Mental Illness Through Menopause

Transcription

1 Mental Illness Through Menopause Susan Hatters Friedman, MD Associate Professor of Psychological Medicine University of Auckland

2 Mental Illness: Depression Bipolar Schizophrenia PTSD & Anxiety Comorbidity Suicide Outline Menopause intersection

3 Major Depression Sleep changes, Interest, (anhedonia) Guilt/ H/H/W, Energy, Concentration, Appetite/ weight changes, Psychomotor slowing, Suicidal thoughts

4 Depression Diagnosis Occurring for 2+ weeks Peak onset age Mean episode length 8 months Approximately 7% annual prevalence Increased in women, 10-25% lifetime

5 Bipolar & Depression

6 Bipolar Disorder Roughly = 1% Depressive episodes Manic episodes: elevated/ irritable mood

7 Mania Syptoms Elevated or irritable mood Grandiose Decreased need for sleep Hypertalkative, racing thoughts Hypersexual Distractible Risk taking (spending, speeding, sex) Poor insight

8 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

9 Are we seeing what we want to see?

10 Risk of Misdiagnosis of Bipolar Treatment with un-opposed antidepressant agent Increased risk of inducing mania & Increased risk of rapid cycling bipolar disorder

11 Psychotic Disorders Roughly = 1% Schizophrenia Schizoaffective disorder Delusional disorder

12 Psychosis Out of touch with reality Delusions Fixed, false belief Not cultural/ religious Hallucinations A/V/T/G/O

13 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?

14 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 1 year (Yonkers; Seeman)

15 Co-Morbidity & Differential Dx

16 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)

17 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)

18 Psychiatric Sequellae of IPV Depression PTSD Suicidality Substance comorbidity

19 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)

20 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)

21 Substance Use Disorders Substance Abuse or Dependence CAGE Cut Down Annoy Guilt Eye Opener Greater consequences in W

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23 NZ SUICIDE AGE-SPECIFIC DEATH RATES, BY 5-YEAR AGE GROUP, Rate Males Females Five-year age group

24 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

25 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)

26 Asking about suicidal thoughts Suicide Ladder: Passive thoughts of death Active suicidal thoughts/ ideation Intent Plan Again, normalising How close? vs. Ever attempted?

27 Mental Illness & the Female Life Cycle: Increased Vulnerability

28 Menstruation Pre-Menstrual Dysphoric Disorder (PMDD) Irritability Dysphoria Tension Mood lability 3-8% of women

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30 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

31 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)

32 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)

33 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

34 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

35 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)

36 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)

37 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

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

39 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

40 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)

41 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 (lower E levels) Higher BMI related to earlier meds = more E= fewer vasomotor sx (Seeman)

42 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)

43 PTSD & Estrogen? Suggest that low estrogen is a vulnerability factor for development of PTSD among women with trauma histories (Glover et al, 2012)

44 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)

45 Among Women Experiencing Hot Flashes 1/3 also report depression Worse QoL Less work productivity Greater health case use (dibonaventura et al, 2012)

46 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.

47 Medication & Therapy

48 Anti-depressants Selective Serotonin Reuptake Inhibitors (SSRI): Fluoxetine, Citalopram, Escitalopram, Paroxetine, Sertraline SNRI/ Novel antidepressants: venlafaxine, mirtazepine, buproprion TCAs

49 Mood Stabilisers Valproate Lithium lamotrigene Atypical antipsychotic agents

50 Antipsychotic Agents Atypicals Typicals Injections vs. orals

51 Therapy Psycho-education Supportive psychotherapy Psychodynamic psychotherapy CBT: Cognitive Behavioural Therapy

52 Hormones? Equivocal evidence in population Individual risk factors (cardiovascular, osteoporosis, etc) & Individual history

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