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Depression in Women: From PMS to Post-partum Blues
Dr.Ali BLdoAssociate Prof.of Psychiatrycopyright2007
Case PresentationJulie is a 25 year old female who just delivered her second child 3 weeks ago. She breaks down in tears for no reason and is irritable with her 3 year old. She is having trouble sleeping, and has no appetite. She admits that she feels guilty for not feeling happy about the new infant in her life. She feels she is not an effective parent to either child. She is returning to work next week and wonders how she will be able to cope.
Statistics Depression is twice as common in women as in
men 20% of women will experience depression at
some point during their life One out of 10 childbearing women will
experience post-partum depression 40% of women have premenstrual symptoms, 5%
of these experience premenstrual dysphoric disorder (PMDD)
Risk Factors For Depression Family history of mood disorder Loss of a parent before age 10 History of sexual or physical abuse Use of hormones
(contraception/HRT/fertility treatments) Persistent life stressors (i.e. loss of job) Loss of social support system
What Is Depression? Psychological
Depressed mood Decreased interest in
activities Feelings of guilt,
hopelessness Suicidal thoughts
Physical symptoms Sleep disturbance Appetite/weight
changes Difficulty
concentrating Fatigue Decreased energy
Gender Differences Women have earlier
onset of depression Episodes may last longer
and recur more often More atypical symptoms Suicide attempts more
frequent but less successful
Less substance abuse than men
More anxiety symptoms than men
More associated eating disorders
More associated migraine headaches
More feelings of guilt More seasonal depression
Treatment For Depression Psychosocial (counseling)- cognitive behavioral
therapy Medications- used with counseling in cases of
moderate to severe depression Alter chemical balance in the body to enhance mood
(norepinephrine, serotonin levels) Many different types- SSRI’s, tricyclics, others St. John’s wort- some studies suggest a benefit Need a minimum of 2 weeks to see an effect Treatment for minimum of 6 months
SSRI’s- Often the First Choice Selective serotonin reuptake inhibitors- allow
more serotonin to be available in the body, enhancing mood
Examples: Prozac, Paxil, Zoloft, Luvox, Celexa Once daily dosing Side effects: nausea, headaches, nervousness,
insomnia/fatigue, sexual dysfunction, weight gain with prolonged use
What’s That About Sexual Dysfunction? Up to 70% of depressed patients experience a loss
of sexual interest If we treat the underlying depression, the libido
often improves SSRI’s may cause problems with libido and
difficulty attaining orgasm Other medications may enhance libido- ie
Wellbutrin, Effexor
Premenstrual Dysphoric Disorder Mood and anxiety symptoms that occur only
during the premenstrual period, or worsen significantly during that time
Can be very debilitating, with a negative impact on the quality of life and relationships
Symptoms usually disappear within a few days after the period starts
There are 11 identified symptoms, of which 5 must be present
Symptoms of PMDD Depressed mood Feelings of personal
rejection Decreased interest in
usual activities Fatigue, no energy Marked appetite
changes/cravings Insomnia or increased
sleep
Anxiety- feeling “on edge”
Irritability, anger Feeling overwhelmed Difficulty concentrating Physical symptoms-
breast tenderness, headaches, “bloated”, muscle pain
Cause of PMDD? Unknown, but felt by many researchers to
result from an abnormal response to normal cycle of hormonal changes in the body
Likely a combination of genetic, environmental, and behavioral factors
Women with PMDD have greater risk of future depression during pregnancy, post-partum period, and perimenopause
Treatment For PMDD Choice of treatment is aimed at the most
troubling symptoms Lifestyle modification Dietary approach Vitamin supplementation Medications Cognitive/behavioral approach
Lifestyle/diet Modification Women who engage in moderate aerobic exercise
3 times weekly have fewer premenstrual symptoms than sedentary women
Low-fat, vegetarian diet has been shown to decrease duration and intensity of menstrual pain
Women with a high caffeine intake have more premenstrual irritability symptoms
Excess of simple carbohydrates (sugar) is associated with mood disturbances
Vitamin Supplementation Controversial- data is conflicting Vitamin B6 100mg/day Magnesium 400 mg/day Manganese 6 mg/day Vitamin E 400 iu/day Calcium 1000 mg/day
Medications for PMDD Anti-inflammatories- effective for pain
relief Oral contraceptives- suppress ovulation Diuretics– when salt restriction not helpful
in reducing significant fluid retention SSRI’s are often first choice- daily versus
premenstrual week only
Cognitive Behavioral Therapy Attempts to reduce negative feelings in the
premenstrual period Improve feelings of self-esteem and
problem solving skills Relaxation therapy may also be helpful
Post-partum Depression 1 of 10 women experience post-partum
depression, but the condition is under-diagnosed
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 last up to one year High risk of recurrence in future
pregnancies
Post Partum Psychosis Rare disorder (Andrea Yates?)- 0.2% women Onset within the first month after delivery Symptoms include mania, agitation, expansive or
irritable mood, avoidance of the infant May have delusions or hallucinations that involve
the infant- possessed by demon, etc. This is a medical emergency- needs
hospitalization
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
To Summarize…. Depression is very common in women May be more likely around times of
hormonal flux- premenstrual, post-partum, perimenopause
There is effective treatment available Don’t hesitate to discuss symptoms with
your doctor
