Clinical Review

Depression: Tailoring treatment to life stage

OBG Manag. 2003 March;15(3):21-34

One in 4 women experiences at least 1 major depressive episode in her lifetime—almost invariably during the reproductive years. A psychiatrist and Ob/Gyn surveys the characteristic symptoms and appropriate treatment strategies specific to each age.

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References

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KEY POINTS

A woman is most biologically vulnerable to psychiatric illness during the postpartum period.
Antidepressant medications are not teratogenic.
Risks associated with untreated postpartum depression have the greatest short- and long-term ramifications for both the patient and her offspring.
Women may seek treatment only for premenstrual worsening of symptoms because they fail to recognize their ever-present depression.
Women with premenstrual exacerbation of underlying depression may be at elevated risk of suicide.

Most of us have heard the statistic: The rate of depression is twice as high in women as in men.

A closer look reveals that the higher rate in women occurs during the reproductive years, when the Ob/Gyn is often the primary care-giver.¹ Because Ob/Gyns are called upon to provide a wide range of general medical care, it is important that we know how to recognize and treat depression in our patients.

Depressive disorders in women often occur in relation to estrogen levels, although nonhormonal factors also pose risks for depressive illness (TABLE 1).

TABLE 1

Risk factors for depressive disorders in women

Personal history of depression or bipolar disorder Family history of depression, bipolar disorder, suicide Childhood sexual abuse Lack of safe environment Substance abuse Recent stressful life events Concurrent medical illness Pregnancy or recent delivery

Presenting symptoms in women

Sleep disturbances (hypersomnia, insomnia), weight gain or loss, and low energy (excessive tiredness, lack of energy, reduced activities) are common presenting complaints; however, some depressed women complain of symptoms such as pain (chronic pelvic pain, headaches, low back pain) or sexual problems (decreased interest in sex, decreased sexual pleasure).

Hormone-related depression

Assessing adolescents. Beginning with puberty, the incidence of depression increases markedly. No evaluation of an adolescent female is complete until she is asked about mood symptoms. This is especially important for adolescents seeking oral contraceptives. Birth control pills may cause depressive symptoms or worsen symptoms in those who are already depressed. Note that a depressed adolescent often appears “mad” rather than 8221;sad.”

Premenstrual exacerbation of underlying depression. Symptoms of depressive disorder almost always worsen premenstrually. Fortunately, premenstrual syndrome (PMS) carries less stigma than it used to, so women today are more likely to mention their symptoms. They may not realize, however, that their symptoms persist throughout the month, and only worsen in the days leading up to menstruation.

Women with dysthymia, for example, often seek treatment only for premenstrual worsening of their symptoms because they fail to recognize their ever-present depression. Patients with other depressive disorders may make the same error. It is essential that the patient keep a daily symptom diary to detect premenstrual exacerbation of underlying depression, since women with this symptom pattern may be at elevated risk of suicide.

Pregnancy. Pregnancy offers no protection against depressive illness. About 10% to 16% of pregnant women meet the criteria for a major depressive episode.² Although these rates are equivalent to those in nonpregnant women, the risk of untreated depressive illness is likely to be greater during gestation.

Depression in pregnant women may be associated with poor self-care, poor weight gain, and “self-medication” with alcohol, tobacco, or illicit drugs. Patients reporting such issues should be questioned about their mood.

Postpartum period. Women are more biologically vulnerable to psychiatric illness during the postpartum period than at any other time in life; further, the risks associated with untreated postpartum depression have the greatest short- and long-term ramifications for both the patient and her offspring.³ It is well documented that untreated postpartum depression is associated with a disturbed maternal-infant relationship, later psychiatric morbidity in children, marital tension, and suicide/infanticide.

Perimenopause. Depressive symptoms commonly recur during the perimenopausal years, although new-onset depression is unlikely in this age group.

Postmenopause. Depressive symptoms tend to decrease after menopause, even in women with a history of depression.⁴

Spectrum of depressive disorders

TABLE 2 lists the symptoms used in the diagnosis of depressive disorders, and displays them with a popular mnemonic, SIG E CAPS.

The diagnosis of a major depressive episode requires that a patient have 5 or more symptoms that cause significant impairment and have persisted for a minimum of 2 weeks. At least 1 of the symptoms must be sadness or a loss of interest.⁵

Major depressive disorder falls within a spectrum of depressive disorders:

Major depressive episode: 5 or more symptoms from TABLE 2.
Minor depressive disorder (also called “subsyndromal” depression): At least 2 symptoms in TABLE 2. Recent research indicates that minor depression can increase the likelihood of recurrent depressive episodes.⁶
Dysthymia: Low-grade depressive symptoms persisting over at least 2 years. As discussed, women with dysthymia often fail to recognize their depression, seeking treatment only for premenstrual worsening of symptoms. In addition, perhaps because of its long duration, dysthymia can be quite resistant to treatment.
Adjustment disorder with depressed mood: Depressive symptoms in response to an identifiable stressor. Women with adjustment disorders can progress to more severe symptoms and become suicidal.
Depressive disorder not otherwise specified, such as premenstrual dysphoric disorder.