Depressive Disorders in Women

1. Depressive Disorders in Women Women’s Health Conference Orlando, Florida March 2011 Norma Jo Waxman MD Associate Professor of Family and Community Medicine Faculty, The Bixby Center for Global Reproductive Health University of California San Francisco njwaxman@fcm.ucsf.edu

2. Objectives At the end of the talk participants will be able to: Describe the range of Mood Disorders women experience Recognize post partum mood disorders Prescribe medications for depression in women and know when to refer

3. Mood Disorders = Affective Disorders • Disturbance in mood • Inappropriate, exaggerated, or limited range of feelings • Everybody gets down, and everybody experiences excitement and pleasure • Mood disorder: feelings are extreme  • Crying, and/or feeling depressed, suicidal • Or excessive energy, sleep not needed for days and decision making significantly hindered

4. Common Disease • 10% of primary care adult patients • 3x visits as non-depressed patients • Occurs in all demographic groups • Occurs in women double the rate in men • 20% lifetime incidence • 50% occurs between ages 25-44 years • Common cause of slow recovery from physical illness

5. Precipitating Events Life events which can precipitate depression • Loss of a parent or sibling in early childhood • Loss of a limb or another part of the body (mastectomy) • domestic violence • miscarriage • loss of self-esteem • divorce or separation

6. Depression and Disability • More disability days than any other chronic condition except coronary artery disease • More chronic pain than any other chronic disease except arthritis • WHO: 2nd most important cause worldwide of life years lost to disability (2020) • $31.3 billion/year in the United States (1990)

7. Poorly Recognized and Treated • Under-recognized • 80% of patients are undiagnosed • Only 20% of patients receive treatment • 80% of patients respond to treatment • Anxiety often due to depression • Patient may present with smiling or able to laugh, w/o obvious depressed mood- known as masked depression • Universal screening is necessary

8. Barriers to Diagnosis: Clinician • Failure to recognize somatization • Distinguishing sadness from depression • Discomfort with emotional issues • Misdiagnose as organic or hormone related • Concern that assessment is time-consuming • Difficulties in obtaining a referral

9. Barriers To Diagnosis: Patients • Resistance to diagnosis of a mental disorder • Belief it is natural to be depressed sometimes • Belief they can will themselves well • Shame • Cultural Issues

10. Suspect The Diagnosis:Clinical Presentation • Multiple visits for vague complaints • Depressed voice, expression, or posture • Pain syndromes: vulva, pelvic, vagina, menses, coitus, urinary tract • Clinician feels sad during or after visit

11. Forms Of Depression In Women • Unipolar forms • Major depressive disorder • Chronic depression (dysthymia) • Bipolar mood disorder (manic-depression) • Other distinct syndromes in women • Eating disorders • Premenstrual dysphoric disorder (PMDD) • Postpartum mood disorders • Grief, adjustment reactions (minor depression)

12. Less Common Variants of Depression • Agitated depression: • agitation severe, common in middle-aged & elderly • Atypical depression: • severe anxiety, severe fatigue, increased sleep & increased appetite. Often medication resistant • Seasonal affective disorder (SAD): • depression same time of the year, usually winter

13. Disorders Major Depression Dysthymia Bipolar I Bipolar II PMDD MDD (Postpartum) Prevalence 4.9% 3.2% 0.8% 0.5% 5.0% 13% Mood Disorders: Prevalence

14. Levels of Unipolar Depression • Major depressive disorder • Mild: extra effort in ADL* • Moderate: often preventsADL* • Severe: always preventsADL* • Chronic depression = dysthymia *ADL: activities of daily living

15. MDD, Single episode Absence of mania or hypomania MDD, Recurrent 2 major depression episodes, separated by at least a 2 month period with more or less normal functioning/mood Major Depression Disorder

16. DSM IV Criteria For Major Depression • At least five of nine symptoms • Depressed mood and/or anhedonia (required) • Low self-esteem (worthlessness) • Sleep disturbance • Change in appetite or weight • Difficulty concentrating • Fatigue, loss of energy • Psychomotor agitation or retardation • Recurrent thoughts of death or suicide

17. DSM IV Criteria For Major Depression • Clinically significant distress or impairment in social, occupational, or other areas of function • Not due solely to physical health condition, prescribed medication, or substance abuse • Symptoms not accounted by bereavement; or: • Persist longer than two months • Marked functional impairment • Suicidal ideas • Psychosis; psychomotor retardation

18. Criteria For Major Depression • Symptoms should be present • Most days • Most of the day • For at least 2 weeks

19. Screening With 2 Questions • Depression is present if 1 or both present: “In the past month have you been often bothered by. . . . . . depressed mood?” . . . lack of interest or pleasure?” Whooley MA, Avins AL, Miranda J, Browner WS. Case-finding instruments for depression: Two questions are as good as many. J Gen Int Med 1997;12:439-445.

20. Direct Questions to Ask • Depressed mood "How's your mood been lately?" • Anhedonia • Loss of interest or pleasure • Lack of enjoyment in most daily activities "What have you enjoyed doing lately?" "Are you getting less pleasure in things you typically enjoy?"

21. Direct Questions to Ask • Other symptoms "Have you been feeling down on yourself?" "How are you eating; sleeping?” "How's your energy level?" "Do you ever feel like life is not worth living?" "How's your concentration?"

22. Mnemonic: “Space Drags” S leep disturbance Pleasure/interest (lack of) Agitation Concentration Energy (lack of)/fatigue Depressed mood Retardation movement Appetite disturbance Guilt, worthless, useless Suicidal thought

23. Criteria For Dysthymia or Chronic Depression • Dysthymia • 2 years depressed mood most days • With 2 or more symptoms of depression • A major depressive episode has not occurred • Treatment • Same as for depression

24. Rule Out Other Etiologies • General medical illness • hypo or hyperthyroidism, anemia, diabetes, multiple sclerosis • Substance abuse • Medication side effects • Beta blockers, ACE inhibitors, • GnRH analogues (Lupron) • Glucocorticoids • Amphetamine withdrawal • Acute grief and mourning

25. Suicidal Assessment • Screen every patient suspected of depression • Asking does not insult patient or initiate thought • Ask direct questions: "Have you had thoughts of hurting yourself?" "Do you sometimes wish your life was over?" "Have you had thoughts of ending your life?"

26. Suicidal Assessment • If yes, assess immediate risk: "Do you feel that way now?” "Do you have a plan?" "Do you have the means to carry out your plan?” "Do you promise to call me immediately if your suicidal thoughts get stronger?”

27. Treatment Of Major Depression • Components • Psychotherapy • Psychopharmacotherapy • Psychosocial interventions • ECT (2nd line or life-threatening) • Alone or in combination

28. Bipolar Disorders • Bipolar I Disorder • Bipolar II Disorder • Cyclothymic Disorder

29. Manic Episode: Diagnostic Criteria A period of abnormally and persistently elevated, expansive, or irritable mood not due to psychosis, meds or organic etiology with marked impairment Plus 3 of the following 7 symptoms: • Inflated self esteem or grandiosity • Decreased need for sleep • More talkative than usual or pressure to keep talking • Flight of ideas, or racing thoughts • Distractibility • Increase in goal directed activity • Excessive involvement in pleasurable activities

30. Hypomania: Diagnostic Criteria • All the criteria of a Manic episode except without marked impairment

31. Bipolar I Alternation of full manic and depressive episodes Average onset is 18 years Tends to be chronic High risk for suicide Bipolar II Alternation of Major Depression with hypomania Average onset is 22 years Tends to be chronic 10% progess to full biploar I disorder Bipolar Disorder

32. Cyclothymia • Many hypomanic episodes and periods with depressed mood not meeting criteria of Major Depression, and lasting 2 years • During 2 yr period of disturbance, never without hypomanic or depressive symptoms more than 2 months at a time • No evidence of MDD or Manic episode during the first two years of disturbance

33. Depression: Genetics Family studies: • Relatives 2-3x more likely to have a mood disorder (usually major depression) Twin studies: • Identical 3x more likely than fraternal twin to have a mood disorder (particularly for bipolar disorder) Women: Heritability rates are higher

34. Grief Reactions • May last up to 2 years after loss or event • Usually falls short of criteria for major depression • Rarely causes prolonged impairment in work and other activities • Cyclicity is common in days, weeks, months • If functional impairment, Rx with SSRI’s for 30 days

35. Premenstrual Dysphoric Disorder • 5% of women, typical age 18-30 years • Symptoms last 5-14 days in the luteal phase • Must abate at onset of menses • Symptoms: depression, anxiety, emotional lability, tension, irritability, anger, sleep and appetite disturbances • Rx with daily or luteal phase SSRIs • Role of OCs with drospirenone Pearlstein T. Drugs 2002;62:1869-85.

36. Chronic Pelvic Pain and Depression • Offer antidepressant early in evaluation • Offer neuropathic drug(s) early in evaluation • Offer NSAID analgesics early in evaluation • Offer early referral to mental health provider for help with depression and developing coping skills

37. Postpartum Mood Disorders

38. 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

39. “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

40. Post-partum Major Depression • Symptoms of depression that last longer than 2 weeks • Usually begins 2-3 weeks after delivery • May start and last up to one year • High risk of recurrence in future pregnancies

41. 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

43. Treatment Of Mood Disorders • Components • Psychotherapy • Psychopharmacotherapy • Psychosocial interventions • ECT (2nd line or life-threatening for MDD) • Alone or in combination

44. Medications Treatment Guidelines • 50% have effect in 2 weeks • Optimal effect may take 4-6 weeks • Titrate to achieve therapeutic dose • If no response by 6 wks, switch agents • If partial response at maximum dose, augment with 2nd drug or get consult • Treat for 6-12 months • 65-70% response to first anti-depressant

45. Partial Or No Response • Effect should be present by 6 weeks • Assess for adherence to daily dosing • Re-evaluate diagnosis: • Other psychiatric disorders • Substance abuse • Organic disorder • Adjust dosage or change medication • Refer to a psychiatrist

47. Daily Dosing Of SSRI’s

48. NEWER AGENTS • SNRIs = serotonin noradrenergic reuptake inhibitor • Desvenlafaxime PristiqR • Venlafaxine Generic, Effexor/ Effexor XRR, • Duloxetine CymbaltaR • Other antidepressants • Bupropion WellbutrinR /SR /XL, Aplenzin™ • Mirtazepine RemeronR • Nefazodone SerzoneR- Hepatic • Trazadone DesyrelR

49. Buproprion (Wellbutrin IR,SR,XLR) • Does not cause sexual dysfunction • Useful as first line or to augment SSRI/SNRI • Start 150mg qd for 1 wk, increase to 150mg bid • Do not exceed 200mg single dose • Maximum dosing = 400mg / day • Avoid use if risk of seizures

50. Medication Side Effects • Agitation/insomnia: • ProzacR > ZoloftR > PaxilR > Tricyclics > RemeronR • Add sedative or hypnotic • Gastrointestinal distress • Don’t use Setraline (Zoloft) • Take medication after meals • Sedation • Take medication at bedtime