Abstract

Purpose: To determine gender differences in trends of anxiety, depression and vital exhaustion levels in an open population aged 25-64 years over long-term period - 23 years in Russia / Siberia (Novosibirsk).

Methods: Within the framework of the screening in 1994-95 under the WHO MONICA-psychosocial (MOPSY) program (n = 1527, 43% males, mean age 44.85 ± 0.4 years), in 2003-2005 under the international project HAPIEE (n=1650, 34,9% males, mean age 54,25±0,2 years), in 2013-2016 (n=975, 43,8% males, mean age 34,5±0,4 years) and 2016-2017 гг.( n=663, 41,3% years 51,95±0,32 years) within the framework of the budgetary theme No. АААА-А17-117112850280-2, random representative samples of men and women in one of districts in Novosibirsk were examined. Anxiety traits studied by means of the Spielberger test. Depression and vital exhaustion assessed by MOPSY questionnaires.

Results: 2/3 of the female population aged 25-64 years had high level of anxiety traits in 1994. It was highest in the younger age groups. High anxiety was found in less than half of the surveyed men, increasing with age. The maximum values of anxiety were noted in 2003-2005 in both genders. The decrease in the incidence of high anxiety which began in 2013-2016, remained only in the female part of the population aged 35-64y but in men the prevalence of anxiety returned to the levels of 1994.

Depression occurred in more than half of the female population in 1994. The overall prevalence among men was less than 30%. At the same time, the frequency of major D in women was 4-fold higher compared with men (p <0.001). Trends in prevalence in 2017 were mixed: a reduction in moderate levels and an increase in major depression in the youngest and oldest age groups.

The prevalence of high vital exhaustion in 1994 was 14.6% and 31% in men and women 25-64 years, respectively (p <0.001). An increase in high exhaustion from younger to older age groups was noted in both sexes. The downward trend in exhaustion in 2017 persisted only among women. At that moment for the first time men began to report high exhaustion more often than women over 23-year of follow-up (16.9% and 15.6% for men and women 35-64y, respectively; n.s.).

Conclusion: The prevalence of affective states is higher in females in general population. Long-term trends in decreasing the prevalence of anxiety, depression and vital exhaustion were not sustainable and returned to levels of 1994.

Keywords: anxiety traits, depression, vital exhaustion, gender differences

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Background

Amid reports about the successes in reducing cardiovascular mortality, an increasing number of cases of depression (D) are being recorded worldwide. It is predicted that major D will become the leading disease in 2030, and is already that among women in some countries. Major depressive disorder in Canada showed a 75% increase in disability between 1990 and 2010. And - this is the second largest after the prevalence of Alzheimer's disease. For comparison, in the United States, growth was 43%. At the same time, the ratio of women and men in the global rate of morbidity and disability from major depression has remained unchanged at about 2: 1 [1, 2].

Epidemiological studies estimated 50% adults have at least one anxiety disorder over lifetime and 30% reporting past year anxiety [3]. According to the National Institute of Mental Health, the past year prevalence of anxiety disorders in the United States decreased slightly over the decade (1990-2003) and it was 23.4% in women and 14.3% in men [3]. More recent studies in Europe do not report any dynamics in anxiety disorders [4].

The term vital exhaustion (VE) proposed Appels A., et al. (1980) to indicate precursors of myocardial infarction. It is a mental state that denotes extreme fatigue, feelings of demoralization, and increased irritability. VE is thought to be a potential response to intractable problems in people's lives, in particular when they are unable to adapt to prolonged exposure of psychological stressors. Reports of the prevalence of VE few in number; in the literature, such "surrogates" as emotional burnout and chronic fatigue are often described [5]. The need for population-based study of sex differences and the dynamics of the prevalence of these affective states in Russia related with the lack of similar studies in our country where the study design (sample set, methods of recording psychological characteristics, etc.) is strictly followed by a single protocol. Thus, the purpose of our study was to establish gender differences in the dynamics of anxiety traits, depression, vital exhaustion levels in an open population of 25-64 years over a long-term period - 23 years in Russia / Siberia.

Material and methods

The results of our study were obtained on the basis of a survey of the male and female population living in one of the districts of Novosibirsk. The examinations were carried out within the framework of screenings 1994-95, 2003-2005, 2013-2016 and 2016-2017. Under the III screening of the WHO program «Multinational Monitoring of Trends and Determinants of Cardiovascular Disease - Optional Psychosocial Sybstudy» (MONICA-MOPSY) representative sample of residents aged 25–64 years examined in 1994-1995 (n=1527, 43% males, mean age 44.85±0.4 years, response rate – 77.3%) [6]. In the course of another international project HAPIEE (Health, Alcohol and Psychosocial factors In Eastern Europe) persons aged 45-64 were examined in 2003-2005 (n=1650, 34.9% males, mean age 54.25±0.2 years, response rate – 66.5%) [7]. In the framework of the screening studies a random representative sample survey of the population aged 25-44 years conducted in 2013-2016 by the budget scientific research theme, Gov.Task № 01201282292 (n=975, 43.8% males, mean age 34.5±0.4 years, response rate – 71.5%). Within the framework of the budget theme No. AAAA-A17-117112850280- survey of persons aged 35-64 was carried out in 2016-2017 (n=663, 41.3% males, mean age 51.95±0.32 years, response rate – 73.6%). The study included residents of the same district of Novosibirsk as in 1994-95, 2003-2005 and 2013-2016.

All samples were formed on the basis of electoral lists of citizens using a table of random numbers. A random mechanical selection procedure was used. The general survey was carried out according to the standard methods accepted in epidemiology and included in the MONICA program [6]. The methods were strictly standardized and complied with the requirements of the MONICA project protocol. Validation and processing of material according to the WHO MONICA-psychosocial program was carried out at the Information Collection Center of the MEDIS Institute in Munich, Germany (Institut für Medizinische Informatik und Systemforschung). Quality control was carried out in MONICA quality control centers: Dundee (Scotland), Prague (Czech Republic), Budapest (Hungary). The presented results were considered satisfactory. The screening survey program included registration of socio-demographic data according to the standard epidemiological protocol of the WHO MONICA-psychosocial program: identification number, place of residence, full name, date of birth, date of registration, gender, marital status, educational level, professional status. The levels of anxiety traits (AT) were assessed using the Spielberger test (subscale anxiety as a personality trait) [8]. Data interpretation was based on the following criteria: an anxiety sign score of less than 30 corresponded to a low level of anxiety (LLA); score from 31 to 44 corresponded to moderate level of anxiety (MLA); and a score of more than 45 indicates a high level of anxiety (HLA).

Depression was assessed using the form of the depression scale - the MOPSY test, consisting of 15 questions. To answer each question, 2 answers are provided: "Agree", "Disagree". The severity of depression was assessed as no depression (ND), moderate (MD), major D.

The level of vital exhaustion was studied using the MOPSY questionnaire (based on Maastricht Vital Exhaustion Questionnaire adopted by MONICA protocol). The test consisted of 14 statements. There are 3 gradations for the answer to each statement: “Yes”, “No”, “I do not know”. The level of vital exhaustion was assessed as: no vital exhaustion, moderate, high. The tests were encoded in the construction of index components and the calculation of points in accordance with the proposed algorithm of the MONICA-MOPSY program. The subjects were asked to answer the questions of the scale themselves according to the instructions placed on the scale. Individuals who did not complete the questionnaire were not included in the analysis. Statistical analysis was performed using the SPSS software package version 11.5. The study participants were standardized by age groups in the analysis. To compare the indicators between screenings, the corresponding age groups were used. To check the statistical significance of differences between groups, we used: the chi-square test (χ2). As a criterion of statistical significance the value of the chi-square was taken into account at a certain number of degrees of freedom. The reliability of analysis was accepted at a significance level of p<0.05.

Results

The prevalence of high levels of anxiety (HLA) in males in an open population of 25-64 years was significantly lower compared to females in 1994 (43.8% and 66.9%; p <0.001).

By 2003, there was an increase in the unfavorable level of anxiety traits by 15-17% in both gender, reaching 60.2% in male and 82.8% in female part of the population 45-64 years (p <0.001). These are the highest HLA levels for the entire twenty-three-year observation period. Women were more likely to report HLA as in 1994. Prevalence of HLA in 2013-2016 markedly decreased in both gender of population aged 25-44 years, especially in men - 2 times (29.3% and 48.2% for men and women, respectively; p <0.001).

The trend of lower HLA levels remained only in the female part of the population aged 35-64y by 2016-2017. But the prevalence of HLA in men increased to levels of 1994. Moreover, there was a trend in the lining of the anxiety levels in men and women over the period (HLA: 44.7% and 49%, respectively; p <0,05). The low level of anxiety did not exceed 10% during the assessed period, with the exception of 2013-2016, when the rate of HLA in male population aged 25-44 was 14% (p <0.001).

The study of sex differences in anxiety levels among age groups revealed the following observations (see Table 1). Among the male population in 1994, there was a clear linear relationship in the increase in high anxiety prevalence from younger to older age groups: from 38.3% in the 25-34 age group, to 60.4% in the 55-64 age group. Among women, on the contrary, high levels of anxiety were more common in young age groups 25-34 and 35-44 years - 64.6% and 69.2%, respectively (p≤0.001).

In 2003-2005, with the exception of men 45-54 years old, there was a significant increase in the incidence of HLA in comparison with the similar group in 1994; especially in the 55-64 age group, reaching maximum values of 68% for men and 86.5% for women (p <0.001). In 2013- significant decrease in the prevalence of HLA in the groups of 25-34 and 35-44 years in both genders was established, in comparison with similar age categories in 1994. Youngest women had demonstrated the most significant decrease in 1.5times(p<0,001).Table

Levels 25-34 years 35-44 years 45-54 years 55-64 years 25-64 years
M F M F M F M F M F
N % N % N % N % N % N % N % N % N % N %
Low 1994 12 6.8 0 0 4 2.2 1 0.6 0 0 1 0.5 0 0 2 1.2 16 4.5 1 0.3
Moderate 96 54.9 56 35.4 86 48.6 48 30.2 57 42 85 46.2 67 39.6 76 45 182 51.7 104 32.8
High 67 38.3 102 64.6 87 49.2 110 69.2 79 58 98 53.3 102 60.4 91 53.8 154 43.8 212 66.9
Total 175 100 158 100 177 100 159 100 136 100 184 100 169 100 169 100 352 100 317 100
χ2=28.982 df=2 p<0.001 χ2=14.338 df=2 p=0.001 χ2=1.39 df=2 p=0.499 χ2=3.193 df=2 p=0.203 χ2=15.937 df=2 p<0.001
Low 2005 7 2.3 2 0.4 8 2.9 0 0 15 2.6 2 0.2
Moderate 135 44.4 113 20.4 79 29 70 13.5 214 37.2 183 17
High 162 53.3 439 79.2 185 68 450 86.5 347 60.2 889 82.8
Total 304 100 554 100 272 100 520 100 576 100 1074 100
χ2=65 df=2 p=0.0001 χ2=45.98 df=2 p<0.001 χ2=14.51 df=2 p<0.001
Low 2013 31 18.8 15 7 29 11.1 15 4.5 60 14.1 30 5.5
Moderate 97 58.8 113 53.1 145 55.3 141 42.1 242 56.7 254 46.4
High 37 22.4 85 39.9 88 33.6 179 53.4 125 29.3 264 48.2
Total 165 100 213 100 262 100 335 100 427 100 548 100
χ2=19.89 df=2 p=0.0001 χ2=27 df=2 p=0.0001 χ2=45.6 df=2 p=0.0001
Low 2017 2 2.9 10 11.2 3 4 15 10.3 7 3 8 5.4 12 4.5 33 8.6
Moderate 33 47.8 38 42.7 45 56 53 36.3 57 48.7 72 48.3 135 50.8 163 42.4
High 34 49.3 41 46.1 32 40 78 53.4 53 45.3 69 46.3 119 44.7 188 49
Total 69 100 89 100 80 100 146 100 117 100 149 100 266 100 384 100
χ2=3.869 df=2 p>0.05 χ2=9.418 df=2 p<0.01 χ2=0.060 df=2 p>0.05 χ2=6.740 df=2 p=0.035
Table 1. Gender differences in the dynamic of anxiety traits levels in age groups of a population aged 25-64 years in 1994 – 2017.

Women of all age groups were in the lead by the level of HLA over men in 2013 as in previous two decades.The distribution of anxiety levels in 2016-2017 differed from other periods. Thus, for the first time, the incidence of HLA in men aged 35-44 years was higher compared to women of the same age group: 49.3% vs 46.1%, although the differences did not reach statistical significance. There was a tendency towards gender parity between the levels of HLA in the oldest age category (45.3% and 46.3%, for men and women, respectively). An apparent increase in low anxiety among both sexes was observed in the 2013-2017 periods. Males were more likely to have low anxiety level which reached a peak 18.8% in those aged 25-34y in 2003- women, low anxiety for the first time exceeded the 10% in 2016-2017 at the age categories 35-44 and 45-54 years (p <0.01). Rates of low anxiety in women prevailed over men in all age groups during this time period. Depression (D) occurred in more than half of the female population aged 25- 1994. The prevalence of D among men was less than 30% (Table 2). At the same time, rates of major D were 4-fold higher in women (p <0.001). The share of women with D decreased by 18% by 2003-2005 while male’s proportion remained unchanged. At the same time, there was a significant decrease in the gap of major D prevalence by gender: 2.6% in men and 4.7% in women 45-64 years (p <0.001).

The prevalence of D among the male population reached its peak values for 30.5% in 2013-2016 over 23-year period. Women also showed an increase in total D but the values did not reach the levels seemed in 1994. It should be noted that the increase in D levels occurred as a result of changes in the structure of D levels due to an increase in major D rates in both genders. The prevalence of major D in young women was the highest in 2013-2016 as well as in opposite sex during the whole of observation (9.4% and 16.4%, for men and women 25-44 years, respectively (p <0.001). A slight decline in the levels of total D compared to the previous period occurred by 2016-2017.The share of persons without D increased to 73% in men and 62.5% in women which approached the levels seemed in 2003. But the prevalence of major D remained at a higher level than in 1994: 5.6% in men and 14.3% in women aged 35-64 years (p<0.01). In 1994, the prevalence of major D dominated in women at all age groups with the exception of 45-54 years where the rate of major D was 2 times higher in men. The prevalence of large D was highest among women 35-44 and 55-64 years: 13.6% and 18.6%, respectively (p <0.001). Men showed vanishingly low levels of major D, especially in the younger age groups 25-34y and 35-44y. In 2003- decrease in major D to 1.3% was noted in male population 45-54 years. The share of men aged 55-64y with a major D did not change and almost equaled with women the same age group. Major D increased by 2% in women 45-54 years in comparison with 1994 but there was a more than 4-fold decrease in the level of major D in the group 55-64y (p <0.05). There was also a decrease in the prevalence of moderate depression level but more likely in female population - by 15-16% in comparison with the 1994. In 2013-2016, there was a significant increase in the levels of major D among men and women in young age groups compared to 1994. At the same time, the incidence of moderate D in the female population significantly decreased. It enlarged share of women without depression to 59.6% and 54.9% for those ones aged 25-34 and 35-44 years. Whereas the proportion of men with moderate and no depression did not change significantly in these age groups (p <0.01). The prevalence of major D in 2016-2017 did not change in males 35-44 year compared to the previous period and was equal to corresponding level in women the same age group (n.s.). The rate of major D was not so high in older men and did not exceed 4%. In contrast, women aged 55-64 showed the highest values 20.1% over the entire history of observations (p <0.001). Despite the growth of major D in the oldest age group of women the share of people without D in male and female populations 45-54 and 55-64 years was higher than in 1994 and, to a greater extent, corresponded to the indicators of 2003-05.

Levels 25-34 years 35-44 years 45-54 years 55-64 years 25-64 years
M F M F M F M F M F
N % N % N % N % N % N % N % N % N % N %
Major 1994 1 0.6 10 9.7 3 1.8 18 13.6 9 6.9 1 2.9 6 4 8 18.6 19 3.1 37 11.8
Moderate 39 23.4 44 42.7 39 23.9 53 40.2 35 26.9 17 48.6 44 29.5 20 46.5 157 25.8 134 42.8
No D 127 76 49 47.6 121 74.2 61 46.2 86 66.2 17 48.6 99 66.4 15 34.9 433 71.1 142 45.4
Total 167 100 103 100 163 100 132 100 130 100 35 100 149 100 43 100 609 100 313 100
χ2=28.674 df=2 p<0.001 χ2=29.695 df=2 p<0.001 χ2=6.219 df=2 p=0.045 χ2=18.210 df=2 P<0.001 χ2=66.724 df=2 p<0.001
Major 2005 4 1.3 28 5.1 11 4 22 4.2 15 2.6 50 4.7
Moderate 75 24.7 179 32.3 62 22.8 161 31 137 23.8 340 31.7
No D 225 74 347 62.6 199 73.2 337 64.8 424 73.6 684 63.7
Total 304 100 554 100 272 100 520 100 576 100 1074 100
χ2=15.036 df=2 p=0.001 χ2=6.088 df=2 P=0.048 χ2=17.541 df=2 p<0.001
Major 2013 11 6.7 36 16.9 29 11.1 54 16.1 40 9.4 90 16.4
Moderate 36 21.8 50 23.5 54 20.6 97 29 90 21.1 147 26.8
No D 118 71.5 127 59.6 179 68.3 184 54.9 297 69.5 311 56.8
Total 165 100 213 100 262 100 335 100 427 100 548 100
χ2=9.97 df=2 p=0.007 χ2=11.08 df=2 p=0.004 χ2=18.531 df=2 p<0.001
Major 2017 8 11.6 11 12.4 3 4 14 9.5 4 3.4 30 20.1 15 5.6 55 14.3
Moderate 11 15.9 22 24.7 17 21 36 24.7 29 24.8 31 20.8 57 21.4 89 23.2
No D 50 72.5 56 62.9 60 75 96 65.8 84 71.8 88 59.1 194 73 240 62.5
Total 69 100 89 100 80 100 146 100 117 100 149 100 266 100 384 100
χ2= 1.980 df=2 p=0.372 χ2=3.239 df=2 p=0.199 χ2=16.430 df=2 p<0.001 χ2=13.779 df=2 p<0.002
Table 2. Gender differences in the dynamic of depression levels in age groups of a population aged 25-64 years in 1994 – 2017.
Levels 25-34 years 35-44 years 45-54 years 55-64 years 25-64 years
M F M F M F M F M F
N % N % N % N % N % N % N % N % N % N %
High 1994 8 4.8 23 22.3 23 13.9 45 33.3 29 22.5 10 25 29 19.3 26 44.8 89 14.6 104 31
Moderate 80 48.5 49 47.6 78 47.3 63 46.7 65 50.4 17 42.5 95 63.3 19 32.8 318 52.2 148 44
No VE 77 46.7 31 30.1 64 38.8 27 20 35 27.1 13 32.5 26 17.3 13 22.4 202 33 84 25
Total 165 100 103 100 165 100 135 100 129 100 40 100 150 100 58 100 609 100 336 100
χ2=21.085 df=2 p=0.001 χ2=20.967 df=2 p=0.001 χ2=0.785 df=2 p=0.675 χ2=17.991 df=2 p<0.001 χ2=36 df=2 p<0.001
High 2005 50 16.4 172 31 59 21.7 148 28.5 109 18.9 320 29.8
Moderate 174 57.2 303 54.7 157 57.7 314 60.4 331 57.5 617 57.4
No VE 80 26.3 79 14.3 56 20.6 58 11.2 136 23.6 137 12.8
Total 304 100 554 100 272 100 520 100 576 100 1074 100
χ2=31.794 df=2 p<0.001 χ2=14.38 df=2 p=0.001 χ2=4.086 df=2 p=0.13
High 2013 7 4.2 24 11.3 19 7.3 65 19.4 26 6.1 89 16.2
Moderate 52 31.5 82 38.5 91 34.7 135 40.3 143 33.5 217 39.6
No VE 106 64.2 107 50.2 152 58 135 40.3 258 60.4 242 44.2
Total 165 100 213 100 262 100 335 100 427 100 548 100
χ2= 10.112 df=2 p=0.006 χ2=26.23 df=2 p=0.001 χ2= 35.77 df=2 p=0.001
High 2017 4 5.8 10 11.2 14 17.5 17 11.6 27 23.1 33 22.1 45 16.9 60 15.6
Moderate 22 31.9 38 42.7 19 23.7 68 46.6 56 47.9 67 45 97 36.5 173 45.1
No VE 43 62.3 41 46.1 47 58.8 61 41.8 34 29 49 32.9 124 46.6 151 39.3
Total 69 100 89 100 80 100 146 100 117 100 149 100 266 100 384 100
χ2=4.425 df=2 p>0.05 χ2=11.401 df=2 p<0.01 χ2=0.451 df=2 p>0.05 χ2=4.927 df=2 p=0.086
Table 3. Gender differences in the dynamic of vital exhaustion levels in age groups of a population aged 25-64 years in 1994 – 2017.

The prevalence of high VE in 1994 was 2 times higher in women compared to men of 25-64 years (14.6% and 31%, respectively; p <0.001). Rates of moderate levels of VE were higher men (Table 3).

In 2003-2005, there was an increase in the moderate VE levels and a decrease in the proportion of those who did not experience vital exhaustion, especially in female population (23.6% and 12.8% for men and women aged 45-64 without VE, respectively). But there remained a significant gap in high VE levels by sex.

The levels of high VE have significantly decreased in 2013-2016: 6.1% in men and 16.2% in women of 25-44 years. The same was for moderate VE: 33.5% and 39.6%, respectively (p <0.01). The proportion of individuals without VE was