Managing Depression during the Menopausal Transition.

The menopausal transition is associated with both first onset of depression and recurrent depression. Risk factors include vasomotor symptoms, a history of premenstrual dysphoria, postpartum depression, major depression, and sleep disturbances. Hormone replacement therapy, complementary and alternative medicine approaches, and counseling implications for assessment, education, advocacy, and self-care are discussed. ********** Women are diagnosed with depression at nearly twice the rate as men are (American Psychiatric Association [APA], 2000), a trend that begins in puberty (APA, 2000) and levels off after menopause (Bebbington et al., 2003). Without question, rates of depression in women are higher during their reproductive years. Although the connections between depression and premenstrual syndrome and the postpartum period are recognized and included in the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; APA, 2000), no such recognition exists for depression during the menopausal transition. Failing to recognize a potential biological component of a disorder and instead emphasizing psychosocial or intrapsychic factors can lead to treatment that is ineffective, if not harmful. Therefore, the purpose of this article is threefold: to discuss hormonally based factors associated with depression during the menopausal transition; to review the benefits and risks of hormone replacement therapy (HRT), selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and complementary and alternative medicine (CAM) approaches to treat depression; and to offer strategies for assessment, advocacy, and intervention. THE MENOPAUSAL TRANSITION AND RISK OF DEPRESSION Efforts to understand possible relationships between depression and reproductive cycles in women consistently point to a strong connection between the menopausal transition and increased occurrences of depression. In a critical review of the research literature, Soares and Zitek (2008) concluded that the menopausal transition seems to present a unique period in which some women are more vulnerable to initial onset or recurrent depressive symptoms and major depressive episodes. Similarly, Schmidt (2005) affirmed that research studies indicate a relationship between perimenopause (the early and late stages of the menopausal transition) and the onset of depression, a relationship that did not extend to the postmenopausal stage. Deecher, Andree, Sloan, and Schechter (2008) likewise concluded that clinical studies show an increase in major depressive disorder during perimenopause compared with such occurrences during premenopause or postmenopause. The authors found that this increased risk was present even in perimenopausal women who had no prior history of major depressive disorder. Findings from longitudinal studies illustrate these conclusions. Results from the Seattle Midlife Women's Study, a prospective study that followed women for approximately fourteen years, showed that the late menopause transition stage was significantly related to depressed mood (Woods et al., 2008). Results were similar for cohorts from another prospective study, the Penn Ovarian Aging Study, an ongoing longitudinal study (as cited in E. W. Freeman et al., 2004). An examination of a 4-year cohort from this study showed that depressive symptoms increased during the menopausal transition and decreased in postmenopause (E. W. Freeman et al., 2004). E. W. Freeman, Sammel, Lin, and Nelson (2006) examined another cohort over an 8-year period from the Penn Ovarian Aging Study. They found that a woman was 4 times more likely to have high depression scores and 2 1/2 times more likely to be diagnosed with depressive disorder when she was in the menopausal transition compared with her premenopausal period. Although no direct associations have been identified in the research between depression during the menopausal transition and specific levels of hormones (e. …