Mood Disorders Specific to Women

ANTENATAL DEPRESSION (Depression during pregnancy) - A subtype of major depression

INTRODUCTION

Between 10 to 27% of pregnant women experience depression and a greater percentage suffer mood symptoms. Onset of symptoms can occur anytime during pregnancy with recent studies suggesting that later onset is more common. The primary risk factor for antenatal depression is a personal or family history of depression; other risk factors are listed in Table 1.

If a depressive episode predates the pregnancy, the symptoms are often exacerbated during the pregnancy. If antenatal depression is left untreated, postpartum depression is predicted. Antenatal mood disorders are associated with low birth weight, increased risk of prematurity and pre eclampsia (an abnormal condition of pregnancy characterized by the onset of hypertension after the twenty-fourth week of gestation). Moreover, the child is at risk of developing impairment in motor skills, a heightened stress response, alteration in frontal lobe activity and behavioural problems.

POSTPARTUM DEPRESSION (PPD)

Following childbirth, it is common to experience the "baby blues". Up to 70% of new mothers experience mood swings, insomnia, dependency, crying, restlessness, irritability and feelings of sadness. For most, the "baby blues" lasts a week or two. If symptoms last longer and become incapacitating, the diagnosis of postpartum depression (PPD) is made. PPD affects up to 8 to 20% of women. For some, symptoms commence in the third trimester, while for others, they feel great after childbirth and experience no symptoms of the "baby blues" yet develop PPD three to six months later.

Those who experience one episode of PPD are more likely to experience a similar episode at a later birth. Moreover, as Table 2 shows, women who have experienced one episode of depression are also at risk. The cause of PPD is unknown. It has been thought that it may be triggered by fluctuating oestrogen and progesterone levels that occur following childbirth. Abnormalities in postpartum thyroid hormones have also been implicated. Medical and non - medical risk factors for PPD are listed in Table 3. Postpartum onset of mood episodes may present with psychotic features, the onset is more likely if previous postpartum mood disturbances have been experienced. PPD has been shown to also occur in men.

SYMPTOMS OF POSTPARTUM DEPRESSION (PPD)

The symptoms of postpartum depression are similar to major depression. (See Table 4) Women suffering postpartum depression often experience higher levels of anxiety and a tendency to ruminate over the health and safety of their newborn. Low levels of suicide have been reported amongst those with PPD.

• A depressed mood most of the day or nearly every day
• A markedly diminished interest or pleasure in all or almost all activities
• Changes in appetite
• Sleep disturbance
• Agitation or slowness in movement everyday
• Fatigue or loss of energy nearly everyday
• Feelings of worthlessness, excessive or inappropriate guilt
• Diminished ability to think or concentrate
• Recurrent thoughts about death or thoughts and plans of suicide

IMPACT OF POSTPARTUM DEPRESSION (PPD)

Whilst many are told that childbirth is going to be the happiest time of their life, sadly, many mothers of newborns suffer agonising bouts of depression and anxiety that impact upon mother/infant bonding, family functioning and cognitive development of the child. Behaviours common in mothers with PPD include emotional withdrawal from the child, showing anger to the child and ignoring or being careless about the child's wellbeing. These adverse effects are likely to be influenced by the severity and duration of the depressive episode.

TREATMENT OF POSTPARTUM DEPRESSION (PPD)

For those with mild to moderate symptoms, supportive psychotherapy and cognitive behavioural therapy is efficacious. If antidepressant use is required, caution is necessary as all antidepressants and/or their metabolites are expressed in the breast milk in small amounts; the baby however absorbs less than is considered dangerous. Most studies, to date, fail to show adverse effects occurring to the infant when simultaneously breast feeding and taking antidepressants. As premature babies are often dependent upon breast milk as their primary source of food, extra caution is required. When making a decision on the use of medications, PPD needs to be weighed against the consequences for the child of non-usage.

POSTPARTUM PSYCHOSIS

One woman in every one thousand will develop postpartum psychosis. The risk factors include a personal or family history of bipolar disorders and a family history of postpartum psychosis. For most, onset occurs within the first two weeks postpartum. It is often abrupt with hospitalisation mandatory as the sufferer is at risk of harming herself and others including the newborn child. Symptoms include hallucinations, confusion, delusions, labile mood, sleep disturbances, fatigue and mood swings. Homicidal and suicidal ideation also commonly occurs. Unfortunately, of those who develop postpartum psychosis, most will continue to have an affective disorder, the most common being bipolar disorders. For those who are at risk of postpartum psychosis, the use of medications prophylactically needs consideration.

PRE - MENSTRUAL DYSPHORIA DISORDER (PMDD)

Many women, sometime prior to menstruation, experience mood swings, anxiety, irritability, breast tenderness and food cravings. These changes have a mild impact upon daily life and interpersonal relationships, the symptoms diminishing during or towards the end of menstruation. However, 3 to 8% of women in their reproductive years experience pre - menstrual dysphoria disorder (PMDD). This diagnosis is made when their pre - menstrual symptoms become incapacitating. A marked feature of this diagnosis is the co-occurrence of major depression. For the diagnosis of PMDD, at least five (or more) of the symptoms listed in table 5 must have been experienced during the past year.

• Markedly depressed mood, feelings of hopelessness, or self-deprecating thoughts.
• Marked anxiety, tension, feelings of being “keyed up” or “on edge”
• Marked affective lability (e.g. feeling suddenly sad or tearful, or increased sensitivity to
  rejection)
• Persistent and marked anger or irritability or increased interpersonal conflicts
• Decreased interest in usual activities (e.g., work, school, friends, hobbies)
• Subjective sense of difficulty in concentrating
• Lethargy, easy fatigability, or marked lack of energy
• Marked change in appetite, overeating, or specific food cravings
• Hypersomnia or insomnia
• A subjective sense of being overwhelmed or out of control
• Other physical symptoms, such as breast tenderness or swelling, headaches, joint or muscle
  pain, a sensation of “bloating”, weight gain.

There is uncertainty over the etiology of PMDD.That genetic factors are involved is suggested from twin studies, which shows PMDD is more likely to occur in monozygotic twins than dizygotic twins. It has also been suggested that the etiology may also be neuro-biological. Non-sufferers of PMDD experience fluctuating levels of two neurotransmitters, serotonin and GABA (gamma-aminobutyric acid), both peaking premenstrually and declining during the follicular phase (the first part of the menstrual cycle when ovarian follicles grow to prepare for ovulation). In PMDD sufferers, during the follicular phase, there is no peak of these neurotransmitters.

MOOD DISORDERS DURING PERI-MENOPAUSAL AND MENOPAUSAL PHASES OF LIFE

The fifth decade of life for most women is a transition from a reproductive to a non-reproductive stage. The peri-menopausal period is the interval of irregular menstrual activity that directly precedes menopause and has an average age onset of 47.5 years. Menopause, defined as the end of menstruation, occurs on average at 51.2 years. The peri-menopausal period is a time of significant hormonal fluctuations including a decrease in oestrogen levels and a rise in follicular stimulating hormones.

The fluctuations of these hormones may translate into an increase in psychiatric illnesses including symptoms of bipolar disorders, mood symptoms and schizophrenic symptoms. An increased susceptibility to depression in a significant number of women has also been reported. Studies however suggest a complex interaction between the hormonal fluctuations of the peri-menopausal period and the onset of depressive symptoms. For example, women with a history of depression are more likely to experience greater hormonal influences earlier during the transition to menopause and an exacerbation of depressive symptoms. Moreover, women are more prone to develop depressive symptoms even in the absence of prior episodes of depression. To date, there is no gold standard treatment of mood disorders during this transition period. Studies do show the Selective Serotonin Reuptake Inhibitors (SSRIs) antidepressants to be beneficial.

Click here for Further Reading