.25, p=0.04) prior to depression onset predicted a first episode of major depression. CONCLUSIONS: Both earlier (e.g. history of anxiety disorders) and more proximal factors (e.g. life stress) may be more important than VMS in contributing to a first episode of major depression during midlife.

Discrimination and unfair treatment: relationship to cardiovascular reactivity among African American and European American women.

This study examined the relationship of cardiovascular reactivity to both interpersonal mistreatment and discrimination in a community-based sample of African American and European American women (N=363) in midlife. Subtle mistreatment related positively to diastolic blood pressure (DBP) reactivity for African American participants but not their European American counterparts. Moreover, among the African American participants, those who attributed mistreatment to racial discrimination exhibited greater average DBP reactivity. In particular, these women demonstrated greater DBP reactivity to the speech task, which bore similarities to an encounter with racial prejudice but not to a nonsocial mirror tracing task. These findings are consistent with the hypothesis that racial discrimination is a chronic stressor that can negatively impact the cardiovascular health of African Americans through pathogenic processes associated with physiologic reactivity.

Psychologic distress and natural menopause: a multiethnic community study.

OBJECTIVES: This study examined the association between psychologic distress and natural menopause in a community sample of African American, White, Chinese, Hispanic, and Japanese women participating in a national women's health study. METHODS: A cohort of 16,065 women aged 40 to 55 years provided information on menstrual regularity in the previous year, psychosocial factors, health, and somatic-psychologic symptoms. Psychologic distress was defined as feeling tense, depressed, and irritable in the previous 2 weeks. RESULTS: Rates of psychologic distress were highest in early perimenopause (28.9%) and lowest in premenopause (20.9%) and postmenopause (22%). In comparison with premenopausal women, early perimenopausal women were at a greater risk of distress, with and without adjustment for vasomotor and sleep symptoms and covariates. Odds of distress were significantly higher for Whites than for the other racial/ethnic groups. CONCLUSIONS: Psychologic distress is associated with irregular menses in midlife. It is important to determine whether distress is linked to alterations in hormone levels and to what extent a mood-hormone relationship may be influenced by socioeconomic and cultural factors.

Is there a menopausal syndrome? Menopausal status and symptoms across racial/ethnic groups.

In recent years, research on menopausal symptomalogy has focused on identifying symptom groupings experienced by women as they progress from premenopausal to postmenopausal status. However, most of these studies have been conducted among Caucasian women from western cultures. This leaves open the question of whether the findings from these studies can be extended to women of other racial/ethnic groups or cultures. Furthermore, many of the previous studies have been conducted on relatively small samples. This paper addresses the diversity of the menopause experience by comparing symptom reporting in a large cross-sectional survey of women aged 40-55 years among racial/ethnic groups of women in the United States (Caucasian, African-American, Chinese, Japanese, and Hispanic). Evaluation of the extent to which symptoms group together and consistently relate to menopausal status across these five samples provides evidence for or against a universal menopausal syndrome. The specific research questions addressed in this paper are: (1) How does the factor structure of symptoms among mid-aged women compare across racial/ethnic groups? (2) Is symptom reporting related to race/ethnicity or menopausal status? and (3) Does the relation between menopausal status and symptoms vary across racial/ethnic groups? Analyses are based on 14,906 women who participated in the multi-ethnic, multi-race, multi-site study of mid-aged women called the Study of Women's Health Across the Nation (SWAN). Study participants completed a 15-min telephone or in-person interview that contained questions on a variety of health-related topics. Items of interest for these analyses include symptoms, menstrual history (to assess menopausal status), health status, and sociodemographics. Factor analysis results showed that across all five racial/ethnic groups, two consistent factors emerged; one consisting of clearly menopausal symptoms -- hot flashes and night sweats -- and the other consisting of psychological and psychosomatic symptoms. Results of regression analyses showed racial/ethnic differences in symptom reporting, as well as differences by menopausal status. Controlling for age, education, health, and economic strain, Caucasian women reported significantly more psychosomatic symptoms than other racial/ethnic groups. African-American women reported significantly more vasomotor symptoms. Perimenopausal women, hormone users, and women who had a surgical menopause reported significantly more vasomotor symptoms. All of these groups, plus postmenopausal women, reported significantly more vasomotor symptoms than premenopausal women. The pattern of results argues against a universal menopausal syndrome consisting of a variety of vasomotor and psychological symptoms.

Factors associated with age at natural menopause in a multiethnic sample of midlife women.

An unprecedented number of women will experience menopause in the next decade. Although the timing of menopause affects long-term disease risk, little is known about factors that affect this timing. In the present 1995--1997 cross-sectional study, the Study of Women's Health Across the Nation, the relation of demographic and lifestyle factors to age at natural menopause was examined in seven US centers and five racial/ethnic groups. All characteristics were self-reported by women aged 40--55 years (n = 14,620). Cox proportional hazards models were used to estimate the probability of menopause by age. Overall, median age at natural menopause was 51.4 years, after adjustment for smoking, education, marital status, history of heart disease, parity, race/ethnicity, employment, and prior use of oral contraceptives. Current smoking, lower educational attainment, being separated/widowed/divorced, nonemployment, and history of heart disease were all independently associated with earlier natural menopause, while parity, prior use of oral contraceptives, and Japanese race/ethnicity were associated with later age at natural menopause. This sample is one of the largest and most diverse ever studied, and comprehensive statistical methods were used to assess factors associated with age at natural menopause. Thus, this study provides important insights into this determinant of long-term disease risk in women.

Life event stress and the association with spontaneous abortion in gravid women at an urban emergency department.

In this study, the authors hypothesized that life event stress is associated with an increased risk of spontaneous abortion. Using a nested case-control design in an emergency department (N = 970), stress was measured using a life event inventory and a sample drawn from R. B. Ness et al.'s (1999) Early Pregnancy Study. Gestational age at time of fetal loss served as a marker of chromosomal status. Women experiencing more than one life event used more alcohol and public assistance. Spontaneous abortion at 11 weeks or greater was associated with more life event stress (adjusted odds ratio 2.9, 95% confidence interval 1.4-6.2), whereas spontaneous abortion at any gestational age was not, implying that life event stress increases the risk of chromosomally normal spontaneous abortion. An analysis of confounders showed tobacco use was associated with an increased risk of spontaneous abortion, whereas prenatal care was only associated with fetal loss at 11 weeks or greater.

Gender and comorbid psychopathology in adolescents with alcohol dependence.

OBJECTIVE: Although several mental disorders have been shown to be common in adolescents with substance use disorders, prior studies have not specifically focused on alcohol dependence and have not had sufficient sample sizes to examine gender effects. This study contrasts mental disorder diagnoses and symptoms between a sample of adolescents with alcohol dependence and a community control sample of adolescents and incorporates gender analyses. METHOD: Adolescents (aged 14 years 0 months to 18 years 0 months) with alcohol dependence (females: n = 55; males: n = 78) and community-dwelling control adolescents without substance use disorders (females: n = 44; males: n = 42) were assessed by means of a semistructured interview for DSM-III-R. RESULTS: While cannabis and hallucinogen use disorders were common in the alcohol dependence group, females and males had similar rates. Conduct disorder (CD), oppositional defiant disorder, attention-deficit hyperactivity disorder, major depression (MD), and posttraumatic stress disorder (PTSD) had significantly higher rates in the alcohol dependence than in the community control group. Depression and PTSD symptoms were more strongly associated with alcohol dependence in females than in males. A configural frequency analysis showed that CD and MD tended to occur together in both female and male adolescents with alcohol dependence. CONCLUSIONS: While alcohol-dependent females and males similarly exhibited more comorbid disorders than control adolescents, gender affects the relationship of alcohol dependence to MD and PTSD. Rather than reflecting distinct types, the comorbid disorders of CD and MD jointly characterize many adolescents with alcohol dependence.

Prospective study of the determinants of age at menopause.

The authors prospectively studied the effect of demographic, reproductive, stress-related, and health behavior factors measured at study entry on age of natural menopause in 185 healthy US women. At study entry, women were 42.5-47.5 years old and premenopausal. After a baseline examination (1983-1985), women were followed for 7-9 years, during which time they reported on a monthly basis their menstrual status and whether they were taking hormones. Menopausal age was defined as age at the last menstrual period prior to stopping menstruation for 12 months (and not taking hormones). Estimated median age at menopause was 51.5 years for the whole sample. Median age at menopause was earlier for women who reported irregular menstrual cycles at study entry (50.2 years), were African-American (49.3 years), were smokers (50.6 years), or were currently on a weight reduction diet (50.5 years). Psychosocial stress was predictive of an even earlier median age at menopause in African Americans (48.4 years) and in those with irregular cycles at baseline (49.4 years). Results suggest that premenopausal women in their forties who are experiencing irregular menstrual cycles, are smokers, are dieting, or are African-American are likely to reach menopause earlier than their contemporaries. African-American women may have a different "biological clock" than white women, especially when under stress, or they may experience more stress of longer duration.

A longitudinal study of the effects of pessimism, trait anxiety, and life stress on depressive symptoms in middle-aged women.

The relative contributions of life stress, menopausal status, and pessimism and trait anxiety during the presence and absence of stress on increases in depressive symptoms across 3 years were examined in a sample of 460 premenopausal women, aged 42-50, who had few depressive symptoms at study entry. Multivariate analyses showed that after statistical adjustments for initial depressive symptoms and education, depressive symptoms at follow-up were higher among women (a) who reported stressful events, especially of a chronic nature, (b) who scored highly on trait anxiety, and (c) who were pessimistic and subsequently experienced a stressful ongoing problem. Change in menopausal status was not related to symptoms. The study confirms that midlife stress and both optimism and trait anxiety are important predictors of depressive symptoms during midlife.

A "feminine" model of vulnerability to depressive symptoms: a longitudinal investigation of middle-aged women.

The authors hypothesized that having traits associated with the female gender role is related to psychological distress in women. Specifically, they investigated the effect of low instrumentality and high expressivity, private self-consciousness, and anger-in on depressive symptoms measured 3 years later in 460 middle-aged women during the menopausal transition and times of stress. Multivariate analyses showed that after adjustment for depressive symptoms and educational level at study entry, depressive symptomatology 3 years later was higher among women who were low in instrumentality and high in self-consciousness at study entry. Women who were self-conscious were the most vulnerable to a subsequent ongoing stressor, and women who tended to suppress angry feelings and who used hormone replacement therapy when they were postmenopausal had more symptomatology than did other women. The study shows that midlife may be problematic for women with certain female gender role traits.

Employment and coronary risk in women at midlife: a longitudinal analysis.

This study investigated the relation between employment and cholesterol in 541 women aged 42-50 years who resided in Allegheny County, Pennsylvania, in 1985-1988. Employment, health-related variables, and cholesterol were assessed at baseline and 3 years later. At baseline, employed and nonemployed women did not differ in cholesterol or health behaviors. However, women employed at baseline had a significant decrease in total high density lipoprotein cholesterol (1.9 mg/dl) and high density lipoprotein2 cholesterol subfraction (3.2 mg/dl) at follow-up. Those who were employed at both assessments had the lowest high density lipoprotein cholesterol at follow-up. These effects could not be accounted for by sociodemographics or employment quality variables. Post hoc analyses were conducted to examine health behaviors as a potential mechanism to account for the association between employment status and cholesterol. Over the study period, those who were employed at baseline were less likely to increase exercise and more likely to gain weight than those who were not employed at baseline. With menopause-related changes in metabolism, this can result in detrimental effects for cholesterol levels and coronary health. The results highlight the importance of longitudinal assessment in the study of employment and health.

Employment status and depressive symptoms in middle-aged women: a longitudinal investigation.

OBJECTIVES: This study investigated the psychological effects of paid employment and nonemployment, cross-sectionally and longitudinally, in 541 middle-aged women. METHODS: Women were seen for an extensive baseline evaluation and were reevaluated in an identical manner 3 years later. They were divided into four "synthetic" cohorts, based upon employment status at these two assessments. RESULTS: At baseline, nonemployed women reported higher levels of depressive symptoms than employed women, with nonemployed women with less education, low support from family and friends, or low marital satisfaction the most symptomatic. Symptoms decreased in women who were nonemployed initially but employed at the later exam; in all other groups, symptoms increased. Unlike the cross-sectional findings, however, the longitudinal findings showed that women who were nonemployed at baseline and had low levels of education, social support, or marital satisfaction did not benefit more from subsequent employment than did their counterparts who had high levels of these factors. CONCLUSIONS: New paid work may have a positive effect on mood for middle-aged women. However, given the contradictions between our cross-sectional and longitudinal results, caution should be exercised in drawing conclusions from cross-sectional studies that likely confound employment status, symptoms, and moderating variables.

Marital support and remission of treated depression. A prospective pilot study of mothers of infants and toddlers.

Eighteen married mothers of infants and toddlers were evaluated before and after 12 weeks of antidepressant treatment for major depressive disorder. The women were assessed at baseline on Snyder's marital disaffection and disharmony subscales and on selected clinical measures to evaluate these factors as correlates of remission. Remission was defined as a Hamilton Rating Scale for Depression score < or = 7 at week 12. Twelve women remitted; six did not. Nonremitted women reported high disaffection toward their husband, were in an episode of which the onset was not childbirth related (i.e., onset not within 3 months after giving birth), or their youngest child was older than 6 months. Results showed that initial symptom severity was no different for the nonremitted and remitted women. Thus, the relationships between low disaffection, late onset, and not having a child under 6 months and nonremission appear to be independent of initial severity of depressive symptoms.

Epidemiology of depression for clinicians.

This article reviews the epidemiology of depression and the ways this information can be useful for clinicians. The article defines frequently used epidemiological terms, presents prevalence rates and risk factors; discusses the impact and consequences of depression; and suggests arenas for prevention, early intervention, and treatment that can help clinicians in their everyday work.