انجمن رفتار بهداشت و سلامت برای اضطراب و افسردگی در بیماران با علائم دستگاه ادراری تحتانی : یک مطالعه مبتنی بر جمعیت در سراسر کشور

Lower urinary tract symptoms (LUTS) have a negative impact on the quality of life, and may relate to anxiety and depression. The objective of this study was to test the hypothesis that LUTS are associated with anxiety and depression using a nationwide population-based database in Taiwan. Data were obtained from a random population sample of about one million enrollees in the National Health Insurance program from 2001 to 2009, and consisted of 22,980 LUTS patients and 45,960 matched controls. The records of healthcare seeking for anxiety and depression were collected 2 years before and after the diagnosis of LUTS. The results showed that patients with LUTS had a significantly higher prevalence of anxiety or depression than the matched controls (11.45% vs. 5.72%). After controlling for sociodemographic variables and other major systemic diseases, the odds ratios for anxiety, depression, either anxiety or depression, and both anxiety and depression, were 2.05, 2.19, 2.14, and 2.56, respectively. There was an association between LUTS and the stress-related common mental disorders, and there seemed to be an additive effect of anxiety and depression on the association with LUTS. These findings imply a psychological role in the pathogenesis or sequelae of LUTS.

Lower urinary tract symptoms (LUTS), including storage, voiding, and postmicturition (Abrams et al., 2010), are highly prevalent worldwide, and the healthcare burden is expected to increase (Irwin et al., 2011). LUTS are known to have a negative impact on health-related quality of life (HRQL), sleep, and mental health (Kannan et al., 2009 and Malmsten et al., 2010). In a previous study in Taiwan, a total of 53.7% of the women sampled suffered from urinary incontinence and related symptoms (Chen et al., 2003). LUTS tend to progress with regression in only a few cases (Malmsten et al., 2010), and the overall prevalence of LUTS increases with age (Chen et al., 2003). The pathogenesis of LUTS is not completely understood, however it is considered to be multi-factorial including neurological, vascular, and connective tissue processes (Banakhar et al., 2012). In addition to interactions between the nervous, vascular, immune, and endocrine systems (Bjorling et al., 2011), psychological factors may also play a significant role in the manifestation of LUTS (Cortes et al., 2012). Anxiety and depression are stress-related common mental disorders and are caused by a combination of multiple genetic and environmental factors affecting certain brain circuits (Nugent et al., 2011). In Taiwan, the 1-week prevalence rate of anxiety and depression has been reported to be approximately 24% (Cheng, 1988). In addition to their overlapping symptomatology and clinical presentation, they are highly comorbid with each other (Johansson et al., 2013). Furthermore, there is accumulating evidence that anxiety and depression are correlated with chronic medical illnesses (Katon et al., 2007). The combination of both anxiety and depression appears to increase comorbid medical conditions, disabilities, quality of life, and healthcare utilization (Katon et al., 2007, Scott et al., 2009 and Johansson et al., 2013). An increasing body of research suggests an association between LUTS, anxiety, and/or depression (Hakkinen et al., 2008, Bogner et al., 2011, Felde et al., 2012 and Milsom et al., 2012), although some studies have reported conflicting results (Watson et al., 2000 and Takao et al., 2011). Moreover, there appears to be an additive effect of LUTS, anxiety, and depression which has been reported to affect both physical and mental health as well as HRQL (Avery et al., 2013). However, most studies have been based on self-reported surveys using rating scales with regards the anxiety/depression rather than on physician confirmed diagnoses. In addition, only a few studies have examined the relationship of LUTS with a combination of anxiety and depression (Felde et al., 2012 and Milsom et al., 2012). Based on a nationwide population-based database containing data on enrollees in the National Health Insurance program in Taiwan, our objective was to test the hypothesis that LUTS are associated with anxiety and depression.

A total of 22,980 patients with LUTS and 45,960 matched controls were enrolled. The demographic information and medical comorbidities of the two groups are shown in Table 1. There were no significant differences in age, gender, hypertension, diabetes mellitus, and CAD between the two groups; however, there were significant differences in income and urbanization level. Table 1. Sociodemographic characteristics and comorbidities in the LUTS and control groups. Non-LUTS (N=45,960) LUTS (N=22,980) P-value ⁎ Age (mean±S.D.) 51.83±13.81 51.83±13.81 0.9995 Age group (years) (%) <40 8699 (18.93) 4531 (18.93) 1.0000 40–49 10,863 (23.64) 5432 (23.64) 50–59 14,385 (31.30) 7192 (31.30) 60–69 7568 (16.47) 3780 (16.47) 70–79 3509 (7.63) 1757 (7.63) ≥80 936 (2.04) 468 (2.04) Gender (%) Female 21,024 (45.74) 10,512 (45.74) 1.0000 Male 24,936 (54.26) 12,468 (54.26) Income (NTD) <20,000 20,027 (43.57) 10,410 (45.30) <0.0001 20,000–40,000 18,489 (40.23) 8988 (39.11) ≥40,000 7444 (16.20) 3582 (15.59) Urbanization levela 1 13,638 (29.67) 8130 (35.38) <0.0001 2 16,044 (34.91) 8784 (38.22) 3 6744 (14.67) 2434 (10.59) ≥4 9534 (20.74) 3632 (15.81) Comorbidity HTN Yes 7130 (15.51) 3565 (15.51) 1.0000 No 38,830 (84.49) 19,415 (84.49) DM Yes 2236 (4.87) 1118 (4.87) 1.0000 No 43,724 (95.13) 21,862 (95.13) CAD Yes 522 (1.14) 261 (1.14) 1.0000 No 45,438 (98.86) 19,160 (98.86) NTD: New Taiwan Dollars (approximately 30 to 1 US. Dollars); HTN: hypertension, DM: diabetes mellitus, CAD: coronary artery disease, CI: confidence interval. ⁎ P-values from the Student׳s t-test for continuous variables and Pearson׳s chi-square test for categorical variables. a Urbanization level 1 most urbanized, level 4: least urbanized. Table options Table 2 presents the associations and ORs for anxiety, depression, either anxiety or depression, and both anxiety and depression, which were all significantly higher in the LUTS group compared to the controls. Patients with LUTS had a significantly higher prevalence of anxiety or depression than the matched controls (11.45% vs. 5.72%). After controlling for age, gender, income, urbanization level, hypertension, diabetes mellitus, and CAD, the adjusted ORs for anxiety, depression, anxiety or depression, and anxiety and depression combined were 2.05 (95%C.I.: 1.92–2.19), 2.190 (95%C.I.: 1.97–2.43), 2.14 (95%C.I.: 2.02–2.26), and 2.56 (95%C.I.: 1.67–3.91), respectively. Table 2. Association and ORs for anxiety, depression, either anxiety or depression, and both anxiety and depression between LUTS and non-LUTS individuals. Non-LUTS (N=45,960) (%) LUTS (N=22,980) (%) p-Value ⁎ Univariate OR (95% CI) Adjusted ORa (95% CI) Anxiety only No 43,975 (95.68) 21,045 (91.58) <0.0001 1.00 (ref.) 1.00 (ref.) Yes 1985 (4.32) 1935 (8.42) 2.04 (1.92–2.18) 2.05 (1.92–2.19) Depression only No 45,276 (98.51) 22,233 (96.75) <0.0001 1.00 (ref.) 1.00 (ref.) Yes 684 (1.49) 747 (3.25) 2.23 (2.00–2.47) 2.19 (1.97–2.43) Anxiety or depression No 43,329 (94.28) 20,348 (88.55) <0.0001 1.00 (ref.) 1.00 (ref.) Yes 2631 (5.72) 2632 (11.45) 2.14 (2.02–2.26) 2.14 (2.02–2.26) Anxiety and depression No 45,922 (99.92) 22,930 (99.78) <0.0001 1.00 (ref.) 1.00 (ref.) Yes 38 (0.08) 50 (0.22) 2.64 (1.73–4.02) 2.56 (1.67–3.91) ⁎ P-values from Pearson׳s chi-square test for categorical variables. a The odds ratios (OR) were derived from conditional logistic regression analysis based on a matched design and adjusted by income and urbanization level. CI: confidence interval. Table options The stratified ORs for anxiety, depression, either anxiety or depression, and both anxiety and depression by age, gender, income, urbanization level, and medical comorbidity are illustrated in Table 3. The OR of anxiety in the LUTS group decreased with increasing age, however the trend was less pronounced with regards to depression. Men had higher ORs of anxiety and depression compared to women, which were even higher when anxiety and depression were combined. The urbanization level and income did not seem to have an obvious influence on the OR concerning anxiety or depression in the subjects with LUTS. Comorbid hypertension and DM had higher ORs of anxiety and depression.