Download Diagnosis and Management of Mood

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
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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
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54% of people with mental illness who seek
treatment are exclusively seen in the “general
medical sector”
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25% of patients in primary care setting have a
diagnosable mental illness
Myth Busters
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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
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Major Depression
Dysthymia
Premenstrual Dysphoric
Disorder (PMDD)
Bipolar Disorder type I and II
Depression: Prevalence and Risk
Factors
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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
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Women are more likely to present with:
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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
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Within a 2 week period there is depressed mood and/or
anhedonia and 5+ following:
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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
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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?
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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
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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
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Maternal Depression may cause:
Preterm birth, low birth-weight, smaller head
circumference, and lower Apgar scores
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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
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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
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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
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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
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Nearly 75% women experience PMS:
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PMDD affects 3-8% women:
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Irritability, tension, dysphoria, lability of mood
Occurs during Luteal phase
Risk factors for PMDD:
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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
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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
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SSRI antidepressants are first-line treatment
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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
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Affects 1.2% US population
Bipolar type I is equal among sexes
 Bipolar type II is more common among women
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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
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Presence of a manic episode (persistently
elevated/irritable mood for at least 1 week) and 3+
symptoms persisted:
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**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
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Presence of a Hypomanic episode (persistently
elevated/irritable mood for at least 4 days) and 3+
symptoms persisted:
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**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
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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
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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
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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
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Mild-moderate bipolar disorder:
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Severe bipolar disorder:
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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
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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
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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
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Mother Risk Program
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Massachusetts General Women’s health
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www.motherisk.org
www.womensmentalhealth.org
United States National Library of Medicine
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http://toxnet.nlm.nih.gov
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