Depressive Disorders in
Women
Women’s Health Conference
Orlando, Florida March 2011
Norma Jo Waxman MD
Associate Professor of Family and Community Medicine
Faculty, The Bixby Center for Global Reproductive Health
University of California San Francisco
njwaxman@fcm.ucsf.edu
Objectives
At the end of the talk participants
will be able to:
Describe the range of Mood Disorders women
experience
Recognize post partum mood disorders
Prescribe medications for depression in women
and know when to refer
Mood Disorders =
Affective Disorders
• Disturbance in mood
• Inappropriate, exaggerated, or limited range of
feelings
• Everybody gets down, and everybody
experiences excitement and pleasure
• Mood disorder: feelings are extreme
• Crying, and/or feeling depressed, suicidal
• Or excessive energy, sleep not needed for days
and decision making significantly hindered
Common Disease
•
•
•
•
10% of primary care adult patients
3x visits as non-depressed patients
Occurs in all demographic groups
Occurs in women double the rate in men
–
–
•
20% lifetime incidence
50% occurs between ages 25-44 years
Common cause of slow recovery from
physical illness
Precipitating Events
Life events which can precipitate depression
• Loss of a parent or sibling in early childhood
• Loss of a limb or another part of the body
(mastectomy)
• domestic violence
• miscarriage
• loss of self-esteem
• divorce or separation
Depression and Disability
• More disability days than any other chronic
condition except coronary artery disease
• More chronic pain than any other chronic
disease except arthritis
• WHO: 2nd most important cause worldwide
of life years lost to disability (2020)
• $31.3 billion/year in the United States (1990)
Poorly Recognized and Treated
• Under-recognized
– 80% of patients are undiagnosed
– Only 20% of patients receive treatment
– 80% of patients respond to treatment
• Anxiety often due to depression
• Patient may present with smiling or able to
laugh, w/o obvious depressed mood- known
as masked depression
• Universal screening is necessary
Barriers to Diagnosis:
Clinician

Failure to recognize somatization

Distinguishing sadness from depression

Discomfort with emotional issues

Misdiagnose as organic or hormone related

Concern that assessment is timeconsuming

Difficulties in obtaining a referral
Barriers To Diagnosis:
Patients

Resistance to diagnosis of a mental
disorder

Belief it is natural to be depressed
sometimes

Belief they can will themselves well

Shame

Cultural Issues
Suspect The Diagnosis:
Clinical Presentation
 Multiple visits for vague complaints

Depressed voice, expression, or posture

Pain syndromes: vulva, pelvic, vagina,
menses, coitus, urinary tract

Clinician feels sad during or after visit
Forms Of Depression In
Women
• Unipolar forms
–
Major depressive disorder
– Chronic depression (dysthymia)
• Bipolar mood disorder (manic-depression)
• Other distinct syndromes in women
Eating disorders
– Premenstrual dysphoric disorder (PMDD)
– Postpartum mood disorders
–
• Grief, adjustment reactions (minor depression)
Less Common Variants of Depression
• Agitated depression:
– agitation severe, common in middle-aged & elderly
• Atypical depression:
– severe anxiety, severe fatigue, increased sleep &
increased appetite. Often medication resistant
• Seasonal affective disorder (SAD):
– depression same time of the year, usually winter
Mood Disorders: Prevalence
Disorders
Major Depression
Dysthymia
Bipolar I
Bipolar II
PMDD
Prevalence
4.9%
3.2%
0.8%
0.5%
5.0%
MDD (Postpartum)
13%
Levels of Unipolar Depression
• Major depressive disorder
– Mild:
extra effort in ADL*
– Moderate: often prevents ADL*
– Severe:
•
always prevents ADL*
Chronic depression = dysthymia
*ADL: activities of daily living
Major Depression Disorder
MDD, Single episode
• Absence of mania or
hypomania
MDD, Recurrent
• 2 major depression
episodes, separated
by at least a 2 month
period with more or
less normal
functioning/mood
DSM IV Criteria For Major
Depression
• At least five of nine symptoms
–
–
–
–
–
–
–
–
Depressed mood and/or anhedonia (required)
Low self-esteem (worthlessness)
Sleep disturbance
Change in appetite or weight
Difficulty concentrating
Fatigue, loss of energy
Psychomotor agitation or retardation
Recurrent thoughts of death or suicide
DSM IV Criteria For Major
Depression
• Clinically significant distress or impairment in
social, occupational, or other areas of function
• Not due solely to physical health condition,
prescribed medication, or substance abuse
• Symptoms not accounted by bereavement; or:
– Persist longer than two months
– Marked functional impairment
– Suicidal ideas
– Psychosis; psychomotor retardation
Criteria For Major Depression
• Symptoms should be
present
–
Most days
– Most of the day
– For at least 2 weeks
Screening With 2 Questions
• Depression is present if 1 or both
present:
“In the past month have you been often
bothered by. . .
. . . depressed mood?”
. . . lack of interest or pleasure?”
Whooley MA, Avins AL, Miranda J, Browner WS. Case-finding
instruments for depression: Two questions are as good as
many. J Gen Int Med 1997;12:439-445.
Direct Questions to Ask
Depressed mood
"How's your mood been lately?"
Anhedonia
–
Loss of interest or pleasure
– Lack of enjoyment in most daily activities
"What have you enjoyed doing lately?"
"Are you getting less pleasure in things you
typically enjoy?"
Direct Questions to Ask
• Other symptoms
"Have you been feeling down on
yourself?"
"How are you eating; sleeping?”
"How's your energy level?"
"Do you ever feel like life is not worth
living?"
"How's your concentration?"
Mnemonic: “Space Drags”
S leep disturbance
D epressed mood
P leasure/interest (lack of) R etardation movement
A gitation
A ppetite disturbance
C oncentration
G uilt, worthless, useless
E nergy (lack of)/fatigue
S uicidal thought
Criteria For Dysthymia or
Chronic Depression
• Dysthymia
– 2 years depressed mood most days
– With 2 or more symptoms of depression
– A major depressive episode has not
occurred
•
Treatment
–
Same as for depression
Rule Out Other Etiologies
• General medical illness
–
hypo or hyperthyroidism, anemia, diabetes,
multiple sclerosis
• Substance abuse
• Medication side effects
–
Beta blockers, ACE inhibitors,
– GnRH analogues (Lupron)
– Glucocorticoids
– Amphetamine withdrawal
• Acute grief and mourning
Suicidal Assessment
• Screen every patient suspected of
depression
• Asking does not insult patient or initiate
thought
• Ask direct questions:
"Have you had thoughts of hurting yourself?"
"Do you sometimes wish your life was over?"
"Have you had thoughts of ending your life?"
Suicidal Assessment
• If yes, assess immediate risk:
"Do you feel that way now?”
"Do you have a plan?"
"Do you have the means to carry out your plan?”
"Do you promise to call me immediately if your
suicidal thoughts get stronger?”
Treatment Of Major
Depression
• Components
•
–
Psychotherapy
–
Psychopharmacotherapy
–
Psychosocial interventions
–
ECT (2nd line or life-threatening)
Alone or in combination
Bipolar Disorders
• Bipolar I Disorder
• Bipolar II Disorder
• Cyclothymic Disorder
Manic Episode: Diagnostic Criteria
A period of abnormally and persistently elevated,
expansive, or irritable mood not due to psychosis,
meds or organic etiology with marked impairment
Plus 3 of the following 7 symptoms:
•
Inflated self esteem or grandiosity
•
Decreased need for sleep
•
More talkative than usual or pressure to keep talking
•
Flight of ideas, or racing thoughts
•
Distractibility
•
Increase in goal directed activity
•
Excessive involvement in pleasurable activities
Hypomania: Diagnostic Criteria
• All the criteria of a Manic episode except
without marked impairment
Bipolar Disorder
Bipolar I
• Alternation of full
manic and depressive
episodes
• Average onset is 18
years
• Tends to be chronic
• High risk for suicide
Bipolar II
• Alternation of Major
Depression with
hypomania
• Average onset is 22
years
• Tends to be chronic
• 10% progess to full
biploar I disorder
Cyclothymia
A. Many hypomanic episodes and periods with
depressed mood not meeting criteria of Major
Depression, and lasting 2 years
B. During 2 yr period of disturbance, never
without hypomanic or depressive symptoms
more than 2 months at a time
C. No evidence of MDD or Manic episode during
the first two years of disturbance
Depression: Genetics
Family studies:
• Relatives 2-3x more likely to have a mood
disorder (usually major depression)
Twin studies:
• Identical 3x more likely than fraternal twin
to have a mood disorder (particularly for
bipolar disorder)
Women: Heritability rates are higher
Grief Reactions
• May last up to 2 years after loss or event
• Usually falls short of criteria for major
depression
• Rarely causes prolonged impairment in work
and other activities
• Cyclicity is common in days, weeks, months
• If functional impairment, Rx with SSRI’s for
30 days
Premenstrual Dysphoric
Disorder
•
•
•
•
5% of women, typical age 18-30 years
Symptoms last 5-14 days in the luteal phase
Must abate at onset of menses
Symptoms: depression, anxiety, emotional
lability, tension, irritability, anger, sleep
and appetite disturbances
• Rx with daily or luteal phase SSRIs
• Role of OCs with drospirenone
Pearlstein T. Drugs 2002;62:1869-85.
Chronic Pelvic Pain and
Depression
• Offer antidepressant early in evaluation
• Offer neuropathic drug(s) early in evaluation
• Offer NSAID analgesics early in evaluation
• Offer early referral to mental health provider for
help with depression and developing coping skills
Postpartum Mood Disorders
Prevalence
Onset
Duration
Treatment
50-80%
1-5 days
<2 weeks
Reassurance
Depression
10%
2wk - 1
year
3-14 mo
Medication or
psychotherapy
Psychosis
0.1-0.2%
2 days to
1 month
Variable
Medication,
hospitalization
Blues
Post-partum Depression
• 1 of 10 women experience post-partum
depression, but the condition is underdiagnosed
• May have significant impact on both
mother and child
• Societal pressures to be “good mother”
may prevent woman from admitting
symptoms
“Baby Blues”
• Occurs in 70-85% of women
• Onset within the first few days after
delivery
• Resolves by 2 weeks
• Symptoms include: mild depression,
irritability, tearfulness, fatigue, anxiety
• May have increased risk of post-partum
major depression later on
Post-partum Major Depression
• Symptoms of depression that last longer
than 2 weeks
• Usually begins 2-3 weeks after delivery
• May start and last up to one year
• High risk of recurrence in future
pregnancies
Treatment for Post Partum
Depression
• Same as for major depression
• SSRI’s work well
• All antidepressants are to some degree,
excreted in the breast milk, but usually
undetectable levels in the infant’s blood
• Avoid Prozac due to long half life- may
accumulate in the infant
Treatment Of Mood Disorders
• Components
•
–
Psychotherapy
–
Psychopharmacotherapy
–
Psychosocial interventions
–
ECT (2nd line or life-threatening for MDD)
Alone or in combination
Medications Treatment Guidelines
•
•
•
•
•
•
•
50% have effect in 2 weeks
Optimal effect may take 4-6 weeks
Titrate to achieve therapeutic dose
If no response by 6 wks, switch
agents
If partial response at maximum dose,
augment with 2nd drug or get consult
Treat for 6-12 months
65-70% response to first antidepressant
Partial Or No Response
• Effect should be present by 6 weeks
• Assess for adherence to daily dosing
• Re-evaluate diagnosis:
–
Other psychiatric disorders
– Substance abuse
– Organic disorder
• Adjust dosage or change medication
• Refer to a psychiatrist
Daily Dosing Of SSRI’s
Medication
name
Citalopram
Brand
name
CelexaR
Start
Range
Maximum
10 mg
10-40 mg
60 mg
Escitalopram
LexaproR 5 mg
5-10 mg
20 mg
Fluoxetine
ProzacR
10 mg
10-40 mg
80 mg
Paroxetine
PaxilR
10 mg
10-40 mg
60 mg
Sertraline
ZoloftR
25 mg
50-100 mg
300 mg
NEWER AGENTS
•
SNRIs = serotonin noradrenergic reuptake
inhibitor
–
–
–
•
Desvenlafaxime
Venlafaxine
Duloxetine
PristiqR
Generic, Effexor/ Effexor XRR,
CymbaltaR
Other antidepressants
–
–
–
–
Bupropion
Mirtazepine
Nefazodone
Trazadone
WellbutrinR /SR /XL, Aplenzin™
RemeronR
SerzoneR- Hepatic
DesyrelR
Buproprion
(Wellbutrin IR,SR,XLR)
• Does not cause sexual dysfunction
• Useful as first line or to augment SSRI/SNRI
–
Start 150mg qd for 1 wk, increase to 150mg bid
–
Do not exceed 200mg single dose
–
Maximum dosing = 400mg / day
–
Avoid use if risk of seizures
Medication Side Effects
• Agitation/insomnia:
– ProzacR > ZoloftR > PaxilR > Tricyclics >
RemeronR
– Add sedative or hypnotic
• Gastrointestinal distress
– Don’t use Setraline (Zoloft)
– Take medication after meals
• Sedation
–
Take medication at bedtime
Medication Side Effects
• Anticholinergic effects
–
Hydration
– Add bulk/ fiber to diet, hard candy
– Stool softener
• Postural hypotension
–
Hydration
– Change positions slowly
– Support hose
•
Sexual dysfunction (worse with SSRIs)
–
Add or Switch to buproprion
SSRI Drug Interactions
• Paroxetine = Fluoxetine > Sertraline >
Citalopram= Escitalopram in P450 inhibition
• Common interactions
– Some anti-hypertensive levels may increase (betablockers and Ca channel blockers)
– May increase digoxin levels
– May increase levels of anticonvulsants such as
carbamazepine (Tegretol) and phenytoin (Dilantin)
Does Hormonal Contraception
Cause or Worsen Depression?
• Older studies suggested progestins could
– Make pre-existing depression worse
– Cause depression in a small % of users
– “More likely” with progestin-only methods
• Newer (and better) studies show that neither
of these assertions are correct
• 2010 CDC Medical Eligibility Criteria (MEC):
– In depressed women, all methods are
categorized as US MEC 1
Depression In Pregnancy
• Include the patient in decision-making
–
–
Overall well-being & Ability to function
Weigh risks and benefits
•
Untreated depression in pregnancy leads to
increased risk of postpartum depression
•
One study found both SSRIs & untreated
depression associated with preterm birth
Major depression and antidepressant treatment: impact on pregnancy and neonatal
outcomes. Wisner KL - Am J Psychiatry - 2009; 166(5): 557-66 Treatment of Mood
Disorders During Pregnancy and Postpartum Cohen et al 2010; 33(2): 273-293
Safety Of Drugs In Pregnancy
•
Fluoxetine best studied SSRI for safety and efficacy in
pregnancy and lactation. >1500 in-utero exposures have
been reported w/o evidence of teratogenicity Avoid
Paroxetine
•
SSRIs and SNRIs are category C
•
Wellbutrin is category B
•
2005 meta-analysis of prospective comparative studies
found no increased risk of anomalies
Einarson TR - Pharmacoepidemiol Drug Saf - 01-DEC-2005; 14(12): 823-7
Safety Of Drugs: Lactation
• Pregnant and lactating women excluded
from controlled trials of new drugs
• SSRI’s and bupropion present in breast milk
–
Limited data on newborn impact
– No findings of effect on growth or development
• Include the patient in decision-making
SSRI Discontinuation
• Somatic and psychological symptoms
– Disequilibrium, gastrointestinal symptoms,
flu-like symptoms, sensory disturbances,
anxiety, irritability
• Onset 1-3 days after stopping Rx, last an average
of 10 days, usually mild and transient
• Case reports of severe discontinuation symptoms
• PaxilR and ZoloftR > ProzacR (shorter half-life)
• Noncompliance leads to discontinuation
symptoms
• Avoid by tapering drug in weekly increments
Herbals
• St John's wort (hypericum perforatum):
–
mild antidepressant, sedation, anxiolysis
–
headache most common side effect
–
Many studies show induction of CYP450
–
Does decrease efficacy of estrogen based
contraception
Follow Up
• Phone call in 3 days to assess side effects
• 1,2 or 4 weeks according to severity
–
Phone can be used to titrate dose
– Use flow sheet to score symptoms
• Remission = normal psychosocial
functioning
• Maintain effective dose for 6-12 months
• Consider role of prophylactic maintenance
Rx if current episode is a relapse
Office Interventions

Assess for adverse personal
relationships

Assess family and community support

Consider self-help groups

Pursue watchful waiting with periodic
follow up
Suicide
•
•
•
•
8th leading cause of death in the U.S.
Overwhelmingly white phenomena
Suicide also high in Native Americans
Rate of suicide is increasing in
adolescents and elderly
• Males are more likely to commit suicide
• Females are more likely to attempt suicide
5 Myths and Facts About
Suicide
Myth #1:
Fact:
• People who talk about • Most people who
killing themselves
commit suicide have
rarely commit suicide.
given some verbal
clues or warnings of
their intentions
5 Myths and Facts About
Suicide
Myth #2:
• The suicidal person
wants to die and feels
there is no turning
back.
Fact:
• Suicidal people are
usually ambivalent
about dying; they may
desperately want to
live but can not see
alternatives to
problems.
5 Myths and Facts About
Suicide
Myth # 3:
• If you ask someone
about their suicidal
intentions, you will
only encourage them
to kill themselves.
Fact:
• The opposite is true.
Asking lowers their
anxiety and helps
deter suicidal
behavior. Discussion
of suicidal feelings
allow for accurate risk
assessment.
5 Myths and Facts About
Suicide
Myth # 4:
• All suicidal people are
deeply depressed.
Fact:
• Although depression
is usually associated
with depression, not
all suicidal people are
obviously depressed.
Once they make the
decision, they may
appear
happier/carefree.
5 Myths and Facts About
Suicide
Myths # 5:
• Suicidal people rarely
seek medical
attention.
Fact:
• 75% of suicidal
individuals will visit a
physician within the
month before they kill
themselves.
Conclusions
• Depression is a chronic, recurrent disease
• Depression is common in women
• Many women suffer needlessly because
their depression is not diagnosed and
treated
• Diagnosing depression is straightforward
• Antidepressant treatment is effective and
practical
• Primary care providers should be able to
recognize and treat depression in women
Mild depressive disorder
• Complains of low mood, lack of energy &
enjoyment and poor sleep.
• Other symptoms include anxiety, phobia &
obsessional symptoms.
• Sleep disturbance often difficult to fall asleep,
restless with period of waking during the night
followed by sound sleep before waking.
• Mood may vary during the day; worse in the
evening than in the morning in contrast to more
severe cases.
• Biological features uncommon.
Moderately severe depressive
disorder
• Appearance-sad appearance & psychomotor retardation
• Low mood-misery, worse in the morning & irritability and
agitation.
• Lack of interest & enjoyment-reduced energy, poor
concentration & memory.
• Depressive thinking-pessimistic & guilty thoughts, selfblame, suicidal ideas & hypochondriacal ideas.
• Biological symptoms-early wakening, weight loss
reduced appetite& reduced sexual drive.
• Other symptoms-obsessional symptoms,
depersonalization etc.
Severe depressive disorder
• All the features described under moderate depressive
disorder occur with greater intensity.
• There may be additional symptoms; namely delusions &
hallucinations
( psychotic depression ).
• Delusion namely; worthlessness, guilt, ill-health, poverty,
hypochodriacal delusions, delusion of impoverishment,
nihilistic delusions & delusion of persecution.
• Perceptual disturbances; fall short of hallucinations but
few experience true hallucinations usually auditory.
• Suicidal ideas & rarely homicidal ideas