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Woman And Infants
Woman And Infants

Web-Exclusive Q&A: Women's Behavioral Health

Depression and mental health issues affect women differently than men. Find out more about how women might be affected and what can be done to help in this month's Q&A with clinicians from W&I's Center for Women's Behavioral Health.

W&I patient shares her struggles with postpartum depression

Does gender play a role in depression and other mental health issues? Is this a culture of Superwomen?
Women are twice as likely as men to have a major depressive disorder episode after puberty. The reasons for this increased prevalence are not fully understood. Possible reasons include hormonal fluctuations during the reproductive years, and the stress of work, childrearing and caring for aging parents.

It is possible that the current expectation of many women that they be able to successfully have a career, raise a family, and support extended family and friends may contribute to depressive episodes. Recent studies suggest that the prevalence of depression in men may be higher than previously thought, possibly underestimated due to societal expectations that men not discuss their depressive symptoms or seek treatment.

Does the stage of a woman's life affect her mental health?
The reproductive years, and particularly times of hormonal fluctuation, represent times of risk for the expression of mood and anxiety disorders in women who have the genetic predisposition to these disorders. Hormonal fluctuations occur each menstrual cycle, leading to problematic premenstrual low mood and irritability in some women. Some women have the onset or exacerbation of mood or anxiety disorders during pregnancy and particularly during the postpartum period when gonadal hormones decrease rapidly.

Another time of risk for the onset of a mood or anxiety disorder is at perimenopause, or the few years preceding the cessation of the menstrual cycle. Perimenopause is characterized by hormonal fluctuations and common symptoms include hot flashes, irritability, mood swings, insomnia, concentration difficulties, decreased sexual interest and vaginal dryness. In a minority of perimenopausal women, the mood and anxiety symptoms are severe enough to warrant treatment.

What are the risk factors for depression?
Risk factors for both men and women include a family history of depression; chronic medical illness; life stresses such as loss of a loved one, chaotic relationships, separation, loss of job or sudden financial burden; and chronic low self-esteem and pessimism. In addition, natural hormonal fluctuations, such as those experienced postpartum or during perimenopause, may trigger an episode of depression in women. Women also often try to "do it all," such as having a challenging career while also being the primary caretaker of children and extended family members.

At what point does the "blues" become cause for concern?
Occasional sadness, feeling "blue" or "having a bad day" is part of the human experience. The persistence of sad feelings, particularly in the absence of a particular stressor such as loss of a loved one or loss of a job, suggests that the low mood may be a mood disorder that needs evaluation and treatment. A major depressive episode is defined as the persistence of depressed mood and/or a loss of interest or pleasure for at least two weeks, accompanied by at least five of the following symptoms:

  • Depressed mood most of the day, nearly every day

  • Markedly diminished interest or pleasure in all, or almost all, activities

  • Significant increased appetite and weight gain or decreased appetite and weight loss, when not dieting

  • Insomnia or hypersomni

  • Fatigue or lethargy

  • Agitation or slowing severe enough to be noted by others

  • Feelings of worthlessness or excessive and inappropriate guilt feelings

  • Decreased concentration or indecisiveness

  • Recurrent thoughts of death, recurrent suicidal thoughts with or without a specific plan for committing suicide

What is postpartum depression and how is it treated?
The signs and symptoms of depression during pregnancy or during the postpartum period are the same as men or women can have at any time (see above). Postpartum women may also note the onset of worries and fears about the newborn, and this is normal and transient in most women. It can be difficult to diagnose depression in pregnant and postpartum women because many of the normal symptoms of pregnancy and being newly postpartum overlap with symptoms common to depression such as trouble sleeping, low energy, and changes in appetite. There are screening instruments specific to depression during pregnancy and the postpartum period. The Edinburgh Postnatal Depression Scale (EPDS) is one example that is commonly used by clinicians.

Since there are many known negative effects of untreated depression - both during pregnancy and postpartum - for the infant, it is very important that pregnant and postpartum women who are depressed receive evaluation and treatment. The negative effects of untreated depression include lower birth weight, impaired mother-infant attachment, and cognitive and behavioral impairment during the child's development. Many perinatal women consider non-medication options for depression such as interpersonal psychotherapy or light therapy.

If a woman's depression does not improve with psychotherapy or other non-medication treatments, antidepressant medication should be considered. Since the medications that treat depression have possible risks for the fetus and infant, a pregnant or breastfeeding woman with depression should consult with a clinician who has the latest information about the safety of medication use with pregnancy and breastfeeding (such as Women's Behavioral Health at WIH). The obstetrician-gynecologist and pediatrician have crucial roles in identifying perinatal women who have depression and referring them for appropriate care.

What is premenstrual dysphoric disorder and how prevalent is it?
About 20 to 40% of menstruating women experience moderate emotional and physical symptoms in the days before menstruation starts, and these women are described as having premenstrual syndrome (PMS).

Approximately 5% of menstruating women experience severe emotional and physical symptoms that can disrupt relationships and functioning at work or home, and that can last up to two weeks before menstruation starts. This severe end of the spectrum of premenstrual symptoms is called premenstrual dysphoric disorder (PMDD). Symptoms of PMDD resolve after menstruation begins. The symptoms of PMDD cause a cyclical disruption in women's lives, and women with PMDD often seek treatment. Common symptoms of PMDD include:

  • Depressed mood, feelings of hopelessness

  • Marked anxiety, tension, feelings of being "keyed up" or "on edge"

  • Mood swings, suddenly tearful, increased sensitivity to rejection

  • Irritability, marked anger, increased interpersonal conflicts

  • Decreased interest in usual activities

  • Decreased concentration

  • Fatigue or lethargy

  • Marked change in appetite, increased appetite, specific food cravings

  • Insomnia or hypersomnia

  • A feeling of being overwhelmed or out of control

  • Abdominal bloating, breast tenderness or swelling, headaches, joint or muscle pain

Treatment can include dietary modifications, exercise, cognitive behavior therapy, oral contraceptives, serotonergic antidepressants, or calcium or chasteberry supplements. Sarafem, Zoloft and Paxil CR are each FDA approved for the treatment of PMDD. The oral contraceptive Yaz is FDA approved for the treatment of PMDD in women desiring oral contraception.

Is depression often associated with other issues, such as an eating disorder?
Many psychiatric disorders can be associated with depression. These include anxiety disorders such as panic disorder, agoraphobia, obsessive-compulsive disorder, post-traumatic stress disorder, and social phobia; alcohol and substance abuse; anorexia nervosa; bulimia nervosa; binge eating disorder; bipolar disorder characterized by episodes of elated mood and other manic symptoms; and other psychotic disorders. In addition, chronic medical illnesses such as heart disease, hypothyroidism, obesity, and dementia are associated with depression.

When does anxiety become a cause for concern?
When symptoms of anxiety lead to substantial distress for an individual and/or impairment of regular functioning, the individual should seek a diagnostic evaluation. An example would be a person with panic attacks who becomes unwilling to stay alone and avoids public places such as the supermarket because she fears having another panic attack. Another example would be a person with severe worries about contamination that leads to several hours per day of cleaning, checking and worrying about germs.

Are there other ways to treat mental health problems besides medication?
Depression and anxiety disorders may benefit from different types of psychotherapy, such as cognitive-behavior therapy, which challenges dysfunctional beliefs, or interpersonal psychotherapy, which promotes social support during role transitions. Psychotherapy can provide support, following either a short-term structured program or a long-term plan such as insight-oriented psychotherapy.

Some studies have suggested that the combination of psychotherapy and medication may be more effective than either treatment alone, particularly with severe depression. Although less well studied, there are reports of benefit for mental health problems with exercise, dietary recommendations and supplements such as fish oil, meditation, massage, acupuncture, and light therapy. Some mental health disorders that do not respond to traditional therapies may respond to vagus nerve stimulation, transcranial magnetic stimulation, deep brain stimulation or electroconvulsive therapy.

In order to provide answers to your most pressing health care questions, the clinicians at Women & Infants participate in an ongoing series of web-exclusive interviews.

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