General discussion 275 Inventory of Depressive Symptomatology-Self Report (IDS-SR), which was subdivided into different subscales in Chapter 2 and Chapter 3. The use of the IDS-SR questionnaire is both a strength and a limitation for the studies. On the one hand, the questionnaire results reflects a direct measurement of perceived depressive symptoms, without the risk of participants reporting socially desirable answers or possibility of physician bias (i.e the possible bias of a physician’s assumptions). Furthermore, since the IDS-SR inquires about the presence and severity of a wide range of depressive symptoms, it also enabled the assessment of subclinical symptoms or specific symptoms or symptom groups. On the other hand, the IDS-SR is less suited for determining clinical diagnoses, since a diagnosis of MDD requires a clinical interview or diagnosis by a professional. In Chapter 2, we also examined the presence of clinical depression or dysthymia in the NESDA study through clinical interviews, and we find that the results from the IDS-SR are in line with results from the clinical interviews. In the interpretation of the results from Chapter 3, in which we find significant differences in self-reported depressive symptoms after feminizing compared to masculinizing GAHT, it should be noted that these results cannot directly be generalized to the risk of a clinical depression diagnosis. Furthermore, we did not study the clinical relevance or real-life impact of depressive symptom changes. In clinical practice, a healthcare provider can inquire the impact of someone’s symptoms on their daily functioning, which can aid in determining the clinical and everyday impact of these depressive symptoms. In the works in this thesis, we have not inquired about participants’ quality of life, meaning we cannot estimate the impact of changes in depressive symptoms on participants’ everyday quality of life. This limitation should be taken into account in the interpretation of our results, and future studies should use both qualitative methods and quantitative methods to better examine the possible effects of changes in depressive symptoms on participants’ daily life after starting OC and GAHT use. 3.5. Multifaceted sleep measurements Differences in subjective sleep and insomnia in OC users compared to naturally cycling women were described in Chapter 2 and Chapter 4. The strengths of both studies included that they focused on subjective sleep and insomnia ratings, which are directly relevant to subjective sleep during OC
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