1

Barriers of antenatal folate-supplementation: The role of depression and trait-anxiety on periconceptional folate-intake

Role of depression and anxiety on folate-intake

Tamás Bödecs M.D.,1 Orsolya Máté,2 Boldizsár Horváth M.D., Ph.D.,3 Lajos Kovács M.D.,4 Zoltán Rihmer M.D., Ph.D., DSc.,5 & János Sándor M.D., Ph.D.2

1

Department of Health Visiting, Institute of Public Health, Recreation and Health Promotion, Faculty of Health Sciences, University of Pécs, Szombathely Campus, Hungary Address: 14 Jókai Str. Szombathely H-9700 Hungary, Tel: (36 94) 311 170 Fax: (36 94) 316 820 Email: [email protected]

2

Department of Public Health and Epidemiology, Institute of Public Health, Recreation and Health Promotion, Faculty of Health Sciences, University of Pécs, Pécs, Hungary Address: 4 Rét Str. Pécs H-7623 Hungary, Tel: (36 72) 535 980 Fax: (36 72) 535 984 Email: [email protected]; [email protected]

3

Department of Midwifery, Institute of Nursing and Patient Care, Faculty of Health Sciences, University of Pécs, Szombathely Campus, Hungary Address: 14 Jókai Str. Szombathely H-9700 Hungary, Tel: (36 94) 311 170 Fax: (36 94) 316 820 Email: [email protected] 4

Vas County Markusovszky Hospital, Department of Obstetrics and Gynecology, Szombathely, Hungary Address: 3 Markusovszky Str. Szombathely H-9700 Hungary, Tel: (36 94) 311 542

2 Fax: (36 94) 327 873 Email: [email protected] 5

Department of Clinical and Theoretical Mental Health, Semmelweis University, Faculty of Medicine, Budapest, Hungary

Address:4 Kútvölgyi Str., Budapest H-1125 Hungary, Tel(36 1) 325-1498, Fax(36 1) 3558498, Email:[email protected]

Correspondence: Zoltán Rihmer M.D., Ph.D., DSc., Department of Clinical and Theoretical Mental Health, Semmelweis University, Faculty of Medicine 4 Kútvölgyi Str., Budapest H-1125 Hungary, Tel(36 1) 325-1498, Fax(36 1) 355-8498, Email:[email protected]

3 Abstract Objective: The aim of the research was to reveal the effect of antenatal depressive symptoms and trait-anxiety on folate supplementation. Higher levels of depression, and trait-anxiety were hypothesized to be associated with insufficient folate intake among pregnant women in early pregnancy. Methods: Level of depressive symptoms, trait-anxiety, self-esteem, social capital, self-related health, and demographic factors (age, number of siblings, marital, educational, employment, and socioeconomic-status) were established among 185 Hungarian women in the I. trimester of their pregnancies. Depressive symptoms and trait-anxiety were evaluated with the Short Hungarian Version of the Beck Depression Inventory and the Hungarian version of the Spielberger State-Trait Anxiety Inventory form Y (STAI-Y). Results: The higher levels of both trait-anxiety and self-esteem decreased the folate-intake significantly, OR=0.925 (95%CI=0.863-0.991; p=0.026) and OR=0.897 (95%CI=0.8080.996; p=0.041) while depressive symptoms did not have an effect on it. The lower level of education (less than 8 elementary years) had similar effects (OR=0.228 [95%CI=0.0640.817], p=0,023). The lack of trust had a significant role too (p=0.043): those, who were distrustful with other people, also had a lower chance of supplementation (OR=0.620; 95%CI=0.390-0.986).

Conclusions: The way to increase the openness towards folate-

supplementation leads through the treatment of psychological disturbances and the restoration of social trust.

Keywords: Depressive symptoms; Trait anxiety; Pregnancy; Self-esteem; Folatesupplementation

4 Objective The importance of folate-intake in early pregnancy One of the most important possibilities to prevent neural-tube defects is supplementing the appropriate amount of folic acid in the period of early pregnancy. The frequency of neuraltube defects in Hungary between 1997 and 2003 are 5.63 ten thousandth by a survey data of the National Epidemiological Centre (National Register of Congenital Growth Disturbances). Two third of the above defects could have been prevented if the folate state was appropriate in the early prenatal period of the pregnancy. However, a representative national survey showed results that the folate intake is insufficient in Hungary. The survey of the National Institute for Food and Nutrition Science showed that only 7.5% of women between18-35 consume more than 0.2 mg of folate, while the intake of 0.4 mg recommended amount during pregnancy is practically never taken in. From the point of view of preventing neural-tube defects it would be accentually significant to improve the folate state of women in reproductive age, but it is technically impossible to take in the appropriate amount with food, therefore it is very important to apply folate-supplementation (products containing folic acid). Although, exploiting the true possibilities of folate supplementation there are tasks of health education as well. Most women are only inclined to change their folate intake habits after they are aware of their pregnancies: in other words, too late, some of them never.

Both clinical and population-based studies indicated that folate deficiency and low folate status have been also linked to depression and poor antidepressant response [1-2] and systematic review of placebo-controlled studies found evidence to suggest that folate may have a role as an augmenting antidepressant response [3-4]. The frequency of antenatal depression is between 7 and 17% [5-8] and around 10% of pregnant women suffer from any kind of anxiety disorders [9-10]. Although one epidemiological study did not find a

5 relationship between folate intake and postpartum depression [11], the well demonstrated connection between low folate level and depression [1-2] suggest that folate supplementation during pregnancy might have, if any, a beneficial effect on mood in pregnant women.

Foetal effects of antenatal depression and antenatal anxiety Depressive and anxiety disorders are the most common psychiatric illnesses occurring during pregnancy and postpartum period [7-8]. The importance of these pathological conditions is underlined by the findings showing that major depression during pregnancy increases the risk of pregnancy and birth complications (particularly premature birth and low birth-weight) and perinatal depression leads to disturbances in the mother-baby relationship resulting in deficits in physical, emotional and cognitive development in the infant [12-13]. Overactivity of the maternal HPA axis elevates maternal and fetal cortisol level, while high levels of cortisol inhibit intra-uterine growth and may alter the regulation of glucocorticoid receptors in the brain of the developing foetus [14]. Hypothalamic and extra-hypothalamic (placental) CHR increase may lead to premature birth by uterus-contractions and softening of the cervix [15]. Extra-hypothalamic CRH in animals leads to a series of stress-like physiological and behavioural phenomena like decreased food-intake, sleep disturbances, psychomotor activation, increased heart rate and respiration, elevated blood pressure and blood sugar level [16]. The damaging effect on the foetus of inadequate health-behaviour accompanying maternal depression, include negative tendencies of lifestyle, like alcohol consumption as a solution to stress, smoking, substance abuse as well as medication non-compliance and negative attitudes to other forms of treatments are well documented [17-19].

The majority of studies also demonstrated a damaging effect of antenatal anxiety mainly premature birth [20-21], the 1 and 5 minutes decreased Apgar-score [10], or the case of

6 increased arterial uterine resistance [22]. Those pregnant women with symptoms of depression or anxiety reported somatic problems and they consulted their physician more often [9]. Mechanisms of anxiety and depression states, which cause bad health status and negative pregnancy outcomes, namely physiological – vegetative changes and self-damaging behaviour tendencies do not separate that much in practice, naturally, they are interacting with one another in a more complex way. Disturbances due to depression and anxiety supposedly reduce the faith in accessibility of health, restrict the openness towards health bettering interventions and thus finally restrict the possibility of interventions.

Foetal effects of maternal of self-esteem, social capital and self-related health Disturbances due to anxiety and depression combine with low self-esteem, so higher level of anxiety or depression assume lower self-esteem [23-24] and trait-anxiety leads to lower selfesteem via producing negative effects [23]. Low levels of social capital (measured by lack of social trust, lack of reciprocity between citizens, and poor help received from civil organisations) were also related to higher anxiolytic-hypnotic drug use [25], poorer selfrelated health [26], and lack of openness towards primary health care [27]. Social capital is also linked to self related health and middle age mortality rates [28].

The aim of the study The present study aimed to investigate the effects of antenatal depression and anxiety on folate-intake among pregnant Hungarian women. Higher levels of depression, and anxiety were hypothesized to be associated with insufficient folate intake among women in early pregnancy. Our secondary aim was to map folate intake amongst pregnant women. Since selfesteem, social capital, and self related health may covariate with depression/anxiety, and may influence openness towards healthcare, all three factors along with demographic covariates

7 (age, number of siblings, marital, educational, employment, and socioeconomic status) were included to our study.

Methods Participants Our study was carried out in the city of Szombathely, in 10 districts of the 18 large district nurse network belonging to the antenatal centre Vas County Markusovszky Hospital. We formed a population monitoring in the area formulated by the 10 nurse districts where our data collection of all women registered for prenatal care was continual between 01.02.2008 and 01.10.2008. Patients with psychiatric diagnosis and those who could not interpret our questionnaire (due to the lack of Hungarian language or extremely restricted cognitive ability) were excluded from the study.

Procedure The place and time of data collection was the registration of pregnant women for prenatal care with the district nurse. In Hungary obstetricians-gynaecologists diagnose the pregnancy and with the medical report pregnant women register for prenatal care at their local district nurse. On the first meeting at the district nurse, we recorded the data necessary for our questionnaire and as part of the protocol the informed consents were filled out at the same time. Participation was voluntary and anonymous. During that time of 196 women 11 refused to participate, therefore 185 (94.4%) participants build up our database.

Explanatory variables Measuring depression and anxiety We measured depressive symptoms with a shortened, 9item version of Beck Depression Inventory [29] that was adapted to Hungarian conditions and

8 widely used in epidemiological research (Short Hungarian Version of the Beck Depression Inventory; [30]). Anxiety was assessed with the Hungarian version [31] of the Spielberger State-Trait Anxiety Inventory form Y [32]. To meet the aims of our research only the traitanxiety block of the questionnaire (STAI-T) was recorded. Because the STAI-Y was not designed or validated to be used with a cut off, the scores were kept in their continuous form for the analysis. For epidemiological aims we only used cut-off values from an earlier Hungarian research: 1) STAI-T 52: clinically significant anxiety; 3) STAI-T= 48 to 52: mild or sub-clinical disorder [33]).

Measuring self-esteem, social capital and self-related health Self-esteem was evaluated by the Rosenberg’s Self-Esteem Scale (RSES) [34]. Social capital was measured by lack of social trust, reciprocity between citizens, and help received from civil organizations on a 0 to 3 scale. Participants were also asked to rate their actual health status on a five point scale (very bad=1; very good=5). There is a widespread agreement that this simple global statement provides a useful summary of how patients perceive their overall health status [35].

Demographic Data The following demographic variables were administered in the survey: age, number of siblings, marital, educational, employment, and socioeconomic-status.

Outcome variable In our questionnaire three questions referred to folate-intake: “Do you take prenatal vitamins?”, “Do you take any multivitamin products?” and “Do you take Folate pills?” Those giving negative answer to all three questions we regarded as not receiving folatesupplementation. Those answering positively to any of the above questions were regarded as supplementation receivers. In Hungary district nurses use standard questionnaires with standard questions referring to different components of regular health behavior prior to conception. Since our study’s questions on folate-, and vitamin-intake were built in this well

9 established and regularly used questionnaire form, all these answers above also referred to regular folate-intake initiated prior to conception.

Statistical methods We tested the relation between our independent variables and the above formulated dichotomous dependent variable (folate-intake) with multivariate logistic regression analysis. Significant associations were quantified with odds ratios (OR) and 95% confidence intervals (95%CI). P