Magazine article Clinical Psychiatry News

Unpacking 'Depression': Depressive Symptoms Distinct in Perimenopause

Magazine article Clinical Psychiatry News

Unpacking 'Depression': Depressive Symptoms Distinct in Perimenopause

Article excerpt

The notion that women in midlife are moody is so pervasive that entire Pinterest boards and Facebook pages are dedicated to menopause jokes. For physicians, however, it's not always so easy to sort out when a patient who says she's down, or short tempered, might really have major depressive disorder or another serious psychiatric diagnosis.

"The key point is that depressive symptoms are not the same as clinical depression," said Hadine Joffe, MD, in an interview that recapped her recent presentation at the annual meeting of the North American Menopause Society (NAMS). "The causal factors and contributions to depressive symptoms and major depression are different."

It's not that clinical depression is a more severe extreme of milder depressive symptoms, but rather a distinct clinical entity, she said, and it's sometimes a point that gets missed.

Practically speaking, this means two things. The first message is that treating common menopausal symptoms can have a positive impact on mood. However, it's also true that clinicians must be educated and vigilant about more serious mood symptoms, and not expect major depression to lift; when a patient starts hormone therapy, according to Dr. Joffe, a psychiatrist and director of the women's hormone and aging research program at Brigham and Women's Hospital, Boston.

Using a novel experimental model, Dr. Joffe and her coinvestigators recently completed work that examined the relationship among daytime and nighttime hot flashes, sleep disturbance, and mood changes. In a small study of 29 healthy premenopausal women, they tracked mood, hormone levels, and sleep fragmentation both before and after suppressing ovarian function with a gonadotropin-releasing hormone agonist. The study found independent and significant effects on mood for nighttime (but not daytime) hot flashes, as well as subjective sleep disturbance (J Clin Endocrinol Metab. 2016;101[10]:3847-55).

"We were struck by the fact that the nighttime hot flashes, separate from the sleep problems, contributed to mood symptoms," Dr. Joffe said.

This study, though small, validates and extends the notion that multiple symptoms of the menopausal transition contribute to the mild mood symptoms that are common during this phase of a woman's life, said Dr. Joffe. To date, most of the studies have been large epidemiologic studies, which while important, tend to assess people at one cross-sectional time point annually, and can't always capture a nuanced and precise view of symptoms and how they relate to hormone levels, she said.

"Perimenopausal hormone changes are dynamic," said Dr. Joffe, and have wide interindividual variation during the menopausal transition. Overall, though, she said, "clinical studies show that mood is better as ovarian activity is more normalized in perimenopausal women. Conversely, the more abnormal the hormonal profile, the worse the mood."

Major depression is another story, said Dr. Joffe. "Menopause-specific factors have not, for the most part, been linked," she said, noting that the best predictors for clinical depression in midlife that have been identified to date are a previous history of clinical depression or anxiety, as well as other traditional psychiatric risk factors such as low socioeconomic status and a low level of social support.

"People often present with all these symptoms all at once; they have mood disturbances, they have hot flashes, they have sleep disturbances. …

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