AND ITS MANAGMENT
Netranee Anju Ramdinny-Purryag
Jean Pharmacy, Mauritius
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
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.
(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
(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
(9) Sudden lack of interest in sex or loss of
Anxiety that is often
Women as a group have received
considerable attention with regard to risk factors for the development of
According to the American Academy of
Family Physicians, the risk factors are as follows:
- Family history of mood disorders
- Past history of mood disorders in early
- Loss of a parent before the age of 10 years
- Childhood history of physical or sexual abuse
- Use of an oral contraceptive, especially one
with a high progesterone content
- Use of gonadotropin stimulants as part of
- Persistent psychosocial stressors (eg loss of
- 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
(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).
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
(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
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
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.
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
(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
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
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
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
(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
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
(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
They secrete less
gastric acid than men.
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.
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.
increases microsomal and monoamine oxidase enzyme activity, whereas estrogen
decreases this activity; these actions affect monoamine neurotransmitters and
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:
Aerobic exercise &
Consumption of complex
Moderation of alcohol
therapy: cognitive restructuring, thought stopping &anger control
Pharmacological measures include the following:
Vitamin B6 :
The results achieved with benzodiazepines have been mixed.22,23
The use of calcium supplementation to reduce symptoms has recently
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
(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
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
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
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
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
(1) Tricyclics: Amitriptyline, Clomipramine,
Desipramine, Nortriptyline, Imipramine
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
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.
Organisation. Nations for Mental Health: A Focus on Women. World Health
Organization. Women's Mental Health: An Evidence Based Review World Health
Organization: Geneva, 2000.
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.
Lopez AD, Mathers CD,
Ezzati M, Jamison DT, Murray CJ. Global Burden of Disease and Risk Factors.
Washington: The World Bank; 2006.
Ustun T.B. et
al. Global Burden of Depressive
Disorders: Methods and Data Sources.British Journal of Psychiatry 2004: 184;
et al. Stress and Psychiatric
Disorder in Rural Punjab: A Community Survey. British Journal of
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.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
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
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.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.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.
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
14.Whisman, M. A.
(2001). Marital adjustment and outcome following treatments for depression. Journal of Consulting and Clinical
Psychology 2001; 69: 125-129.
15. McCullough, J. P.
Treatment for chronic depression: Cognitive Behavioral Analysis System of
Psychotherapy (CBASP). Journal
of Psychotherapy Integration 2003;13: 241-263.
16.Gorman J.M. Gender
differences in depression and response to psychotropic medication. Gender
Medicine 2006; 3.2:93-109.
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
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.
24. 24.Cohen LS, Rosenbaum JF. Psychotropic
drug use during pregnancy: weighing the risks. J Clin Psychiatry 1998;59(suppl
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
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.