Socioeconomic Status, Anxiety/depression, & Third-line Therapy in an OAB Cohort

Objectives: Women with overactive bladder (OAB) are more likely to have clinically significant anxiety, potentially due to hypothalamic-pituitary-adrenal axis dysregulation and central sensitization, rather than the psychological impacts of incontinence alone. Lower socioeconomic status (SES) resulting in chronic stress compounds this effect, necessitating higher therapy lines. Our objectives were to describe prevalence of and characteristics associated with anxiety/depression within a cohort treated for OAB, and explore factors associated with receipt of third-line therapy and cost barriers to treatment. We hypothesized that lower SES would be associated with presence of depression/anxiety, receipt of third-line therapy, and cost barriers to OAB treatment.

Methods: We conducted a retrospective chart review of patients presenting (2021-2023) for treatment of OAB in a Urogynecology clinic within an urban academic hospital. At the initial visit, age, insurance status, self-reported race and ethnicity, PFDI-20 scores, indicators of mental health concerns (MHC, prescription of anxiolytic or antidepressant, or diagnosis of anxiety or depression) were abstracted. Hardship index (HI), a geospatial marker representing a combination of socioeconomic indicators of public health significance within a “community area” ranging from 1 (low) to 98 (high hardship), was also abstracted from the subset of patients with available data. Logistic regression models were fitted to examine sociodemographic and clinical characteristics associated with prevalence of baseline MHC, foregoing treatment due to cost, and receipt of third-line therapy.

Results: In 173 patients median age was 67 years (IQR: 52, 74); 74% were White, and 46% had a combination of Medicare and private insurance (46%). In 51 patients with available data (29%), median HI was 21 (IQR: 8, 53) (Table 1). Most patients had MHC at baseline (71%); 29% and 49% of patients with anxiety and depression were taking anxiolytics and antidepressants, respectively. No differences in demographic, clinical, or SES characteristics were detected in patients with and without MHC at baseline.

Approximately a third (36%) of patients received third-line therapy, including onabotulinumtoxinA or neuromodulation, and 21% of patients forewent treatment due to cost. After adjustment (Table 2), patients with Medicare insurance had higher odds of third-line therapy (aOR (95% CI) = 2.91 (1.53 to 5.66)). No differences in demographic, clinical, or SES characteristics were detected in patients who did and did not forgo therapy due to cost.

Conclusions: Consistent with existing literature, most patients presenting for OAB treatment had a coexisting MHC. Medicare was associated with receipt of third-line therapy. Mechanisms may include age-related disease progression, or improved insurance coverage. No differences in prevalence of MHC, receipt of third-line therapy, or cost barriers were detected for higher HI in the subsample where this was available; however, analysis of populations at greater risk of experiencing place-related socioeconomic stress is needed to fully evaluate potential associations with MHC in patients with OAB.