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Depression in Women: Diagnostic and Treatment Considerations

American Family Physician, July, 1999 by Subhash C. Bhatia, Shashi K. Bhatia

Women experience depression twice as often as men. The diagnostic criteria for depression are the same for both sexes, but women with depression more frequently experience guilt, anxiety, increased appetite and sleep, weight gain and comorbid eating disorders. Women may achieve higher plasma concentrations of antidepressants and thus may require lower dosages of these medications. Depending on the patient's age, the potential effects of antidepressants on a fetus or neonate may need to be considered. Research indicates no increased teratogenic risk from in utero exposure to selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants. SSRIs are effective in treating premenstrual dysphoric disorder and many comorbid conditions associated with depression in women. Psychotherapy may be used alone in women with mild to moderate depression, or it may be used adjunctively with antidepressant drug therapy. Women who have severe depression accompanied by active suicidal thoughts or plans should usually be managed in conjunction with a psychiatrist. (Am Fam Physician 1999;60:225-40.)

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Over the course of a lifetime, depression occurs in approximately 20 percent of women compared with 10 percent of men.1 Although the exact reason for this difference is not known, the higher prevalence of depression in women is most likely due to a combination of gender- related differences in cognitive styles, certain biologic factors and a higher incidence of psychosocial and economic stresses in women.2 Possible biologic mechanisms may include differences in brain structure and function, genetic factors and the cognitive-behavioral or mood- related effects of female gonadal steroids on neurotransmitters and enzyme functions in vulnerable persons.3,4 Some risk factors for depression in women are listed in Table 1.5-7

Diagnosis

The diagnostic criteria for major depression, as established in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), are the same for women and men (Table 2).8 The nine symptoms of depression are divided into two subgroups: psychologic (four symptoms) and physical (five symptoms). The diagnosis of depression requires the presence of depressed mood or the inability to experience pleasure, plus four other symptoms. Thus, five of nine symptoms must be present. Inclusion, exclusion and duration criteria must also be met.

Although the same diagnostic criteria are used for both genders, the presentation and course of depression are sometimes different in women (Table 3).2,4,7,9 Compared with men, women may more often experience seasonal depression9 and symptoms of atypical depression (i.e., hypersomnia, hyperphagia, carbohydrate craving, weight gain, a heavy feeling in the arms and legs, evening mood exacerbations and initial insomnia).8 In addition, women more frequently have symptoms of anxiety, panic, phobia, eating disorders and dependent personality. Women also have a higher incidence of hypothyroidism, a condition that can cause depression.7 Thus, it is important to screen depressed female patients for hypothyroidism. Finally, exogenous and endogenous gonadal steroids may have a greater impact on mood in women than in men.

Depression and Suicide

Depression is a significant risk factor for suicidal behavior in both sexes. Women, especially those younger than 30 years of age, more often attempt suicide, whereas men more often complete the act of self- destruction.10 In fact, the male-to-female ratio for completed suicides is greater than 4:1,10 possibly because women frequently choose less lethal methods. In addition, women often attempt suicide to change the dynamics of interpersonal relationships. Significant risk factors for suicide by women are listed in Table 4.10-12

During the initial visit, every patient with depression should be screened for suicidal thoughts, intent and plan, as well as the availability and lethality of a method for committing suicide. This screening may provide an opportunity for lifesaving intervention.10

Self-poisoning is the method employed in 70 percent of all suicide attempts by women.11 Thus, at the initial visit with a depressed female patient, it is prudent to prescribe only one week of an antidepressant (especially one that is potentially lethal in overdose, such as a tricyclic agent). It is also important to enlist the aid of at least one of the patient's family members or friends to monitor intake of the prescribed antidepressant so that the patient does not hoard the medication for use in a suicide attempt.

Hospitalization is necessary for patients with severe depression, psychosis, substance abuse, severe hopelessness or limited social support. Patients should also be hospitalized if they articulate or display a strong urge to act on suicidal thoughts or if they have a specific suicide plan that is likely to be successful. Typically, such patients require management by a psychiatrist.

Outpatient management is appropriate for patients with less severe depression who have infrequent suicidal thoughts, who are willing to contract for safety and let go of their instrument of suicide, who have good social support and who are willing to return for regular follow- up.12

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Depression in Women: Diagnostic and Treatment Considerations

American Family Physician, July, 1999 by Subhash C. Bhatia, Shashi K. Bhatia

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