In this study, the prevalence of depression and anxiety was 27.9% (possible depression: 20.3%; probable depression: 7.6%) and 42.2% (possible depression: 23.5%; probable depression: 18.7%) respectively, which revealed significantly worse psychological status in infertile women in terms of depression and anxiety. In addition, the prevalence of co-morbidity was 22.4% in this study, indicating that depression and anxiety coexisted in Chinese women with infertility. This result was similar to previous studies [22, 34]. This situation should be remarkable because co-morbidity of depression and anxiety showed severer symptoms, lower compliance for treatment and poorer prognosis than patients with a single mental problem in infertile women.
Besides, compared with other studies, the prevalence of mood disorders in our study was higher. For instance, Chiaffarino et al reported that the prevalence of depression and anxiety was 17.9% and 14.7% among women with undergoing assisted reproductive treatment in an Italian infertility department based on 1000 couples . Biringer et al found that 17.0% of infertile women had anxiety and depression was 7.0% in study of Norway based on 12 584 Norwegian women from 1995 to 1997 . In addition, Peterson et al showed that depression was reported in 11.6% of 1131 infertile women in Denmark . Several reasons might explain this difference of prevalence in depression and anxiety among women with infertility. At first, the results of our study might be overrated because of small sample size and high data fluctuation. Furthermore, above research that mainly were conducted in high-income or developed countries had lower level of depression and anxiety compared with developing or low-countries, like China. People in developed or higher income countries tend to possess more adequate health resources and health literacy to deal with mental problems. At last, the continuity of ethnicity is one of the crucial cores in terms of Chinese traditional culture, and Chinese culture places great emphasis on female reputation. However, infertile women fail to achieve a clinical pregnancy. Thus, it is very imperative to find out the crucial influencing factors and targeted solutions to improve mental health in Chinese women with infertility.
According to the results of univariate analyses, our study found income, education, history of infertility treatment, sleep disorders and exercise were associated with depression and anxiety. Education has been significantly associated with the development of depression, which was in line with the findings of previous studies [35, 37]. High education level was related to lower depression because women with higher education may have different life roles or social/work opportunities than becoming mothers and fixing themselves on this life goal. This aspect may allow them to accept infertility in a way to some extent less distressing. Previous study has also found that monthly family income was important factor of depression . Family income has been put an additional strain on psychological and psychological status of couples struggling with infertility . The improvement in educational level and family income might increase the feelings of control and self-confidence in female infertility patients, which relieved depression to some extent. Several articles reported that (mostly unsuccessful) infertility treatments increased the probability of negative emotions , especially in depression and anxiety . Patients with high income had low scores of depressions in our study. Besides, recent study poor sleep quality contributed to the development of depression and anxiety in infertile women with vitro fertilization treatment .
Results of this study showed that after adjusting for control variables, infertility-related stress was an important factor affecting mood disorders in infertile women. More specifically, infertility-related stress was significantly and positively related to depression and anxiety, which was in accordance with several studies. Infertility diagnosis as a neglect stressor increases the feelings of stigma and guilt, which induces series of negative emotions. According to the stress-health theory, high and long-time stress could damage an individual’s immune system, and even lead to psychological and physical vulnerability . Other studies concerning infertility in women reported that infertility-related stress exhibited significant main effect on psychological distress (e.g., depression and anxiety) [18, 19]. Besides, infertility-related stress could decrease the well-being and increase marital conflicts [43, 44]. Noticeably, the mean score of infertility-related stress in our study was higher than other countries [45, 46]. The possible interpretation may be the differences of traditional culture. In China, couples are more inclined to give priority to the needs of family members (e.g., having babies) over their own interest, and they without children are regard as losers. Therefore, female infertility might become more vulnerable to comments about a child, and easily induce uncomfortable feelings, which results in more mental problems.
An increasing number of scholars have become interested in the effects of positive psychological resources on mental health outcomes. Our research extended this research direction to the integrative and independent contributions of these positive psychological to depression in heterogeneous sample of female infertility patients. Self-esteem accounted for a mediating proportion of variance in depression (27.8%) and anxiety (23.8%). As an important inner resource for psychological and social functioning, self-esteem was found to be negatively correlated with trait of depression and anxiety, which were consistent with the findings in previous study [22, 23]. Moreover, self-esteem was independently associated with infertility-related stress, indicating that each form of positive expectations had a unique association with infertility-related stress. These results contributed to the understanding that self-esteem was positive resource for combating mental problems and encouraged us to explore the mediating roles of positive psychological resources in the relationship of infertility-related stress with depression and anxiety in this population.
In the present study, self-esteem played a partial mediating role in the relationship of infertility-related stress with depression and anxiety. In other words, women with fertility who perceived more infertile-related stress would be more likely to experience lower levels of positive psychological resources which in turn increased the possibilities of developing depression. Compared with decreasing patient’s infertility-related stress, it is a more positive and strategic way for people to develop programs to increase the inner positive resources of their patients, thus to enhance the mental health in the long run. Besides, our study found self-esteem moderated the effect of infertility-related stress on depression and anxiety in female infertility. Simple slope analysis showed that when fertile women possessed high self-esteem, depression and anxiety significantly decreased with the high levels of infertility-related stress, compared with low level of infertility-related stress. In other words, women with fertility possess high level of self-esteem, they can better maintain mental health even at a higher level of infertility-related stress. Therefore, resilience should be emphasized and developed to deal with mental problems.