The North American Menopause Society published a practice pearl recently written by Dr. Soares of Queen’s University School of Medicine. Here is a synopsis:
Many women have experienced mood changes during times of hormonal change such as pregnancy, premenstrually, postpartum, and during the menopausal transition. During the menopausal transition, many factors also affect mood including health problems, medication use, vasomotor symptoms, sleep disturbances, and stressful life events.
When considering treatment for depression, several considerations are important.
The clinician must differentiate between a major depressive disorder and depressive symptoms such as low mood and decreased enjoyment of normal activities. Major depression has certain diagnostic criteria that are well documented.
Studies have shown that both depressive symptoms and major depressive episodes occur more commonly in the perimenopause and early postmenopausal years. Having had a previous depressive episode is a major risk factor for developing depressive symptoms with menopause.
There are many psychosocial risk factors that are contributory including: unemployment, low education, being African American or Hispanic, poor health, greater body mass index, smoking, low social support, history of anxiety, and multiple life stressors.
Risk factors include wider variations of hormone levels (vs. low estrogen), vasomotor symptoms, sleep problems, poor health, lack of social support, and life stresses which may all contribute to the timing of depression. Studies have demonstrated that sleep problems and distressing life events led to more persistent or recurrent depression. Prolonged perimenopause and surgical menopause seemed to have a higher relation to depression.
Antidepressant are the first line treatment, especially if the symptoms are severe, there is a history of multiple episodes of depression, or if a woman’s ability to function is impaired, or there is suicidal ideation. Trying a previously successful drug is a good start, but for women who have never been on an antidepressant, the SSRI’s and SNRI’s are often effective. When choosing an antidepressant, considerations should include tolerability ad side effects. Some of the antidepressants are more effective in eliminating hot flashes, while others may also be effective in reducing pain.
What about estrogen? Estrogen has benefits in enhancing mood because of its interaction with neurotransmitters. The benefit in reducing hot flashes and improving sleep may also be contributory to their antidepressant effect.
The clinical approach that I find helpful in my practice is to begin with an extensive history which includes menstrual cycle, previous history of depression, depressive symptoms, vasomotor symptoms, social history, and medical history. I determine if a trial of estrogen is a reasonable option. If a patient’s symptoms are mostly depressive, or if they have any contraindications to hormones, I will begin with an antidepressant. In some cases, I may prescribe both, but often sequentially rather than concurrently. That makes it easier to monitor benefits and side effects.