By Chiara Ghetti, MD
Associate Professor of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Washington University School of Medicine, St. Louis
Dr. Ghetti reports no financial relationships relevant to this field of study.
In November 2018, the American College of Obstetricians and Gynecologists published an update to the 2015 Committee Opinion: Screening for Perinatal Depression.1 Perinatal depression affects up to one in seven women, and more than half of women with depression before pregnancy have depression during pregnancy.2 As OB/GYNs, we strive to screen women for perinatal depression both in pregnancy and postpartum. Although depression frequently affects reproductive-age women, it is common in women throughout the lifespan. Women are at elevated risk for depression during several reproductive periods of increased vulnerability. These periods correspond to adolescence, pregnancy, postpartum period, and the menopausal transition. So, what do we really know about depression in perimenopausal women?
In 2018, Maki et al, on behalf of the Board of Trustees for the North American Menopause Society (NAMS) and the Women and Mood Disorders Task Force of the National Network of Depression Centers, published the Guidelines for the Evaluation and Treatment of Perimenopausal Depression.3 I will briefly discuss the authors’ key recommendations and explore the role of OB/GYNs in the evaluation and treatment of depression.
The guidelines are consensus recommendations for the evaluation and management of perimenopausal depression. An expert panel developed these recommendations through systematic review of existing literature. The guidelines pertain specifically to depression in women in the menopausal transition (including early through late transition and early postmenopause), which is considered a time of vulnerability for both depressive symptoms and major depressive episodes. The authors reviewed the evidence relating to epidemiology, clinical presentation, therapeutic effects of antidepressant medications, effects of hormone therapy, and the efficacy of other therapies.
The main reported finding is that similar to depression during other reproductive phases, the majority of women who experience a major depressive episode in the perimenopausal period have experienced previous episodes. Although depression during the midlife period presents with the classic defined symptoms of depression (feeling down or sad, little interest in doing things, changes in sleeping habits, decreased energy, change in appetite, difficulty concentrating, having thoughts of hurting oneself), often, it is interwoven with menopausal vasomotor symptoms and sleep disturbances. These menopausal symptoms can complicate its evaluation and treatment. Diagnosis of perimenopausal depression requires the determination of the appropriate reproductive stage, alongside the assessment of the coexisting menopausal and psychiatric conditions, as well as an awareness of the psychosocial factors that commonly affect midlife women. The menopausal transition may coincide with numerous psychosocial stressors, which may include children leaving the home, dealing with aging parents, illness and death of parents or a significant other, medical illnesses, and changes in marital status. Each of these may affect a woman’s psychological well-being.
Providers should attempt to develop a thorough differential diagnosis and use validated screening tools to diagnose their patients accurately. A simple validated tool is the PHQ-9,4 a self-administered measure that assesses depressive symptom severity over the prior two weeks and correlates highly with the diagnosis of major depression by the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders. Regarding treatment, to date, there have been no large randomized trials of antidepressants in a well-defined population of perimenopausal and postmenopausal women with major depressive disorder. The main therapeutic options for this midlife population correspond to the accepted therapies for depression, including pharmacotherapy and psychotherapy. While estrogen therapy is not approved for the treatment of perimenopausal depression, it has demonstrated antidepressant effects in perimenopausal women and, in particular, those experiencing vasomotor symptoms.
The Role of THE OB/GYN in Evaluating and Treating Depression
OB/GYNs are in the unique position of seeing women throughout their lifespan and through many vulnerable reproductive and life course periods. Patients frequently consider OB/GYNs their primary care providers, and we often see ourselves as primary care providers.5 In addition, many conditions OB/GYNs treat are risk factors for (or highly associated with) depressive symptoms or major depressive episodes.
Although most OB/GYNs view mental health issues as important, significant variations have been reported in screening and treatment practices among providers. In 2003, LaRocco et al surveyed 282 obstetricians and found that less than half screened patients for depression regardless of symptoms.6 In 2018, Fedock et al reported from a random national sample of obstetric providers and found that providers employed universal postpartum screening but had significantly lower screening rates in pregnant patients.7
La Rocco et al reported that providers find depression screening difficult to carry out in everyday practice, and some providers are unsure as to whether screening improves outcomes.6 Leddy et al found that OB/GYNs are not confident in their abilities to diagnose mental health conditions and frequently express concern about the adequacy of their training in screening and treatment of these conditions.8
Several abstracts addressing depression screening were presented at the annual meeting of the 2018 American College of Obstetricians and Gynecologists. Hadley et al reported that although a large number of providers regularly screen for postpartum depression and anxiety, only a subset of these feel confident treating these conditions.9 Lau et al found that while OB/GYN and family medicine providers employed near-universal screening in postpartum patients after a didactic session on perinatal depression, only three-fourths of those who screened positive were referred to a behavioral health specialist and only 18% were treated with medications.10
Several authors have recommended supplemental training in mental health topics for OB/GYNs. In addition to more training, other models may aid us in better serving women’s mental health needs. In 2014, Melville et al reported a randomized trial of a collaborative depression care intervention in an OB/GYN clinic compared to usual care.5 Collaborative care models use an embedded team of mental health specialists who work with clinicians to help manage symptoms. Melville et al demonstrated that the subjects randomized to the collaborative care intervention had a greater improvement in depressive symptoms and improved functioning compared to the usual care group. Their findings make a strong case for mental health care integrated into healthcare settings for women. In 2017, Bhat et al eloquently presented the dramatic effect that OB/GYNs can have on women’s well-being by adopting a clinical paradigm that involves regular depression screening and early treatment in the phases of adolescence, pregnancy, peripartum, and the menopausal transition.11 Although a collaborative care model may not be accessible to all of us, we are in a unique position to significantly affect women’s lives.
REFERENCES
- ACOG Committee Opinion No. 757: Screening for perinatal depression. Obstet Gynecol 2018;132:e208-E212.
- Dietz PM, et al. Clinically identified maternal depression before, during, and after pregnancies ending in live births. Am J Psychiatry 2007;164:1515-1520.
- Maki PM, et al. Guidelines for the evaluation and treatment of perimenopausal depression: Summary and recommendations. J Womens Health (Larchmt) 2018; Sep 5. doi: 10.1089/jwh.2018.27099.mensocrec. [Epub ahead of print].
- Spitzer RL, et al. Validation and utility of a self-report version of PRIME-MD: The PHQ primary care study. Primary care evaluation of mental disorders. Patient Health Questionnaire. JAMA 1999;282:1737-1744.
- Melville JL, et al. Improving care for depression in obstetrics and gynecology: A randomized controlled trial. Obstet Gynecol 2014;123:1237-1246.
- LaRocco-Cockburn A, et al. Depression screening attitudes and practices among obstetrician-gynecologists. Obstet Gynecol 2003;101:892-898.
- Fedock GL, Alvarez C. Differences in screening and treatment for antepartum versus postpartum patients: Are providers implementing the guidelines of care for perinatal depression? J Womens Health (Larchmt) 2018;27:1104-1113.
- Leddy MA, et al. Obstetrician-gynecologists and women’s mental health: Findings of the Collaborative Ambulatory Research Network 2005-2009. Obstet Gynecol Surv 2011;66:316-323.
- Hadley EE, et al. Screening and treatment practices of OB/GYN providers for postpartum depression and anxiety. Obstet Gynecol 2018;131:130S.
- Lau K, Pardanani S. Implementing a universal perinatal depression screening and treatment program in a community setting. Obstet Gynecol 2018;131:157S.
- Bhat A, et al. The obstetrician-gynecologist’s role in detecting, preventing, and treating depression. Obstet Gynecol 2017;129:157-163.
