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Depression in Women: From PMS to Post-partum Blues. Kimberley Guida, MD Pullman Family Medicine.

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Depression in women from pms to post partum blues

Depression in Women: From PMS to Post-partum Blues

Kimberley Guida, MD

Pullman Family Medicine


Case presentation

Julie is a 25 year old female who just delivered her second child 3 weeks ago. She breaks down in tears for no reason and is irritable with her 3 year old. She is having trouble sleeping, and has no appetite. She admits that she feels guilty for not feeling happy about the new infant in her life. She feels she is not an effective parent to either child. She is returning to work next week and wonders how she will be able to cope.

Case Presentation


Statistics
Statistics child 3 weeks ago. She breaks down in tears for no reason and is irritable with her 3 year old. She is having trouble sleeping, and has no appetite. She admits that she feels guilty for not feeling happy about the new infant in her life. She feels she is not an effective parent to either child. She is returning to work next week and wonders how she will be able to cope.

  • Depression is twice as common in women as in men

  • 20% of women will experience depression at some point during their life

  • One out of 10 childbearing women will experience post-partum depression

  • 40% of women have premenstrual symptoms, 5% of these experience premenstrual dysphoric disorder (PMDD)


Risk factors for depression
Risk Factors For Depression child 3 weeks ago. She breaks down in tears for no reason and is irritable with her 3 year old. She is having trouble sleeping, and has no appetite. She admits that she feels guilty for not feeling happy about the new infant in her life. She feels she is not an effective parent to either child. She is returning to work next week and wonders how she will be able to cope.

  • Family history of mood disorder

  • Loss of a parent before age 10

  • History of sexual or physical abuse

  • Use of hormones (contraception/HRT/fertility treatments)

  • Persistent life stressors (i.e. loss of job)

  • Loss of social support system


What is depression

Psychological child 3 weeks ago. She breaks down in tears for no reason and is irritable with her 3 year old. She is having trouble sleeping, and has no appetite. She admits that she feels guilty for not feeling happy about the new infant in her life. She feels she is not an effective parent to either child. She is returning to work next week and wonders how she will be able to cope.

Depressed mood

Decreased interest in activities

Feelings of guilt, hopelessness

Suicidal thoughts

Physical symptoms

Sleep disturbance

Appetite/weight changes

Difficulty concentrating

Fatigue

Decreased energy

What Is Depression?


Gender differences

Women have earlier onset of depression child 3 weeks ago. She breaks down in tears for no reason and is irritable with her 3 year old. She is having trouble sleeping, and has no appetite. She admits that she feels guilty for not feeling happy about the new infant in her life. She feels she is not an effective parent to either child. She is returning to work next week and wonders how she will be able to cope.

Episodes may last longer and recur more often

More atypical symptoms

Suicide attempts more frequent but less successful

Less substance abuse than men

More anxiety symptoms than men

More associated eating disorders

More associated migraine headaches

More feelings of guilt

More seasonal depression

Gender Differences


Treatment for depression
Treatment For Depression child 3 weeks ago. She breaks down in tears for no reason and is irritable with her 3 year old. She is having trouble sleeping, and has no appetite. She admits that she feels guilty for not feeling happy about the new infant in her life. She feels she is not an effective parent to either child. She is returning to work next week and wonders how she will be able to cope.

  • Psychosocial (counseling)- cognitive behavioral therapy

  • Medications- used with counseling in cases of moderate to severe depression

    • Alter chemical balance in the body to enhance mood (norepinephrine, serotonin levels)

    • Many different types- SSRI’s, tricyclics, others

    • St. John’s wort- some studies suggest a benefit

    • Need a minimum of 2 weeks to see an effect

    • Treatment for minimum of 6 months


Ssri s often the first choice
SSRI’s- Often the First Choice child 3 weeks ago. She breaks down in tears for no reason and is irritable with her 3 year old. She is having trouble sleeping, and has no appetite. She admits that she feels guilty for not feeling happy about the new infant in her life. She feels she is not an effective parent to either child. She is returning to work next week and wonders how she will be able to cope.

  • Selective serotonin reuptake inhibitors- allow more serotonin to be available in the body, enhancing mood

  • Examples: Prozac, Paxil, Zoloft, Luvox, Celexa

  • Once daily dosing

  • Side effects: nausea, headaches, nervousness, insomnia/fatigue, sexual dysfunction, weight gain with prolonged use


What s that about sexual dysfunction
What’s That About Sexual Dysfunction? child 3 weeks ago. She breaks down in tears for no reason and is irritable with her 3 year old. She is having trouble sleeping, and has no appetite. She admits that she feels guilty for not feeling happy about the new infant in her life. She feels she is not an effective parent to either child. She is returning to work next week and wonders how she will be able to cope.

  • Up to 70% of depressed patients experience a loss of sexual interest

  • If we treat the underlying depression, the libido often improves

  • SSRI’s may cause problems with libido and difficulty attaining orgasm

  • Other medications may enhance libido- ie Wellbutrin, Effexor


Premenstrual dysphoric disorder
Premenstrual Dysphoric Disorder child 3 weeks ago. She breaks down in tears for no reason and is irritable with her 3 year old. She is having trouble sleeping, and has no appetite. She admits that she feels guilty for not feeling happy about the new infant in her life. She feels she is not an effective parent to either child. She is returning to work next week and wonders how she will be able to cope.

  • Mood and anxiety symptoms that occur only during the premenstrual period, or worsen significantly during that time

  • Can be very debilitating, with a negative impact on the quality of life and relationships

  • Symptoms usually disappear within a few days after the period starts

  • There are 11 identified symptoms, of which 5 must be present


Symptoms of pmdd

Depressed mood child 3 weeks ago. She breaks down in tears for no reason and is irritable with her 3 year old. She is having trouble sleeping, and has no appetite. She admits that she feels guilty for not feeling happy about the new infant in her life. She feels she is not an effective parent to either child. She is returning to work next week and wonders how she will be able to cope.

Feelings of personal rejection

Decreased interest in usual activities

Fatigue, no energy

Marked appetite changes/cravings

Insomnia or increased sleep

Anxiety- feeling “on edge”

Irritability, anger

Feeling overwhelmed

Difficulty concentrating

Physical symptoms- breast tenderness, headaches, “bloated”, muscle pain

Symptoms of PMDD


Cause of pmdd
Cause of PMDD? child 3 weeks ago. She breaks down in tears for no reason and is irritable with her 3 year old. She is having trouble sleeping, and has no appetite. She admits that she feels guilty for not feeling happy about the new infant in her life. She feels she is not an effective parent to either child. She is returning to work next week and wonders how she will be able to cope.

  • Unknown, but felt by many researchers to result from an abnormal response to normal cycle of hormonal changes in the body

  • Likely a combination of genetic, environmental, and behavioral factors

  • Women with PMDD have greater risk of future depression during pregnancy, post-partum period, and perimenopause


Treatment for pmdd
Treatment For PMDD child 3 weeks ago. She breaks down in tears for no reason and is irritable with her 3 year old. She is having trouble sleeping, and has no appetite. She admits that she feels guilty for not feeling happy about the new infant in her life. She feels she is not an effective parent to either child. She is returning to work next week and wonders how she will be able to cope.

  • Choice of treatment is aimed at the most troubling symptoms

  • Lifestyle modification

  • Dietary approach

  • Vitamin supplementation

  • Medications

  • Cognitive/behavioral approach


Lifestyle diet modification
Lifestyle/diet Modification child 3 weeks ago. She breaks down in tears for no reason and is irritable with her 3 year old. She is having trouble sleeping, and has no appetite. She admits that she feels guilty for not feeling happy about the new infant in her life. She feels she is not an effective parent to either child. She is returning to work next week and wonders how she will be able to cope.

  • Women who engage in moderate aerobic exercise 3 times weekly have fewer premenstrual symptoms than sedentary women

  • Low-fat, vegetarian diet has been shown to decrease duration and intensity of menstrual pain

  • Women with a high caffeine intake have more premenstrual irritability symptoms

  • Excess of simple carbohydrates (sugar) is associated with mood disturbances


Vitamin supplementation
Vitamin Supplementation child 3 weeks ago. She breaks down in tears for no reason and is irritable with her 3 year old. She is having trouble sleeping, and has no appetite. She admits that she feels guilty for not feeling happy about the new infant in her life. She feels she is not an effective parent to either child. She is returning to work next week and wonders how she will be able to cope.

  • Controversial- data is conflicting

  • Vitamin B6 100mg/day

  • Magnesium 400 mg/day

  • Manganese 6 mg/day

  • Vitamin E 400 iu/day

  • Calcium 1000 mg/day


Medications for pmdd
Medications for PMDD child 3 weeks ago. She breaks down in tears for no reason and is irritable with her 3 year old. She is having trouble sleeping, and has no appetite. She admits that she feels guilty for not feeling happy about the new infant in her life. She feels she is not an effective parent to either child. She is returning to work next week and wonders how she will be able to cope.

  • Anti-inflammatories- effective for pain relief

  • Oral contraceptives- suppress ovulation

  • Diuretics– when salt restriction not helpful in reducing significant fluid retention

  • SSRI’s are often first choice- daily versus premenstrual week only


Cognitive behavioral therapy
Cognitive Behavioral Therapy child 3 weeks ago. She breaks down in tears for no reason and is irritable with her 3 year old. She is having trouble sleeping, and has no appetite. She admits that she feels guilty for not feeling happy about the new infant in her life. She feels she is not an effective parent to either child. She is returning to work next week and wonders how she will be able to cope.

  • Attempts to reduce negative feelings in the premenstrual period

  • Improve feelings of self-esteem and problem solving skills

  • Relaxation therapy may also be helpful


Post partum depression
Post-partum Depression child 3 weeks ago. She breaks down in tears for no reason and is irritable with her 3 year old. She is having trouble sleeping, and has no appetite. She admits that she feels guilty for not feeling happy about the new infant in her life. She feels she is not an effective parent to either child. She is returning to work next week and wonders how she will be able to cope.

  • 1 of 10 women experience post-partum depression, but the condition is under-diagnosed

  • May have significant impact on both mother and child

  • Societal pressures to be “good mother” may prevent woman from admitting symptoms


Baby blues
“Baby Blues” child 3 weeks ago. She breaks down in tears for no reason and is irritable with her 3 year old. She is having trouble sleeping, and has no appetite. She admits that she feels guilty for not feeling happy about the new infant in her life. She feels she is not an effective parent to either child. She is returning to work next week and wonders how she will be able to cope.

  • Occurs in 70-85% of women

  • Onset within the first few days after delivery

  • Resolves by 2 weeks

  • Symptoms include: mild depression, irritability, tearfulness, fatigue, anxiety

  • May have increased risk of post-partum major depression later on


Post partum major depression
Post-partum Major Depression child 3 weeks ago. She breaks down in tears for no reason and is irritable with her 3 year old. She is having trouble sleeping, and has no appetite. She admits that she feels guilty for not feeling happy about the new infant in her life. She feels she is not an effective parent to either child. She is returning to work next week and wonders how she will be able to cope.

  • Symptoms of depression that last longer than 2 weeks

  • Usually begins 2-3 weeks after delivery

  • May last up to one year

  • High risk of recurrence in future pregnancies


Post partum psychosis
Post Partum Psychosis child 3 weeks ago. She breaks down in tears for no reason and is irritable with her 3 year old. She is having trouble sleeping, and has no appetite. She admits that she feels guilty for not feeling happy about the new infant in her life. She feels she is not an effective parent to either child. She is returning to work next week and wonders how she will be able to cope.

  • Rare disorder (Andrea Yates?)- 0.2% women

  • Onset within the first month after delivery

  • Symptoms include mania, agitation, expansive or irritable mood, avoidance of the infant

  • May have delusions or hallucinations that involve the infant- possessed by demon, etc.

  • This is a medical emergency- needs hospitalization


Treatment for post partum depression
Treatment for Post Partum Depression child 3 weeks ago. She breaks down in tears for no reason and is irritable with her 3 year old. She is having trouble sleeping, and has no appetite. She admits that she feels guilty for not feeling happy about the new infant in her life. She feels she is not an effective parent to either child. She is returning to work next week and wonders how she will be able to cope.

  • Same as for major depression

  • SSRI’s work well

  • All antidepressants are to some degree, excreted in the breast milk, but usually undetectable levels in the infant’s blood

  • Avoid Prozac due to long half life- may accumulate in the infant


To summarize
To Summarize…. child 3 weeks ago. She breaks down in tears for no reason and is irritable with her 3 year old. She is having trouble sleeping, and has no appetite. She admits that she feels guilty for not feeling happy about the new infant in her life. She feels she is not an effective parent to either child. She is returning to work next week and wonders how she will be able to cope.

  • Depression is very common in women

  • May be more likely around times of hormonal flux- premenstrual, post-partum, perimenopause

  • There is effective treatment available

  • Don’t hesitate to discuss symptoms with your doctor


This presentation is available online at

This Presentation Is Available Online At: child 3 weeks ago. She breaks down in tears for no reason and is irritable with her 3 year old. She is having trouble sleeping, and has no appetite. She admits that she feels guilty for not feeling happy about the new infant in her life. She feels she is not an effective parent to either child. She is returning to work next week and wonders how she will be able to cope.

www.pullmanfamilymed.com

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