Perimenopausal depression challenging to diagnose

Evelyn Lewin

4/12/2018 1:00:36 PM

Mental health issues and high suicide rates in perimenopausal women may be related to biological changes.

Statistics on suicide rates in perimenopausal women are concerning.
Statistics on suicide rates in perimenopausal women are concerning.

While the symptoms of depression in the general population are well-known, the symptoms of depression in perimenopausal women are less recognised.
Yet, the risk of serious depression is ‘significantly increased’ in that demographic, Melbourne psychiatrist Professor Jayashri Kulkarni wrote in Perimenopausal depression – an under-recognised entity’, an article published in the latest edition of Australian Prescriber.
According to the Australian Bureau of Statistics (ABS), perimenopausal women are the most likely females of any age group in Australia to commit suicide.
While the number of males who die by suicide exceeds the number of females for every age group, of the females who commit suicide, the highest proportion are aged 45–49 years (12.1%), followed by those aged 50–54 years (10.4%), the ABS reports.
According to Professor Kulkarni, the rate of suicide in perimenopausal women may relate to biological changes relating to menopause.
‘It is not appropriate to deem this type of depression as minor or presume that, once the hormonal fluctuations settle, the depression will improve,’ she wrote.
‘The process of menopause can take many years, during which the patient’s quality of life and that of her family, may deteriorate irreparably. Tragically, suicide in middle-aged women is becoming a more common occurrence.’
While Professor Kulkarni believes research into this field is ‘lacking’, she also noted the condition itself can be difficult to diagnose because its symptoms can differ from those seen in depression in other groups of people.
Furthermore, perimenopausal symptoms can fluctuate in severity, adding to the ‘diagnostic difficulty’.
The common symptoms of perimenopausal depression are detailed in the Meno-D questionnaire, a unique tool for clinicians and researchers to measure the presence of perimenopausal depression that consists of 12 symptoms relating to five factors  – self, sexual, somatic, cognitive and sleep.
Those symptoms include low energy, decreased self-esteem, decreased sexual interest and hostility.
‘In particular, the cognitive symptoms, paranoia and irritability are marked in perimenopausal depression compared to symptoms of major depressive disorders seen in men or younger women,’ Professor Kulkarni wrote.
When it comes to diagnosing perimenopausal depression, Professor Kulkarni noted the importance of ruling out other causes for physical symptoms, such as thyroid diseases and autoimmune disorders.
Once a diagnosis has been made, treatment of perimenopausal depression needs a holistic, biopsychosocial approach.
Fortunately, it has been found that most women with depression relating to such changes respond well to treatment, medical and non-drug.
Psychotherapy and other non-drug recommendations include education about menopause, regular exercise, mindfulness techniques and dietary advice, along with minimising alcohol intake.
Medical treatment differs from treatment for ‘typical’ depression, as most treatments for mental illnesses have been developed in men and may not be optimal for women suffering poor mental health related to menopause.
Medical treatment for perimenopausal women usually includes antidepressants along with gonadal hormones, but may consist of hormone therapy alone in women without suicidality, Professor Kulkarni wrote.
When it comes to gonadal hormones, tibolone, a synthetic steroid with mixed hormonal profile, has shown benefit in treating perimenopasual depression. But limited safety and dosing data on bioidentical hormones means they’re not recommended by the International Menopause Society.
As for antidepressants, the usual starting point for perimonopausal depression is a selective serotonin reuptake inhibitor (SSRI). If not effective, serotonin noradrenaline reuptake inhibitors (SNRIs) are often second-line. However, both have agitating adverse effects and may exacerbate such symptoms.
Professor Kulkarni wrote that to minimise such symptoms, Agomelatine is ‘a newer antidepressant with positive sedative impact and fewer adverse effects in women with perimenopausal depression’.
Recognising the symptoms of perimenopausal depression and the ‘serious nature’ of this depression is imperative.
‘Clinicians need to provide a tailored management approach for these women,’ Professor Kulkarni wrote.
According to the RACGP’s Guidelines for preventive activities in general practice (Red Book), low-risk patients in the 45–64 year old age group should be asked about possible depression.
Perimenopause relates to the time leading up to menopause and can start up to 10 years or more before menopause, according to health direct. Professor Kulkarni wrote that this phase typically occurs between 42–52 years of age.
In 2017 the median age at death for suicide in females was 45.7 years and the proportion of suicide deaths decreased among those over 55 years, for both males and females.
‘The social and psychological costs of depression and anxiety in women are extraordinarily high, especially when you consider the impact on families, communities and workplaces where women have vital roles,’ Professor Kulkarni wrote.
‘A tailored management approach is essential to maintain the quality of life for women experiencing perimenopausal depression.’

mental health perimenopausal depression Perimenopause women's health women's mental health

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