Diagnosis and

Management of Mood
Disorders in Women in a
Primary Care Setting
UCF: Department of Psychology
W. Steven Saunders, Psy.D.

Reference: Katherine C. Smith, D.O.

Goals for Today
 Gender differences with diagnosis and
treatment of mood disorders
 Clinical pearls regarding the diagnosis of
Mood Disorders in Women
 Effective screening tools in the primary care
setting
 Treatment overview
 Resources
Psychiatry in Primary Care

 54% of people with mental illness who seek

treatment are exclusively seen in the “general
medical sector”
 25% of patients in primary care setting have a
diagnosable mental illness
 Myth Busters
 Men attempt suicide more often than women
 Antidepressants are first-line treatment for
Bipolar Disorder
 Women are more prone to bipolar disorder
than men
 Pregnancy is a time of emotional well-being
 There is a specific algorithm for the treatment
of women during childbearing years
 Mood Disorders in Women
 Major Depression
 Dysthymia
 Premenstrual Dysphoric
Disorder (PMDD)
 Bipolar Disorder type I and II
 Depression: Prevalence and Risk
Factors
 Depression is twice as common in women than
men
 Hormonal factors increase vulnerability to
depression
 Genetic contribution to depression
 Differences in coping strategies may lead to
more severe depression in women
 Women are more susceptible to depressive
symptoms in response to stressful life events
and trauma
Kendler, K.S., Prescott C.A. A Population Based twin Study of Lifetime Major Depression in Men and Women. Archives of General
Psychiatry, 56, 39-44, 1999.
 Presentation and Course of
Illness
 Women are more likely to present with:
 increased appetite and weight gain, disturbed sleep,
anxiety, somatization and expressed anger.
 Women are three times more likely than men to
attempt suicide
 Depressed women are more likely to have co morbid
anxiety disorders, thyroid disease and pain
syndromes
 Women have longer episodes of depression, and a
chronic recurrent course
 Many women experience depression related to
reproductive-cycle events
Depression Diagnosis and
Screening
 Within a 2 week period there is depressed mood
and/or anhedonia and 5+ following:
 Weight changes
 Insomnia or hypersomnia
 Psychomotor agitation or retardation
 Fatigue
 Guilt
 Indecisiveness or decreased concentration
 Suicidal ideations

 Center for Epidemiological Studies Depression Scale

 Edinburgh Post Partum Depression Scale
 PHQ-9

www.phqscreeners.
com
 Unintended Pregnancies in the U.S.

The proportion of
unintended
pregnancies was
unchanged from 1994

Risk Factors:

Women ages 18-24

Low-income
Cohabitation
Minority
Finer, L and Henshaw K. Disparities in Rates of Unintended Pregnancy in the United States, 1994 and 2001.
Perspectives on Sexual and Reproductive Health. Vol 38 (2), 90-96, 2006.
 MDD in pregnancy
 10-16% of women have major depression during
pregnancy
 Associated with problems for both mother and fetus
 When emerges in pregnancy, is frequently
overlooked
 Pregnancy is neither protective, nor exacerbating for
depressive disorders
 Under-recognized and under-treated in primary care
settings

Cohen L, Nonacs R (editors): Mood and Anxiety Disorders During Pregnancy and Postpartum (Review of Psychiatry Series, Vol
24, Number 4). Washington, DC, APPI, 2005
Why is this important?

 All women of childbearing years are

potentially pregnant until proven otherwise
 Approximately 50% pregnancies are
unplanned
 10-16% women have major depression during
pregnancy
 Risk benefit analysis ideally prior to
conception, every medication change!
Weighing the Risks and Benefits
 Risk of untreated mental illness
 Risk of relapse of psychiatric illness
 Effects of psychiatric illness on the fetus
 Teratogenicity of psychotropic medications
 Long term behavioral effects
 Incomplete reproductive safety data for
medications
 Risk of Untreated Psychiatric
Illness in Pregnancy
 Maternal Depression may cause:
 Preterm birth, low birth-weight, smaller head
circumference, and lower Apgar scores
 Contribute to poor self-care, inattention to prenatal
care
 Women are more likely to smoke, use alcohol or
illicit drugs
 Children of depressed mothers are more likely to
have behavioral problems, delays in cognitive, motor
and emotional development
 Risk for suicide

Nonacs R, Viguera A, Cohen L. Psychiatric Aspects of Pregnancy. Womens Mental Health, a Comprehensive Textbook. Ed. Susan
Kornstein and Anita Clayton. New York, NY, 2002.
 Anxiety and Stress in Pregnancy
 Lead to poor outcomes
 Increase cortisol and adrenocorticotropic
hormone levels
 May be associated with preeclampsia
 May reduce uteroplacental blood-flow
 Antenatal anxiety predicts postpartum anxiety
and depression
Cohen L, Nonacs R (editors): Mood and Anxiety Disorders During Pregnancy and Postpartum (Review of Psychiatry Series, Vol. 24,
Number 4). Washington, DC, APPI, 2005
Heron J, O;Connor T et al. The course of anxiety and depression through pregnancy and the postpartum in a community sample. J. Affect.
Disord 80:65-73,2004.
 Depression Relapse in Pregnancy:
Cohen et al. 2006:
43% of the women
experienced relapse
during pregnancy

26% who maintained

medication relapsed

68% who discontinued

medication relapsed

Cohen L, Altshuler L, Harlow B et al. Relapse of Major Depression During Pregnancy in Women Who Maintain or Discontinue
Antidepressant Treatment. JAMA Vol 295 (5),: 499-507, 2006.
 Recommendations for
Antidepressant Treatment in
Pregnant Women
 Psychotherapy is first line for mild-moderate
depression
 Psychotherapy + antidepressant recommended for
moderate to severe depression
 Individualized risk-benefit analysis

 No hx of antidepressant treatment: SSRI

antidepressant considered first-line
 Successful history of antidepressant treatment: data
should be reviewed with mom, and considered first
line
Altshuler L, Cohen, L, Moline M et al. Treatment of Depression in Women: A Summary of the Expert Consensus Guidelines.
Journal of Psychiatric Press: 185-208, May, 2001.
 Recommendations continued
 ECT for psychotic depression
 Review all risks and benefits of treatment
 Mom’s should be monitored carefully for
increased depression, mania or psychosis
 Dosages may need to be adjusted
 Goal is monotherapy and minimal effective
dosage

Altshuler L, Cohen, L, Moline M et al. Treatment of Depression in Women: A Summary of the

Expert Consensus Guidelines. Journal of Psychiatric Press: 185-208, May, 2001
 PMS versus Premenstrual
Dysphoric Disorder
 Nearly 75% women experience PMS:
 Bloating, weight gain, breast tenderness & swelling, aches
and pains, poor concentration, sleep and appetite changes.
 PMDD affects 3-8% women:
 Irritability, tension, dysphoria, lability of mood
 Occurs during Luteal phase
 Risk factors for PMDD:
 genetics, normal ovarian function and serotonin
 Age, past or current psychiatric illness
 Sexual trauma
 Diagnosis of PMDD is obtained by 2 consecutive
months of prospective daily symptom ratings
PMDD versus Premenstrual
Exacerbation

 A recent study reported that 64% the first 1500

women enrolled in the STAR*D study
retrospectively reported premenstrual
exacerbation of depression
 When a mood or anxiety disorder is present,
worsening of symptoms during luteal phase is
considered premenstrual exacerbation
Treatment of PMDD
 SSRI antidepressants are first-line treatment
 Lower doses are efficacious
 Continuous dosing more beneficial than intermittent luteal
dosing
 GNRH agonists reduce physical and emotional
symptoms
 Ethinyl Estradiol and Drospirenone is FDA approved
for PMDD
 Ovariectomy reserved for last resort treatment
 Light therapy reduces depression, irritability, and
physical symptoms
 Cognitive Behavioral Therapy and Group Therapy
Bipolar Disorder: Clinical
Features and Course
 Affects 1.2% US population
 Bipolar type I is equal among sexes
 Bipolar type II is more common among women

 Rapid cycling, mixed mania, and more

frequent episodes of depression
 30-90% patients with rapid cycling bipolar
disorder have hypothyroidism
 Mood disturbances reported with menstrual
cycle
 Bipolar type I
 Presence of a manic episode (persistently
elevated/irritable mood for at least 1 week) and 3+
symptoms persisted:
 **Decreased need for sleep**
 Inflated self-esteem
 Pressured speech
 Flight of ideas
 Distractibility
 Goal-directed activity
 Excessive involvement in pleasurable activities
 Screening: Mood Disorders Questionnaire (MDQ)
 Bipolar type II
 Presence of a Hypomanic episode (persistently
elevated/irritable mood for at least 4 days) and 3+
symptoms persisted:
 **Decreased need for sleep**
 Inflated self-esteem
 Pressured speech
 Flight of ideas
 Distractibility
 Goal-directed activity
 Excessive involvement in pleasurable activities
 No psychotic symptoms!!
General Treatment Guidelines
 Mixed states and rapid cycling are more common in
women
 Antidepressants worsen: mania, hypomania, cycling,
and depression
 First line treatment always begins with a mood
stabilizer
 Lithium, Carbamazepine, Valproic Acid, Lamotrigine
 Atypical antipsychotics
 Once mood is stabilized, if depressive symptoms still
persist, then consider augmentation with antidepressant
Bipolar Disorder and Pregnancy

 Pregnancy seems to be “risk neutral”

 Relapse increases with medication
discontinuation
 Majority of relapses in pregnancy are
depressive episodes
 Estimates of post-partum relapse may be as
high as 50%
 Relapse in pregnancy is a strong predictor of
post-partum relapse

Cohen L. Treatment of Bipolar Disorder During Pregnancy. J. Clinical Psychiatry 68 (9), 2007: 4-9.
 Recommendations for
Treatment
in Pregnant Women
 Mild-moderate bipolar disorder:
 May taper or discontinue mood stabilizer prior to
conception, during first trimester or throughout pregnancy
 Severe bipolar disorder:
 May continue medication throughout pregnancy
 Consider typical high potency antipsychotic as augmentation
 Psychotherapy
 ECT
 Goal is monotherapy and minimal effective dosage

Cohen L. Treatment of Bipolar Disorder During Pregnancy. J. Clinical Psychiatry 68 (9), 2007, 4-9.
 Conclusions
 SSRI antidepressants are first line treatment
for depression and PMDD
 The hallmark diagnostic feature of bipolar
disorder is decreased need for sleep
 Mood stabilizers are first line treatment for
bipolar disorder
 All women of childbearing years are
potentially pregnant until proven otherwise
 Conclusions
 For women with depression who become
pregnant, psychotherapy and SSRI
antidepressants are considered first line
treatment
 For women with bipolar disorder who become
pregnant, psychotherapy and mood stabilizers
are considered first line treatment
 Proposed Treatment
Algorithm for Women

Illness Risk of Risk of Risk to

Severity Untreated Relapse Fetus
Illness

Goal is Sustained Lowest Effective

Healthy Mental State Dosage

Monotherapy

Consult!
 Resources

 Mother Risk Program

 www.motherisk.org
 Massachusetts General Women’s health
 www.womensmentalhealth.org
 United States National Library of Medicine
 http://toxnet.nlm.nih.gov
A New
Resource in
Richmond…