Are Severe Depressive Symptoms Associated With Infertility-related Distress in Individuals and Their Partners?

Brennan D. Peterson; Camilla S. Sejbaek; Matthew Pirritano; Lone Schmidt

Disclosures

Hum Reprod. 2014;29(1):76-82. 

In This Article

Discussion

This study adds to the growing body of literature that examines the dyadic impact of a partner's response to infertility (Berghuis and Stanton, 2002; Benyamini et al., 2009; Knoll et al, 2009; Peterson et al., 2009, 2011) by providing support that severe depressive symptoms are significantly associated with personal, marital and social infertility-related distress at the individual and partner level. Although there are studies that have examined the dyadic impact of depression in couples pursuing infertility treatments (Berghuis and Stanton, 2002; Knoll et al., 2009), to our knowledge, this is the first study to demonstrate that severe depressive symptoms are significantly associated with individual and partner infertility distress.

The current study used severe depressive symptoms as the independent variable in the study analysis. Although we cannot draw predictive conclusions relative to severe depressive symptoms and infertility-related distress, the purpose of the current study was to examine if such an association exists so that baseline data can lay the groundwork for future longitudinal studies. In our sample, 11.6% of women and 4.3% of men reported severe depressive symptoms; these rates compared favourably with a large sample of infertility patients reporting depression in Sweden (10.9% women, 5.1%, men) (Volgsten et al., 2008). The fact that two studies found such high rates of depressive symptoms in men and women prior to pursuing infertility treatments illustrates the significance of studying the possible association between severe depressive symptoms and infertility-related distress. Furthermore, it is possible that these rates even underrepresent the actual percentage of depressed men and women experiencing infertility, as researchers have found that depression can act as a barrier to seeking out medical advice for infertility (Herbert et al., 2010).

It has been well documented that infertility is commonly linked with depression, particularly in women (Domar et al, 1992), and that an infertility diagnosis and the subsequent stress of treatments have been linked with increased infertility distress (Newton et al., 1999; Greil et al., 2010). In the current study, women reported higher levels of infertility distress when compared with men, a finding supported by a wide body of literature (Newton et al., 1999; Greil et al., 2010). In addition, a significantly higher percentage of women reported severe depressive symptoms when compared with men. This is consistent with depression rates in the general population where women are two to three times as likely to be depressed as men (Kessler, 2003).

It is noteworthy that the current study used a sample of men and women that included people who reported severe depressive symptoms. A meta-analysis of 28 studies examining the relationship between depression and women experiencing polycystic ovary syndrome found that over 50% of the studies reported depression scores in the non-clinical range, while the remaining studies were in the mild depression range (Veltman-Verhulst et al., 2012). Using a sample of couples with severe depressive symptoms helps give voice to an understudied and at-risk population of women and men. Furthermore, the current study answered calls of previous researchers to use multilevel models that enhance our understanding of the dyadic impact of an individual's severe depressive symptoms on one's partner (Lund et al., 2009). The finding of the current study that an individual's severe depressive symptoms are related to increased infertility-related distress in the partner supports this call, and underscores the importance of conceptualizing infertility as a couples-level stressor.

A large number of studies examining the relationship between depression and infertility have done so by examining the impact of depression on pregnancy outcomes. While it is encouraging that recent meta-analyses and studies have found that depression prior to infertility treatment does not influence pregnancy rates, a finding that can reduce the amount of self-blame a woman may feel following unsuccessful treatment (Boivin et al., 2011; Matthiesen et al., 2011; Pasch et al., 2012), the findings from this study underscore possible risk factors for depressed men and women pursuing infertility treatments. It has been shown that higher depression in women prior to IVF treatment was associated with higher depression following IVF treatment (Pasch et al., 2012). This finding may be explained in part because men and women, who are depressed prior to treatments, are likely experiencing greater amounts of infertility distress compared with non-depressed couples. Because this distress increases at both the individual and partner level, and because depressed individuals have fewer emotional resources to cope with this distress, this group may be at particular risk of future depression following treatment failure.

The findings from the current study may have implications for medical and mental health professionals (Peterson et al., 2012). Pasch et al. (2012) recommended that psychological interventions be focused on helping couples cope with the stress of infertility and treatment failure, as opposed to using psychological treatments to reduce stress in an attempt to become pregnant. This may be particularly true for men and women entering treatment with severe depressive symptoms, as their levels of infertility stress may be higher than those without depressive symptoms.

The findings from this study must be interpreted in the context of the study's limitations. First, due to the cross-sectional study design, we cannot make conclusions that depressive symptoms cause increased infertility distress in individuals or partners, or that infertility distress causes an increase in an individual's or partner's depressive symptoms. These findings only represent the association between severe depressive symptoms and infertility distress, and therefore cannot be used to infer any causality or directionality of this relationship. Second, the COMPI scales used in this study have not yet been validated in large-scale psychometric studies. The fertility problem stress scales were adopted from an existing scale (Abbey et al., 1991) and further developed based on findings from in-depth detailed qualitative research and interviews with Danish fertility patients (Schmidt, 1996). Explanatory factor analyses showed infertility-specific distress in three different domains (personal, marital, social) (Schmidt et al., 2003), and the infertility-specific scales are being used in several other studies in different countries, with a cross-cultural validation study currently being carried out. Third, the multilevel analyses are unadjusted, although the findings show that the couples are intertwined and that the dyadic analyses add information about couples and their influence on each other. Fourth, the MHI-5 was developed to assess mental health in general and was not designed to assess severe depressive symptoms. However, a study comparing clinical diagnosis with MHI-5 found good agreement for mood disorders and the MHI-5 (Rumpf et al., 2001), which indicates that it is plausible to use the MHI-5 as a proxy for severe depressive symptoms. Finally, the cut-point of the MHI-5 could have been higher (e.g. 56 or 60), hence identifying more individuals with severe depressive symptoms. However, because the MHI-5 is not a clinical instrument, the lowest cut-point identified was used. This is also in accordance with other studies (Holmes, 1998; Strand et al., 2003; Rugulies et al., 2012) that found ≤52 as the best cut-point. Given these limitations, 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 in increasing our understanding of the complex relationship that exists between these variables.

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