LA CONSULTA SEMANAL

CONSULTA

1: Postgrad Med  2002 Sep;112(3):45-50; quiz 2 [Texto completo]

Depression in women of reproductive age. Considerations in selecting safe, effective therapy.

Young SA, Campbell N, Harper A.

Department of Neuropsychiatry and Behavioral Science, University of South Carolina School of Medicine, 3555 Harden St Extension, Columbia, SC 29203, USA. youngsay@aol.com

The understanding of biologic and psychologic underpinnings of depression in women of reproductive age continues to grow. Overall, the news is good. Increased knowledge, safer treatments, and early identification have combined to reduce the morbidity of depression in this population. Many treatments appear to be safe and well tolerated by mother and infant alike. No matter how safe the treatment, however, a poor perinatal outcome will prompt both physician and patient to second-guess the intervention. Women who are pregnant or breast-feeding and have a history of depression or are currently experiencing symptoms need to be educated about the risks and benefits of treatment and nontreatment. Whenever possible, another family member should be involved in this discussion. Ultimately, the decision to medicate or not comes down to whether the risk of treatment outweighs the risk of no treatment. Untreated depression is not without its own risks and morbidity. Psychotherapy remains an important tool that can be used independent of or in addition to medication. It is especially helpful for the many women who refuse any and all medications when they are pregnant or breast-feeding.

2: J Clin Psychiatry  2002 Apr;63(4):284-7

The impact of reproductive events on the course of bipolar disorder in women.

Freeman MP, Smith KW, Freeman SA, McElroy SL, Kmetz GE, Wright R, Keck PE Jr.

Department of Psychiatry, University of Arizona College of Medicine, Tucson 85724-5002, USA. marlenef@email.arizona.edu

BACKGROUND: Little is known about the impact of female reproductive hormones on the course of bipolar disorder. This study was designed to assess the influence of reproductive events and hormonal therapies on the course of bipolar disorder in women. METHOD: Fifty women with DSM-IV bipolar disorder completed a structured clinical interview to assess the impact of reproductive events on the course of their illness. RESULTS: The onset of bipolar disorder occurred before menarche in 32% (N = 16) of women; 18% (N = 9) experienced the onset within 1 year of menarche. Most women did not receive an accurate diagnosis of nor treatment for bipolar disorder until after they had children, and therefore the majority were not treated with mood stabilizers during or immediately after pregnancies. Of women with children, 20 (67%) of 30 experienced a postpartum mood episode. Of the women who had postpartum episodes after delivery of a first child, all had episodes after subsequent pregnancies. Having a postpartum mood episode after a first pregnancy significantly increased the risk of a postpartum episode after subsequent deliveries (p = .02). Postpartum episodes were almost exclusively depressive. Increased depressive symptoms during pregnancy were significantly associated with postpartum mood episodes (p = .01). Women who were not using hormone replacement therapy (HRT) were significantly more likely than those who were using HRT to report worsening of symptoms during perimenopause/menopause (p = .02). CONCLUSION: These data suggest that hormonal fluctuations are associated with increased risk of affective dysregulation and mood episodes in women with bipolar disorder.

3: J Clin Psychiatry  2002;63 Suppl 7:9-15

Epidemiology of depression throughout the female life cycle.

Burt VK, Stein K.

University of California School of Medicine, Los Angeles, USA.

Women are at an increased risk for first onset of major depression from early adolescence until their mid-50s and have a lifetime rate of major depression 1.7 to 2.7 times greater than that for men. There is accumulating evidence that certain reproductive-related hormonal changes place women at increased risk for depression. For example, puberty marks the beginning of increased risk for depression in women. Most women report physical or emotional symptoms premenstrually, with some severe enough to be diagnosed as premenstrual dysphoric disorder. While pregnancy does not increase the risk for depression, women with past histories of depression are at risk for recurrent episodes or relapse if antidepressant medications are discontinued. Hormonal changes during the postpartum period also increase the incidence of depression. Similarly, women transitioning through perimenopause, particularly those with past psychiatric histories, report depressive symptoms. Prophylaxis and treatment to minimize severity in cases of recurrence are discussed in the article, using reproductive transitional events as markers.

Publication Types:

Review

4: J Clin Psychiatry  2001;62 Suppl 24:11-7

The evaluation and management of depression in women across the life span.

Kornstein SG.

Department of Psychiatry, Medical College of Virginia, Virginia Commonwealth University, Richmond 23298-0710, USA.

Depression is more common in women than in men, particularly during the childbearing years. Women may present with different depressive symptoms than men and may respond differently to antidepressant treatment. In addition, depression in women can surface in association with specific points in the reproductive cycle, such as during the premenstrual period, during pregnancy and the postpartum period, and during the perimenopausal years. Antidepressant medications may be used effectively at all stages in a woman's life. In the case of premenstrual dysphoric disorder, serotonergic agents have demonstrated efficacy in both full-cycle and luteal-phase dosing strategies. For depressed women who are pregnant or breastfeeding, the limited safety data available on antidepressants suggest minimal danger to the fetus or infant, and the risks and benefits to both mother and child must be weighed against the risks of untreated illness. Treatment of depression in middle-aged and elderly women should take into account the possible influence of both menopausal status and hormone replacement therapy on antidepressant response. This article will focus on special considerations in the evaluation and management of depression in women across the life span.

Publication Types:

Review

5: Obstet Gynecol  2001 Sep;98(3):391-7

Sleep quality, estradiol levels, and behavioral factors in late reproductive age women.

Hollander LE, Freeman EW, Sammel MD, Berlin JA, Grisso JA, Battistini M.

Department of Obstetrics and Gynecology, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania 19104-4283, USA. loriholl@mail.med.upenn.edu

OBJECTIVE: To estimate the prevalence of perceived poor sleep in women aged 35-49 years and to correlate sleep quality with levels of gonadal steroids and predictors of poor sleep. METHODS: A cohort of 218 black and 218 white women aged 35-47 years at enrollment (aged 37-49 at final follow-up) with regular menstrual cycles was identified through random digit dialing for a longitudinal study of ovarian aging correlates. Data obtained at four assessment periods, including enrollment, over a 2-year interval were collected between days 1 and 6 (mean = 3.9) of the menstrual cycle. The primary outcome measure was subjects' rating of sleep quality at each assessment period. Associations of sleep quality with hormone levels (estradiol, follicle-stimulating hormone, luteinizing hormone, testosterone, and dehydroepiandrosterone sulfate) and other clinical, behavioral, and demographic variables were examined in bivariable and multivariable analyses. RESULTS: Approximately 17% of subjects reported poor sleep at each assessment period. Significant independent associations with poor sleep included greater incidence of hot flashes (odds ratio [OR] 1.52; 95% confidence interval [CI] 1.08, 2.12, P =.02), higher anxiety levels (OR 1.03; 95% CI 1.00, 1.06, P =.04), higher depression levels (OR 1.05; 95% CI 1.02, 1.07, P <.001), greater caffeine consumption (OR 1.25; 95% CI 1.04, 1.49, P =.02), and lower estradiol levels in women aged 45-49 (OR 0.53; 95% CI 0.34, 0.84, P =.006), after adjustment for current use of sleep medications. CONCLUSION: Both hormonal and behavioral factors were associated with sleep quality. Estradiol levels are an important factor in poor sleep reported by women in the 45-49 age group. Further evaluation of estrogen treatment for poor sleep of women 45 years and older is warranted.

6: Can J Psychiatry  2001 Jun;46 Suppl 1:63S-76S

Clinical guidelines for the treatment of depressive disorders. VI. Special populations.

Thorpe L, Whitney DK, Kutcher SP, Kennedy SH;  CANMAT Depression Work Group.

Department of Psychiatry, University of Saskatchewan, Regina, Saskatchewan.

BACKGROUND: The Canadian Psychiatric Association and the Canadian Network for Mood and Anxiety Treatments partnered to produce clinical guidelines for psychiatrists for the treatment of depressive disorders. METHODS: A standard guidelines development process was followed. Relevant literature was identified using a computerized Medline search supplemented by review of bibliographies. Operational criteria were used to rate the quality of scientific evidence, and the line of treatment recommendations included consensus clinical opinion. This section, "Special Populations," is 1 of 7 articles that were drafted and reviewed by clinicians. Revised drafts underwent national and international expert peer review. RESULTS: This section reports on the prevalence, course, and outcome of depression for specific populations. Psychological, pharmacologic, and other biological treatment options for these populations--children and adolescents, the elderly, women at times of increased risk within the reproductive cycle, and specific ethnocultural groups--are critically evaluated. CONCLUSIONS: Major depressive disorder (MDD) is prevalent across the lifespan. In general, clinical presentations are more similar than different across age, sex, and cultural divides. Although less evidence is available for the efficacy of treatments in these subpopulations than in mid-life patients, comparable rates of response for pharmacotherapies, electroconvulsive therapy (ECT), and, in some cases, evidence-based psychotherapies have been reported.

7: Arch Gen Psychiatry  2001 Jun;58(6):529-34

Efficacy of estradiol for the treatment of depressive disorders in perimenopausal women: a double-blind, randomized, placebo-controlled trial.

Soares CN, Almeida OP, Joffe H, Cohen LS.

Perinatal and Reproductive Psychiatry Clinical Research Program, Massachusetts General Hospital, Harvard Medical School, 15 Parkman St, WACC 812, Boston, MA 02114, USA. csoares@partners.org

BACKGROUND: Results of previous studies suggest that estrogen improves somatic and mild depressive symptoms experienced by perimenopausal women. This study investigated the efficacy of 17beta-estradiol for the treatment of clinically significant depressive disorders in endocrinologically confirmed perimenopausal women. METHODS: Perimenopausal women (aged 40-55 years, with irregular menstrual periods and serum concentrations of follicle-stimulating hormone >25 IU/L), meeting criteria for major depressive disorder, dysthymic disorder, or minor depressive disorder, according to DSM-IV, were randomized to receive transdermal patches of 17beta-estradiol (100 microgram) or placebo in a 12-week, double-blind, placebo-controlled study. A 4-week washout period followed the 12-week treatment phase. Outcome measures were the Montgomery-Asberg Depression Rating Scale and Blatt-Kupperman Menopausal Index scores. RESULTS: Fifty women were enrolled in the study; 26 met DSM-IV criteria for major depressive disorder, 11 for dysthymic disorder, and 13 for minor depressive disorder. Remission of depression was observed in 17 (68%) women treated with 17beta-estradiol compared with 5 (20%) in the placebo group (P =.001). Subjects responded similarly to estradiol treatment, regardless of DSM-IV diagnosis. Patients treated with estradiol sustained antidepressant benefit of treatment after the 4-week washout period, although somatic complaints increased in frequency and intensity. Treatment was well tolerated and adverse events were rare in both groups. CONCLUSION: Transdermal estradiol replacement is an effective treatment of depression for perimenopausal women.

Publication Types:

Clinical Trial

8: J Clin Psychiatry  2001 Feb;62(2):82-6

Prevention of recurrent postpartum depression: a randomized clinical trial.

Wisner KL, Perel JM, Peindl KS, Hanusa BH, Findling RL, Rapport D.

Department of Reproductive Biology, Case Western Reserve University School of Medicine, Cleveland, Ohio 44106, USA. klw6@po.cwru.edu

BACKGROUND: Women who have suffered one episode of postpartum-onset major depression (PPMD) comprise a high-risk group for subsequent episodes. We conducted a double-blind, randomized clinical trial to test the efficacy of nortriptyline in the prevention of recurrent PPMD. METHOD: Nondepressed women who had at least one past episode of PPMD (Research Diagnostic Criteria) were recruited during pregnancy. Subjects were randomly assigned to nortriptyline or placebo. Treatment began immediately postpartum. Each subject was assessed for 20 sequential weeks with the Hamilton Rating Scale for Depression and Research Diagnostic Criteria for recurrence of major depression. RESULTS: No difference was found in the rate of recurrence in women treated with nortriptyline compared with those treated with placebo. Of 26 subjects who took nortriptyline preventively, 6 (0.23, 95% exact confidence interval [CI] = 0.09 to 0.44) suffered recurrences. Of 25 subjects who took placebo, 6 (0.24, 95% exact CI = 0.09 to 0.45) suffered recurrence (Fisher exact p = 1.00). CONCLUSION: Nortriptyline did not confer additional preventive efficacy beyond that of placebo. The rate of recurrence of PPMD (one fourth of women) was unacceptably high.

Publication Types:

Clinical Trial

9: Arch Gen Psychiatry  2000 Dec;57(12):1163-4

Gonadal hormones, reproductive age, and women with depression.

Halbreich U.

State University of New York at Buffalo, SUNY Clinical Center, BB-170, 462 Grider St, Buffalo, NY 14215, USA.

Publication Types:

Comment

10: Arch Gen Psychiatry  2000 Dec;57(12):1157-62

Alteration in the hypothalamic-pituitary-ovarian axis in depressed women.

Young EA, Midgley AR, Carlson NE, Brown MB.

Mental Health Research Institute, 205 Zina Pitcher Place, Ann Arbor, MI 48109, USA.

BACKGROUND: Stress and corticotropin-releasing hormone inhibit the reproductive axis. We hypothesized that reproductive axis hormone secretion, particularly luteinizing hormone secretion, is inhibited in women with depression, similar to what has been observed to be caused by stress in numerous species. METHODS: Blood samples were collected every 10 minutes for 12 hours in 25 untreated premenopausal women with depression and 25 nondepressed women who were matched by age and menstrual cycle day. Samples were assayed for luteinizing hormone, follicle-stimulating hormone, estradiol, and progesterone. RESULTS: The mean plasma estradiol level was 30% lower in the follicular phase in women with depression than in their matched controls: 191 + 136 vs 261 + 169 pmol/L (52 + 37 vs 71 + 46 pg/mL). The half-life of luteinizing hormone was significantly shorter in women with depression than in their matched controls during both the follicular (22% shorter) and luteal (15% shorter) phases. CONCLUSIONS: The blood levels of reproductive hormones were mostly normal in women with depression, but the blood level of estradiol was significantly lower. Estradiol is known to affect a number of neurotransmitter systems in the brain.

11: Am J Psychiatry  2000 Jun;157(6):924-30

Effects of gonadal steroids in women with a history of postpartum depression.

Bloch M, Schmidt PJ, Danaceau M, Murphy J, Nieman L, Rubinow DR.

Behavioral Endocrinology Branch, NIMH, NIH, Bethesda, MD 20892-1276, USA.

OBJECTIVE: Endocrine factors are purported to play a role in the etiology of postpartum depression, but direct evidence for this role is lacking. The authors investigated the possible role of changes in gonadal steroid levels in postpartum depression by simulating two hormonal conditions related to pregnancy and parturition in euthymic women with and without a history of postpartum depression. METHOD: The supraphysiologic gonadal steroid levels of pregnancy and withdrawal from these high levels to a hypogonadal state were simulated by inducing hypogonadism in euthymic women-eight with and eight without a history of postpartum depression-with the gonadotropin-releasing hormone agonist leuprolide acetate, adding back supraphysiologic doses of estradiol and progesterone for 8 weeks, and then withdrawing both steroids under double-blind conditions. Outcome measures were daily symptom self-ratings and standardized subjective and objective cross-sectional mood rating scales. RESULTS: Five of the eight women with a history of postpartum depression (62.5%) and none of the eight women in the comparison group developed significant mood symptoms during the withdrawal period. Analysis of variance with repeated measures of daily and cross-sectional ratings of mood showed significant phase-by-group effects. These effects reflected significant increases in depressive symptoms in women with a history of postpartum depression but not in the comparison group after hormone withdrawal (and during the end of the hormone replacement phase), compared with baseline. CONCLUSIONS: The data provide direct evidence in support of the involvement of the reproductive hormones estrogen and progesterone in the development of postpartum depression in a subgroup of women. Further, they suggest that women with a history of postpartum depression are differentially sensitive to mood-destabilizing effects of gonadal steroids.

Publication Types:

Clinical Trial

12: Obstet Gynecol  2000 Jan;95(1):55-60

Ethnic differences in depressive symptomatology among young women.

Rickert VI, Wiemann CM, Berenson AB.

Department of Obstetrics & Gynecology, The University of Texas Medical Branch at Galveston, USA. vaughn_rickert@smtplink.mssm.edu

OBJECTIVE: To examine racial and ethnic differences in moderate to severe depressive symptoms among young women seeking reproductive health care. METHODS: Nine hundred four white, black, or Hispanic women between 14 and 26 years of age completed an anonymous questionnaire that assessed demographic and reproductive characteristics; recent substance use, including binge drinking; sexual behaviors; occurrence of assault; and depressive symptoms. Logistic regression analysis was used to develop adjusted odds ratios (OR) and 95% confidence intervals for correlates of depressive symptomatology for each racial or ethnic group. RESULTS: Twenty-one percent (68 of 321) of whites, 28% (88 of 316) of blacks, and 29% (77 of 267) of Hispanics reported moderate to severe depressive symptoms. White females with moderate to severe depressive symptoms were more likely to report sexual assault (OR = 3.1); being a high school dropout (OR = 2.6); unemployment (OR = 2.4); two or more episodes of binge drinking (OR = 2.1); and having a mother with less than a high school education (OR = 2.4). Black females with depressive symptoms were more likely to report smoking one to nine cigarettes per day (OR = 3.5); sexual assault (OR = 3.2); and unemployment (OR = 2.1). Hispanic females with depressive symptoms were more likely to report adolescent age (OR = 3.5); physical assault (OR = 3.2); and smoking one or more cigarettes per day (OR = 2.4). CONCLUSION: Twenty to 25% of young women, regardless of race or ethnicity, have moderate to severe depressive symptoms, and behavioral markers vary according to ethnicity.