Depression during the menopausal transition: experts discuss diagnosing and treating it, explore the link between estrogen and depression, and give practical advice.
The idea that the menopausal transition might trigger depression flies in the face of researchers' long-held presumption that declining reproductive function plays no role in the onset of depression. But could there be something to it?
The relationship between menopause and mood disorders in women has been contentious. Fortunately, most women do not experience depression during the menopausal transition-the years between the onset of menstrual cycle irregularity and a patient's final menstrual period (FMP) (Table 1). But for those who do, depressions had been assumed to result either from the sleep-disturbing effects of hot flushes or from the coincidental reappearance of depression in women with histories of mood disorders who could be at an increased risk for a relapse anyway. Recent studies, however, suggest that these presumptions are not completely correct.
Recent community-based, longitudinal studies, however, show a subgroup of women to be at increased risk for depression during the menopausal transition.1-5 In these studies the menopausal transition was defined by the onset of menstrual cycle irregularity (a change in cycle length of more than 7 days) and an elevated plasma FSH level greater than 2 standard deviations above the normal range for reproductive-aged women. This definition is consistent with the stages of the reproductive aging workshop (STRAW) criteria for the menopausal transition.6
The syndrome of depression was confirmed by either a structured clinical interview to diagnose its presence, or by a CES-D score greater than 16, consistent with clinically significant depression. Three of these studies prospectively followed women with no history of depression until they entered the menopausal transition. Women going through this transition were seen to have a 2- to 2.5-fold greater risk for the first onset of depression than those who were premenopausal (i.e., with regular menstrual cycles).4,5,7 Thus, studies have linked the menopausal transition-but not menopause-with both recurrent and first-onset depression, compared with age-matched women who were in the premenopause.
Types of depression in perimenopause
Both major and minor depressions are associated with the menopausal transition, as they are with the postpartum.8,9
MAJOR DEPRESSION, which affects roughly twice as many women as men, has an estimated lifetime prevalence of 20% in women.10 The exact prevalence of minor depression is less clear due to differences in diagnostic criteria; however, it's thought to be nearly as prevalent as major depression. Both major and minor depressions are associated with considerable disease-related disability in developed countries. Indeed, major depression is rapidly becoming a leading source of disease-related disability worldwide.11
MINOR DEPRESSIONS, even though they have by definition less severe and fewer symptoms (at least two, but less than five of the symptoms listed in the next paragraph) than major depression, they tend to be just as disabling as major depression.12
Of the American Psychiatric Association's nine core symptoms of major and minor depression, all but the ninth symptom must be present nearly every day during the same 2-week period.13 They are: (1) depressed mood most of the day; (2) markedly diminished interest or pleasure in all, or almost all, activities most of the day; (3) significant weight loss when not dieting or weight gain (a change of >5% of body weight within a month), or drop or increase in appetite; (4) insomnia or hypersomnia; (5) psychomotor agitation or retardation; (6) fatigue or loss of energy; (7) feelings of worthlessness or excessive or inappropriate guilt (which may be delusional-beyond mere self-reproach or guilt about being sick); (8) reduced ability to concentrate or think, or indecisiveness; (9) recurring thoughts of death (not just fear of dying), recurring suicidal ideation with no specific plan, or a suicide attempt or a specific plan for ending one's life.
Importantly, these symptoms must represent a change from previous functioning and at least one of the symptoms must be (1) depressed mood or (2) loss of interest or pleasure.