Depression in Women: From PMS to Postpartum Blue

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Depression in Women From PMS to Post-partum Blues

• Kimberley Guida, MD
• Pullman Family Medicine

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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.

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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)

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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

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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

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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

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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- SSRIs, tricyclics, others
• St. Johns wort- some studies suggest a benefit
• Need a minimum of 2 weeks to see an effect
• Treatment for minimum of 6 months

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SSRIs- 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

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Whats 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
• SSRIs may cause problems with libido and
  difficulty attaining orgasm
• Other medications may enhance libido- ie
  Wellbutrin, Effexor

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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

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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

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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

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Treatment For PMDD

• Choice of treatment is aimed at the most
  troubling symptoms
• Lifestyle modification
• Dietary approach
• Vitamin supplementation
• Medications
• Cognitive/behavioral approach

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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

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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

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Medications for PMDD

• Anti-inflammatories- effective for pain relief
• Oral contraceptives- suppress ovulation
• Diuretics when salt restriction not helpful in
  reducing significant fluid retention
• SSRIs are often first choice- daily versus
  premenstrual week only

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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

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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

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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

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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

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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

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Treatment for Post Partum Depression

• Same as for major depression
• SSRIs work well
• All antidepressants are to some degree, excreted
  in the breast milk, but usually undetectable
  levels in the infants blood
• Avoid Prozac due to long half life- may
  accumulate in the infant

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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
• Dont hesitate to discuss symptoms with your
  doctor

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This Presentation Is Available Online At

• www.pullmanfamilymed.com
• Thank You