DEPRESSION IN GYN PATIENTS

Recognizing depression in gynecologic patients

By Kimberly A. Yonkers, MD, Megan V. Smith, MPH, Wendy L. Brunetto, MPH, and Mary Acri Cavaleri, LCSW

Nearly twice as many women as men suffer from clinical depression, and up to 50% of ob/gyn patients have the disorder or its symptoms. Since you may be the only clinician many of these women see, you're uniquely positioned to detect its presence and steer patients toward appropriate treatment.

Your perinatal patients aren't the only patients likely to suffer from depression. Major depressive disorder (MDD) affects up to 22% of gynecologic patients.^1,2 And even though women seen for gynecology visits may be twice as likely to screen positive for depression as patients coming in for pregnancy or well-care visits,³ depression is often underrecognized in this patient population.^2,4

In Part One of this two-part article (April), we discussed mood disorders during the pre- and postnatal period. In this installment, our goal is to raise awareness among ob/gyns of the symptoms of several depressive disorders in gynecologic patients, and to underscore some unique symptom clusters, like the relationship between chronic pelvic pain and menopause and depression. Finally, we'll describe some effective tools commonly used for depression screening that can help you identify patients before the condition gets out of control.

Epidemiology of depression in women

MDD is a serious medical condition that will afflict up to 21% of women at some point in their lives.⁵ The second leading cause of disability worldwide among women, MDD disables more women than do infections or obstetrical and gynecologic conditions.⁶ In fact, depressive disorders cause as great—or greater—disability than do arthritis, back problems, lung disease, and gastrointestinal disorders.⁷

Worldwide, women are more likely than men to suffer from all unipolar depressive illnesses.⁸ While boys and girls have a similar risk for a depressive disorder, the rates rise for both sexes around puberty. Figure 1 shows the steep rise in risk for females just as they enter the fertile period of their lives.^9,11 Furthermore, psychiatric epidemiology shows that the likelihood of suffering from depression is particularly high among reproductive-aged women.¹⁰

Diagnosing major depression. The diagnostic criteria for MDD stipulate that the individual suffer from at least five of a possible nine symptoms and that at least one symptom be "depressed, low, or blue mood most of the day, nearly every day," or markedly diminished interest and pleasure in most activities.¹² The other seven are (1) decrease or increase in appetite nearly daily, (2) insomnia or hypersomnia nearly daily, (3) psychomotor agitation or retardation nearly daily, (4) fatigue or loss of energy nearly daily, (5) trouble thinking, concentrating, or making decisions nearly daily, (6) feelings of worthlessness or excessive or inappropriate guilt nearly daily, and (7) recurrent thoughts of death, suicidal ideation, or a suicide attempt or specific plan. MDD adversely affects appetite, energy, and sleep, illustrating how the illness can affect the body.

Diagnosing minor depression. Minor depressive disorder (Min D) requires three or four symptoms rather than a minimum of five, and as the term implies, it's less severe than MDD; but can still cause substantial impairment.¹¹ To be diagnosed with MDD or Min D, women must have symptoms for 2 weeks at minimum; however, these illnesses commonly last for 1 to several months.^11,13,14

Dysthymic symptoms. Dysthymic disorder, another unipolar mood disorder, is characterized by fewer symptoms than MDD (Table 1), but lasts at least 2 years. The symptoms for all three disorders according to DSM-IV occur nearly every day for most of the day during the symptomatic period.¹²

TABLE 1
Criteria for dysthymic disorder

Depressed mood for most of the day, most days for 2 years or more*

Poor appetite or overeating

Low energy or fatigue

Low self-esteem

Poor concentration or difficulty making decisions

Feelings of hopelessness

Insomnia or hypersomnia

*Starred item is requisite for diagnosis

Source: Diagnostic and statistical manual of mental disorders: DSM-IV. 4th ed. Washington, DC: American Psychiatric Association; 1994.¹²

The clinical course of depressive disorders, which are more likely to be episodic and recurrent rather than chronic, heightens the illnesses' overall morbidity and impact.¹³ Among patients recruited from psychiatric settings, MDD lasted a median of 4 weeks and an average of 20 weeks.¹³

Depressive disorders often occur together with other psychiatric disorders, which compounds the morbidity. Particularly striking is their comorbidity with anxiety and substance use disorders. More than 50% of patients with MDD will also have either generalized anxiety disorder (17%), agoraphobia (16%), social phobia (27%), panic disorder (10%), or post-traumatic stress disorder (20%).¹⁵ About one in four patients with MDD will be alcohol dependent and 13% will be drug dependent.

Gender differences in depression

One of the biggest mysteries surrounding depression—including dysthymic disorder—is the disproportionate rate at which it affects women.^5,8 Moreover, women are more likely than men to have chronic and recurring illness, which can make it harder for patients and clinicians alike to identify the illness, since it may be perceived as nothing different from "usual."^16,17 For women, it appears that adverse life events and stressors are the strongest predictors of slower recovery from MDD.¹⁴

Women manifest depressive symptoms differently than men, being more likely to describe themselves as having feelings of worthlessness, decreased sexual interest, feelings of guilt, expressed anger, increased appetite, functional impairment in marital and family roles, psychomotor retardation, and weight gain (with appetite and weight gain two of the most frequent findings).^18-23 Women with MDD seem more likely to have anxious and somatic symptoms such as pelvic pain.^24-26 Differing gender-based symptom profiles are often explained by the male tendency to deny symptoms and rely on distractions from symptoms versus the female tendency to ruminate and focus on symptoms.^20,22,27 Depressed women have more co-existing anxiety disorders, including panic disorder and obsessive-compulsive disorder, while women with eating disorders are more likely to have concurrent depression.²⁸ It's important to understand these comorbidities when assessing female patients in primary care.

For both sexes, unipolar or bipolar depression in one or both parents increases the likelihood of depression in the offspring.²⁹ However, there are some gender-specific risk factors for depression in women including: lack of social support, less than a high school education, lack of work outside the home, presence of young children in the home, unstable marital history, feelings of helplessness, and coexisting anxiety disorders.^10,30-32

Premenstrual dysphoric disorder

The depressive symptoms of women with these disorders are commonly exacerbated during the luteal phase of the menstrual cycle.^33,34 Some women experience moderate-to-severe mood symptoms premenstrually but lack an ongoing mood disturbance throughout the menstrual cycle. Premenstrual dysphoric disorder (PMDD) is an illness characterized by severe mood and behavioral symptoms that cyclically recur during the luteal phase of the ovarian cycle and cease within a few days of the onset of menstruation.¹² This disorder has a lifetime prevalence of roughly 2% to 10% in menstruating women,^35-38 compared to up to 50% for the less restrictive moderate PMS.^39-41 The DSM-IV's diagnostic category for PMDD differs from premenstrual syndrome (PMS) in that PMDD patients must experience at least five symptoms (one of which is affective) and functional impairment due to the disorder.

The typical PMDD symptoms are depression, tension, irritability, anger, anxiety, sleep, and appetite disturbances.^42,43 Symptoms last from 1 to 2 weeks during nearly every menstrual cycle. While premenstrual disturbances like PMDD are often trivialized, they can be quite severe and chronic, and can have a serious effect on interpersonal relationships. Given PMDD's average age of onset of 16 years, women who have symptoms 7 to 10 days each cycle until their mid-30s will experience more than 200 potentially symptomatic cycles or 2,000 symptomatic days (5 to 6 years' worth).⁴⁴ It's even worse for the portion of women who continue suffering from PMDD until menopause, who'll have symptoms for twice that number of years.

Since PMDD can affect one's marital role, parental activities, and social and leisure activities, it can rival the impairment found for MDD.^12,45,46 Suicide attempts and ideation by many women with this illness speak to the severity of PMDD.⁴⁷ In one study, some 63% of PMS clinic patients had suicidal ideation and 15% had previously attempted suicide.⁴⁸

The cause of PMDD remains unknown. Current hypotheses posit that symptoms result from normal gonadal hormone levels but abnormal signaling to the CNS during usual menstrual cycles.⁴⁹ This theory is consistent with findings showing dysregulation in neurotransmitters systems, including serotonin and

-aminobutyric acid (GABA).⁵⁰

Studies show that selective serotonin reuptake inhibitors (SSRIs) are effective in the acute phase treatment of PMDD (roughly 70% of women will respond).^50-53 Moreover, this class of drugs is more effective than other antidepressant agents, which show little benefit compared to placebo.^51-54 SSRIs may be administered daily (which does seems to be more effective) or only during the luteal phase.

Depression and menopause

Certainly, perimenopause is a period of great hormonal flux.⁵⁵ Many women also experience mood lability, irritability, and anxiety.^55-58 Not every study finds a rise in depressive disorders among menopausal women.^55,58-61 However, women who've undergone surgical menopause tend to have higher rates of depressive disorders than naturally menopausal women.⁶² Some groups of women may be particularly susceptible to an episode of major depression during perimenopause, such as those with: a family history of psychiatric illness, "affective disorders," a personal history of a mood disorder, poor health, and recent periods of stress.^62-65 One investigator found that health problems, age, socio- economic situation, sexual abuse during childhood, and recent periods of stress were all associated with the onset of depression during menopause.⁶⁵

Although perimenopausal women undergo a host of adjustments, depression during this period doesn't manifest itself much differently from other periods in the lifespan. The course of depression during menopause is unpredictable, however, and risk factors such as a history of depression may play a role in delaying its resolution. Some women who were depressed before menopause may continue to be so throughout but not after menopause, while others may continue to be depressed afterwards, and still others may find that their mood fluctuates throughout the climacteric.⁶¹

Instrumental to treating depression at any stage of a woman's life is a thorough physical assessment and a psychiatric history. While antidepressants in general are likely to be effective for symptoms, mirtazepine is the only one specifically tested in perimenopausal women.⁶⁶

The efficacy of hormone replacement therapy on mood disturbances in perimenopause is unclear. Two small studies found that estrogen decreased depressive symptoms in these women.^67-69 Some research suggests estrogen may do so during menopause by enhancing the efficacy of antidepressants.⁷⁰ Many studies—but not all—have found that giving both an antidepressant and HT to postmenopausal women decreases depression.^71,72 Clearly, due to these mixed findings and the recent Women's Health Initiative results suggesting that HT increases the risk of cardiovascular disease and breast cancer, health-care providers should weigh the benefits and risks of HT over standard antidepressant therapy before deciding to administer estrogen.⁷³

Chronic pelvic pain and co-existing depression

Making it even more difficult to diagnosis depressive illnesses is the link between mood disorders and certain somatic disorders—particularly pain disorders. Studies show that up to 80% of primary-care patients with mood disorders will complain of pain and that the likelihood of a co-existing mood disorder increases sixfold if the patient has two pain complaints and eightfold with three.^74,75 Chronic pelvic pain (CPP) is defined as pain of unknown cause in the lower abdomen that persists for at least 6 months.⁷⁶ Its estimated prevalence may be as high as 40% among women seeking primary care.⁷⁶ As ob/gyns know only too well, most CPP patients will undergo months of extensive evaluation and try various treatments. Psychological factors should always be considered, of course, but especially when the pain persists for at least 6 months and the prescribed regimens fail.

Up to about 60% of women with CPP also suffer from depression; however, the cause-and-effect relationship remains elusive.^76,77 Is the CPP causing the depression, or vice versa—or are the two conditions working in unison, creating a vicious cycle? We can't say. Regardless, studies have revealed psychological differences among women who suffer from CPP of an unknown cause compared to their counterparts with a known cause.^78-83 Specifically, major depression is significantly more prevalent among women with CPP than in the comparison group.⁸²

The most effective treatment option is a multidisciplinary approach that combines physical, psychological, and social aspects of the pain. For example, tricyclic antidepressants (TCAs) are an effective way to treat women suffering from CPP, because they improve pain tolerance, restore sleeping patterns, and reduce symptoms of depression.^84-92 In addition to pharmacotherapy, psychological counseling will also benefit patients with any underlying anxiety or depression, also helping them to improve their overall level of functioning and quality of life.

Do OCs induce depression?

That's the common perception; however, most of the evidence supporting this notion is merely anecdotal. To date, of the four placebo-controlled studies that have evaluated the relationship between OCs and depression, only one found a dose-response relationship between the two.^86-90 In fact, one actually found that progestin improved mood.⁸⁷ Therefore, available data to date do not support the contention that OCs, particularly those containing high progestin levels, induce depression or other mood changes. Rather, several studies have shown that OCs are often an effective way to treat PMS, because they help alleviate many negative symptoms.^91-93

Be cautious when prescribing OCs to certain women who seem to be at greater risk for becoming depressed while taking OCs: those with a history of depression, moderate-to-severe premenstrual depression, painful menstrual periods, depression during pregnancy or postpartum, or a high level of psychological distress.^90,94-96 However, because OCs differ with regards to their ingredients (e.g., estrogen vs. progestin), dosage, and temporal sequence of dosing (e.g., monophasic, biphasic, or triphasic), clinicians can alter types of oral contraceptives to best suit their patients presenting with depressive symptoms or negative mood.

Strategies for identifying depression in ob/gyn practices

Research has shown that organ-ized screening programs in obstetrics/gynecology practices to identify depression do improve patient outcomes.³ There are several strategies for identifying mood disorders.

Two screening questionnaires. You can administer a screening scale such as the Inventory Depressive Symptomatology (IDS), or Primary Care Evaluation of Mental Disorders (PRIME-MD) depression module (Table 2).^97,98 Both are short, easy to administer, and measure severity of symptoms. The IDS measures severity of cognitive features of depression/anxiety and vegetative symptoms of depression (sleep, appetite, and energy) and is comprehensive, despite being short (28-items). The PRIME-MD, which records diagnoses of MDD and Min D, has been used in ob/gyn settings and takes from 5 to 20 minutes. Both screening tools diagnose specific syndromes of MinD or MDD, in addition to gauging severity of symptoms.

TABLE 2
Depression screening instruments for a gyn setting

PRIME-MD Depression Module

14-item self-report questionnaire (accompanying clinician evaluation guide) Provides diagnosis of major and minor depressive disorders and measures severity 5 to 20 minutes to complete

Copies and permission to use can be obtained by e-mailing:
Robert L. Spitzer, MD
Chief, Biometrics Research and Professor of Psychiatry
Columbia University
e-mail: RLS8@Columbia.edu

Inventory of Depressive Symptomatology (IDS)

28 to 30-item self-report form (IDS-SR) or clinician-administered (IDS-C) form
Provides measure of illness severity
15 to 30 minutes to complete

Copies and permission to use can be obtained by writing:
A. John Rush, MD
University of Texas Southwestern Medical Center
5323 Harry Hines Boulevard
Dallas, Tex. 75235-9101

Each of these screening questionnaires includes questions on suicidality. Asking the patient about any past suicidal thoughts and attempts is good clinical practice and gives you valuable information about her psychiatric history. Be sure to follow up any positive response to the suicidal ideation questions on a screening questionnaire with questions that center around the three areas of ideation, intent, and plan.

• Suicidal ideation

"Have you ever thought about suicide or death?"

"Do you currently think of suicide or death?"

Follow up these questions with questions on how often the patient thinks these thoughts and when these thoughts began.

• Suicidal intent

"Is there anything that would stop you from committing suicide?"

• Plan

"Do you have a suicide plan?"

"Do you have access to (specific weapon, place, etc.)?"

Clinicians should consult with mental health professionals when managing high-risk patients and should be aware of and/or develop internal procedures to triage patients who are very likely to attempt suicide.

What next? Once a patient is identified as depressed, clinicians often ask, "What next?" While you'll want to refer some patients, you may wish to directly treat others, where appropriate. Screening programs in a gynecologic setting that have proven successful routinely screen for depression, recruit staff members to assist in patient education, and collaborate with others through referrals to specialty mental health-care services.^99,100

Conclusions

Recent studies suggest that up to 22% of patients at ob/gyn practices suffer from MDD. Because for many women, their gynecologist serves as their only source of health care, these clinicians must understand and seize the unique opportunities they have for better—and earlier—recognition and treatment of depression across a patient's lifespan. What are your treatment and planning options for depressed patients? You can provide direct care of many depressive illnesses either by pharmacotherapy or targeted psychotherapy. Alternatively, or in conjunction with this, you can develop collaborative arrangements with mental health-care professionals who can offer treatment to women with more severe and comorbid illness or to women who prefer psychotherapy as their primary treatment. A combination of depression screening and active treatment and/or referral, is likely to advance the overall well-being of women seen in gyn practice.

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DR. YONKERS is an Associate Professor in the Department of Psychiatry at Yale University School of Medicine, New Haven, Conn., and directs the Premenstrual Syndrome and Perinatal Treatment Research Program. Her laboratory has been conducting studies to identify treatments that work for women with PMDD and she currently is the Principal Investigator for an NIMH-funded trial of drug therapy for PMS/PMDD.

MS. SMITH is a Research Associate, Department of Psychiatry, MS. BRUNETTO is a Research Associate, Department of Epidemiology; and MS. CAVALERI is a Social Worker, Department of Psychiatry, Yale University School of Medicine, New Haven, Conn.

Take-home messages

• Women are about twice as likely as men to suffer from depressive illness and their risk rises steeply beginning with their first period. Moreover, women seen for gynecology visits are twice as likely to screen positive for depression compared to women coming in for pregnancy or well-care visits.

• The depressive disorders and anxiety and substance use disorders frequently exist side by side.

• Suicide attempts and ideation speak to the severity of premenstrual dysphoric disorder (PMDD).

• Along with psychological counseling, tricyclic antidepressants are an effective way to treat the up to 60% of women with chronic pelvic pain who also suffer from depression.

 

Kimberly Yonkers, Wendy Brunetto, Megan Smith, Mary Caveleri. Recognizing depression in gynecologic patients. Contemporary Ob/Gyn Jun. 1, 2004;49:63-73.