A wealth of evidence describes an independent association between urinary incontinence (UI) and depression in the general population. However, it’s still unclear which individuals with UI are at the greatest risk of depression.

Dejan K. Filipas, MD, a clinical fellow in the Center for Surgery and Public Health at Brigham and Women’s Hospital, Elodi J. Dielubanza, MD, formerly an associate surgeon in the Department of Urology and now at the University of Southern California, Quoc-Dien Trinh, MD, MBA, director of ambulatory clinical operations in the Department, and colleagues used data from the National Health and Nutrition Examination Survey (NHANES) to examine this question. In Urology, they conclude the risk is greatest among men and socioeconomically disadvantaged people.

Methods

Conducted each year by the Centers for Disease Control and Prevention, NHANES assesses the health and nutritional status of non-institutionalized U.S. adults. It oversamples people living at or below the federal poverty level as well as various minoritized groups.

In this analysis, the researchers included 8,295 respondents ages ≥20 years who completed the NHANES urinary and mental health questionnaires between 2017 and March 2020.

The nine-item Patient Health Questionnaire was used to screen for depression. The NHANES mental health questionnaire included the question, “How difficult have these problems [depressive symptoms] made it for you to do your work, take care of things at home, or get along with people?” Respondents who answered “somewhat difficult,” “very difficult,” or “extremely difficult” were considered to have clinical depression.

Characteristics of the Weighted Sample

In analyzing the results of NHANES, sampling weights are created to account for differential probabilities of selection and nonresponse and obtain nationally representative estimates. In this analysis, the weighted sample was 233.5 million people, 49% male, 55% married, and 63% non-Hispanic white.

The weighted estimated prevalence of depression was 8.7%. The weighted prevalence of UI was 35% overall, 51% among women and 18% among men.

Urinary Incontinence As a Predictor of Depression

UI was an independent predictor of depression but not clinical depression, and the association increased with the severity of UI. Compared with respondents without UI, the odds of depression were:

• Respondents with moderate UI—adjusted OR (aOR), 1.7; P=0.032
• Respondents with severe UI—aOR, 2.6; P<0.001

Subgroup Analyses

Compared with respondents who did not have UI, the odds of depression were higher in women with severe UI and men who had either moderate or severe UI:

• Women with severe UI—aOR, 2.15; P=0.012
• Men with moderate UI—aOR, 3.51; P=0.002
• Men with severe UI—aOR, 5.23; P=0.010

Interaction Analyses

In multivariable analyses, the association between UI and depression was significantly influenced by both gender and income levels:

• Men with UI were more likely to have depression (OR, 3.62; P<0.001) than women with UI (OR, 1.29; P=0.147) (P for interaction = 0.002)

• Respondents with UI who had the lowest socioeconomic status (≤100% of the federal poverty threshold) were more likely to have depression (OR, 2.2; P=0.005) than those without UI living at >400% of the federal poverty threshold

There was no interaction between UI and age or race.

Recommendations for Primary Care Clinics

In many cases, UI may be a modifiable risk factor for depression. Primary care clinicians have an important role in screening for UI as a tool to reduce depression in the general population.

This study could not directly assess quality of life, but depression may be an indirect result of reduced quality of life due to UI. Workers in activity-intensive blue-collar jobs, such as production or construction, are more likely to be negatively affected than those who have sedentary jobs, and UI may even be a threat to their job security.