Focus on Women: Mental Health Throughout the Life Cycle
by Anne Lambert, MS
The psychosocial and biological components of mental illness differ in presentation and prevalence among women and men. For example, major depression has an estimated lifetime prevalence of 17% and affects approximately twice as many women as men.(1) Guideline-based treatment for depression is not “one-size-fits-all,” and physicians need to pay attention to gender and biological differences that impact an array of outcomes including treatment response. Scientists have demonstrated the effect of hormones on brain chemistry that controls emotions and mood, and are studying the connection between the occurrence of mental illness and the changes in female hormones during specific times in a woman’s life including puberty, before menstrual periods, the antenatal and postpartum periods, and perimenopause.(2)
After puberty, some women may experience premenstrual dysphoric disorder (PMDD), which is characterized by depression, anxiety, irritability, and mood swings the week before menstruation and a few days into each period, to a degree that severely limits normal functioning.(3) Previously, researchers have demonstrated that women with PMDD have an abnormal response to normal hormone levels and are sensitive to their own hormone changes.(3-5) New research has shown that PMDD is a heritable mood disorder that is triggered by gonadal steroids during the luteal phase in susceptible women.(6) David Rubinow, MD, Meymandi Distinguished Professor and Chair of Psychiatry, University of North Carolina School of Medicine, Chapel Hill, notes that these findings "may help fill in the picture of how changes in ovarian hormones can lead to depression and why they do so only in a small subset of women."
The need for physician education is crucial in this area. In a recent survey, nine out of every 10 women said they would be reluctant to seek medical treatment even if they thought they had PMDD because they thought they could cope with their problems on their own. Twenty-seven percent of respondents said that they had never discussed PMS or PMDD with a doctor and felt that their complaints would not be taken seriously. Jean Endicott, PhD, Director of the Premenstrual Evaluation Unit at Columbia Presbyterian Medical Center, said "They fear becoming the target of jokes or that seeking help is a sign of weakness. Informing women and providers about diagnosing and treating PMDD helps clear the way to effective medical care."
The occurrence of pregnancy-related depression is an ongoing challenge for psychiatrists and healthcare professionals. In general, it is desirable to minimize or avoid the use of any medication during early pregnancy. To date, psychotropic drugs have not been approved by the Food and Drug Administration for use during pregnancy; studies have also raised concerns about the teratogenicity and neonatal complications associated with commonly used antidepressants.(7) These concerns and the absence of predictive data from large sample studies makes choosing the best strategy uncertain.(8) In clinical practice, patient assessment often minimizes the risks associated with untreated maternal depression.(9)
Ten to twenty percent of pregnant women experience antenatal depression,(9,10) which has been associated with prematurity, fetal distress, neonatal behavioral differences,(11) and a greater risk of postpartum depression.(12) In a sample of pregnant women with a history of major depressive disorder, 43% experienced a major depressive episode during pregnancy; among women who discontinued antidepressant medication at the start of the pregnancy, the rate was 68%.(13) There is an urgent need to educate psychiatrists and other healthcare professionals about the risks of untreated mental illness in pregnant women. Clearly, this is a complicated educational topic with a real gap in optimal patient outcomes.
The postpartum period may also be a time of increased vulnerability for mental disorders. One study found that postpartum women are at an increased risk for several mental disorders, including depression, for several months after childbirth.(8) Women with bipolar disorder are at particularly high risk for a postpartum episode.(14) For women who choose to breastfeed their infants, treatment selection during the postpartum period must be done with great care.
All medications pass into infant circulation to varying degrees, although a direct relationship between concentration of these medications (and their active metabolites) on infant physiology, behavior, and development is unknown.(15)
Nonpharmacological approaches may offer some relief. Psychotherapy has proven to be helpful for women experiencing antenatal or postpartum depression.(16-18) Bright light therapy also appears to be a promising treatment,(19,20) as does exercise. The American College of Obstetricians and Gynecologists recommends 30 minutes of exercise daily during pregnancy.(21,22) In cases of severe depression during pregnancy, ECT is considered an effective treatment option.(23)
Studies have also found that omega-3 fatty acids for treatment of depression in pregnant and postpartum women are well tolerated.(24) Dr. Kuan-Pin Su, of China Medical University Hospital, Taiwan, and his colleagues propose that "a profound decrease of omega-3 fatty acids in the mother during pregnancy is associated with the higher demand of fetal development and might precipitate the occurrence of depression."(25)
Depression during perimenopause can be associated with significant disability and morbidity. While the relationship between the onset of depressive illness and perimenopause is still being elucidated, clinic-based studies have documented that, for some middle-aged women, perimenopause is associated with an increased vulnerability to depression.(26) Cohen and colleagues found that premenopausal women with no lifetime history of major depression who entered perimenopause were twice as likely to develop significant depressive symptoms as women who remained premenopausal. The increased risk for depression was somewhat greater in women with self-reported vasomotor symptoms.(27) As science investigates the causes and associations of mental disorders associated with the change in female hormones over the life cycle, it is of utmost importance for clinicians to be informed and to have access to cutting-edge, evidence-based data to help their patients.
The research community continues to examine how genetic, biological, chemical, hormonal, environmental, psychological, and social factors may intersect to contribute to mental disorders in women.(2) Scientists are also finding that female hormones have a neuroprotective effect in some disorders, such as schizophrenia(28) and Alzheimer’s disease.(29) Psychiatrists and other healthcare professionals must stay abreast of the new developments, evidence-based data, and the clinical expertise of colleagues to provide optimized patient outcomes for women from menarche to menopause.
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- Schmidt PJ, Rubinow DR. Reproductive ageing, sex steroids and depression. J Br Menopause Soc 2006;12:178-185.
- National Institute of Mental Health. Women and Mental Health. Available at: http://www.nimh.nih.gov/health/topics/women-and-mental-health/index.shtml. 2008.
- Rubinow DR, Schmidt PJ. Gonadal steroid regulation of mood: the lessons of premenstrual syndrome. Front Neuroendocrinol 2006;27:210-216.
- Rubinow DR, Schmidt PJ, Roca CA. Estrogen-serotonin interactions: implications for affective regulation. Biol Psychiatry 1998;44:839-850.
- Schmidt PJ, Nieman LK, Danaceau MA, Adams LF, Rubinow DR. Differential behavioral effects of gonadal steroids in women with and in those without premenstrual syndrome. N Engl J Med 1998;338:209-216.
- Huo L, Straub RE, Roca C, et al. Risk for premenstrual dysphoric disorder is associated with genetic variation in ESR1, the estrogen receptor alpha gene. Biol Psychiatry 2007;62:925-933.
- Marcus SM, Flynn HA, Blow FC, Barry KL. Depressive symptoms among pregnant women screened in obstetrics settings. J Womens Health (Larchmt) 2003;12:373-380.
- Rubinow DR. Antidepressant treatment during pregnancy: between Scylla and Charybdis. Am J Psychiatry 2006;163:954-956.
- Freeman MP. Antenatal depression: navigating the treatment dilemmas. Am J Psychiatry 2007;164:1162-1165.
- Evans J, Heron J, Francomb H, Oke S, Golding J. Cohort study of depressed mood during pregnancy and after childbirth. BMJ 2001;323:257-260.
- Wisner KL, Zarin DA, Holmboe ES, et al. Risk-benefit decision making for treatment of depression during pregnancy. Am J Psychiatry 2000;157:1933-1940.
- Stowe ZN, Hostetter AL, Newport DJ. The onset of postpartum depression: Implications for clinical screening in obstetrical and primary care. Am J Obstet Gynecol 2005;192:522-526.
- Cohen LS, Altshuler LL, Harlow BL, et al. Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment. JAMA 2006;295:499-507.
- Hunt N, Silverstone T. Does puerperal illness distinguish a subgroup of bipolar patients? J Affect Disord 1995;34:101-107.
- Burt VK, Suri R, Altshuler L, Stowe Z, Hendrick VC, Muntean E. The use of psychotropic medications during breast-feeding. Am J Psychiatry 2001;158:1001-1009.
- Spinelli MG, Endicott J. Controlled clinical trial of interpersonal psychotherapy versus parenting education program for depressed pregnant women. Am J Psychiatry 2003;160:555-562.
- Zlotnick C, Miller IW, Pearlstein T, Howard M, Sweeney P. A preventive intervention for pregnant women on public assistance at risk for postpartum depression. Am J Psychiatry 2006;163:1443-1445.
- Dennis CL. Psychosocial and psychological interventions for prevention of postnatal depression: systematic review. BMJ 2005;331:15.
- Oren DA, Wisner KL, Spinelli M, et al. An open trial of morning light therapy for treatment of antepartum depression. Am J Psychiatry 2002;159:666-669.
- Epperson CN, Terman M, Terman JS, et al. Randomized clinical trial of bright light therapy for antepartum depression: preliminary findings. J Clin Psychiatry 2004;65:421-425.
- Trivedi MH, Greer TL, Grannemann BD, Chambliss HO, Jordan AN. Exercise as an augmentation strategy for treatment of major depression. J Psychiatr Pract 2006;12:205-213.
- Artal R, O'Toole M. Guidelines of the American College of Obstetricians and Gynecologists for exercise during pregnancy and the postpartum period. Br J Sports Med 2003;37:6-12; discussion 12.
- Miller LJ. Use of electroconvulsive therapy during pregnancy. Hosp Community Psychiatry 1994;45:444-450.
- Freeman MP, Hibbeln JR, Wisner KL, Brumbach BH, Watchman M, Gelenberg AJ. Randomized dose-ranging pilot trial of omega-3 fatty acids for postpartum depression. Acta Psychiatr Scand 2006;113:31-35.
- Su KP, Huang SY, Chiu TH, et al. Omega-3 fatty acids for major depressive disorder during pregnancy: results from a randomized, double-blind, placebo-controlled trial. J Clin Psychiatry 2008;69:644-651.
- Steinberg EM, Rubinow DR, Bartko JJ, et al. A cross-sectional evaluation of perimenopausal depression. J Clin Psychiatry 2008;69:973-980.
- Cohen LS, Soares CN, Vitonis AF, Otto MW, Harlow BL. Risk for new onset of depression during the menopausal transition: the Harvard study of moods and cycles. Arch Gen Psychiatry 2006;63:385-390.
- Kulkarni J, de Castella A, Fitzgerald PB, et al. Estrogen in severe mental illness: a potential new treatment approach. Arch Gen Psychiatry 2008;65:955-960.
- Rocca WA, Bower JH, Maraganore DM, et al. Increased risk of cognitive impairment or dementia in women who underwent oophorectomy before menopause. Neurology 2007;69:1074-1083.