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Depression - Women's Health Adviser

OB/GYN News, Feb 1, 2003 by Michelle Sullivan

Asking a few simple questions about mood and life enjoyment during a routine exam can pinpoint women who might be suffering from depression and set the stage for further evaluation and treatment.

Questions like "What have you enjoyed doing lately?" "How does the future look to you?" and "How has your mood been lately?" are probably as effective as formal screening tools in identifying depressed patients, and are much easier to use in an ob.gyn setting. The U.S. Preventive Services Task Force recommends that all primary care providers screen patients for depression.

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Because depression is much more common in women, ob.gyns. are more likely than other primary care providers to encounter depressed patients. The illness strikes 1 in 4 women, but only 1 in 10 men. Despite its prevalence, up to 50% of depression goes unrecognized, contributing to the continuing high level of morbidity associated with the condition.

Diagnosis. Several factors play a role in the onset of depression. Serotonin and norepinephrine deficiencies can cause some symptoms. Last year, depression was linked to genetic factors as well. And environmental dynamics, like exposure to violence, neglect, abuse, or poverty, can also play a part.

Depression most often occurs in patients aged 24-44. years. The basic screening questions address depression's main diagnostic indicators: at least 2 weeks of persistent feelings of sadness or anxiety, or loss of interest or pleasure in usual activities. Additional symptoms include:

* Changes in appetite that result in weight loss or gain not related to diet. Insomnia or oversleeping.

* Loss of energy or increased fatigue. Restlessness or irritability.

* Feelings of worthlessness or inappropriate guilt.

* Difficulty thinking, concentrating, or making decisions.

* Thoughts of death or suicide, or suicide attempts.

Some depressed women, however, will be unaware of, or deny, the presence of depressive symptoms. Instead, they may complain of things like chronic pain, especially of the pelvis and low back, headache, or sexual problems. Without an apparent underlying cause, these symptoms should raise the index of suspicion for depression.

Initiating a relaxed, nonjudgmental dialogue is the best way to discern signs of depression, since many women internalize feelings that might hint at the condition or withhold communication about such issues if they feel they are imposing on the physician's time, or are being rushed through an appointment.

The "baby blues"--affective lability demonstrated by sudden mood. changes or tearfulness--can affect up to 75% of new mothers, This reaction to hormonal changes and a new lifestyle as a mother usually subsides spontaneously within 14 days of giving birth.

In about 10% of new mothers, postpartum depression occurs, usually within the first 2 or 3 weeks of delivery. Women with mild to moderate postpartum depression respond equally well to psychotherapy or medication; women with moderate. to severe depression require medication, with or without psychotherapy.

Postpartum psychosis affects about 1 in 5001,000 women, most often during the first month after delivery. Patients are seriously impaired, experiencing paranoia, hallucinations, and sometimes, command delusions that instruct the mother to injure herself or others. Even if successfully treated, the disorder may reemerge within 2 years of delivery, even without a new birth.

Treatment. Depression is usually treated with any of the selective serotonin reuptake inhibitors, including Prozac, Zoloft, Paxil, Celexa, and Lexapro. Most of these drugs have few side effects; some can cause initial nausea, which subsides as the body adjusts to the drug. This problem can be eliminated with titrated dosing schedules.

More serious postpartum depression responds well to a combination of antidepressants and psychotherapy. Cases of postpartum psychosis are treated with antipsychotics, antidepressants, and mood stabilizers. For most otherwise healthy patients who screen positive for depression, there's no need to refer to a psychiatrist for antidepressant prescribing. It's important to treat through any initial side effects and to keep treating until the drug rakes effect. Most antidepressants need 3-4 weeks to achieve maximum effectiveness.

If symptoms persist, if a second medication is indicated, or if there are significant environmental factors contributing to the depression, it's probably a good idea to refer for psychotherapy.

Sources: DR. DIANA DELL of the departments of psychiatry and obstetrics/gynecology, fluke University Durham, N.C.; and DR. CAROL C. KLEINMAN, a psychiatrist in private practice, Chevy Chase, Md.

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Depression - Women's Health Adviser

OB/GYN News, Feb 1, 2003 by Michelle Sullivan

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