The “Aging Males’ Symptoms” (AMS) Scale assesses depression and anxiety

Abstract

Objective: Emotional distress may be associated with severe aging symptoms. This study aimed to investigate aging symptoms in male psychiatric outpatients and their relationship with anxiety and depression.

Method: About 176 male psychiatric outpatients aged 40–80 years were enrolled into this single-center cross-sectional study, and completed self-reported questionnaires including “Aging Males’ Symptoms” (AMS) scale and the Hospital Anxiety and Depression Scale (HADS).

Result: Age was correlated with less anxiety (r = −0.23), less psychological (r = −0.16) and more sexual symptoms (r = 0.31). After controlling demographic variables, the partial correlation coefficients of HADS and AMS scores ranged from 0.30 to 0.73. Four groups were defined by HADS: control (C; n = 103), depression (D; n = 18), anxiety (A; n = 26) and mixed anxiety and depression (M; n = 29). The M group had the most severe aging symptoms, and the C group the least. The A group had more psychological and less sexual symptoms than the D group. “Impaired sexual potency” was the only aging symptom in males not significantly different among the four groups.

Conclusions: Anxiety and depression was associated with more severe aging symptoms in male psychiatric outpatients. Sexual dysfunction could be regarded as the core manifestation to differentiate aging symptoms from syndromal emotional distress.

• Aging Males’ Symptoms (AMS)
• anxiety
• depression
• psychiatric outpatients
• sexual dysfunction

Introduction

The interest of clinic al research in aging males is increasing in recent years, thereby the interest to measure symptoms and health-related quality of life. Aging men may experience various symptoms at the time when women experience their menopausal transition. However, males overlook their symptoms usually. Aging symptoms in males encompass psychological, somatic and sexual dimensions. Various tools have been developed for measurement of aging symptoms in males. The “Aging Male’s Symptoms” (AMS) scale is the best studied and internationally validated and accepted tool in the field [1,2]. AMS scale is a self-administered questionnaire and developed to assess severity of symptoms of aging among groups of males over age of 40 years [3]. The test–retest coefficient of the total score range between 0.8 and 0.9 and the internal consistency coefficients range between 0.7 and 0.8 [2]. A Chinese version of AMS scale (AMS-C) has been validated in the Taiwanese Chinese-Speaking population in the previous study, with a Cronbach α 0.90 and test–rest reliability 0.72 [4]. The previous studies have shown that major depressive disorder is associated with more severe aging symptoms in males, indicated as the higher total score of AMS scale (AMS-T) [5,6]. The prevalence of major depressive disorder ranges from 42% to 48.2% in male climacteric outpatients [5,6], substantially higher than 13.9% in primary care [7]. Screening of major depressive disorder is recommended in aging males [5]. Unlike major depressive disorder, the relationship between aging symptoms and other common emotional distress, such as anxiety and minor depression, is much less investigated. In this regard, the goal of this study was to clarify the relationship between aging symptoms and emotional distress (i.e. depression and anxiety) among male psychiatric outpatients.

Methods

Design and setting

The sample was previously recruited for validation of the Chinese version of the AMS scale, and a more detailed description has been published [4]. One hundred seventy-six Taiwanese men, 40–80 years of age (Mean ± SD: 54.3 ± 10.7 years), attending the psychiatric outpatient service of Chang Gung Memorial Hospital at Linkou (convenience sample) participated in the study. The protocol for the research project has been approved by the Institution Research Board (IRB) of Chang Gung Memorial Hospital at Linkou. All participants reported neurotic symptoms, such as anxiety, depression, insomnia and somatic complaints. The participants were asked to complete questionnaires and had received general psychiatric evaluations during their initial visits. The exclusion criteria included history of psychotic, bipolar, and cognitive disorders, and psychoactive substance abuse. The participants did not receive any psychopharmacotherapy, and had no history of chronic medical diseases, such as hypertension, diabetes mellitus and other medical diseases. The demographic data including body mass index (BMI) were obtained through clinical interviews. Table 1 demonstrates the demographic characteristics of all 176 subjects. The interspousal age gap (IAG) was defined as the absolute age difference between the participants and their spouses.

Table 1. Demographic data and characteristics of the initial participant sample (N = 176).

		n [%]
Age (years)
Mean ± SD	54.3 ± 10.7
40–49		74 [42.0]
50–59		45 [25.6]
60–69		38 [21.6]
70–79		18 [10.2]
80 or more		1 [0.6]
Married		157 [89.2]
Spousal age (years)
Mean ± SD	51.0 ± 10.1
IAG (years)
Median (IQR)	3 (1, 5)
0–2		73 [46.5]
3–5		44 [28.0]
6 or more		40 [25.5]
BMI (kg/m^2)
Mean ± SD	24.4 ± 2.8
Normal (<24.0)		77 [43.8]
Overweight (24.0–26.9)		70 [39.8]
Obesity (27.0 or more)		29 [16.4]
Employed		104 [59.1]
Years of education
0–6		47 [26.7]
7–12		84 [47.7]
13 or more		45 [25.6]

SD = standard deviation, IQR = interquartile range (25th and 75th percentiles), IAG = interspousal age gap, BMI = body mass index.

Main outcome measure

AMS scale

The AMS scale consists of 17 items and three subscales: psychological (AMS-PSY), somatovegetative (AMS-SOM) and sexual (AMS-SEX). AMS-PSY consists of five symptoms (“increased irritability”, “more nervousness”, “more anxiety”, “more depressive” and “burned out”). AMS-SOM consists of seven symptoms (“impaired well-being”, “more joint complaints”, “increased sweating”, “more sleep need”, “more sleep disturbance”, “physical exhaustion” and “muscular weakness”). AMS-SEX consists of five symptoms (“passed peak”, “decreased beard growth”, “impaired sexual potency”, “less morning erection” and “disturbed libido”). Each item is rated on a Likert 5-point scale, with a response of “5” representing “extremely severe” and “1” representing “none”.The total score (AMS-T) measures the overall severity of aging symptoms. The AMS scale is moderately correlated with the Beck Depression Inventory [6,8] and the Hospital Anxiety and Depression Scale (HADS) [4].

Hospital Anxiety and Depression scale

The HADS, a 14-item self-administered questionnaire comprised of a 7-item anxiety scale (HADS-A) and a 7-item depression scale (HADS-D) scored on a Likert 4-point scale (0–3), is designed to provide a simple, yet reliable screening tool for depression and anxiety in various clinical settings with good internal consistency reliabilities for anxiety and depression (0.80 and 0.76, respectively) [9–11], and good sensitivity and specificity (∼0.8) for identifying psychiatric cases [12]. The total score (HADS-T) measures severity of emotional distress. Clinically significant anxiety is defined as a HADS-A ≥ 11; clinically significant depression is defined as a HADS-D ≥ 11 [11].

Groups of emotional distress

In this study, we hypothesized that anxiety and depression would have different effects, and mixed anxiety and depression have a greater effect than either anxiety or depression alone on aging symptoms in males. To determine the effect of emotional distress, the control group (C) was defined as participants having a HADS-A < 11 and a HADS-D < 11, the anxiety group (A) as a HADS-A ≥ 11 and a HADS-D < 11, the depression group (D) as a HADS-A < 11 and a HADS-D ≥ 11, and the mixed anxiety and depression group (M) as a HADS-A ≥ 11 and a HADS-D ≥ 11.

Statistical methods

Statistical analyses were performed using R version 2.14.1 for Windows. The Shapiro-Wilk and Bartlett tests were used to test the parameter distribution. Pearson’s and partial correlation coefficients were obtained. We used nonparametric (Wilcoxon rank sum and Kruskal–Wallis tests) and parametric tests [Student’s t test and one-way analysis of variance (ANOVA)] as appropriate. Either a post hoc nonparametric multiple comparison utilizing multi-t distribution and Tukey method or a Tukey HSD test was used to discern the subgroup difference as appropriate. Fisher’s exact test was used to test for an association between two categorical variables. p Values were two-tailed. The α-level was set at 0.05.

Results

Association among demographic variables

Age was negatively correlated with the HADS-A (r = −0.23, p = 0.003) and AMS-PSY (r = −0.16, p = 0.035) and positively correlated AMS-SEX (r = 0.31, p < 0.001). There was no significant association between the other demographic variables (i.e. IAG, BMI, education, employment and marital status) and HADS and AMS scores.

Partial correlations between HADS and AMS scores

Table 2 showed the partial correlation coefficients between HADS and AMS scores after controlling demographic variables including age, IAG, BMI, education, employment and marital status. All HADS scores were moderately-to-highly correlated with AMS scores. Anxiety symptoms were more associated with psychological symptoms than depressive symptoms, while the depressive symptoms were more associated with sexual symptoms than anxiety symptoms.

Table 2. Partial correlation coefficient of the HADS and AMS scores.

	AMS-T	AMS-PSY	AMS-SOM	AMS-SEX
HADS-T	0.68	0.73	0.59	0.39
HADS-A	0.63	0.73	0.54	0.30
HADS-D	0.56	0.54	0.49	0.38

Demographic variables (age, interspousal age gap, body mass index, education, employment, marital status) were partialized.

HADS = Hospital Anxiety and Depression Scale, HADS-T = total score, HADS-A = anxiety score, HADS-D = depression score, AMS-T = “Aging Males’ Symptoms” (AMS) scale – total score, AMS-PSY = psychological score, AMS-SOM = somatovegetative score, AMS-SEX = sexual score.

Groups of emotional distress

There were 103 (58.5%) participants in the C group, 18 (10.2%) participants in the D group, 26 (14.8%) participants in the A group and 29 (16.5%) participants in the M group. Table 3 shows demographic differences among the groups of emotional distress. Figure 1 shows the differences of the 17 aging symptoms in males across the groups of emotional distress. Table 4 demonstrates the results of ANOVA of AMS scores in the groups of emotional distress. There were significant differences in the IAG, AMS-T, AMS-PSY, AMS-SOM, AMS-SEX and all aging symptoms in males except “impaired sexual potency” (p = 0.056) among groups of emotional distress. A post hoc Tukey test showed that the D group had a significantly higher IAG than the A group.

Figure 1. (a) Psychological symptoms, (b) somatic symptoms and (c) sexual symptoms.

Table 3. Demographic differences in groups of emotional distress.

	C (N = 109)	D (N = 18)	A (N = 26)	M (N = 29)	p
Age (years)
Median (IQR)	54 (46, 62)	55.5 (47.5, 67.5)	48.5 (42.3, 60.8)	52 (46, 55)	0.246*
Spousal age (years)
Mean ± SD	51.6 ± 10.3	52.8 ± 11.8	49.9 ± 9.8	48.9 ± 8.96	0.535†
IAG (years)
Median (IQR)	3 (1, 5)	6 (3, 11.3)	2 (0.5, 5)	2 (1, 6)	0.047*
BMI (kg/m^2)
Mean ± SD	24.5 ± 2.9	23.4 ± 2.9	25.1 ± 2.8	24.2 ± 2.5	0.257†
Married (%)	89.3	88.9	88.5	89.7	1‡
Employed (%)	56.3	50	73.1	62.1	0.376‡
Education (%)					0.210‡
0–6 years	32.0	27.8	15.4	17.2
7–12 years	48.6	44.4	53.8	41.4
>12 years	19.4	27.8	30.8	41.4

C = the control group, D = the depression group, A = the anxiety group, M = the mixed anxiety and depression group, IAG = interspousal age gap, BMI = body mass index, SD = standard deviation, IQR = interquartile range (25th and 75th percentiles).

*Kruskal–Wallis test.

†One-way analysis of variance (ANOVA).

‡Fisher’s exact test.

Table 4. Analysis of variance (ANOVA) of AMS scores in groups of emotional distress.

	C	D	A	M	F (3, 172)
AMS-T	39.4 ± 8.4	44.8 ± 9.5	44.3 ± 8.5	52.3 ± 10.3	36.2***
AMS-PSY	9.5 ± 2.9	12.1 ± 3.3	14.5 ± 3.7	17.5 ± 4.1	52.7***
AMS-SOM	14.6 ± 4.0	18.3 ± 4.3	17.6 ± 3.9	20.8 ± 4.7	19.9***
AMS-SEX	10.4 ± 3.4	14.3 ± 4.4	12.2 ± 3.9	14.0 ± 4.0	11.3***

C = the control group, D = the depression group, A = the anxiety group, M = the mixed anxiety and depression group, AMS-T = “Aging Males’ Symptoms” (AMS) scale – total score, AMS-PSY = psychological score, AMS-SOM = somatovegetative score, AMS-SEX = sexual score.

***p < 0.001.

The D group had significantly higher scores on AMS-T, AMS-PSY, AMS-SOM, “more depression”, “burn out”, “impaired well-being”, “more sleep disturbance”, “physical exhaustion”, “muscle weakness”, “passed peak”, “less morning erection” and “disturbed libido” than the C group. The A group had significantly higher scores on AMS-T, AMS-PSY, AMS-SOM, all five psychological symptoms, “increased sweating”, “physical exhaustion” and “passed peak” than the C group. The M group had significantly higher scores on all AMS scores and aging symptoms in males except “decreased beard growth” and “impaired sexual potency” than the C group. The D group had significantly higher scores on “muscle weakness”, and significantly lower scores on “more anxiety” than the A group. The M group had significantly higher scores on AMS-PSY, all five psychological symptoms, “physical exhaustion” and “muscle weakness” than the D group. The M group had significantly higher scores on AMS-T, AMS-SOM, AMS-SEX, “more depression”, “burn out”, “physical exhaustion” and “muscle weakness” than the A group.

Discussion

In the present study, we examined the clinical characteristics of aging symptoms in males in psychiatric outpatients with neurotic complaints. Age was negatively correlated with anxiety and psychological symptoms, replicating findings of the previous studies [13,14]. Advanced age is associated with less worry [14], and the age-related difference is partially explained by anxiety sensitivity and intolerance of uncertainty [13]. Age was positively correlated with sexual symptoms, paralleling facts of age-related sexual dysfunction [15].

Large age gap may place more psychological burden on couples from differences in sexual function, age identity, health status and social life [16]. In one study of men with symptomatic benign prostate hyperplasia, the IAG is positively correlated with increased symptoms and partner burden [17].

As predicted, both anxiety and depression was associated with more severe aging symptoms in males, and their effects seemed additive. There were minor differences in aging symptoms in males regarding depression and anxiety. Anxiety was associated with more psychological symptoms than depression. Anxiety and depression was associated with similar somatic symptoms. Depression was associated with more “muscle weakness” than anxiety. Among sexual symptoms, anxiety was associated with “passed peak” and depression associated with “passed peak”, “less morning erection” and “disturbed libido”.

It is notable that “impaired sexual potency” was the only symptom not significantly associated with anxiety and depression. The question of “impaired sexual potency” asks subjects to identify the degree of decrease in the ability/frequency to perform sexually, and hence to measure the severity of erectile dysfunction [3]. The bidirectional link between anxiety and depression and sexual dysfunction is well documented in the literature, particularly the loss of libido [18]. Male sexual functioning is significantly correlated with depression and anxiety after controlling age, marital status and education [19]. Depressive symptoms predicts sexual dysfunction [19] and may increase risk of sexual dysfunction with an odds ratio of 1.69 [20]. Sexual dysfunction may increase risk of depression by 3-fold [20]. Up to 50% of men who have erectile dysfunction show depressive symptoms and depression is two to three times more likely in men with erectile dysfunction [18]. In middle-aged and elderly men, erectile dysfunction is associated with severe depressive symptoms, regardless of age, health habit or comorbidity [21]. Anxiety is associated with erectile dysfunction [18,22,23] and disturbed libido [18,22]; however, it was not the case in the present study. The unusual findings in the present study may be explained as follows. First, erectile dysfunction may be a distinguishing aging symptom in psychiatric patients, which is independent from anxiety and depression. Second, depression may have a more pervasive effect on male sexual dysfunction than anxiety [19]. Third, Asian men tend to accept sexual disorder as part of aging, and keep quiet about discussion for sexual dysfunction [15]. Sexual dysfunction is a taboo and culturally restricted topic. Hence, the severity of sexual symptoms might be under-rated. In particular, men may be embarrassed by erectile dysfunction as the cultural beliefs of loss of masculinity and vigor [15].

Limitations

The present study is one of the few reports to investigate relationships between aging symptoms in males and emotional distress, but it is indeed with several methodological limitations. First, we did not record potential confounding factors, such as income, marriage duration, partner relationship and psychosocial stressors, which may contribute to depression and anxiety. Psychosocial assessment may be difficult during the initial visits. Very often, Taiwanese males are often less willing to talk about their private data and conservative about their partner relationship. Second, we did not have detailed medical assessment, and could not exclude the possibility of co-existing general medical condition. There is a lack of hormonal data such as prolactin and testosterone levels. Sexual dysfunction may be explained by vascular diseases, anatomic changes, endocrine abnormalities (e.g. testosterone deficiency and hyperprolactinemia) and neuropsychiatric disorders [24]. Nevertheless, it would be difficult to ask psychiatric patients to undergo blood draws during the initial visit. A comprehensive assessment is often restrained by economic and technical reasons. Third, the result may not be applied to the community-dwelling population due to the small sample size and hospital-based population. However, only 2.3% of patients in the clinics of a university teaching hospital in Taiwan were referred from primary clinics [25]. Therefore, although our sample was collected from a medical center, it did not greatly differ from the demographic patterns of patients attending primary psychiatric clinics.

Conclusions

Anxiety and depression were associated with more severe aging symptoms in males. Specifically, anxiety was associated with more psychological symptoms than depression. Anxiety and depression was associated with similar somatic symptoms. Depression was associated with more sexual symptoms than anxiety. “Impaired sexual potency” is the only aging symptom in males not associated with emotional distress. Psychiatric assessment of aging symptoms in males is important for further differential diagnosis and therapeutic intervention in clinical practice. Further research is needed to clarify the relationship between sexual symptoms and emotional distress in aging males of Asian population.

Declaration of interest

The authors report no conflicts of interest in this work.

Acknowledgements

All of the participants are acknowledged with appreciation.