Women mental health

2. “The burden of mental
disorders, such as depression
and anxiety, fall
disproportionately on women of
childbearing and childrearing
age.”
Psychiatric Clinics of North America, 2007

3. Rates of severe mental illness similar between
men and women, but differences in diagnoses,
age of onset, course.
 Rates of Major Depression and Dysthymia are
about twice as high for women as for men
 Prevalence rates for most Anxiety Disorders
(panic disorder, agoraphobia, specific phobia,
GAD, PTSD) are 2-3x higher in women
(exceptions are OCD and social phobia: rates
are =)

4.  Bipolar Disorder – Type I rates = in men and
women, Type II women > men
› More mixed episodes, rapid cycling
› Later age of onset, more depressive episodes
 Schizophrenia – Lifetime prevalence = in men and
women.
› Women have later age of onset (25-35) with bimodal
distribution
› Higher premorbid functioning and social functioning
› More “benign” course
 Eating Disorders – Anorexia Nervosa 95% female;
Bulimia 80% female

5.  Substance Abuse : Men 2-4 x more likely to
have dx of substance abuse or dependence
› Women with affective illness more vulnerable
 Personality Disorders:
› Women > Men in Borderline, Histrionic (?)
› Men > Women in Antisocial, Narcissistic,
Obsessive-Compulsive

6. 0
5
10
15
20
25
MDE DD SAD PMDD BPD
Female
Male

7.  Biologic Vulnerability
 Reproductive Events
 Psychosocial Factors

8.  Gender based violence (rape, sexual abuse,
domestic violence)
 Socioeconomic status
 Caregiving responsibilities, multiple roles

9.  Menstrual Cycle
 Infertility
 Pregnancy
 Postpartum Period
 Menopausal Transition/Perimenopause
 Hormonal Therapies

10.  Higher incidence of MDD in women starting at
puberty, less marked post-menopause
 Suicidal behavior may be more common in low
estrogen states
 5% rate of PMDD
 Rates of postpartum admissions and psychosis
elevated immediately after childbirth
 Perimenopausal mood d/o’s vs. post-
menopause

11. Kessler et al, 1993 (National Comorbidity Survey)

12. Fig. 1. Phases of the menstrual cycle positively correlated with suicide attempts and
changes in oestrogen concentration during the cycle. * Denotes studies where results were
statistically significant. Saunders et al, 2006

14.  Estrogen
 Progesterone
 FSH
 LH
 Testosterone
 HCG
 Prolactin

15. E2
PROG 
MAO / COMT
E2  MAO & COMT -  5HT
PROG  MAO & COMT -  SHT
MAO: Monoamine Oxidase
COMT: Catechol-O-Methyl
Transferase
5HT: Serotonin
TRYP
5HT Re-uptake Site
5HT
Estroge
n

17. Psychological Symptoms
 Depression
 Anger, Irritability
 Affective lability
 Anxiety
 Sensitivity to rejection
 Poor concentration
 Sense of feeling
overwhelmed
 Social withdrawal
Physical Symptoms
 Lethargy or fatigue
 Sleep disturbance
(usually hypersomnia)
 Appetite disturbance
(usually increased)
 Abdominal bloating
 Breast tenderness
 Muscle aches, joint pain
 Swelling of extremities

18.  Affects 3-8% of menstruating women
 Symptoms begin during Luteal Phase,
resolve completely with onset of menses
 ≥5 symptoms in most cycles
 Marked decrease in social or occupational
functioning
 Distinguish from underlying mood disorder
(no symptoms Follicular Phase)
 Abnormal serotonin neurotransmission?

19.  Lifestyle interventions, exercise
 Calcium, Vit B6, Magnesium, Vit E
 Herbal remedies (chasteberry)
 Psychotherapy
 SSRI’s (fluoxetine, paroxetine, sertraline)
› Immediate effect
› Intermittent vs. continuous dosing
 Hormonal therapies

20.  Increased risk for first episode depression
during menopausal transition
 Lower risk for first episode depression in
post-menopausal women
 Women with a history of depression remain
at risk for future episodes
 Estrogen replacement effective for mild
symptoms, but not Major Depression

22. Is pregnancy a time of emotional
wellbeing for women?

24.  Pregnancy is NOT protective against psychiatric
illness
 Rates of Major Depression during pregnancy
10-15% Anxiety disorders may be higher.
 High rate of relapse when antidepressant
medications are stopped during pregnancy
(~50-70%)
 Pregnant Bipolar women have same risk for
relapse off meds as non-pregnant Bipolar
women. Post partum risk 4x higher.

25.  Past history of depression
 Poor overall health
 Greater alcohol use
 Smoking
 Being unmarried
 Unemployment
 Lower education level

26. Level of suffering – for mom and partner
Decreased ability to care for herself and the
pregnancy – suicide risk in severe cases
Increased risk for pre-term delivery,
preeclampsia, and low birth weight
Higher rates of smoking, alcohol and substance
use
Risk of post-partum depression, negative effects
on child and family

27. Non-Pharmacologic Treatments:
 Psychotherapy
 Light Therapy
 Omega-3 Fatty Acids
 Psychosocial supports

28. Psychotropic Medications in Pregnancy – are
they safe?
 No Psychotropics are FDA-approved for use
during pregnancy
 All medications cross the placenta
 Principals of management: maximize non-
medication options, minimize exposure to
meds and to depression

29.  Teratogenesis
› No increase in overall rate of fetal malformations
› Some evidence linking inc risk of rare defects (i.e.
paroxetine and cardiac malformations)
 Pregnancy Outcomes
› Mixed evidence on birth weight, early pregnancy loss,
preterm labor (depression effects?)
 Neonatal Toxicity
› Neonatal Abstinence Syndrome
› Persistent Pulmonary Hypertension of the Newborn
 Long-term effects
› No evidence to date of long-term developmental effects in
children exposed in utero

30. “Baby
Blues”
Postpartum
Depression
Postpartum
Psychosis

31. Y axis: Rates of psychiatric hospitalization
X axis: Years pre- and post- childbirth

32. “When I delivered the placenta, I felt like I fell off
a cliff.”

33.  Occurs in 50-85% of women
 Characterized by mood lability, tearfulness,
anxiety and irritability
 Symptoms peak at day 4-5
 May last a few hours to several days
 Symptoms do not interfere with functioning
 Reassurance rather than treatment
 If symptoms persist > 2 weeks, patient should
be evaluated for a more serious mood disorder

34.  Occurs in 1-2 per 1000 women
 Onset 24hrs – 3 weeks postpartum
 Rapid mood swings, insomnia, obsessive thoughts
 Delusions, hallucinations, impaired reality testing.
Delusions involving infant are common
 Shifting mental status , disorientation, confusion,
disorganized behavior
 High risk of suicide and/or infanticide
 Psychiatric emergency – needs evaluation immediately
 Differential: medical causes of delirium, PPD, SCZ
 >70% appears to be a presentation of bipolar disorder.
Bipolar women at very high risk of PPP

35.  Estimates of prevalence between 10-15%
 Risk factors:
› Prior episodes depression or anxiety, including
during pregnancy
› Marital discord
› Unwanted or unplanned pregnancy
› Infant medical problems
› Lack of social support
› Low socioeconomic status
 Differential: anemia, diabetes, thyroid

36. Symptoms:
• Depressed mood
• Tearfulness
• Loss of interest in usual activities
• Feelings of guilt
• feelings of worthlessness or incompetence
• Fatigue
• Sleep disturbance
• Change in appetite
• Poor concentration
• Suicidal thoughts

37.  Milder cases overlap with normal feelings in the
postpartum period – i.e. fatigue, altered sleep,
appetite, energy
 Hopelessness, worthlessness, suicidal ideation
are not normal in the postpartum period
 Comorbid anxiety with obsessional thoughts
about the baby is common
› Important to distinguish from psychosis
 Edinburgh Postnatal Depression Scale
› 10-item self-rating scale measuring mood, anxiety
and SI

38.  Psychotherapy: IPT, CBT, Supportive,
Psychodynamic, Couples, Group
 Improved social supports
 Help with infant care
 Light therapy
 Medications: SSRI’s, Tricyclics,
Benzodiazepines for comorbid anxiety

39.  All psychotropic medications are secreted into
breast milk
 Concentrations in breast milk vary widely
 Peak concentrations are attained at 6-8 hours
 Infant toxicity depends on exposure and hepatic
metabolism
 Relationship between infant serum
concentrations and infant physiology, behavior
and development is unknown
 Carefully monitor breast fed infants

40.  Mood and Anxiety disorders disproportionately affect
women of reproductive age
 Times of hormonal change may be periods of particular
vulnerability
 Many women are reluctant to seek treatment, diagnoses
often missed
 Treatment of psychiatric illness is complicated by
potential pregnancy, pregnancy, postpartum issues
 Risks and benefits of both treatment and non-treatment
must be carefully considered