“The burden of mental
disorders, such as depression
and anxiety, fall
disproportionately on women
of childbearing and
childrearing age.”
Psychiatric Clinics of North America, 2007
Rates of severe mental illness similar between
men and women, but differences in
diagnoses, age of onset, course.
 Rates of Major Depression and Dysthymia
are about twice as high for women as for
men
 Prevalence rates for most Anxiety Disorders
(panic disorder, agoraphobia, specific
phobia, GAD, PTSD) are 2-3x higher in
women (exceptions are OCD and social
phobia: rates are =)

Bipolar Disorder – Type I rates = in men and
women, Type II women > men
› More mixed episodes, rapid cycling
› Later age of onset, more depressive episodes

Schizophrenia – Lifetime prevalence = in men
and women.
› Women have later age of onset (25-35) with bimodal
distribution
› Higher premorbid functioning and social functioning
› More “benign” course

Eating Disorders – Anorexia Nervosa 95%
female; Bulimia 80% female

Substance Abuse : Men 2-4 x more likely
to have dx of substance abuse or
dependence
› Women with affective illness more vulnerable

Personality Disorders:
› Women > Men in Borderline, Histrionic (?)
› Men > Women in Antisocial, Narcissistic,
Obsessive-Compulsive
25
20
15
Female
Male
10
5
0
MDE
DD
SAD
PMDD
BPD
Biologic Vulnerability
 Reproductive Events
 Psychosocial Factors

Gender based violence (rape, sexual
abuse, domestic violence)
 Socioeconomic status
 Caregiving responsibilities, multiple roles
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Menstrual Cycle
Infertility
Pregnancy
Postpartum Period
Menopausal Transition/Perimenopause
Hormonal Therapies
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Higher incidence of MDD in women starting
at puberty, less marked post-menopause
Suicidal behavior may be more common in
low estrogen states
5% rate of PMDD
Rates of postpartum admissions and
psychosis elevated immediately after
childbirth
Perimenopausal mood d/o’s vs. postmenopause
Kessler et al, 1993 (National Comorbidity Survey)
Fig. 1. Phases of the menstrual cycle positively correlated with suicide attempts and
changes in oestrogen concentration during the cycle. * Denotes studies where
results were statistically significant. Saunders et al, 2006
Estrogen
 Progesterone
 FSH
 LH
 Testosterone
 HCG
 Prolactin

TRYP
Estrogen
5HT
5HT Re-uptake Site
E2
PROG 
MAO: Monoamine Oxidase
COMT: Catechol-O-Methyl
Transferase
5HT: Serotonin
MAO / COMT
E2  MAO & COMT -  5HT
PROG  MAO & COMT -  SHT
Psychological Symptoms
 Depression
 Anger, Irritability
 Affective lability
 Anxiety
 Sensitivity to rejection
 Poor concentration
 Sense of feeling
overwhelmed
 Social withdrawal
Physical Symptoms
 Lethargy or fatigue
 Sleep disturbance
(usually hypersomnia)
 Appetite disturbance
(usually increased)
 Abdominal bloating
 Breast tenderness
 Muscle aches, joint
pain
 Swelling of extremities
Affects 3-8% of menstruating women
 Symptoms begin during Luteal Phase,
resolve completely with onset of menses
 ≥5 symptoms in most cycles
 Marked decrease in social or
occupational functioning
 Distinguish from underlying mood
disorder (no symptoms Follicular Phase)
 Abnormal serotonin neurotransmission?

Lifestyle interventions, exercise
 Calcium, Vit B6, Magnesium, Vit E
 Herbal remedies (chasteberry)
 Psychotherapy
 SSRI’s (fluoxetine, paroxetine, sertraline)

› Immediate effect
› Intermittent vs. continuous dosing

Hormonal therapies
Increased risk for first episode depression
during menopausal transition
 Lower risk for first episode depression in
post-menopausal women
 Women with a history of depression
remain at risk for future episodes
 Estrogen replacement effective for mild
symptoms, but not Major Depression

Is pregnancy a time of emotional
wellbeing for women?
Pregnancy is NOT protective against
psychiatric illness
 Rates of Major Depression during
pregnancy 10-15% Anxiety disorders may
be higher.
 High rate of relapse when antidepressant
medications are stopped during pregnancy
(~50-70%)
 Pregnant Bipolar women have same risk for
relapse off meds as non-pregnant Bipolar
women. Post partum risk 4x higher.
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Past history of depression
Poor overall health
Greater alcohol use
Smoking
Being unmarried
Unemployment
Lower education level
 Level
of suffering – for mom and partner
 Decreased ability to care for herself and the
pregnancy – suicide risk in severe cases
 Increased risk for pre-term delivery,
preeclampsia, and low birth weight
 Higher rates of smoking, alcohol and
substance use
 Risk of post-partum depression, negative
effects on child and family
Non-Pharmacologic Treatments:
 Psychotherapy
 Light Therapy
 Omega-3 Fatty Acids
 Psychosocial supports
Psychotropic Medications in Pregnancy –
are they safe?
 No Psychotropics are FDA-approved for
use during pregnancy
 All medications cross the placenta
 Principals of management: maximize
non-medication options, minimize
exposure to meds and to depression

Teratogenesis
› No increase in overall rate of fetal malformations
› Some evidence linking inc risk of rare defects (i.e.
paroxetine and cardiac malformations)

Pregnancy Outcomes
› Mixed evidence on birth weight, early pregnancy
loss, preterm labor (depression effects?)

Neonatal Toxicity
› Neonatal Abstinence Syndrome
› Persistent Pulmonary Hypertension of the Newborn

Long-term effects
› No evidence to date of long-term developmental
effects in children exposed in utero
“Baby
Blues”
Postpartum
Depression
Postpartum
Psychosis
Y axis: Rates of psychiatric hospitalization
X axis: Years pre- and post- childbirth
“When I delivered the placenta, I felt like I
fell off a cliff.”
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Occurs in 50-85% of women
Characterized by mood lability, tearfulness,
anxiety and irritability
Symptoms peak at day 4-5
May last a few hours to several days
Symptoms do not interfere with functioning
Reassurance rather than treatment
If symptoms persist > 2 weeks, patient
should be evaluated for a more serious
mood disorder
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Occurs in 1-2 per 1000 women
Onset 24hrs – 3 weeks postpartum
Rapid mood swings, insomnia, obsessive thoughts
Delusions, hallucinations, impaired reality testing.
Delusions involving infant are common
Shifting mental status , disorientation, confusion,
disorganized behavior
High risk of suicide and/or infanticide
Psychiatric emergency – needs evaluation
immediately
Differential: medical causes of delirium, PPD, SCZ
>70% appears to be a presentation of bipolar
disorder. Bipolar women at very high risk of PPP
Estimates of prevalence between 10-15%
 Risk factors:

› Prior episodes depression or anxiety,
›
›
›
›
›
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including during pregnancy
Marital discord
Unwanted or unplanned pregnancy
Infant medical problems
Lack of social support
Low socioeconomic status
Differential: anemia, diabetes, thyroid
Symptoms:
• Depressed mood
• Tearfulness
• Loss of interest in usual activities
• Feelings of guilt
• feelings of worthlessness or incompetence
• Fatigue
• Sleep disturbance
• Change in appetite
• Poor concentration
• Suicidal thoughts
Milder cases overlap with normal feelings in
the postpartum period – i.e. fatigue, altered
sleep, appetite, energy
 Hopelessness, worthlessness, suicidal
ideation are not normal in the postpartum
period
 Comorbid anxiety with obsessional
thoughts about the baby is common

› Important to distinguish from psychosis

Edinburgh Postnatal Depression Scale
› 10-item self-rating scale measuring mood,
anxiety and SI
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Psychotherapy: IPT, CBT, Supportive,
Psychodynamic, Couples, Group
Improved social supports
Help with infant care
Light therapy
Medications: SSRI’s, Tricyclics,
Benzodiazepines for comorbid anxiety
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All psychotropic medications are secreted
into breast milk
Concentrations in breast milk vary widely
Peak concentrations are attained at 6-8
hours
Infant toxicity depends on exposure and
hepatic metabolism
Relationship between infant serum
concentrations and infant physiology,
behavior and development is unknown
Carefully monitor breast fed infants
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Mood and Anxiety disorders disproportionately
affect women of reproductive age
Times of hormonal change may be periods of
particular vulnerability
Many women are reluctant to seek treatment,
diagnoses often missed
Treatment of psychiatric illness is complicated by
potential pregnancy, pregnancy, postpartum
issues
Risks and benefits of both treatment and nontreatment must be carefully considered