Comparison of heart rate variability between mild and severe depression in
menopausal women with low exercise behavior
Wen-Dien Chang, Assistant Professor, Ph.D.,
Department of Sports Medicine, China Medical University.
Present address: No. 91 Hsueh-Shih Road, Taichung City, Taiwan (R.O.C)
[E-mail: changwendien@mail.cmu.edu.tw]
Chia-Lun Lee, Associate Professor, Ph.D.,
Department of Recreational Sports Management, Yu Da University
Present address: No. 168, Hsueh-fu Road, Tan-Wen Village, Chao-Chiao Township, Miaoli
County, Taiwan (R.O.C)
[E-mail:
cl_lee41@yahoo.com.tw]
Chien-Tsung Tsai, MD.,*
Department of Rehabilitation, Da Chien General Hospital,
No. 6, Shin Guang Street, Miaoli City, Taiwan (R.O.C).
[E-mail: tsai_chien_tsung@yahoo.com.tw]
* Correspondence author:
Chien-Tsung Tsai, MD.,*
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
Department of Rehabilitation, Da Chien General Hospital,
Present address: No. 6, Shin Guang Street, Miaoli City, Taiwan (R.O.C).
TEL: (886)-37-357125; FAX: (886)-37-336274
E-mail: tsai_chien_tsung@yahoo.com.tw
ABSTRACT
〔Purpose〕Insufficient exercise leads most middle-aged women to have a higher risk of depression arising from menopausal symptoms. We hypothesized that heart rate variability (HRV) would show the adjustment of the autonomic nervous system reflecting degrees of depression in menopausal women with low exercise behaviors,and the aim of this studywas to compare HRV between mild and
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
severe depression cases to explore the potential of HRV as a diagnostic tool for depression.
〔Subjects and Methods 〕This was a cross-sectional study, and subjects were community-recruited menopausal women with low exercise behaviors. After subjects had completed the Taiwanese depression questionnaire (TDQ), electrocardiographic signals of the subjects with mild and severe depression were recorded for analysis of the HRV variables, and to create receiver operating characteristic curves.
〔Results〕Twenty-eight women with mild depression (TDQ score: 11.62 ± 1.81) and 20 women with severe depression (TDQ score: 24.71 ± 1.57) agreed to analysis of their electrocardiographic signals. The between-group comparisons of high frequency (HF), low frequency (LF) and the LF/HF ratio showed statistically significant differences, and provided significant contributions to predicting depression in both groups. The area under the receiver operating characteristic curve for LF was significantly greater than that of HF.
〔Conclusions〕LF and the LF/HF ratio better distinguish between subjects of different severity of depression than HF. This means that observation of the tone of sympathetic activity and the balance of the autonomic nervous system are better at distinguishing the severity of depression.
Key words: Menopausal women, Heart rate variability, Exercise behavior.
INTRODUCTION
The number of middle-aged women with depression continues to increase because of the psychological and physiological effects of menopause1). The World Health Organization (WHO)
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
defines menopause as a period without menstruation for 12 consecutive months2). Previous studies
have shown that cardiovascular symptoms, depression, and anxiety increase significantly during menopause3, 4). Some studies have also shown that women with menopausal symptoms often
experience deterioration in their quality of life4, 5). Female hormone imbalance, aging, and social and
psychological factors often contribute to these menopausal symptoms. Middle-aged women with menopausal symptoms may benefit from regular exercise, which reduces the psychological symptoms associated with menopause6). However, insufficient exercise leads most middle-aged women to have a
higher risk of depressionbecause of menopausal symptoms.
Heart rate variability (HRV) is a well-known predictor of cardiovascular disease, and can also show the adjustment function of the autonomic nervous system7). The variables of HRV can reflect the
sympathetic or parasympathetic tone, and the balance of both is an important indicator of the cardioregulatory autonomic function. Thus, we hypothesized that HRV would show the adjustment of the autonomic nervous system reflecting the degrees of depression, anxiety, and psychological pressure experienced by menopausal women. Previous studies have which have investigated psychological reactions in menopausal women failed to examine the relationship between HRV and depression 8, 9). Thus, we compared the variables of HRV, including standard deviation of normal to
normal intervals (SDNN), the low frequency (LF) and high frequency (HF) components, and the LF/HF ratio of menopausal women with mild and severe depression.
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
SUBJECTS AND METHODS
This was a cross-sectional study involving community-recruited middle-aged women. The study procedure was approved by the Medical Ethics Committee of a teaching hospital, and all subjects signed a consent form. The inclusion criteria were menopause for 12 consecutive months and low exercise behaviors (exercise participation degree < 6) 10). We calculated the exercise behavior test
based on a questionnaire of exercise participation degree: Exercise participation degree = exercise frequency × (exercise intensity + exercise duration) 10). Exercise frequency represents the number of
days per week on which exercise was performed; exercise intensity represents the number of times the subject felt a rapid heart rate during exercise; and exercise duration represents the duration of the exercise. Each item is scored on a 3-point scale, and exercise participation degree has a maximum possible score of 18. The exclusion criteria were hormone replacement therapy, heart disease or surgery, a history of smoking, and taking any medication, caffeine or alcohol within 24 hours prior to the examination.
We recorded subjects’ basic information, such as age, body mass index, and onset of menopause. All subjects completed a questionnaire, called the Taiwanese depression questionnaire (TDQ), shown in Table 1. This questionnaire contains 18 items, and uses a numerical ranking that indicates the frequency of depression (0 = little or none, or once a week; 1 = occasionally, or 1 to 2 days a week; 2 = often, or 3 to 4 days a week; 3 = always, or 5 to 7 days a week). The maximum possible score is 54, and five levels of depression are categorized. A score of < 8 represents stable emotions; 9 to 14
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
represents mild depression; 15 to 18 represents moderate depression; 19 to 28 represents moderate to severe depression; and > 29 represents the most severe depression. The TDQ is a culturally relevant questionnaire, with a sensitivity of 0.89 and a high specificity of 0.9211). It is an appropriate
questionnaire for screening depression in Taiwan.
Subjects with mild and severe depression received an electrocardiography assessment following the TDQ. We used the limb lead electrocardiography device (CheckMyHeart DailyCare BioMedical, Taiwan) to collect the electrocardiographic signals. Surface electrodes (Ag / AgCl electrodes, Kendall, Germany) were attached to the wrists to record the pulses of the bilateral radial arteries. We analyzed 5-min electrocardiography signals using HRV analysis software (DailyCare BioMedical, Taiwan). We used the frequency-domain method to analyze the electrocardiographic signals and calculate HF, LF, and the LF/HF ratio, and the time-domain method to calculate SDNN. The frequency spectrum range from 0.15 to 0.4 Hz is HF, from 0.04 to 0.15 Hz is LF, and the LF/HF ratio is the ratio of the two values12).
We used the independent t-test to compare the subjects’ basic information and HRV variables to determine the statistical differences between the mild and severe depression groups. We used the Spearman correlation coefficient to analyze the correlations among age, BMI, and HRV variables, and used multiple regression analysis to find predictors. These analyses involved the use of statistical software, SPSS 15 (SPSS Inc., Chicago, USA). We plotted the sensitivity against 1-specificity at different HRV variables to create receiver operating characteristic curves using MedCalc software
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
(Version 9.3.6.0, Mariakerke, Belgium). The areas under the curve with 95% CI for each of the HRV variables determined the accuracy13).
RESULTS
We recruited 200 middle-aged women with menopause to participate in this study. Among them, 28 women (exercise participation degree: 3.21 ± 2.01) with mild depression (TDQ score: 11.62 ± 1.81) and 20 women (exercise participation degree: 3.11 ± 2.54) with severe depression (TDQ score: 24.71 ± 1.57) agreed to provide electrocardiograph signals. Table 2 shows the data obtained from the questionnaire and the electrocardiograph assessment performed at the beginning of the study. No statistical differences between the mild and severe depression groups appeared in between-group comparisons of the subjects’ age, body mass index, onset of menopause, exercise participation degree and SDNN. However, the between-group comparison of HF, LF, and the LF/HF ratio, showed statistical differences (p < 0.05) with the severe depression group showing higher values.
Table 3shows the results of correlation analysis of age, BMI, and HRV variables, showing that HF was significantly and positively correlated with LF (r = 0.78, p < 0.05), and negatively correlated with the LF/HF ratio (r = －0.63, p < 0.05). LF was significantly positively correlated with the LF/HF ratio (r = 0.59, p < 0.05). The subjects’ age, BMI, and HRV variables were included in the multiple linear regression analyses. The LF, HF, and LF/HF ratio made significant contributions to predicting
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
137
138
depression in both groups. However, the variables for age, BMI and SDNN of both groups did not predict depression.
Receiver operating characteristic curve analysis showed that the LF values were the best for discriminating between mild and severe depression in middle-aged women (Fig. 1). The area under the receiver operating characteristic curve for LF (0.72, 95% CI 0.57－0.84) was significantly (p < 0.05) greater than that of HF (0.61, 95% CI 0.45－0.74), but there was no significant difference between LF and the LF/HF ratio (0.77, 95% CI 0.62－0.88).
DISCUSSION
The meta-analysis results of a previous study show that exercise can improve depression symptoms in depression patients, compared with no treatment or other interventions14). Wang et al. showed that
regular exercise by older adults is important for maintaining and improving mental health15). Our results showed no significant difference in the degree of exercise participation which was dependent of the severity of depression. However,we did not compare these results with those of healthy women. Thus, we must presume that there is a psychological benefit to exercise in menopausal women.
This study used SDNN, which represents the cyclic interval changes of heart rate, to identify abnormal cardiac function16). This parameter is a common predictor of cardiovascular disease17).
Because middle-aged women tend to have a lower SDNN as they age18), a decreased SDNN becomes
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
obvious after menopause. Our results show that the mild depression group had a lower SDNN than the severe depression group; they also show that SDNN did not differ significantly between the two groups. Thus, SDNN cannot predict depressive symptoms. Although SDNN is suitable forpredicting cardiovascular disease, we did not investigate heart disease in the subjects. Therefore, it is unclear if an association of depressive symptoms with cardiovascular disease can be directly inferred from SDNN.
The clinical meaning of HF is the tone of parasympathetic activity. A greater HF component indicates a parasympathetic response including decreased blood pressure and heart rate, and physical relaxation19). LF represents the tone of sympathetic activity. A greater LF component indicates a
sympathetic nervous system response, including increased blood pressure, and heart rate, and body tension19). The LF/HF ratio shows the balance between the two states. Clays et al. found that mental
stress causes a decrease in HF and an increase in LF20). They also showed that increasing sympathetic
activity and declining parasympathetic activity cause an imbalance in the autonomic nervous system under stress. This change in autonomic nervous activity can be assessed by HRV to predict the subjects’ psychological status. Moodithaya et al. also found that, because of the interference of physical and psychological symptoms during menopause, middle-aged women with menopause have lower HF, but higher LF and LF/HF18). Their results are similar to those of our present study.
According to Lee et al., HF, LF and the LH/HF ratio differ depending on the level of anxiety in
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
middle-aged women1). Their results are also in agreement with ours. Lee et al. indicated that
menopausal symptoms are major factor affecting the psychological changes1).
The results of our present study suggest that LF and the LF/HF ratio are better than HF at distinguishing between people with different levels of depression.This means that observing the tone of sympathetic activity and the balance of the autonomic nervous system enables determination of severity of depression. Therefore, the findings of the receiver operating characteristic curve are consistent with the suggestion that LF is more sensitive than HF in showing the severity of depression in menopausal women with low exercise behaviors.
REFERENCES
1) Lee JO, Kang SG, Kim SH, et al.: The relationship between menopausal symptoms and heart rate variability in middle aged women. Korean J Fam Med, 2011, 32: 299－305.
2) Martini J, Wittchen HU, Soares CN, et al.: New women-specific diagnostic modules: the Composite International Diagnostic Interview for Women (CIDI-VENUS). Arch Womens Ment Health, 2009, 12: 281－289.
3) Kuczmarski MF, Weddle DO, Jones EM: Maintaining functionality in later years: a review of nutrition and physical activity interventions in postmenopausal women. J Nutr Elder, 2010, 29: 259－292.
175
176
177
178
179
180
181
182
183
184
185
186
187
188
189
190
191
192
4) Kumari M, Stafford M, Marmot M: The menopausal transition was associated in a prospective study with decreased health functioning in women who report menopausal symptoms. J Clin Epidemiol, 2005, 58: 719－727.
5) Colenda CC, Legault C, Rapp SR, et al.: Psychiatric disorders and cognitive dysfunction among older, postmenopausal women: results from the Women's Health Initiative Memory Study. Am J Geriatr Psychiatry, 2010, 18: 177－186.
6) Villaverde Gutiérrez C, Torres Luque G, Ábalos Medina GM, et al.: Influence of exercise on mood in postmenopausal women. J Clin Nurs, 2012, 21: 923－928.
7) Chang WD, Lin HY, Lai PT: Comparison of blood pressure and heart rate variability in Saunders cervical traction at three different forces. J Phys Ther Sci,2012, 24: 509－514.
8) Blasco-Lafarga C, Martínez-Navarro I, Sisamón ME, et al.: Linear and nonlinear heart rate dynamics in elderly inpatients. Relations with comorbidity and depression. Medicina, 2010, 46: 393－400.
9) Kumari M, Stafford M, Marmot M: The menopausal transition was associated in a prospective study with decreased health functioning in women who report menopausal symptoms. J Clin Epidemiol, 2005, 58: 719－727.
10) Rauff EL, Downs DS: Mediating effects of body image satisfaction on exercise behavior, depressive symptoms, and gestational weight gain in pregnancy. Ann Behav Med, 2011, 42: 381 －390.
193
194
195
196
197
198
199
200
201
202
203
204
205
206
207
208
209
210
211
11) Lee Y, Yang MJ, Lai TJ, Chiu NM, Chau TT: Development of the Taiwanese Depression Questionnaire. Chang Gung Med J, 2000, 23: 688－694.
12) Task Force of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology: Heart rate variability: Standards of measurement, physiological interpretation, and clinical use. Eur Heart J, 1996, 17: 354－381.
13) McNeil BJ, Hanley JA: Statistical approaches to the analysis of receiver operating characteristic (ROC) curves. Med Decis Making, 1984, 4: 137–150.
14) Rimer J, Dwan K, Lawlor DA, et al.: Exercise for depression. Cochrane Database Syst Rev, 2012, 11: CD004366.
15) Wang CY, Yeh CJ, Wang CW, et al.: The health benefits following regular ongoing exercise lifestyle in independent community-dwelling older Taiwanese adults. Australas J Ageing, 2011, 30: 22–26.
16) Shehab A, Elnour AA, Struthers AD: Heart rate variability as an indicator of left ventricular systolic dysfunction. Cardiovasc J Afr, 2009, 20: 278–283.
17) Greiser KH, Kluttig A, Schumann B, et al. Cardiovascular diseases, risk factors and short-term heart rate variability in an elderly general population: the CARLA study 2002-2006. Eur J Epidemiol, 2009, 24: 123–142.
18) Moodithaya SS, Avadhany ST: Comparison of cardiac autonomic activity between pre and post menopausal women using heart rate variability. Indian J Physiol Pharmacol, 2009, 53: 227–234.
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
19) Cervantes Blásquez JC, Rodas Font G, Capdevila Ortís L: Heart rate variability and precompetitive anxiety in swimmers. Psicothema, 2009, 21, 4: 531–536.
20) Clays E, De Bacquer D, Crasset V, et al.: The perception of work stressors is related to reduced parasympathetic activity. Int Arch Occup Environ Health, 2011, 84: 185–191.
