I DEPRESSION ^392 ^451 ^610
Major depressive disorders may begin at any age, with the average age of onset in the mid-20s. In one half of women, the onset of depression occurs between age 20 years and 50 years.
Depression can be overdiagnosed in women who have experienced grief reactions or who are undergoing situational stress. However, it can be underdiagnosed if clinicians do not maintain a high level of suspicion.Mood disorders, especially depression, are among the most common psychiatric illnesses in women. Many patients treated by obstetriciangynecologists will have a depressive illness. The lifetime prevalence of major depressive disorders in adults in the United States is 16.6%, and women are approximately 70% more likely than men to experience depression during their lifetime. The reasons for this disparity are multidimensional and may include biologic, social, and economic issues that are specific to women.
According to the World Health Organization, depression is the leading cause of disability in women, which accounts for $30 billion to $50 billion in lost productivity and direct medical costs in the United States each year. The lives of 19 million adults and millions more family members and friends are affected.
Health care providers who work with women have a unique advantage in identifying and diagnosing depression. Routine screening for depression is recommended in clinical practices that have systems in place to ensure accurate diagnosis, effective treatment, and follow-up. If depression is identified, it can be effectively treated in up to 85% of cases. It is estimated that nearly two thirds of individuals affected do not get the help they need. Treatment may include medication, psychotherapy, or both. Clinicians will need to provide follow-up care for any patients that have not been referred elsewhere. The likelihood of a recurrence is 50% after a major episode of depression, and it continues to increase with each occurrence.
Symptoms
The presenting symptoms of depressive disorders may be somatic or behavioral and sometimes can be attributed to an organic condition. In some cases, depression may be related to a condition for which a woman is receiving care, such as infertility, perinatal loss, postpartum depression, or other medical condition. Several tools utilizing a series of questions have been used to screen for depression and other mood disorders. Box 3-38 includes an example of an abbreviated tool and its sample questions that are appropriate for initial screening for depression in women. These questions may be included on a written screening questionnaire or asked as part of the interview process, particularly if other risk factors are present.
When the initial screening suggests a depressive disorder, a more comprehensive assessment is in order. Psychologic symptoms, such as depressed mood, crying spells, loss of interest or pleasure in usual activities, or suicidal thoughts, are obvious, but a high index of suspicion is needed in the differential diagnosis, regardless of symptoms. Diagnostic criteria, such as those provided in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, can be useful (see Box 3-39). Patients should be screened for psychosocial stressors.
Box 3-38. Sample Questions Appropriate for Depression Screening
Over the past 2 weeks, have you felt down, depressed, or hopeless?
Over the past 2 weeks, have you felt little interest or pleasure in doing things?
Not at all Several days More than half the days Nearly every day
(0) (1) (2) (3)
The recommended cutoff when used for screening is a score of 3 or greater.
Data from Whooley MA, Avins AL, Miranda J, Browner WS. Case-finding instruments for depression. Two questions are as good as many. J Gen Intern Med 1997;12:439-45., and Spitzer RL, Williams JB, Kroenke K, Linzer M, deGruy FV,3rd, Hahn SR, et al. Utility of a new procedure for diagnosing mental disorders in primary care.
The PRIME-MD 1000 study. JAMA 1994;272:1749-56.Box 3-39. Diagnostic Criteria for Major Depressive Disorder ^
A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either 1) depressed mood or 2) loss of interest or pleasure. Note: Do not include symptoms that are clearly attributable to another medical condition.
1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (eg, feels sad, empty, or hopeless) or observation made by others (eg, appears tearful). (Note: In children and adolescents, can be irritable mood.)
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation).
3. Significant weight loss when not dieting or weight gain (eg, a change of more than 5% of body weight in a month) or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gains.)
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or suicide attempt or a specific plan for committing suicide.
B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C. The episode is not attributable to the physiologic effects of a substance or to another medical condition.
(continued)
Box 3-39. Diagnostic Criteria for Major Depressive Disorder (continued)
Note: Criteria A-C represent a major depressive episode.
Note: Responses to a significant loss (eg, bereavement, financial ruin, losses from a natural disaster, a serious medical illness or disability) may include the feelings of intense sadness rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A, which may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to the significant loss should also be carefully considered. This decision inevitably requires the exercise of clinical judgment based on the individual’s history and the cultural norms for the expression of distress in the context of loss.[§§§§]
D. The occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders.
E. There has never been a manic episode or a hypomanic episode. Note: This exclusion does not apply if all of the manic-like or hypomanic-like episodes are substance-induced or are attributable to the physiologic effects of another medical condition.
The clinician should be alert for additional symptoms of depression, which may include, but are not limited to, the following:
• Persistent physical symptoms that do not respond to treatment or do not have an identifiable physical cause, such as headaches, digestive disorders, or chronic pain
• Exaggerated or prolonged depressive symptoms following common reproductive events, conditions, or procedures, such as miscarriage, stillbirth, premature delivery, infertility, hysterectomy, mastectomy, childbirth, or menopause
• Multiple somatic problems that may include dysmenorrhea, dyspareunia, sexual dysfunction, and fatigue
— Chronic, clinically unconfirmed vulvovaginitis, idiopathic vulvodynia, or chronic vaginal pain and burning
— Chronic pelvic or genitourinary tract pain
—Severe, incapacitating premenstrual syndrome
All depressed patients should be evaluated for suicidal thinking and previous suicide attempts.
This evaluation is best done by direct questioning. If a woman has specific plans or significant risk of suicide, such as prior attempts or hopelessness, a mental health specialist should be consulted immediately. Of all people hospitalized for depression, 15% will eventually take their own lives.Differential Diagnosis
The clinician must keep in mind other conditions and distinguish them from depression; these conditions include bipolar disorder, grief, substance abuse, schizophrenia, dementia, medical illness, and medication effects. Patients who report symptoms of mania may have a bipolar disorder, and medical treatment will be different from the treatment for depression. Antidepressant medications can induce mania and should be used with caution in a patient previously treated for mania. In such cases, referral to a psychiatrist is recommended. Screening for medical conditions, such as thyroid dysfunction, should be considered because it has been found in up to 10% of patients with depression.
Management
The obstetrician-gynecologist may elect to treat depression in some individuals. Although some patients might be unable to participate in their treatment (eg, individuals who are severely depressed, who display psychotic features, or who have made suicide attempts), the selection of treatment should be a collaborative decision between practitioner and patient whenever possible. Such shared decision making is likely to increase adherence and, therefore, treatment effectiveness. Medications should be considered for patients with moderate or severe depression, prior positive response to medication, or recurrent depression, as well as for patients who prefer medication to psychotherapy. Obstetrician-gynecologists should be familiar with several drugs in different categories that they would feel comfortable prescribing. Psychotherapy alone often is effective in treating patients with mild or moderate depression, and a psychotherapy referral should be considered for patients with relatively mild depression when it is the patient’s preference.
Combined treatment with psychotherapy and medication should be considered when the depression is more severe, there is an important psychosocial issue that would respond to therapy, or the patient has a history of treatment nonadherence or recurrent depression. Referral generally is recommended for the following situations:• Depression with suicide risk
• Bipolar disorder
• Depression with psychotic symptoms (hallucinations, delusions)
• Depression in a pediatric or adolescent patient (some medications may increase suicide risk in this age group) (see Bibliography)
• Failure to respond to previous interventions
• The need for combination or multiple medications
• Substance abuse (such patients are at higher risk of suicide and require additional therapeutic interventions)
• Practitioner’s lack of comfort with treating the patient
The major categories of antidepressant medication are tricyclic agents, selective serotonin-reuptake inhibitors (SSRIs), heterocyclic agents, and monoamine oxidase inhibitors. No one antidepressant is clearly more effective than another. The choice of an appropriate antidepressant generally is made on the basis of safety, adverse effect profiles, and cost. Safety of the medication and lack of significant adverse effects make SSRIs a first choice in antidepressants. Tricyclic agents often are used because of lower initial cost and greater experience with their use. However, several studies indicate that SSRIs are as cost-effective as tricyclic agents because they have fewer adverse effects, require less frequent medication changes, and have a higher rate of adherence. An example in which an adverse effect profile may be important in selecting an antidepressant is avoidance of drugs that may cause sexual dysfunction.
Fluoxetine is a widely used medication for the treatment of depression. It also is used to treat premenstrual dysphoric disorder (see also the “Premenstrual Syndrome” section in Part 4). Like the SSRIs, bupropion, trazodone, and heterocyclic agents appear to be safer than tricyclic agents in cases of potential overdose. Clinicians should be aware that bupropion is marketed under the name Zyban for smoking cessation. Note that monoamine oxidase inhibitors can have adverse effects and fatal interactions with other medications; only practitioners with substantial experience with monoamine oxidase inhibitors should prescribe them.
The American Psychiatric Association advises that the recommended length of treatment with medication is until the patient is symptom free. This is generally up to 6 months for the first episode of depression; in the case of recurrent episodes, the duration of treatment generally will be at least as long as the previous episodes of treatment, but frequently will be longer. Frequent recurrences may require prolonged treatment of up to several years.
Bibliography
American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-5. 5th ed. Washington, DC: APA; 2013.
Gjerdingen DK, Yawn BP. Postpartum depression screening: importance, methods, barriers, and recommendations for practice. J Am Board Fam Med 2007;20:280-8. [PubMed] [Full Text]
Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication [published erratum appears in Arch Gen Psychiatry 2005;62:768]. Arch Gen Psychiatry 2005;62:593-602. [PubMed] [Full Text]
Lock J, Walker LR, Rickert VI, Katzman DK. Suicidality in adolescents being treated with antidepressant medications and the black box label: position paper of the Society for Adolescent Medicine. Society for Adolescent Medicine. J Adolesc Health 2005;36:92-3. [PubMed]
Screening for depression in adults: U.S. preventive services task force recommendation statement. U.S. Preventive Services Task Force. Ann Intern Med 2009;151: 784-92. [PubMed] [Full Text]
Spitzer RL, Williams JB, Kroenke K, Linzer M, deGruy FV,3rd, Hahn SR, et al. Utility of a new procedure for diagnosing mental disorders in primary care. The PRIME-MD 1000 study. JAMA 1994;272:1749-56. [PubMed]
Whooley MA, Avins AL, Miranda J, Browner WS. Case-finding instruments for depression. Two questions are as good as many. J Gen Intern Med 1997;12:439-45. [PubMed] [Full Text]
Resources
American College of Obstetricians and Gynecologists. Depression. Patient Education Pamphlet AP106. Washington, DC: American College of Obstetricians and Gynecologists; 2012.
American College of Obstetricians and Gynecologists. Mental health disorders in adolescents. Guidelines for adolescent health care [CD-ROM]. 2nd ed. ed. Washington, DC: American College of Obstetricians and Gynecologists; 2011. p. 85-96.
American College of Obstetricians and Gynecologists. Postpartum depression. ACOG Patient Education Pamphlet AP091. Washington, DC: American College of Obstetricians and Gynecologists; 2013.
American College of Obstetricians and Gynecologists. Primary and preventive health care for female adolescents. Guidelines for adolescent health care [CD-ROM]. 2nd ed. ed. Washington, DC: American College of Obstetricians and Gynecologists; 2011. p. 25-42.
American Psychiatric Association. Key topics: depression. Available at: http://www. psychiatry.org/mental-health/key-topics/depression. Retrieved July 31, 2013.
American Psychological Association. Psychology topics: depression. Available at: http://www.apa.org/topics/depress/index.aspx. Retrieved July 31, 2013.
Dell D. Mood and anxiety disorders. Clin Update Womens Health Care. 2008; VII(5):1-98.
Medicines for treating depression: a review of the research for adults. Effective Health Care Program. AHRQ Pub. No. 12-EHC012-A. Rockville (MD): Agency for Healthcare Research and Quality; 2012. Available at: http://effectivehealthcare.ahrq. gov/ehc/products/210/1142/sec_gen_anti_dep_cons_fin_to_post.pdf. Retrieved September 16, 2013.
Mental Health America. Available at: http://www.mentalhealthamerica.net. Retrieved July 31, 2013.
Second-generation antidepressants for treating adult depression: an update. Effective Health Care Program. AHRQ Pub. No. 12-EHC012-3. Rockville (MD): Agency for Healthcare Research and Quality; 2012. Available at: http://effectivehealthcare. ahrq.gov/ehc/products/210/1143/sec_gen_anti_dep_clin_fin_to_post.pdf. Retrieved September 16, 2013.