Guidelines for Treating Perimenopausal Depression Released

Studies suggest women are at an increased risk of depression during perimenopause—the time right before menopause when female hormones start to decline. A multi-institute expert panel convened by the North American Menopause Society and the National Network on Depression Centers Women and Mood Disorders Task Group has now developed and published the first-ever guidelines for the evaluation and treatment of perimenopausal depression.

The guidelines were jointly published in the journals Menopause and the Journal of Women's Health.

“The notion of a menopause-associated depression … has been the focus of clinical and scientific debate for years,” wrote the panel members. “The lack of consensus on this issue has also led to a lack of clarity [on] how to evaluate and treat depression in women during the menopausal transition and postmenopausal period.”

The expert panel, co-chaired by Pauline Maki, Ph.D., of the University of Illinois at Chicago College of Medicine and Susan Kornstein, M.D., of Virginia Commonwealth University focused on five areas: epidemiology, clinical presentation, effects of antidepressants, effects of hormone therapy, and efficacy of other therapies such as psychotherapy and exercise.

The recommendations made by the panel include the following:

• Proven therapeutic options for depression such as antidepressants and psychotherapy are best for treating major depressive episodes during perimenopause.
• Existing data suggest that antidepressants can be given to perimenopausal women at doses typically prescribed to adults.
• There is some evidence that estrogen therapy has antidepressant effects when administered to perimenopausal women with depression. However, estrogen therapy has been shown to be ineffective as a treatment for depressive disorders in postmenopausal women.
• Hormonal contraceptives may improve depressive symptoms in women approaching menopause.

To read more about depression and menopause, see the Psychiatric News article “Older Age at Menopause May Reduce Risk of Depression.”

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Hormonal Contraception May Increase Risk of Suicide, Study Suggests

Women who use hormonal birth control may be more likely to attempt or die by suicide than those who never use the medication, according to a study of women aged 15 to 33 in Denmark. The findings were published in AJP in Advance.

“Adolescent women experienced the highest relative risk,” wrote Charlotte Wessel Skovlund, Ph.D., and colleagues of the University of Copenhagen. “Patch, vaginal ring, and progestin-only products were associated with higher risks than oral combined [estrogen and progestin] products, and a similar association was suggested for suicide.”

To assess associations between their use of hormonal birth control and the risk of a first suicide attempt or suicide, Skovlund and colleagues followed a national cohort of Danish women who turned 15 during the study period, which extended from 1996 to 2013, and who had no history of hormonal contraceptive use. Women with prior suicide attempts, antidepressant use, and psychiatric diagnoses were excluded from the analysis.

The study included nearly half a million women followed on average for 8.3 years with a mean age of 21 years. A total of 6,999 first suicide attempts and 71 suicides were identified. The association between hormonal birth control and a first suicide attempt peaked after two months of use. 

Compared with women who never used hormonal birth control (“never users”), users of hormonal birth control aged 15 to 33 years had a relative risk of 1.97 for a first suicide attempt and 3.08 for suicide. The relative risk of a first suicide attempt increased rapidly after initiation of hormonal contraception use, compared with never use, and it remained at least doubled until one year after initial use. 

Following that, the risk estimates decreased, but remained higher compared with never users after more than seven years of use. The relative risk of suicide attempt with hormonal contraceptive use was for 2.06 for the 15-19 age group, 1.61 for the 20-24 age group, and 1.64 for the 25-33 age group.

“Our data indicate that adolescent women are more sensitive than older women to the influence of hormonal contraceptive on risk of a first suicide attempt,” the authors wrote. This age difference may be due to the fact “adolescent women are particularly vulnerable to risk factors for suicide attempt,” they noted.

They concluded, “Considering the severity of these little-recognized potential side effects of hormonal contraceptives, health professionals and women starting hormonal contraceptives should be informed about them.”

For related information, see the Psychiatric News article “Increased Risk of Depression Tied to Some Contraceptive Use.”

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Experts Suggest Cautious Response to a Study Linking Contraceptives and Depression

A study of more than one million young women in Denmark published this week in JAMA Psychiatry suggested that women using hormonal contraception were more likely to be diagnosed with depression or prescribed an antidepressant for the first time than those not taking the medication. However, experts who spoke with Psychiatric News say clinicians and patients should be cautious about jumping to conclusions about the results.

Compared with nonusers, users of combined oral contraceptives experienced a relative risk (RR) of a first use of antidepressants of 1.2, wrote Charlotte Wessel Skovlund, M.Sc., and colleagues from the Department of Gynecology at the University of Copenhagen. Women using medroxyprogesterone acetate depot had the highest relative risk at 2.7. The RRs of a first diagnosis of depression were slightly lower or similar. The authors noted an important age difference, as well.

“Our data indicate that adolescent girls are more sensitive than older women to the influence of hormonal contraceptive use on the risk for first use of antidepressants or first diagnosis of depression,” wrote Skovlund and colleagues. “This finding could be influenced by attrition of susceptibility, but also that adolescent girls are more vulnerable to risk factors for depression.”

Former APA President Nada Stotland, M.D., said the findings should not result in precipitate action by patients or their physicians. While the effects are significant, clinicians must compare them to what could happen if women were not on hormonal contraceptives, she added.

“Women, especially adolescents, who are not taking these contraceptives may instead experience anxiety about negotiating with partners or getting pregnant,” said Stotland. “We must take into account the importance of contraception as an important element of women’s overall health, including mental health.”

Maureen Van Niel, M.D., president of the APA Women’s Caucus and a private practitioner in Cambridge, Massachusetts, agreed. “The relative risk is indeed elevated in women who have used contraceptives but the degree of elevation is not alarming,” she said. 

(Image: iStock/crankyT)