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WOMEN DEPRESSION AND ITS MANAGME

WOMEN DEPRESSION AND ITS MANAGMENT

Dr. Netranee Anju Ramdinny-Purryag

Consultant,St. Jean Pharmacy, Mauritius

 
Introduction

Gender has been described as a critical determinant of mental health and mental illness.1 Gender differences in mental disorders have been reported, particularly, in the prevalence of common mental disorders including depression, anxiety disorders and somatoform disorders.2,3 Depression is not only the most common women's mental health problem but may be more persistent in women than men..

Burden of disorder

The report on Global Burden of Disease estimates the point prevalence of unipolar depressive episodes to be 1.9% for men and 3.2% for women, and the one-year prevalence has been estimated to be 5.8% for men and 9.5% for women.4 Depression is a feminized issue: It afflicts twice as many women as men across different countries and settings.5 While there is considerable variation in the rates of depression in different countries, an average of 6 percent to 10 percent of women in developing countries are suffering from the condition, although higher rates have been reported from some settings such as rural Pakistan.6  Much higher rates of depression have been found in women attending primary health care centers in developing countries. In India, for instance, between 25 to 33 percent of women attending these centers may be suffering from depressive disorders.7

According to the National Mental Health Association, approximately 12 million women in the United States experience clinical depression each year and about one in every eight women can expect to develop clinical depression during their lifetime.

 

Clinical features

(1)   Consistent sad and anxious mood associated with irritability in daily activities.

(2)   Aches and pains, including headache & digestive problems which persist after medications.

(3)   Mood swings with difficulty concentrating, poor memory and difficulty in taking decisions.

(4)   Extreme loss of energy even without much physical activity: feeling of fatigue and slowing down at work due to lack of energy.

(5)   Change in appetite leading to either weight loss or weight gain.

(6)   Changes in sleeping habits which leads to staying up late at night and waking up early in the morning.

(7)   An unexplainable guilt feeling, despair and feeling of worthlessness: a sort of existential crisis wherein identity seems to be diluted.

(8)   Loss of pleasure in life & trouble resuming to normal activities like sports, games, music, dance and other hobbies.

(9)   Sudden lack of interest in sex or loss of libido

(10)     Anxiety that is often prolonged

 

Risk factors                               

Women as a group have received considerable attention with regard to risk factors for the development of depressive disorders.

According to the American Academy of Family Physicians, the risk factors are as follows:

  1. Family history of mood disorders
  2. Past history of mood disorders in early reproductive years
  3. Loss of a parent before the age of 10 years
  4. Childhood history of physical or sexual abuse
  5. Use of an oral  contraceptive, especially one with a high progesterone content
  6. Use of gonadotropin stimulants as part of infertility treatment
  7. Persistent psychosocial stressors (eg loss of job)
  8. Loss of social support system or the threat of such a loss

Many studies pertaining to women have been conducted in India and the following reported:

(1) In an incidence study of common mental disorders, Patel et al.8 reported that poverty, being married as compared with being single, use of tobacco, experiencing abnormal vaginal discharge and reporting a chronic physical illness were associated with the risk of developing a common mental disorder. 8

(2) Studies have also reported that economic and interpersonal relationship difficulties, partner violence and sexual coercion by the partner are common causal factors related to development of depression. 9,10,11,12,13

(3) It has been shown that gender of the newborn child is an important determinant of postnatal depression.9,11,and 12

(4) An Indian study in a slum community north of Mumbai indicates a high incidence of alcoholism among men and verbal abuse of women by their husbands (Shebang R. Parkar, Johnson Fernandes, and Mitchell G. Weiss 2003).

Women are particularly vulnerable and they often disproportionately bear the burden of changes associated with urbanization. Domestic violence is also highly prevalent in urban areas. In both developed and developing countries, women living in urban settings are at greatest risk to be assaulted by their mates (Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB (1995).

Etiology

According to the World Health Organization, women are about twice as likely as men to suffer from depression. This two to one difference persists across racial, ethnic and economic divides around the world. Factors implicated include biological, psychological and social factors.

Biological causes

(1)   Premenstrual hormonal fluctuations

Hormonal fluctuations during the premenstrual period cause the familiar symptoms of premenstrual syndrome such as bloating, irritability, fatigue and emotional reactivity. While for some women, the symptoms are mild, yet for others, they warrant a diagnosis of premenstrual dysphoric disorder

A study of 433 women published in the journal of Psychological Medicine in 2005 found that 64 percent of the women reported worsening of their depressive symptoms before their menstrual cycle began. In 2006, Psychological Medicine followed up with a study connecting menstrual cycle and an increase in non-fatal suicidal behavior.

(2)   Pregnancy and infertility

Hormonal changes that occur during pregnancy can contribute to depression, particularly in women already at risk. Issues related to pregnancy such as miscarriage, unwanted pregnancy and infertility also play a role in depression.

(3)   Postpartum

Many new mothers experience the “baby blues”, a normal reaction which tends to subside. However, some women experience severe, lasting depression, a condition termed postpartum depression which is believed to be influenced in part, by hormonal fluctuations.

(4)   Perimenopause and menopause

Increased risk of depression during the perimenopausal and menopausal periods is explained by the rapid fluctuation of reproductive hormones.

Women with past histories of depression are at an increases risk of depression during menopause.


Social and cultural causes

(1)   Role strain

Research indicates that single mothers are three times more likely than married mothers to experience an episode of major depression. The more roles a woman is expected to play (mother, wife, working woman), the more vulnerable she is to role strain and subsequent depression.

(2)   Unequal power and status 

Examples are discrimination in the workplace leading to underemployment or unemployment, low socioeconomic status and society’s emphasis on youth, beauty and thinness, traits which to a large extent are out of women’s control.

(4) Relationship dissatisfaction

An unsuccessful marriage turns into a stressor, which often causes depression among females and leads females to alcohol abuse. Stressful marriage is the leading cause for depression among women.14 Marital distress can also occur if the distressed partner’s behavior triggers negative effects in the spouse. In the large proportion of couples experiencing marital distress, at least one partner is clinically depressed, adding even more stress to the other partner .15

 

Psychological causes

(1)   Weak coping mechanisms

Women are more likely to ruminate when depressed. Rumination maintains depression and even worsens it. Men, on the other hand, tend to distract themselves when they feel low which tends to curtail the depression.

(2)   Stress hormone

Some studies show that women are more likely than men to develop depression under low level of stress.

Females produce more stress hormones than men do, and the female sex hormone progesterone prevents the stress hormone system from turning itself off as it does in men.

      (3) Puberty and body image

Gender difference in depression begins in adolescence. Some researchers point to body dissatisfaction which is more marked in girls during puberty. Body image is closely linked to self-esteem.

Difference between male & female depression symptoms

Men and women share the same core set of depression symptoms: depressed mood, lack of interest, changes in appetite, sleep disturbances, lack of motivation, guilt feelings and difficulty in concentrating. Studies however, suggest differences in the symptom pattern exhibited by men and women.16,17

(1)       One study, which looked at how sadness is expressed in men and women, found that women more often showed visible signs of emotion, such as crying, while men tended to be more rigid and show  less emotion.16,17

(2)       Another study carried out on 151 depressed patients’s revealed men suffered about twice as often as the women from anger attacks. In addition, the frequency of these attacks was about three times higher in men.16,17

(3)       One other notable way in which symptoms differ is that women are more likely than men to exhibit the atypical symptoms of depression like sleeping excessively and overeating, in contrast to the typical symptoms, such as insomnia and loss of appetite.16,17

 

Management      

Hospitalisation is indicated in the following circumstances:

(1)   Severe depression

(2)   Women articulating or displaying a strong urge to act on suicidal thoughts

(3)   Women having a specific suicide plan that is likely to be successful

Outpatient treatment is indicated in the following circumstances:

(1)   Less severe depression with infrequent suicidal thoughts

(2)   Women willing to contract for safety and let go of their instrument of suicide

(3)   Women having a good social support

(4)   Women willing to return for regular follow up

Psychosocial and pharmacologic treatments

(1) Psychosocial therapies should address issues such as competing roles and conflicts. Commonly used treatments include psychotherapy to correct interpersonal conflicts and to help women develop interpersonal skills; cognitive-behavioral therapy to correct negative thinking and associated behavior; and couples therapy to reduce marital conflicts. In patients with mild to moderate depression, psychosocial therapies may be used alone for a limited period, or they may be used in conjunction with antidepressant medication.

(2) The pharmacokinetics of antidepressant drugs differ somewhat in men and women .19,20,21 Currently, little is known about these pharmacokinetic differences because many more men than women have participated in investigational drug studies. Nonetheless, certain gender-related differences merit consideration.21

Absorption of antidepressants may be enhanced in women because

1.      They secrete less gastric acid than men.

2.      Gastrointestinal transit time may be slower in women, especially during high progesterone phases of the reproductive cycle. This slower transit time may also enhance the absorption of antidepressant medications.

3.      Another difference is the higher ratio of body fat to muscle in women; this ratio  becomes even greater with age and increases the volume of distribution for many drugs.

4.        Progesterone increases microsomal and monoamine oxidase enzyme activity, whereas estrogen decreases this activity; these actions affect monoamine neurotransmitters and drug metabolism.7

Thus, female patients with depression may require lower dosages of antidepressants than their male counterparts. Women may also experience drug side effects more frequently.

Premenstrual dysphoric disorder

Both no pharmacologic and pharmacologic measures have been employed in the treatment of PMDD.

Non pharmacological measures include the following:

(1)   Aerobic exercise & relaxation training

(2)   Consumption of complex carbohydrates

(3)   Caffeine restriction

(4)   Moderation of alcohol intake

(5)   Light therapy

(6)   Cognitive behavioral therapy: cognitive restructuring, thought stopping &anger control

Pharmacological measures include the following:

(1)   Vitamin B6 : pyridoxine

(2)   Calcium

(3)   Oestrogen & Progesterone therapy

(4)   Diuretics: spirinolactone

(5)   Nsaids

(6)   Antidepressants: ssris & Tricyclics

(7)   Mood stabilizer: Lithium

(8)   Gonadotropin releasing hormone agonist

The results achieved with benzodiazepines have been mixed.22,23

The use of calcium supplementation to reduce symptoms has recently attracted interest.

Depression during pregnancy

 (1) Non Pharmacological treatment:

Interpersonal and cognitive-behavioral therapies may have a special advantage in pregnant patients with less severe depression. These techniques can be helpful in resolving interpersonal and psychosocial conflicts, resulting in a positive outcome without exposing the mother or fetus to drugs.

(2) Pharmacological treatment:

Pharmacotherapy for depression during pregnancy requires an assessment of the risks and benefits of treatment for both mother and fetus. The risks of treatment should be compared with the risks of not treating depression. The risks of not treating the depression include suicide, poor maternal and fetal nutrition, an adverse neonatal obstetric outcome and the continuation of depression into the postpartum period. Untreated depression may also affect mother-child bonding and may be a cause of chronic depression and treatment resistance.

Studies on pharmacotherapy in pregnancy:

1. A prospective European study27 of 689 women exposed to therapeutic dosages of tricyclic and noncyclic antidepressants during the first trimester of pregnancy found no causal relationship between in utero exposure to these drugs and adverse pregnancy outcomes. Similar findings were reported for another study of 400 pregnant women with documented exposure to tricyclic antidepressants.24

2. One study involving 228 pregnant women treated with fluoxetine during the first trimester found no increase in teratogenicity but did note perinatal neurobehavioral effects.29 Other investigators observed no effect on global intelligence quotient, language or behavioral development in preschool children exposed in utero to either tricyclic antidepressants or fluoxetine.25

3. No increase in teratogenic risk was reported in another prospective study 26 of in utero exposure to the ssris (fluvoxamine, paroxetine and sertraline). In addition to being safe for use in pregnancy, these agents have favorable side effect profiles and therefore may be considered first-line therapy for depression severe enough to justify the use of medication during pregnancy.

ECT in pregnancy

Electroconvulsive therapy has been used to treat depression in pregnancy for over 50 years. This technique has been reported to be relatively safe in pregnant women with severe, refractory depression.27

Depression during the postpartum period

(1)Non Pharmacological treatment:

Patient education and reassurance are generally adequate treatment measures.28

(2)Pharmacological treatment:

Nonpuerperal and puerperal depression are treated similarly unless the mother is breast-feeding.

Data regarding the excretion of antidepressants in breast milk are limited.29 The American Academy of Pediatrics Committee on Drugs35 concluded that "antidepressants are drugs whose effect on nursing infants is unknown but may be of concern." Based on some reports, antidepressants considered to have no adverse effects on breast-fed infants may be considered for use in women with postpartum depression. These antidepressants are the following:

(1)   Tricyclics: Amitriptyline, Clomipramine,  Desipramine, Nortriptyline, Imipramine

(2)   Bupropion

(3)   Ssris: Sertraline

Some investigators have found that estrogen therapy may be effective in patients with postpartum major depression.30

ECT in postpartum period

Electroconvulsive therapy may be of value in patients who have severe depression with psychosis and an increased risk of suicide.

Depression during the perimenopausal period

Depression during both no menopausal and menopausal phases is treated in a similar manner. Estrogen replacement alone can provide relief of vasomotor symptoms, and minor cognitive and mood symptoms. This therapy is also useful in preventing osteoporosis. However, hormone replacement therapy has limited benefit in the treatment of major depression unless patients receive concomitant antidepressant drug therapy and/or psychotherapy.

Depression associated with infertility, miscarriage or prenatal loss

The grief reaction related to infertility, miscarriage or prenatal loss of an infant is usually self-limited. If this reaction persists beyond eight weeks and self-esteem is reduced, patients should be evaluated for an adjustment disorder with depressed mood or major depression. If diagnosed, these disorders should be treated.

References

1.        .World Health Organisation. Nations for Mental Health: A Focus on Women. World   Health Organization: Geneva,1997.

2.        2.World Health Organization. Women's Mental Health: An Evidence Based Review World Health Organization: Geneva, 2000. 

3.        3.Patel V, Araya R, de Lima MS, Ludermir A, Todd C. Women, poverty and common mental disorders in four restructuring societies. Soc Sci Med 1999;49:1461-71.

4.        Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJ. Global Burden of Disease and Risk Factors. Washington: The World Bank; 2006.

5.        Ustun T.B. et al. Global Burden of Depressive Disorders: Methods and Data Sources.British Journal of Psychiatry 2004: 184; 386-92.

6.        6.Mumford D.B. et al. Stress and Psychiatric Disorder in Rural Punjab: A Community    Survey. British Journal of Psychiatry 1997;170:473-78.

7.        7.Patel V. The Epidemiology of Common Mental Disorders in South Asia. NationalInstitute of Mental Health and Neurosciences Journal 17, no. 4 (1999): 307-27.

8.        8.Patel V, Kirkwood BR, Pednekar S, Weiss H, Mabey D. Risk factors for common mental disorders in women Population-based longitudinal study. British J Psychiatry 2006;189:547-55.     

9.        9.Chandran M, Tharyan P, Muliyil J, Abraham S. Post-partum depression in a cohort of women from a rural area of Tamil Nadu, India Incidence and risk factors. British J Psychiatry 2002;181:499-504. 

10.     10.Pereira B, Andrew G, Pednekar S. The explanatory models of depression in low income countries: Listening to women in India. J Affect Disord 2007;102:209-18. 

11.     11.Patel V, Rodrigues M, DeSouza N. Gender, Poverty, and Postnatal Depression: A study of mothers in Goa, India. Am J Psychiatry 2002;159:43-7. 

12.     12.Rodrigues M, Patel V, Jaswal S, De Souza N. Listening to mothers: Qualitative studies on motherhood and depression from Goa, India. Soc Sci Med 2003;57:1797-806.

13.     13.Verma D, Chandra PS, Thomas T, Carey MP. Intimate partner violence and sexual    coercion among pregnant women in India: Relationship with depression and post-traumatic stress disorder. J Affect Disord 2007;102:227-35.

14.     14.Whisman, M. A. (2001). Marital adjustment and outcome following treatments for depression. Journal of Consulting and Clinical Psychology 2001; 69: 125-129.

15.     15. McCullough, J. P. Treatment for chronic depression: Cognitive Behavioral    Analysis System of Psychotherapy (CBASP). Journal of Psychotherapy Integration 2003;13: 241-263.

16.     16.Gorman J.M. Gender differences in depression and response to psychotropic medication. Gender Medicine 2006; 3.2:93-109.

17.     17.Winkler D, Edda P, Siegfried K. Gender specific symptoms of depression and anger attacks. The Journal of Men’s Health & Gender 2006; 3.1:19-24.

18.     18.Akiskal HS, Benazzi F. The DSM-IV and ICD-10 categories of recurrent [major] depressive and bipolar II disorders: Evidence that they lie on a dimensional spectrum. Journal of Affective Disorders 2006;92(1):45–54. 

19.     Kornstein SG. Gender differences in depression: implications for treatment. J Clin Psychiatry 1997; 58(suppl 15):12-8.

20.     Pajer K. New strategies in the treatment of depression in women. J Clin Psychiatry 1995;56(suppl 2):30-7.

21.     21.Yonkers KA, Kando JC, Cole JO, Blumenthal S. Gender differences in pharmacokinetics and pharmacodynamics of psychotropic medication. Am J Psychiatry 1992;149:587-95.

22.     22. Schmidt PJ, Grover GN, Rubinow DR. Alprazolam in the treatment of premenstrual   syndrome. A double-blind, placebo-controlled trial. Arch Gen Psychiatry 1993;50:467-73.

23.     Harrison WM, Endicott J, Nee J. Treatment of premenstrual dysphoria with alprazolam. A controlled study. Arch Gen Psychiatry 1990;47:270-5.

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25.     25.Nulman I, Rovet J, Stewart DE, Wolpin J, Gardner HA, Theis JG, et al. Neurodevelopment of children exposed in utero to antidepressant drugs. N Engl J Med 1997;336:258-62.

26.     Kulin NA, Pastuszak A, Sage SR, Schick-Boschetto B, Spivey G, Feldkamp M, et al. Pregnancy outcome following maternal use of new selective serotonin reuptake inhibitors: a prospective controlled multicenter study. JAMA 1998;279:609-10.

27.     27. Miller LJ. Use of electroconvulsive therapy during pregnancy. Hosp Community   1994;45: 444-50.

28.     Nonacs R, Cohen LS. Postpartum mood disorders: diagnosis and treatment guidelines. J  Clin Psychiatry 1998;59(suppl 2):34-40.

29.     Physician's desk reference. 52nd ed. Montvale, N.J.: Medical Economics, 1998.

30.     Gregoire AJ, Kumar B, Everitt B, Henderson AF, Studd JW. Transdermal oestrogen for treatment of severe postnatal depression. Lancet 1996;347:930-3.