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Diagnosis and Management of Mood Disorders in Women in a Primary Care Setting UCF: Department of Psychology W. Steven Saunders, Psy.D. Reference: Katherine C. Smith, D.O. Goals for Today Gender differences with diagnosis and treatment of mood disorders Clinical pearls regarding the diagnosis of Mood Disorders in Women Effective screening tools in the primary care setting Treatment overview Resources Psychiatry in Primary Care 54% of people with mental illness who seek treatment are exclusively seen in the “general medical sector” 25% of patients in primary care setting have a diagnosable mental illness Myth Busters Men attempt suicide more often than women Antidepressants are first-line treatment for Bipolar Disorder Women are more prone to bipolar disorder than men Pregnancy is a time of emotional well-being There is a specific algorithm for the treatment of women during childbearing years Mood Disorders in Women Major Depression Dysthymia Premenstrual Dysphoric Disorder (PMDD) Bipolar Disorder type I and II Depression: Prevalence and Risk Factors Depression is twice as common in women than men Hormonal factors increase vulnerability to depression Genetic contribution to depression Differences in coping strategies may lead to more severe depression in women Women are more susceptible to depressive symptoms in response to stressful life events and trauma Kendler, K.S., Prescott C.A. A Population Based twin Study of Lifetime Major Depression in Men and Women. Archives of General Psychiatry, 56, 39-44, 1999. Presentation and Course of Illness Women are more likely to present with: increased appetite and weight gain, disturbed sleep, anxiety, somatization and expressed anger. Women are three times more likely than men to attempt suicide Depressed women are more likely to have co morbid anxiety disorders, thyroid disease and pain syndromes Women have longer episodes of depression, and a chronic recurrent course Many women experience depression related to reproductive-cycle events Depression Diagnosis and Screening Within a 2 week period there is depressed mood and/or anhedonia and 5+ following: Weight changes Insomnia or hypersomnia Psychomotor agitation or retardation Fatigue Guilt Indecisiveness or decreased concentration Suicidal ideations Center for Epidemiological Studies Depression Scale Edinburgh Post Partum Depression Scale PHQ-9 www.phqscreeners. com Unintended Pregnancies in the U.S. The proportion of unintended pregnancies was unchanged from 1994 Risk Factors: Women ages 18-24 Low-income Cohabitation Minority Finer, L and Henshaw K. Disparities in Rates of Unintended Pregnancy in the United States, 1994 and 2001. Perspectives on Sexual and Reproductive Health. Vol 38 (2), 90-96, 2006. MDD in pregnancy 10-16% of women have major depression during pregnancy Associated with problems for both mother and fetus When emerges in pregnancy, is frequently overlooked Pregnancy is neither protective, nor exacerbating for depressive disorders Under-recognized and under-treated in primary care settings Cohen L, Nonacs R (editors): Mood and Anxiety Disorders During Pregnancy and Postpartum (Review of Psychiatry Series, Vol 24, Number 4). Washington, DC, APPI, 2005 Why is this important? All women of childbearing years are potentially pregnant until proven otherwise Approximately 50% pregnancies are unplanned 10-16% women have major depression during pregnancy Risk benefit analysis ideally prior to conception, every medication change! Weighing the Risks and Benefits Risk of untreated mental illness Risk of relapse of psychiatric illness Effects of psychiatric illness on the fetus Teratogenicity of psychotropic medications Long term behavioral effects Incomplete reproductive safety data for medications Risk of Untreated Psychiatric Illness in Pregnancy Maternal Depression may cause: Preterm birth, low birth-weight, smaller head circumference, and lower Apgar scores Contribute to poor self-care, inattention to prenatal care Women are more likely to smoke, use alcohol or illicit drugs Children of depressed mothers are more likely to have behavioral problems, delays in cognitive, motor and emotional development Risk for suicide Nonacs R, Viguera A, Cohen L. Psychiatric Aspects of Pregnancy. Womens Mental Health, a Comprehensive Textbook. Ed. Susan Kornstein and Anita Clayton. New York, NY, 2002. Anxiety and Stress in Pregnancy Lead to poor outcomes Increase cortisol and adrenocorticotropic hormone levels May be associated with preeclampsia May reduce uteroplacental blood-flow Antenatal anxiety predicts postpartum anxiety and depression Cohen L, Nonacs R (editors): Mood and Anxiety Disorders During Pregnancy and Postpartum (Review of Psychiatry Series, Vol. 24, Number 4). Washington, DC, APPI, 2005 Heron J, O;Connor T et al. The course of anxiety and depression through pregnancy and the postpartum in a community sample. J. Affect. Disord 80:65-73,2004. Depression Relapse in Pregnancy: Cohen et al. 2006: 43% of the women experienced relapse during pregnancy 26% who maintained medication relapsed 68% who discontinued medication relapsed Cohen L, Altshuler L, Harlow B et al. Relapse of Major Depression During Pregnancy in Women Who Maintain or Discontinue Antidepressant Treatment. JAMA Vol 295 (5),: 499-507, 2006. Recommendations for Antidepressant Treatment in Pregnant Women Psychotherapy is first line for mild-moderate depression Psychotherapy + antidepressant recommended for moderate to severe depression Individualized risk-benefit analysis No hx of antidepressant treatment: SSRI antidepressant considered first-line Successful history of antidepressant treatment: data should be reviewed with mom, and considered first line Altshuler L, Cohen, L, Moline M et al. Treatment of Depression in Women: A Summary of the Expert Consensus Guidelines. Journal of Psychiatric Press: 185-208, May, 2001. Recommendations continued ECT for psychotic depression Review all risks and benefits of treatment Mom’s should be monitored carefully for increased depression, mania or psychosis Dosages may need to be adjusted Goal is monotherapy and minimal effective dosage Altshuler L, Cohen, L, Moline M et al. Treatment of Depression in Women: A Summary of the Expert Consensus Guidelines. Journal of Psychiatric Press: 185-208, May, 2001 PMS versus Premenstrual Dysphoric Disorder Nearly 75% women experience PMS: PMDD affects 3-8% women: Irritability, tension, dysphoria, lability of mood Occurs during Luteal phase Risk factors for PMDD: Bloating, weight gain, breast tenderness & swelling, aches and pains, poor concentration, sleep and appetite changes. genetics, normal ovarian function and serotonin Age, past or current psychiatric illness Sexual trauma Diagnosis of PMDD is obtained by 2 consecutive months of prospective daily symptom ratings PMDD versus Premenstrual Exacerbation A recent study reported that 64% the first 1500 women enrolled in the STAR*D study retrospectively reported premenstrual exacerbation of depression When a mood or anxiety disorder is present, worsening of symptoms during luteal phase is considered premenstrual exacerbation Treatment of PMDD SSRI antidepressants are first-line treatment Lower doses are efficacious Continuous dosing more beneficial than intermittent luteal dosing GNRH agonists reduce physical and emotional symptoms Ethinyl Estradiol and Drospirenone is FDA approved for PMDD Ovariectomy reserved for last resort treatment Light therapy reduces depression, irritability, and physical symptoms Cognitive Behavioral Therapy and Group Therapy Bipolar Disorder: Clinical Features and Course Affects 1.2% US population Bipolar type I is equal among sexes Bipolar type II is more common among women Rapid cycling, mixed mania, and more frequent episodes of depression 30-90% patients with rapid cycling bipolar disorder have hypothyroidism Mood disturbances reported with menstrual cycle Bipolar type I Presence of a manic episode (persistently elevated/irritable mood for at least 1 week) and 3+ symptoms persisted: **Decreased need for sleep** Inflated self-esteem Pressured speech Flight of ideas Distractibility Goal-directed activity Excessive involvement in pleasurable activities Screening: Mood Disorders Questionnaire (MDQ) Bipolar type II Presence of a Hypomanic episode (persistently elevated/irritable mood for at least 4 days) and 3+ symptoms persisted: **Decreased need for sleep** Inflated self-esteem Pressured speech Flight of ideas Distractibility Goal-directed activity Excessive involvement in pleasurable activities No psychotic symptoms!! General Treatment Guidelines Mixed states and rapid cycling are more common in women Antidepressants worsen: mania, hypomania, cycling, and depression First line treatment always begins with a mood stabilizer Lithium, Carbamazepine, Valproic Acid, Lamotrigine Atypical antipsychotics Once mood is stabilized, if depressive symptoms still persist, then consider augmentation with antidepressant Bipolar Disorder and Pregnancy Pregnancy seems to be “risk neutral” Relapse increases with medication discontinuation Majority of relapses in pregnancy are depressive episodes Estimates of post-partum relapse may be as high as 50% Relapse in pregnancy is a strong predictor of post-partum relapse Cohen L. Treatment of Bipolar Disorder During Pregnancy. J. Clinical Psychiatry 68 (9), 2007: 4-9. Recommendations for Treatment in Pregnant Women Mild-moderate bipolar disorder: Severe bipolar disorder: May taper or discontinue mood stabilizer prior to conception, during first trimester or throughout pregnancy May continue medication throughout pregnancy Consider typical high potency antipsychotic as augmentation Psychotherapy ECT Goal is monotherapy and minimal effective dosage Cohen L. Treatment of Bipolar Disorder During Pregnancy. J. Clinical Psychiatry 68 (9), 2007, 4-9. Conclusions SSRI antidepressants are first line treatment for depression and PMDD The hallmark diagnostic feature of bipolar disorder is decreased need for sleep Mood stabilizers are first line treatment for bipolar disorder All women of childbearing years are potentially pregnant until proven otherwise Conclusions For women with depression who become pregnant, psychotherapy and SSRI antidepressants are considered first line treatment For women with bipolar disorder who become pregnant, psychotherapy and mood stabilizers are considered first line treatment Proposed Treatment Algorithm for Women Illness Severity Risk of Untreated Illness Goal is Sustained Healthy Mental State Risk of Relapse Risk to Fetus Lowest Effective Dosage Monotherapy Consult! Resources Mother Risk Program Massachusetts General Women’s health www.motherisk.org www.womensmentalhealth.org United States National Library of Medicine http://toxnet.nlm.nih.gov A New Resource in Richmond…