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Mood and anxiety disorders are more common in women. About 25% of women will have a mood disorder in their lifetime. Another 30% will have some type of anxiety disorder. So women are about twice as likely as men to have some kind of mood or anxiety disorder. I’m going to talk first about the premenstrual syndromes, then I am going to move on to psychiatric illness during pregnancy, postpartum disorders and then finish up quickly with the mood disorders which emerge during menopause.
So we have premenstrual syndromes, or PMS as they are commonly known, and premenstrual dysphoric disorder. Typically when people use PMS, the acronym PMS, it’s kind of a loose term which is used to refer to a constellation of mild mood and visible symptoms. Premenstrual dysphoric disorder on the other hand is more like an Axis I diagnosis. It can cause very significant disruptions in mood. In both PMS and PMDD you have a growth of psychological or mood symptoms associated with physical symptoms and there are very classic mood symptoms associated with PMS and PMDD. On the top of the list is irritability, anger.
Now it’s interesting that these moods sometimes and the related symptoms are very similar, if not exactly the same, as what we see in major depression which has led many to suggest that PMDD is merely a variance of a major depression. What makes it a little bit different is that you have these characteristic physical symptoms. You have the bloating, the weight gain, breast tenderness, joint.
In terms of diagnosing PMDD, it’s important to remember that PMDD only occurs in about 5% of women. Now this is in contrast to PMS, which is the milder form, which occurs in about 30-40% of women. It’s also very interesting that PMDD does not really emerge with the onset of menarche in the teens. It emerges more commonly during the 20’s and 30’s. Often we see clinically women who present for the first time with PMDD after the birth of a child. We don’t quite understand why that happens, but that is a typical presentation. In this population this period of major depression is very common and we also know that women with PMDD.
Next, I am going to move on to talking about psychiatric illness for pregnancy, which is a topic that brings fear into many people’s hearts. It’s kind of nice because it shows what I think is a common conception of pregnancy as being this idyllic time, as this time of rosy cheeks and healthy complexions. For some women it is that, but you have to remember not all women will experience pregnancy in that way. Particularly if they have a history of psychiatric illness. One of the big questions we have is, " What is the impact of pregnancy on psychiatric illness?" Is pregnancy really a time of emotional well-being? Although there is this clinical lore.
The longitudinal course of bipolar disorder in women during pregnancy. At time zero all of the women are doing fine. They are doing well, they are on their mood stabilizer. But we have two groups. This upper group, which is hard to see - but there is a picture in the outline that might be a little bit easier to see - is the group who continued their medication. This lower group down here is the group who discontinued their mood stabilizer either early in the course of pregnancy or prior to conception.
When we think about using a medication during pregnancy the first thing we start to worry about is the fetus. Will the medication do some harm to the fetus which is developing? When we think about risk to the infant we think about three types of risk. The first risk is the risk of some type of congenital malformation. Does the medication cause a birth defect? In the general population of women there is a 3-4% risk of any type of a birth defect in the absence of any significant exposure. We look to find out if certain medication increases the frequency of congenital malformations in general. We also look to see if the medication causes a particular clustering of one type of birth defects. The classic example of that is lithium and it’s connection with Epstein’s anomaly. Another type of risk we worry about is the risk of DNA toxicity or withdrawal. This is a risk that we see in the infant after it is born. Does the infant show any signs of exposure to the medication? Some of the typical signs of neonatal toxicity, as reported in the literature.
I don’t want to forget about ECT, which many patients do not want to use but it is important to remember that it is rapid, it is safe and it is quite effective. We use it mostly in patients with mania or very severe depression. What it lets you do is really minimize the exposure to medications. There are obviously some medications involved in ECT but they are not used on a daily basis and very small doses are used and we’ve seen, at least in our site, no significant problems with this type of treatment.
Just to leave you with some guidelines for treating patients during pregnancy. You always want to make decisions on a case-by-case basis. You might see two women on the same day, same disorder, taking the same medication but you may propose very different plans for them. There are some women with depressive disease who absolutely refuse to take medication during pregnancy, and sometimes that’s what you will have to do. You’ll have to meet them where they are and make a plan that is agreeable to them.
We are going to move on to the postpartum mood disorders. Kendall and colleagues looked at the hospitalization rate before, during and after pregnancy and right after delivery within the first three months you see the sharp rise in the number of hospitalizations. It’s really clear that the postpartum period is really a time of increased risk for women with psychiatric illness. When we talk about postpartum depression we divide it into three subtypes; postpartum blues, postpartum depression and postpartum psychosis. You’ll find none of these diagnoses in the DSM IV but what you’ll notice is there is a postpartum onset specifier which can be used.
Postpartum blues isn’t really a disorder. It’s probably a normative experience of pregnancy or of delivery, of childbirth. Fifty to 70 % of women will present with it. By definition it is transient. It lasts a couple of days, maybe a week and it is over by the second week. It’s not quite like depression. Most women will have a characteristic mood lability. They will tell you that they cry at the drop of a hat and they do not experience pessimism or feeling depressed or disheartened or hopeless.
Postpartum psychosis is the most severe of the postpartum mood disorders, and fortunately the most rare. Affecting about 1-2 per thousand women. Its onset is very rapid, very dramatic and very hard to miss. It looks like a manic psychosis or a mixed psychosis. Most women typically present first with restlessness with sleep disturbance. Delusions are very common and often centered on the infant. That there’s something wrong with the infant. That the infant is possessed, that the infant is genetically altered.
Many groups have tried to define risk factors which will help us identify those women at risk for postpartum depression. Several groups have looked at various demographic factors and it appears that there is no type correlation between age, marital status, socioeconomic status or parity in risk for postpartum depression. The one exception is that teen mothers appear to be at very high risk with about 25% of women under 18 developing postpartum depression. Some groups have looked at psychosocial factors and it appears that women who report marital problems or lack of adequate supports are at higher risk. The big risk factor.
Postpartum depression is really a tragedy because women can miss out on a very important part of their child’s life. And there’s a lot of data to suggest that depression in a mom has a lot of implications for the children. There are more prone to emotional dysregulation and behavioral disturbances and later on, at higher risk for depression. So you really want to treat postpartum depression aggressively and effectively when you see it. More importantly, you want to look for it.
We are almost done. We are at the end of life, and menopause. Basically the data on menopause and mood disorders is skimpy at this stage but I think it’s an exciting area. It looks like the perimenopause is a time of increased risk for the development or the exacerbation of mood disorders. Once a woman is into postmenopause her risk for depression is about the same as before she hit menopause. So it seems that a woman is more at risk at this time of flux, when she is experiencing menstrual irregularity, when she has the physical symptoms - the hot flashes, night sweats and sleep disturbance. There’s a lot of interesting data on estrogen replacement in this population. It looks to improve mood and cognition. If you see them in either menopausal or perimenopausal depression you want to treat them as you would treat anybody else. You want to use the conventional antidepressant agents. If they have a lot of physical symptoms or if they have severe memory loss, you might suggest that they pursue the option of estrogen replacement therapy. There is also some data to suggest that in those women who respond incompletely to an antidepressant.