DEPRESSION IN WOMEN 
|
|
|
MARIA DEL PILAR YAG�E, R.N.
|
|
|
DEPRESSION IN WOMEN
Abstract:
Depression strikes twice as many women as men. The dramatic changes in psychoactive hormones like estrogen and progesterone that occur during menstrual cycles and during pregnancy are believed to be key factors. According to the 4th Edition of the Diagnostic and Statistical Manual (DSM-IV), the diagnosis of depression requires that specific criteria be met: depressed mood or loss of interest or pleasure of at least 2 weeks' duration plus at least 4 of the following additional symptoms: change in weight, altered sleep pattern, psychomotor agitation or retardation, fatigue, difficulty concentrating, feelings of worthlessness or guilt, and suicidal ideation. Several new drug therapies are available for treating major depressive illness.
Suicidal thoughts are not just thoughts of how someone might end her life. When people get very depressed, they don't necessarily have those kinds of thoughts, but they have thoughts about wishing for death. They'll say, "You know, I was crossing the street. I saw a bus coming and I wondered to myself, why step out of the way?" This would be what we call a passive suicidal thought, but it is a suicidal thought nevertheless. It may be a wish for death or just the sense that it doesn't matter whether you protect your life or not.
To make the diagnosis of major depressive disorder, the physician must determine that the woman has had the necessary number of symptoms for at least 2 weeks. A lot of times people have had the symptoms far longer. In fact, most people with depression don't actually receive treatment. Depression is usually self-remitting. That means that, if the patient waits long enough, even without treatment, the depression will lift and sometimes even go away entirely. However, the patient can have a very torturous time waiting to get better, and some will never recover fully without treatment. Depression thus turns out to be a very important illness to recognize and diagnose.
What is most significant here is that about 7% of women in the US had gone through a depression, compared with only about 3% of men. In the similar studies done in Edmonton, Canada, Puerto Rico, Paris, and West Germany, about twice as many women had had a serious depression using these criteria compared with men. The most interesting observation is that no matter where these studies were conducted, women had more episodes of depression than men.
The first of these is initial maternal indifference. Not everybody would call that a mood problem. But that should be in the differential diagnosis when the physician sees someone who's having difficulty postpartum. Initial maternal indifference is usually seen right after delivery in the hospital. The mother reports having no particular feelings one way or the other for the baby. The typical onset is day 1 of delivery, and the typical duration is 3 days, which is very short. Prevalence is high--as many as 40% of women experience initial maternal indifference with their first child. The potential for suicide or infanticide is very low.
To illustrate this, I use myself as an example. I was in the hospital for 5 days after a cesarean section, and my newborn was rooming in with me. On about day 4, it suddenly occurred to me that the baby needed her diapers changed. It hadn't occurred to me until then, because someone else had been changing her diapers, obviously. That may have been a touch of initial maternal indifference. Appropriate management includes child care education and support for the mother, as this is a self-limited problem.
At the next level of severity is postpartum blues, or "baby blues," which is very common. About 70% of women have at least some symptoms. The onset occurs anywhere from 3 days to 1 month after delivery, but usually postpartum blues is seen in the first few days after delivery. It is rare to see symptoms presenting after a month. The duration is very short, less than 10 days.
How do women behave when they have postpartum blues? They cry. They can't sleep. They feel confused. They don't understand why they're not excited and happy because they just had a beautiful baby, and everyone else around them--their parents, their husbands, other family members and friends--is so happy. Postpartum blues are so common that we don't call the symptoms a disorder. They are just phenomena that travel with being pregnant and having a baby. But the physician needs to consider postpartum blues in the differential diagnosis if a patient is having mood problems after delivery. The prognosis for baby blues is very good. The woman doesn't need any specific treatment. She just needs education about what the condition is, reassurance that it will pass quickly, and emotional support until it does.
The most serious pregnancy-related disorder is postpartum psychosis. The prevalence is rare, about 1 in 500 deliveries. In psychiatry, we hardly ever see anybody who is more ill than a woman who has a postpartum psychosis. These women hallucinate, they're delusional, they're very agitated. They can't care for the baby, and they can't care for themselves. Their reality testing is so poor that they may be a danger to themselves and others, including their infants.
Usually, if postpartum psychosis develops, it begins in the first month after delivery, most often between 1 and 2 weeks. The woman must be treated immediately, as postpartum psychosis doesn't go away by itself. It is dangerous. People usually can't stay at home. There is significant risk of suicide, and there's significant risk of infanticide.
What causes postpartum psychosis? This is not well understood, but we have some valuable clues. One clue is that if a woman has a previous history of bipolar (manic-depressive) illness, her chances for developing a postpartum psychosis increase from 1 in 500 to 1 in 5. This suggests that there is a relationship between postpartum psychosis and bipolar illness or similar affective disorders. As soon as a pregnant woman's history of bipolar illness, postpartum psychosis, or both is identified, the physician needs to talk with the woman and her family well before delivery about making plans to prevent and/or treat a postpartum psychotic episode, should it occur.
The last effective disorder is nonpsychotic major postpartum depressive disorder--one of the most common postpartum disorders. The prevalence is 10% to 15%. Women who have a prior history of depression are at higher risk. The woman may have suicidal ideation but usually is not psychotic. Sometimes, but not always, hospitalization is needed for effective treatment.
Many women have had postpartum depressions of this kind. These women frequently, though not always, require treatment with antidepressants, such as the tricyclic antidepressants (eg, imipramine, nortriptyline) or the selective serotonin reuptake inhibitors (eg, fluoxetine, sertraline, and paroxetine). This is a difficult issue, particularly if the woman is breast-feeding. Variable amounts of medication can pass into the breast milk, potentially affecting the infant, whose nervous system is still developing. The conservative approach is to recommend that a woman stop breast-feeding if she is significantly depressed and requires antidepressants.
During the course of a full-term pregnancy, the levels of hormones secreted by the corpus luteum and the placenta rise dramatically. For instance, from 8 to 38 weeks, progesterone rises 7-fold, estradiol 130-fold, and prolactin levels 19-fold.[6]
A major reason why these hormone levels are so high is that the placenta is an endocrine organ that produces hormones, many of which are psychoactive. When the baby and placenta are delivered, estrogen and progesterone drop precipitously. What is most impressive is that not every woman gets depressed with changes like this. In fact, most people keep it together. They don't feel all that depressed. They feel good, happy, and stable. A woman's body is an incredible system.
However, not everyone's body works perfectly. Some people are more vulnerable to hormonal changes, and thus are more vulnerable to getting depressed or sometimes hypomanic. The people who are the most vulnerable are the ones who have a history of affective illness either independent of or related to reproductive events.
On the other hand, about 3% to 5% of menstruating women develop premenstrual dysphoric disorder (PDD), which can be a very impairing condition. PDD is not an accepted diagnosis in the DSM-IV, but it is listed in the appendix as "needing further study."
Many interesting articles have been written about this diagnosis, and some have argued that it "pathologizes" women. That is, it creates a pathologic category for a condition that is part of reproductive life. There is hot political debate about whether a diagnosis like this, which only applies to women, is appropriate to make, or whether it perpetuates sexist treatment of women, particularly in the workplace or legal system.
From a physician's standpoint, I find that PDD is a meaningful concept. The diagnosis should only be used for somebody who has very severe premenstrual changes, but these women do stand out. The definition, as found in the DSM-IV, is precise: First, there is a requirement that the woman must have the disorder almost every month. If a symptom occurs only in 5 out of 12 menstrual cycles, it can not be attributed to PDD. Then, there have to be 5 or more symptoms within a characteristic time frame. The symptoms must be present, invariably, the week before the woman starts menstruating, and must have disappeared by the week after she has finished menstruating. Symptoms include depression, anxiety, lability, irritability, loss of interest or pleasure in things, difficulty concentrating, lethargy, appetite changes, hypersomnia or insomnia, feeling out of control, and other physical symptoms, such as breast pain or headaches.
These criteria are very stringent. The only way to know whether these criteria are met is to show patients how to keep a diary. A record of feelings and symptoms must be kept on a daily basis. The diagnosis cannot be based on the woman's memory of her feelings and symptoms, because retrospective distortion is too great.
Many women with PDD have physical symptoms, but emotional symptoms are the crux. Symptoms such as depression, anxiety, irritability, loss of interest in things, difficulty concentrating, lethargy, appetite, and sleep changes are similar to those seen in a major depressive episode, but the pattern is different: The woman has to have these symptoms for at least a week, premenstrually, and they must disappear completely after she finishes menstruation.
The typical woman with PDD is very busy, yet is motivated enough to keep a diary and to find the time to make the trip to a specialty clinic for evaluation. When you see her, she says something like, "You know, I'm like Dr. Jekyll and Mr. Hyde. I'm the nicest person, the sweetest person; I do a lot of things; I'm very even-tempered almost all month. But the week before I get my period, I'm like a different person. I can't control my temper, I yell at the kids, my husband wants to move into a hotel, and I don't know what to do. The littlest thing gets me all upset."
Often, she describes something really awful that has happened to make her seek treatment. For instance, one woman said she had saved for 6 months to buy some really expensive wallpaper for her dining room. One day when she was premenstrual, after the new wallpaper had been hung, one of her children spoke to her disrespectfully after she had made dinner, so she picked up a plate of spaghetti and threw it against the wall. She was not somebody who ordinarily would do that. She really valued that wallpaper, but she just couldn't control herself. Her behavior was self-destructive.
Often, these women said that the reason they were seeking evaluation was that they were afraid they would start hitting their children. Thus, they were highly motivated to seek help. As there are very good treatments available, it was possible to help these women substantially.
Commonly recommended treatments for premenstrual dysphoria include nonmedication approaches such as exercising regularly, eating more frequently, and exercising more. But some women need to do more than that. Anxiolytic drugs (eg, alprazolam) have been tested and found to be very effective in some women when used according to a specific schedule with increasing doses during symptomatic days, then rapid tapering once menses begins.[7] However, anxiolytics can lead to habituation and may be contraindicated for any patient with a tendency toward substance abuse. Antidepressants also have been found to be extremely effective for many women with severe premenstrual dysphoria.[8]The newer antidepressants like fluoxetine, paroxetine, and sertraline, which are selective serotonin reuptake inhibitors, produce fewer side effects than the older antidepressants. They are very well accepted and have been shown to help many women.[9,10]
Most of the women who have PDD have also had previous episodes of major depressive illness. So these difficulties tend to turn up in the same person. One way to think about it is that all of us are particularly vulnerable to some symptoms. Some people, when they get stressed, get headaches; others don't sleep well, some get abdominal cramps, and some get depressed. The stressor can be an emotional event, or it can be a physical event like a change in hormonal levels. Obviously, when multiple stressors occur at the same time, a person is more likely to develop symptoms.
There are many other contributors to depression in women besides hormones. In some parts of our culture, women are badly treated, have much responsibility and little autonomy, are economically dependent, and are in abusive relationships they can't get out of. These situations also have been shown to contribute to depression. I don't mean to imply that the cause is only physical. But the physical aspect is one major reason, I think, why women have more depression and related illnesses than men do.
On the other hand, the part of the perimenopausal period before menses cease (corresponding roughly to the forties) is associated with an increase in a variety of somatic and behavioral symptoms including hot flashes, sleep difficulties, and depressive affect. A number of investigators have noted an increased incidence of depression in women with somatic estrogen deficiency symptoms or prolonged periods of physical symptomatology.[14,15] It is unclear whether this relationship exists because all these symptoms--both emotional and physical--are reactions to estrogen withdrawal in women who are biologically vulnerable (a direct effect), or because physical symptoms have a negative effect on well-being (an indirect effect).
The hormonal events occurring during the menopausal period are complex. In general, as the ovaries fail, they produce less estrogen and progesterone. In turn, the pituitary gonadotropins FSH and LH increase. Sherwin[16] has reported that surgically menopausal women treated with hormone replacement levels of estrogen or estrogen/androgen combination experienced more positive moods. Estrogen treatment was associated with better performance on verbal memory tasks, while the women receiving androgens alone or in combination with estrogens had higher levels of sexual desire and arousal.[16] Generally, however, the doses of estrogen used for hormone replacement, although contributing to positive mood states in normal menopausal women, do not relieve clinical levels of depression.
Thus, the physician who sees menopausal women with a variety of physical and emotional complaints must evaluate the pattern, severity, and duration of both kinds of difficulties. If there are no contraindications to hormone replacement therapy (HRT), and the woman's physical symptoms of estrogen deficiency are significant, HRT should be considered. If the emotional symptoms do not resolve with HRT or if they are severe and lasting, antidepressants are likely to be useful. Obviously, past history is also important--a woman who has a past history of major depressive episodes that required treatment with psychotropic medication should receive them again, because HRT alone is unlikely to relieve her symptoms. Some women with menopausal loss of libido will respond positively to the addition of low-dose androgens to their hormone replacement regimen. These should be considered in women with recent onset of loss of sexual interest and excitement if they have no medical contraindications and there is no environmental explanation for the change in libido.
It is critical to back research that includes women. Of course, it is difficult to study women because of cyclic hormonal changes and because women can't be given medicines should they become pregnant while participating in a study. Countless medicines have only been tested on men because of the possibility that women may get pregnant while on the medication and that something may happen to the baby. This situation leads to ignorance about treatments that can potentially help women, and it must change.
We need more information about mechanisms underlying mood disorders to find out why some people are so sensitive to hormonal changes and other people aren't. Much research that has been done to date to predict which women are going to suffer from a postpartum depression, for example, has failed to answer critical questions. This is because when researchers measured hormones in the women who got sick and in those who didn't get sick, they found no differences. Apparently, they weren't measuring the right thing. The difference may be in brain sensitivity, not in peripheral hormone levels. We don't know nearly enough yet about the mechanism of the interaction of hormones and mood disorders. If we understood the mechanisms better, we could much more effectively identify who is at risk and treat them in a timely fashion.
Finally, we health professionals need to back better treatment arrangements and better interventions. For example, in England, when a new mother is hospitalized for psychiatric reasons, such as postpartum psychosis, the newborn often is permitted to stay with the mother in a mother-baby unit. It's a very intensive nursing care situation, as you might imagine, because these babies are not safe with the unsupervised mothers. Yet, it is much easier to encourage women to accept treatment if they don't have to be separated from their baby. We need to make interventions like that available to women in this country so that they can get treatment when they really need it. |
|
|
|
