Depression in Women: From PMS to Post-partum Blues Kimberley Guida, MD Pullman Family Medicine

Case Presentation Julie 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 Physical symptoms 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

This Presentation Is Available Online At: www.pullmanfamilymed.com Thank You