Women and Depression

Did you know that, the highest age-specific suicide rate for females in Australia in 2009 was observed in the 50-54 age group (8.8 per 100,000)*? Middle – aged women are more at risk of suicide than younger and older women. This fact is not widely known or discussed but when we consider the special issues facing this group, the awful statistics make sense.

Perimenopause is the time period that denotes the transitional process of menopause. On average it begins at about age 50 and can take 4-5 years, although in some women it can be longer. This is a time of enormous mental upheaval for many women. Of course most women sail through this period of their lives, with no real issues, but for many it can be a time of despair with the new onset of depression or a relapse of a previous mental illness. The entity “perimenopausal depression” is not well recognised or treated in our community, and can cause great loss of the quality of life for the woman and her family. In the worst case, it can lead to actual suicide – hence the statistic described above.

We have developed a rating scale called “The Meno-D” to attempt to delineate the symptoms better. This is available on request (email maprc@alfred.org.au ). Essentially, the symptoms include: - low energy, - paranoid thinking, - irritability, - low self esteem, - feeling isolated, - anxiety symptoms, - somatic symptoms, - sleep disturbance, - weight gain, - loss of sexual interest, - poor memory - poor concentration.

A particularly difficult issue for the diagnosis of this condition is that the hormone changes of the menopause can impact in the brain up to 5 years before the well-known body symptoms such as hot flushes occur. In particular, declining estrogen levels can be associated with the development of new depression or relapse of a previously well-treated disorder. Estrogen has a “neuroprotective “effect in the brain and can act as a mild antipsychotic or antidepressant drug. Hence, the loss of some of this neuroprotective effect leads to an uncovering or worsening of a mental disorder.

Perimenopausal depression can be a severe, life threatening condition. Unfortunately, labeling it as “just part of the change of life” all too often dismisses it. Advice that may be given includes a minimization of distress by stating this is “natural or normal”, that it is short – lived, or that it is less important in a public health sense than youth mental health. Such advice or attitude is wrong and unhelpful. For too long, women with severe postnatal depression were dismissed as just having the “baby blues”; and now we see women again dismissed as just being “grumpy old women with the change of life” Perimenopausal depression can be a severe mental disorder that has mortality. It certainly contributes to loss of productivity in the workplace; break up of relationships and poor quality of life. The ripple effects can be transgenerational if a middle- aged woman, the mother in a family, is debilitated by depression. In her early 50’s, she may well be caring for her adolescent children, a partner/ spouse and aged parents. She may also be a senior member of the workforce with high-level responsibilities. All of this can be adversely impacted if she has severe perimenopausal depression. Furthermore, her own enjoyment of life, which she has worked hard to achieve, can be totally diminished.

TREATMENTS There are effective treatments, which involve an integrated approach: - hormone treatments (both prescribed and natural types), - antidepressant treatment, - exercise, - healthy nutrition - psychological therapies. It is important that a holistic approach is adopted, because there are many cases of women with a past history of well-treated depression who relapse in the perimenopause. The resulting severe depression often does not respond to standard antidepressant treatments. Adding in hormone treatments such as combined estrogen plus progesterone can make a big difference. Some women who experience severe depression for the first time ever in the perimenopause respond best to hormone treatment alone, and in fact can get very agitated with standard antidepressant treatment, such as an SSRI.

EMPOWERMENT STRATEGIES Empowerment strategies for the woman are imperative, since the loss of self-esteem and confidence is a devastating symptom. Relationships may need work and informed partners can provide much needed support. Understanding the symptoms of perimenopausal depression can also help partners comprehend some of the woman’s distress and put symptoms of irritability and hostility into a more tolerable framework. Women who have a history of premenstrual depression and postnatal depression are much more likely to be prone to experiencing perimenopausal depression. Women whose mothers experienced perimenopausal depression also seem more likely to develop it themselves.

COMMUNITY AWARENESS We need greater community awareness of this entity of “perimenopausal depression” to enable early diagnosis and tailored treatments to be available for the middle – aged women who experience it. Persistent depression in women due to the hormone triggers of menopause must be treated effectively and as quickly as possible. As our population’s longevity increases, it is vital that the middle to later years of life remain fulfilling and rewarding for all.


Published: 01/12/2011 by PROFESSOR JAYASHRI KULKARNI 

 MAPrc Multidisciplinary Alfred Psychiatry Research Centre, Level 4, 607 St Kilda Road, Melbourne 3004