We seek to determine if there is a link between menopausal status and depression and anxiety among primary care patients. Menopause is reached when changes in hormone levels result in the end of periods for at least a year, typically occurring from 45 to 55 years of age. Symptoms including mood swings, "brain fog" and irregular periods, known collectively as vasomotor symptoms, can start years before periods stop (perimenopause) and carry on afterwards (postmenopause). Hormone Replacement Therapy (HRT) is often prescribed to ease vasomotor symptoms. Medical records from the Clinical Practice Research Datalink (CPRD) will be used to identify patients according to menopausal status. We will then look for subsequent diagnoses for mental health disorders - anxiety and/or depression, comparing these outcomes to a group of men of the same age, and a group of women of the same age without recordings for menopausal status or HRT. We also want to understand the relationship between menopausal stage and mental health disorders. In our analyses we will look at how factors such as socioeconomic deprivation, ethnicity, other illnesses, reproductive history and body mass index (BMI) effect these relationships. We will also look at outcomes according to age of menopause onset, menopause symptoms and/or age at HRT initiation. This will develop our understanding of the characteristics and stages in the life course for women that indicate high risk of developing anxiety and depression, helping to identify those who require treatment or preventative action to avoid potentially consequent diagnoses such as dementia.
The menopause transition (MT) is typically initiated by menstrual cycle irregularity and vasomotor symptoms and menopause is its final stage, defined as 12 months of amenorrhea. The MT involves phases of intense endocrinological changes, including neuropsychiatric changes that can lead to mental health disorders. We will use the Clinical Practice Research Datalink (CPRD) Aurum to conduct a population-based cohort study, evaluating depression and anxiety among patients who have initiated MT compared to an age-matched cohort of male patients, and another age-matched cohort of female patients without MT codes in their records. Existing research in the field often focuses on hormone replace therapy (HRT) prescriptions. We will therefore assess the quality of clinical recording of menopausal status, vasomotor symptoms and HRT prescriptions. Logistic regression models will examine the outcome of anxiety or depression status following MT in a given calendar year, adjusting for covariates including ethnicity and deprivation. We will evaluate effect modification by age at menopause initiation, HRT use, surgical/non-surgical menopause and history of mental health disorders. Hierarchical Poisson regression models will test associations between menopause and the count of patients with anxiety and/depression within the study period, adjusting for important covariates. Secondary analysis will use logistic regression models to test the association of menopausal phase on the outcome of anxiety or depression status in a given calendar year. Multi-state regression models will assess depression and anxiety disease trajectories according to escalation of treatment, symptom and referral codes and hospitalisation and/or death over the study period. To visualise the association of age at menopause and anxiety and depression onset, smooth curves will be fitted using restricted cubic splines. A better understanding of the relationship between menopause and mental health disorders will help to facilitate the effective targeting of risk prevention strategies at this critical phase of the female life course.
Primary analysis:
- Depression prevalence: A clinical recording of depression recorded in the year of interest, or a historical recording of depression and a prescription for antidepressants recorded in the year of interest.
- Anxiety prevalence: A clinical recording of anxiety recorded in the year of interest, or a historical recording of anxiety and a prescription for anti-anxiety medication recorded in the year of interest.
Secondary analyses:
- Incidence and prevalence rates of anxiety and depression and how they are affected by menopausal status recorded according to 1) Clinical recording of menopausal status; 2) Clinical recording of vasomotor symptoms; 3) Drug issue recording of HRT.
- Trajectory of initial anxiety/depression diagnosis according to whether medical codes are identified in one or multiple subsequent years in the clinical record.
- Increased severity of initial anxiety/depression diagnosis during the study period as defined by: 1) Increased severity of clinical code; 2) Escalation of treatment (dosage, drug type, therapy type); 3) Hospitalisation; 4) Psychotherapy and Improving Access to Psychological Therapies (IAPT) referrals; 5) Death.
- Depression incidence: A new clinical recording (medical code) of depression after the index date with no historical recording of depression.
- Anxiety incidence: A new clinical recording (medical code) of anxiety after the index date with no historical recording of anxiety.
Emma Rezel-Potts - Chief Investigator - King's College London (KCL)
Emma Rezel-Potts - Corresponding Applicant - King's College London (KCL)
Alex Dregan - Collaborator - King's College London (KCL)
Martin Gulliford - Collaborator - King's College London (KCL)
Veline L'Esperance - Collaborator - King's College London (KCL)
Patient Level Index of Multiple Deprivation;Practice Level Index of Multiple Deprivation