mental illness through menopause north/1630 fri room 4 susan...• 39% of community battered women...
TRANSCRIPT
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