Abstract and Introduction
Abstract
Study question Are severe depressive symptoms in women and men associated with individual and dyadic infertility-related stress in couples undergoing infertility treatment?
Summary answer Severe depressive symptoms were significantly associated with increased infertility-related distress at both the individual and partner level.
What is known already? An infertility diagnosis, the stress of medical treatments and a prior history of depression are risk factors for future depression in those undergoing fertility treatments. Studies examining the impact of severe depressive symptoms on infertility-related distress in couples are lacking.
Study design, size, duration This cross-sectional study included 1406 couples who were consecutively referred patients undergoing fertility treatments in Denmark in the year 2000. A total of 1049 men and 1131 women were included in the study.
Participants/materials, setting, methods Participants were consecutively referred patients undergoing a cycle of medically assisted reproduction treatment at five Danish public and private clinics specializing in treating fertility patients. Severe depressive symptoms were measured by the Mental Health Inventory 5 from the Short Form Health Survey 36. Infertility distress was measured by the COMPI Fertility Problem Stress Scales. Multilevel modelling using the actor–partner interdependence model was used to study the couple as the unit of analysis.
Main results and the role of chance Severe depressive symptoms were reported in 11.6% of women and 4.3% of men, and were significantly associated with increased infertility-related distress at the individual and partner level. There was no significant interaction for gender indicating that men and women did not differ in how severe depressive symptoms were associated with infertility distress.
Limitations, reason for caution Because of the cross-sectional study design, the study findings only show an association between severe depressive symptoms to individual and partner distress at a single point in time; however, nothing is known about causality.
Wider implications of the findings This study adds to the growing body of literature using the couple as the unit of analysis to study the relationship between depression and infertility distress. Recommendations for medical and mental health professionals that underscore the potential risk factors for depressed men and women who are pursuing infertility treatments are provided. Additional studies using a longitudinal study design to track the impact of depression on distress over the course of the infertility treatment cycle would be valuable for increasing our understanding of the complex relationship that exists between these psychosocial factors.
Study funding/competing interests Authors Brennan Peterson and Matthew Pirritano have no financial disclosures for this study. Camilla Sandal Sejbaek and Lone Schmidt have received research grants from the Danish Health Insurance Foundation (J. nr. 2008B105) and Merck Sharp & Dohme. The funders had no influence on the data collection, analyses or conclusions of the study.
Introduction
The experience of infertility is commonly linked with unexpected stressors that can impact one's personal life, social support networks and marital relationships (Newton et al., 1999). These stressors can cause significant disruption in one's life and be related to increased psychological distress in men and women (Wichman et al., 2011). One of the key types of distress reported in infertility patients is depression. An infertility diagnosis and the stress of medical treatment can put women at risk of depressive symptoms, particularly after treatment failure (Newton et al., 1990; Domar et al., 1992; Verhaak et al., 2007; Volgsten et al., 2010). On the other hand, women with depressive symptoms may be more likely to experience infertility due to depression's impact on the biological mechanisms that influence hormone production and ovulation (Lapane et al, 1995; Williams et al., 2007). Adding to the already complicated relationship that exists between these variables, a prior history of depression is a risk factor for future depression in women undergoing fertility treatments (Vahratian et al., 2011; Pasch et al., 2012).
The majority of studies examining the relationship between depression and infertility have examined the impact of depression on pregnancy and live birth rates. While some studies have found that depression is linked with lower pregnancy rates in couples pursuing assisted reproductive technologies (ART) (Klonoff-Cohen, 2005), two recent meta-analyses have found that depression was not associated with a reduced chance of pregnancy outcome (Boivin et al., 2011; Matthiesen et al., 2011). However, a recent study using a national register-based cohort found that of the 42 880 Danish women participating in ART treatments, women with a depression diagnosis prior to fertility treatments participated in fewer ART cycles and had fewer ART live births when compared with the non-depressed group (Sejbaek et al., 2013). This supports a previous research finding that women with major depression reported the lowest live birth rate among study participants (Volgsten et al., 2010).
For infertility patients who undergo ART, a prior depression history is the strongest risk factor for future depression (Vahratian et al., 2011; Pasch et al., 2012). Men and women with depression prior to infertility treatment likely have less physical, emotional and social resources to cope with the stress of infertility treatments and treatment failure, and thus may be considered an 'at risk' group. In a Swedish study of 545 couples undergoing in vitro fertilization (IVF), 10.9% of women and 5.1% of men had major depression at treatment initiation (Volgsten et al., 2008). In this study, major depression was measured by the Primary Care Evaluation of Mental Disorders (PRIME-MD) based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). This is a substantial percentage of the patients seen for infertility treatments, and because we currently know very little about the association between pre-existing depressive symptoms and infertility-related distress in infertility patients, it is important to establish a baseline if such an association exists.
In addition to our limited understanding of the association between severe depressive symptoms and infertility-related distress, we know very little about how depression is associated with infertility distress at the dyadic level. In other words, is there an association between an individual's severe depressive symptoms and a partner's levels of infertility-related distress? To address the lack of studies using the couple as the unit of analysis, researchers have begun to use a data analytic technique called the actor–partner interdependence model (APIM) (Kenny et al., 2006), to study how the stressors of infertility are related to individual and partner outcomes (Peterson et al., 2008, 2009, 2011; Benyamini et al., 2009). A small number of these studies have used depression as a study variable and have examined its relationship with coping (Berghuis and Stanton, 2002), marital conflict (Proulx et al., 2009) and the transmission of depressive symptoms between partners undergoing fertility treatments (Knoll et al., 2009). However, few studies have examined how depression is associated with infertility distress, and particularly how depressive symptoms are associated with both the individual's and partner's levels of distress. Because infertility is ultimately a shared stressor that exists between both members of the couple, more studies are needed to utilize dyadic analyses in order to provide a more complete picture of the infertility experience.
The current study attempted to examine how severe depressive symptoms in women and men are associated with individual and dyadic infertility-related distress. The study asked the following research questions: (i) Prior to fertility treatments, do men and women with severe depressive symptoms experience higher levels of infertility distress when compared with men and women who do not report severe depressive symptoms? (ii) Are an individual's severe depressive symptoms associated with increased infertility-related distress in the individual and in their partner?