DEPRESSION IN SPECIAL POPULATIONS
Ellen Haller, MD, Professor of Psychiatry, and Director, Adult Psychiatry Clinic and the WomanCare Mental
Health Program, University of California, San Francisco, School of Medicine
From New Frontiers in Depression Research and Treatment, presented by the University of California, San
Francisco, School of Medicine
Depression in Women: PMS/PMDD, Postpartum, and Perimenopause
| Premenstrual syndrome (PMS)/premenstrual dysphoric disorder (PMDD): PMS described for centuries and
across cultures; 60% to 80% of women have some PMS symptoms at some time during their menstrual life, 30%
have more significant PMS symptoms, and 3% to 5% have PMDD; diagnosis based on symptoms; have woman
keep daily symptom diary for entire month; tell her to pick 3 symptoms that bother her most and rate them daily
on scale of 0 (mild) to 3 (severe); symptoms usually start in week before menses begin, resolve with onset of
menses
|
 | Treatment: start with basic wellness behaviors (decreasing salt, caffeine, sugar, and alcohol, and increasing intake
of fluids, fresh fruits, and whole grains, and exercise; smoking cessation); stress management techniques helpful
(including educating woman that symptoms not “all in her head,” but very real); next, increase calcium intake to
1200 mg/day; third, give selective serotonin reuptake inhibitors (SSRIs), either continuously or on days 14
through 28 of each menstrual cycle
|
| Depression in pregnancy: myth that pregnancy protects against depression; 10% to 20% of pregnant women develop
major depressive disorder; risk factors include history of depression, socioeconomic problems, marital or relationship
discord, ambivalence about pregnancy, already having several children (the more children at home, the greater the
risk for depression); in study, when women taking antidepressants became pregnant and discontinued antidepressants,
50% to 75% had recurrence of depression during pregnancy; depression during pregnancy carries risks for
mother (including poor prenatal care, smoking and substance abuse, suicide, preterm delivery, and increased risk for
postpartum depression) and for infant (including low birth weight and lower Apgar score); treatment options include
interpersonal psychotherapy (IPT) and antidepressants; all antidepressants cross placenta
|
| Tricyclic antidepressants: “lots of data” indicate no increased risk for congenital malformations; desipramine tends
to be best tolerated by pregnant woman; mother and infant may have anticholinergic side effects, but none life-
threatening, “just sort of annoying”; baby should be monitored by pediatrician or family practitioner
|
| SSRIs: conflicting data; case comparison found 15.5% of babies exposed to fluoxetine had minor malformations,
compared to 6.5% of babies not exposed, but definition of “minor” ambiguous; other authors found no
differences between babies exposed to fluoxetine and those not exposed; Food and Drug Administration
(FDA) recently reclassified paroxetine to “not recommended in pregnancy,” based on data provided by manufacturer
that indicated babies exposed to paroxetine had increased risk for major congenital malformation
(odds ratio 2.2); another study found no difference between exposed babies and those not exposed; not much
data available for other SSRIs
|
| Perinatal effects of SSRIs: most occur in first 4 days after birth; may include agitation, tremor, restlessness, rigidity;
thought due to serotonin withdrawal or to increased serotonergic activity; consider reducing dose or discontinuing
SSRI before delivery
|
| Postpartum depression: ranges from mild to severe; “postpartum blues”—affects 50% to 70% of women; by definition,
mild and transient; typically occurs in first week after delivery and resolves within “just a few days”;
marked by emotional lability; unclear whether it increases risk for postpartum depression; postpartum
depression—“looks just like any other kind of depression”; occurs in 10% to 15% of women; Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition (DSM-IV) states it must start within first month after delivery,
but researchers say within 6 mo; risk factors include history of PMS/PMDD, relationship problems, family history
of depression or bipolar disorder; risk of developing depression with history of depression not during pregnancy
25%, with history of depression during previous pregnancy 50%, and with history of depression during current
pregnancy 50% to 75%; screen all women for depression at 6-wk follow-up visit; all antidepressants excreted in
breast milk, but levels in babies so low as to be undetectable; treat with psychotherapy first, then medications if
necessary; most data on safety and tolerability exist for sertraline, paroxetine, and nortriptyline; postpartum
psychosis—medical emergency, requires psychiatric hospitalization; extremely rare (1 to 2 cases out of every
1000 deliveries)
|
| Perimenopausal depression: menopause is retrospective diagnosis that can be made only after woman has had no
period for 12 mo; period of irregularity before that called perimenopause, which usually starts in mid to late 40s;
average duration 4 to 5 yr; ovulation still occurs, but less frequently and at irregular intervals; fertility decreased
but not ended; menstrual cycles irregular and unpredictable; myth that all women get depressed during perimenopause
(rate of depression not higher than that in other women); risk factors include history of depression, history of
hormonally mediated mood symptoms, prolonged perimenopause, concomitant medical problems, and psychosocial
stress; treatment—brief psychotherapy; exercise; stress management; changes in lifestyle (eg, consumption of
less caffeine, alcohol, and spicy foods; having several small meals instead of 3 large ones; using bed clothes made
of natural fibers); consider brief hormone therapy; if necessary, use SSRI or selective norepinephrine reuptake inhibitor
(SNRI)
|
Depression in Lesbian, Gay, Bisexual, and Transgender Populations
| Definitions: lesbian is woman attracted to women; gay is man attracted to men; bisexual is person attracted to both
sexes; transgender refers to gender identity, not to sexual orientation; labels are not behavior—erotic interests (to
whom is one sexually attracted?); sexual behavior (with whom is one having sex?); emotional attachments (to
whom does one turn for emotional support?); self-identity (what does one call himself or herself?); humans have
variable congruency, which means their sex activity can be exclusively heterosexual, exclusively homosexual, or
mixed; fluidity over time means one’s sexual activity may change over time
|
| More definitions: sexual orientation—to whom is one attracted? (does not speak to behavior); gender identity—
with which sex does one identify? (does not speak to sexual orientation); gender expression—how does one communicate
to others his or her gender identity? is one’s gender expression typical or atypical? coming out—process
by which one communicates, first to self and then to others, his or her sexual orientation; in our society, heterosexuality
expected, so individual who discovers that he or she not heterosexual must go through process of recognizing
that, accepting it in himself or herself, and sharing it with others; being closeted—means individual hides his or
her sexual orientation from others; homophobia—fear of people who are not heterosexual; heterosexism—
expectation and presumption that heterosexuality inherently better than homosexuality or bisexuality; queer—
term increasingly used in homosexual, bisexual, and transgender populations to describe themselves, in attempt to
make it less pejorative
|
| Epidemiology: survey of members of gay/lesbian-oriented advocacy and health organization had 57% response rate;
found that 42% of respondents had sought mental health services in previous 12 mo (compared to 10% to 12% of
general population); 25% of those with mental health contact described care as poor or inappropriate; 46% described
therapist as homophobic; 10% said therapist attempted or suggested “reparative therapy,” although none
entered therapy because they wanted to become heterosexual (position statements by American Psychiatric Association,
American Psychologic Association, National Association of Social Workers, and others state that reparative
therapy unethical)
|
| Reasons for seeking therapy: “same as anyone else,” eg, problems with relationships, jobs, families, symptoms of
psychiatric disorder such as depression or anxiety
|
| Special reasons: coming out—nonlinear, individualized process; timing varies considerably; concealment has psychologic
burden (eg, constant decision making about disclosure, need for constant vigilance if closeted, lack of
social support and affiliation); no role models in family
|
| Societal discrimination against lesbian, gay, bisexual, and transgender people: similar to and different from discrimination
faced by others due to ethnicity, sex, age, and/or socioeconomic status; similarities—stereotyping
and assumptions; prejudice, discomfort, hatred; exclusion from housing and jobs; violence; differences—ability to
pass (eg, very difficult to hide skin color, but very easy to hide sexual preferences); lack of equal rights and protections;
lack of role model in family to show individual how to act and how to cope; potential for rejection by
family, friends, peers, coworkers, religious acquaintances; magnitude of hatred and discomfort from many different
sources
|
| External homophobia and transphobia: consequences include discrimination, hate crimes, poor relationship with
family of origin, discrimination in health care, lack of equal civil and legal rights
|
| Internalized homophobia: individual unconsciously picks up biases of his or her society; desire to change sexual
orientation to that of mainstream; may lead to feeling of isolation, limitations on career and other achievements,
lack of success in relationships, depression, substance abuse, anxiety, and suicidal ideation
|
| Relationship issues: partners being at different phases of coming-out process; issues of sameness, blending, merging;
risk for verbal or physical violence; shame; denial; legal issues—lack of rights and responsibilities of legal
marriage; lack of societal and familial embracing of couple and of honoring their commitment to each other; lack
of social or legal rules about breaking up; lack of social support during separation or break-up; parenting issues
|
| Mental health in lesbian, gay, and bisexual populations: difficult to do research; early on, homosexuality and bisexuality
seen as pathology, but removed from that category in 1973; what little research done finds mental health
statistics in these populations no different from those in heterosexual population; population-based studies done
only since 1998; most studies found higher rates of major depression and alcohol abuse in homosexual and bisexual
groups than in heterosexual groups (transgender people not identified separately, so no statistics available); one
study found very high rates of substance abuse in transgender people in minority ethnic groups
|
| Treatment issues: many homosexual, bisexual, and transgender people fear therapy will be unsafe place; they may
have had negative experiences with therapy; they worry that therapist may be disgusted by them; they may
present same false self to therapist that they present to family and others
|
| What therapist can do: do not assume heterosexuality; use open-ended, gender-neutral questions to gather family
or social history; do not push individual to accelerate coming-out process; determine whether patient’s sexual
orientation or gender identity is focus or context of his or her presentation; screen for violence; be open to patient’s
own assumptions, prejudices, and feelings; know about resources; seek consultation or supervision
when necessary
|
| Resources: Association of Gay and Lesbian Psychiatrists (www.aglp.org); Center for Lesbian Health Research at
UCSF (www.lesbianhealthinfo.org); UCSF Transgender Resources and Neighborhood Space (www.caps.ucsf.edu/
TRANS/); for patients, recommend reading Queer Blues: The Lesbian and Gay Guide to Overcoming Depression
by Hardin, Hall, and Berzon (Oakland, CA: New Harbinger Publications, 2001)
|
Educational Objectives
| The goal of this program is to educate the listener about treating women with premenstrual syndrome (PMS), premenstrual
dysphoric disorder (PMDD), and postpartum and perimenopausal depression, and about the causes of depression
in lesbian, gay, bisexual, and transgender populations. After hearing and assimilating this program, the
clinician will be better able to:
|
| 1. Describe the three levels of treatment available for PMS and PMDD.
|
| 2. Educate women about the use of antidepressants during pregnancy, the postpartum period, and breast-feeding.
|
| 3. Discuss the approach to depression in the perimenopause.
|
| 4. Relate the similarities and differences between the causes of depression in the heterosexual population and
those of homosexual and bisexual populations.
|
| 5. Help homosexual, bisexual, and transgender people feel safer and more comfortable in the therapeutic setting.
|
Discussed on This Program
Desipramine hydrochloride [Norpramin]
Fluoxetine hydrochloride [Prozac, Prozac Pulvules, Prozac Weekly, Sarafem, Sarafem Pulvules
Paroxetine hydrochloride [Paxil, Paxil CR, Pexeva]
Suggested Reading
Clements-Nolle K et al: HIV prevalence, risk behaviors, health care use, and mental health status of transgender persons:
implications for public health intervention. Am J Public Health 91:915, 2001; Cochran SD, Mays VM, Sullivan
JG: Prevalence of mental disorders, psychological distress, and mental health services use among lesbian, gay,
and bisexual adults in the United States. J Consult Clin Psychol 71:53, 2003; Craft EM, Mulvey KP: Addressing
lesbian, gay, bisexual, and transgender issues from the inside: one federal agency’s approach. Am J Public Health
91:889, 2001; Dimmock PW et al: Efficacy of selective serotonin-reuptake inhibitors in premenstrual syndrome: a
systematic review. Lancet 356:1131, 2000; Flores DL, Hendrick VC: Etiology and treatment of postpartum depression.
Curr Psychiatry Rep 4:461, 2002; Gjerdingen D: The effectiveness of various postpartum depression treatments
and the impact of antidepressant drugs on nursing infants. J Am Board Fam Pract 16:372, 2003; Gold LH:
Postpartum disorders in primary care: diagnosis and treatment. Prim Care 29:27, 2002; Hallberg P, Sjoblom V: The
use of selective serotonin reuptake inhibitors during pregnancy and breast-feeding: a review and clinical aspects. J
Clin Psychopharmacol 25:59, 2005; Hardin KN, Hall M, Berzon B: Queer Blues: The Lesbian and Gay Guide to
Overcoming Depression. Oakland, CA: New Harbinger Publications, 2001; Lattimore KA et al: Selective serotonin
reuptake inhibitor (SSRI) use during pregnancy and effects on the fetus and newborn: a meta-analysis. J Perinatol
25:595, 2005; Lumley J, Miller LJ: Postpartum depression. JAMA 287:762, 2002; Misri S, Kostaras X: Benefits
and risks to mother and infant of drug treatment for postnatal depression. Drug Saf 25:903, 2002; Newport DJ et al:
The treatment of postpartum depression: minimizing infant exposures. J Clin Psychiatry 63(Suppl 7):31, 2002; Nonacs
R, Cohen LS: Depression during pregnancy: diagnosis and treatment options. J Clin Psychiatry 63(Suppl 7):24,
2002; Nulman I et al: Child development following exposure to tricyclic antidepressants or fluoxetine throughout fetal
life: a prospective, controlled study. Am J Psychiatry 159:1889, 2002; Nulman I et al: Child development following
exposure to tricyclic antidepressants or fluoxetine throughout fetal life: a prospective, controlled study. Am J
Psychiatry 159:1889, 2002; Simon GE, Cunningham ML, Davis RL: Outcomes of prenatal antidepressant exposure.
Am J Psychiatry 159:2055, 2002; Spinelli MG, Endicott J: Controlled clinical trial of interpersonal psychotherapy
versus parenting education program for depressed pregnant women. Am J Psychiatry 160:555, 2003; Ward
RK, Zamorski MA: Benefits and risks of psychiatric medications during pregnancy. Am Fam Physician 66:629;
2002; Weissman AM et al: Pooled analysis of antidepressant levels in lactating mothers, breast milk, and nursing infants.
Am J Psychiatry 161:1066, 2004; Willging CE, Salvador M, Kano M: Brief reports: unequal treatment: mental
health care for sexual and gender minority groups in a rural state. Psychiatr Serv 57:867, 2006; Wisner KL,
Parry BL, Piontek CM: Clinical practice. Postpartum depression. N Engl J Med 347:194, 2002.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue,
Dr. Haller disclosed that she is on the Speakers’ Bureau of Forest Laboratories, GlaxoSmithKline, Pfizer, and Wyeth.
Dr. Haller was recorded at New Frontiers in Depression Research and Treatment, held March 24-26, 2006, in San
Francisco, CA, and sponsored by the University of California, San Francisco, School of Medicine. The Audio-Digest
Foundation thanks Dr. Haller and UCSF for their cooperation in the production of this program.
|
