Mental Illness Through Menopause

Susan Hatters Friedman, MDAssociate Professor of Psychological Medicine

University of Auckland

Outline

• Mental Illness:

– Depression

– Bipolar

– Schizophrenia

– PTSD & Anxiety

– Comorbidity

– Suicide

• Menopause intersection

Major Depression•Sleep changes,

•Interest, (anhedonia)

•Guilt/ H/H/W,

•Energy,

•Concentration,

•Appetite/ weight changes,

•Psychomotor slowing,

•Suicidal thoughts

Depression Diagnosis

• Occurring for 2+ weeks

• Peak onset age 25-45

• Mean episode length 8 months

• Approximately 7% annual prevalence

• Increased in women, 10-25% lifetime

Bipolar & Depression

Bipolar Disorder

•Roughly = 1%

•Depressive episodes

•Manic episodes: elevated/

irritable mood…

Mania Syptoms

• Elevated or irritable mood

• Grandiose

• Decreased need for sleep

• Hypertalkative, racing thoughts

• Hypersexual

• Distractible

• Risk taking (spending, speeding, sex)

• Poor insight

Asking about Manic Sx…

• “Has there ever been a time when you’ve been the Opposite of depressed,

• …without using drugs…”

• Ascertain that it meets criteria

• Keeping in mind, poor insight

Are we seeing what we want

to see?

Risk of Misdiagnosis of Bipolar

• Treatment with un-opposed antidepressant agent

• Increased risk of inducing mania &

• Increased risk of rapid cycling bipolar disorder

Psychotic Disorders

• Roughly = 1%

• Schizophrenia

• Schizoaffective disorder

• Delusional disorder

Psychosis

• Out of touch with reality

• Delusions

– Fixed, false belief

– Not cultural/ religious

• Hallucinations

– A/V/T/G/O

Asking about Psychotic Sx…

• “Sometimes when people are under a lot of stress…

• …or depressed…

• They have experiences of hearing things that maybe aren’t really there, or seeing things…

• …I need to ask if that’s been happening to you?”

PTSD & Anxiety

• Women at higher risk of almost all anxiety disorders than men, throughout life

• PTSD: 11% women & 7% men

• 31% of women exposed to major trauma

• 19% of counterpart men

• Women predominate among those with persisting sx @ 1 year

(Yonkers; Seeman)

Co-Morbidity & Differential Dx

Scope of IPV

• “Across 18 studies, the weighted mean

prevalence of depression among battered

women was 47.6%…..weighted mean

odds ratio was 3.80….evidence for a

dose-response relationship.” (Golding,

1999)

Victimization Effects

• Loss of self-esteem and individual identity

• May come to believe that they invited the

abuse, deserved, that they are to blame

for the violence

• Feel unsafe in their own homes

(Smith, 1994; Friedman & Loue, 2007)

Psychiatric Sequellae

of IPV

• Depression

• PTSD

• Suicidality

• Substance comorbidity

Psych Meds & IPV

• “Psychotropic drugs can dull her ability to

respond to threatening situations and to

take appropriate actions to protect herself

or to escape from danger.” (Fischbach, 1997)

IPV & Major Depression

• Decrease in depressive symptoms over

time after leaving or after cessation (Campbell, 1995; Kernic, 2003)

• 39% of community battered women met

criteria for MDE (Campbell, 1997); Half of

women in shelters do (Sato, 1992)

• Of ER abuse victims, 80% had moderate

depression (Rounsaville, 1977)

Substance Use Disorders

•Substance Abuse or Dependence

–CAGE

–Cut Down

–Annoy

–Guilt

–Eye Opener

•Greater consequences in W

NZ SUICIDE AGE-SPECIFIC DEATH RATES, BY 5-YEAR AGE GROUP, 2010

0

10

20

30

40

50

60

15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–74 75–79 80–84 85+

Five-year age group

Males

Females

Rate

Suicide Risk Factors

Depression/ Bipolar/ Schizophrenia

Substance abuse

Personality disorder

(acute unwellness, suicidal thoughts)

Previous suicide attempt

Family history of suicide

Poor social support

Serious medical condition/ serious pain

Recent stressful life events/ loss

Relationship conflict/ bullying/ loss of job

+ Access to lethal means

Suicidality in IPV

• “Evidence also suggests that physical

abuse may be the single most important

etiologic factor of female suicide.” (Dienemann)

• 80% of women with attempted suicide

give relationship conflicts as reason (Stark)

Asking about suicidal thoughts…

Suicide Ladder:

Passive thoughts of death

Active suicidal thoughts/ ideation

Intent

Plan

Again, ‘normalising’

“How close?” vs. “Ever attempted?”

Mental Illness & the Female Life Cycle:

Increased Vulnerability

Menstruation

•Pre-Menstrual Dysphoric

Disorder (PMDD)

–Irritability

–Dysphoria

–Tension

–Mood lability

3-8% of women

Menopause Potential Issues

• “Change of life” meaning to individual, role

• Vasomotor symptoms (hot flushes, night sweats)

• Sleep disturbances

• Sexual dysfunction (dyspareunia, dryness, libido)

• Risk osteoporosis

Menopause

• Transition Starts around age 47

• & Lasts 4-7 years

• Final Menstrual Period mean age 51

• By 55, almost all women are post-menopausal

(Almeida et al, 2014)

Peri-Menopausal Mood Disorder

• More than 50% of peri-menopausal women report worsened mood (Freeman et al, 2002)

• 20% of post-menopausal women report severe mood problems (Blehar et al, 1998)

• Higher risk before Final Menstrual Period, lower risk after, esp 2 years after. (Freeman et al, 2014)

SWAN Study

• Study of Women's Health Across the Nation (USA) (Bromberger et al 2011)

• Women 2x as likely as men to suffer depression

• Periods of reproductive change

• Risk for depressive symptoms greater during & after menopause transition

SWAN Study (2)

• Also consider other risk factors: especially history of depression

• Effect of menopausal status was independent of history of depression & upsetting life events, vasomotor symptoms, psychotropic medication use, & serum levels/ changes in reproductive hormones

First Episode of Depression in Midlife

• Over 7 years, 16% of Women developed depression

• First episode of depression in midlife predicted by:

• Lifetime history of anxiety disorder

• Role limitations due to physical health

• Very stressful life event

• & were more important than vasomotor symptoms (hot flashes/ night sweats) in contribution

(Bromberger et al, 2009)

Menopause Among Chronically Mentally Ill Women

• Cross-sectional assessment of perimenopausal and postmenopausal women, ages 45-55, diagnosed with schizophrenia/schizoaffective disorder, bipolar disorder, or major depression in psychiatric care

• Menopause Specific Quality of Life Scale (MENQOL)• Women with severe mental illnesses who were peri- and

post-menopausal experienced considerable vasomotor, physical, sexual, and psychosocial symptoms related to menopause.

• On seven of 29 MENQOL items, women with major depression reported problems significantly more often than women with other serious mental illnesses.

(Friedman, Sajatovic, et al, 2005)

STEP-BD Study

• 164 patients with Bipolar followed for 30 months

• The transition to menopause:

• More visits due to depressive symptoms

• When compared with other women & all men

New Bipolar in Menopause?

• New onset mania in menopause rare & should trigger dementia eval/ medical workup (Friedman et al, 2007)

Depression & Estrogen?

• May decrease susceptibility to depression

– In some vs. all

• Influences serotonin & Nepi

• Thus may potentiate some effects of antidepressants

• Thus Benefit may be independent of effect on physical sx

Surgical Menopause?

• Higher rates of depression than natural menopause

• Abrupt estrogen deprivation in younger women may increase depression risk

• Psychological reaction? Identity? Negative feelings & Individual factors

• (Llaneza, 2012)

Schizophrenia & Estrogen?

• Often improved sx during high E phase of menstrual cycle, with aggravation of sx premenstrually

• Second peak of Schiz onset in women: age 45-50 (lower E levels)

• Higher BMI related to earlier meds = more E= fewer vasomotor sx

• (Seeman)

Schizophrenia & Estrogen? (2)

• Some women postmenopausally have decreased response to antipsychotic agents

– Genetic polymorphisms in E-metabolising enzymes?

• Also checking Prolactin levels to determine actual menopause vs. med-induced amenorrhoea

• (Seeman)

PTSD & Estrogen?

• Suggest that low estrogen is a vulnerability factor for development of PTSD among women with trauma histories…

• (Glover et al, 2012)

What About Estrogen & Men?

• Testosterone partially converted to estradiol in the brain

• Slows with age

• Symptoms of schizophrenia taper off in men vs. may increase in severity in women

• (Seeman)

Among Women Experiencing Hot Flashes…

• 1/3 also report depression

• Worse QoL

• Less work productivity

• Greater health case use

(diBonaventura et al, 2012)

Hot off the Presses

• Healthy perimenopausal/postmenopausal women with hot flashes

• Double blind, placebo controlled

• Low dose oral estrogen vs. venlafaxine on QoL

• Treatment with either improved QoL: E2 in domains other than psychosocial; VFX only in psychosocial domain

• Caan et al, Menopause, June 2015.

Medication & Therapy

Anti-depressants•Selective Serotonin Reuptake

Inhibitors (SSRI):

Fluoxetine, Citalopram, Escitalopram,

Paroxetine, Sertraline

•SNRI/ Novel antidepressants:

venlafaxine, mirtazepine, buproprion

•TCAs

Mood Stabilisers

• Valproate

• Lithium

• lamotrigene

• Atypical antipsychotic agents

Antipsychotic Agents

• Atypicals

• Typicals

• Injections vs. orals

Therapy

• Psycho-education

• Supportive psychotherapy

• Psychodynamic psychotherapy

• CBT: Cognitive Behavioural Therapy

Hormones?

• Equivocal evidence in population

• Individual risk factors (cardiovascular, osteoporosis, etc)

• & Individual history