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Neuropsychopharmacology: The Fifth Generation of Progress |
Mood Disorders Linked to the Reproductive Cycle in Women
Barbara L. Parry and Patricia Haynes
In both medicine and psychiatry
there are gender-differentiated predispositions to certain illnesses. For example, men are at greater risk to develop
cardiovascular disorders, alcoholism, and sociopathy, whereas women have a greater
lifetime risk for thyroid disease, eating disorders, late life schizophrenia
and depression (91). Sex differences
in the prevalence of depression begin to appear after puberty and are maintained
throughout the reproductive years (126). More recent
evidence indicates that major depressive disorders are increasing with time,
that the age of onset is becoming earlier, and that women continue to show an
increased incidence of the disorder. Furthermore,
female offspring of depressed patients have earlier onsets of depressive disorders
(125).
Women, as compared with men, have a greater lifetime
risk for depression. They predominate
with respect to unipolar depression (127), the depressive subtype of bipolar illness and cyclical
forms of affective illness such as rapid cycling manic-depressive illness and
seasonal affective disorder. In addition, events associated with the reproductive
cycle are capable of provoking affective changes in predisposed individuals.
Examples include depression associated with oral contraceptives (79), the luteal phase of the menstrual cycle (22) the postpartum period and menopause. The fluctuation of gonadal steroids during
specific phases of the reproductive cycle may bear some relationship to the
particular vulnerability of women for affective changes. The reproductive hormones could exert their
effects on mood directly or indirectly by their effect on neurotransmitter,
neuroendocrine, or circadian systems, all of which have been implicated in the
pathogenesis of affective illness. In addition, the rate of hormonal change
may play an important contributory role in mood disturbances (39).
Several clinical models can be used to examine
the role of reproductive hormones on affective illness in women. As most patients with rapid cycling manic-depressive
illness and seasonal affective disorder (SAD) are women, reviewing the factors
that predispose women to the development of mood cyclicity may shed light on
how reproductive hormones may influence the course of affective illness. Also,
the cyclicity inherent in rapid cycling mood disorders is similar to the presentation
of other forms of affective illness, such as those associated with the reproductive
cycle. An understanding of disorders associated with changes in reproductive
hormones, such as premenstrual dysphoric disorder and postpartum depression,
can be furthered by the study of these forms of cyclic mood disturbances, in
which women predominate.
Rapid
Cycling Affective Illness
Rapid cycling manic-depressive illness, defined
as four or more affective episodes a year, predominates in women. Kraepelin
(55), in describing patients with regular, daily fluctuations
of periodic excitement noted "in contrast to other forms, in which there
was a preponderance of men, two thirds of these patients were women in whom
the periodicity of sexual life obviously favors this kind of development."
A recent meta-analysis (113) of 10 studies and 2,057 bipolar patients found that
of the rapid cycling cases, 72% were women and 28% were men. Rapid cycling was also more common in bipolar
women (30%) than men (17%). The rates
of rapid-cycling varied from 17-67% among women; however, higher rates have
also been reported. For instance, Wehr et al (122) indicated that 92 percent of patients with rapid cycling
and 64 percent with nonrapid cycling affective disorder were women.
Women's Risk Factors for Rapid-cycling Affective Illness
In addition to being a woman, two other factors
appear to be associated with the rapid cycling form of bipolar illness: 1) treatment
with tricyclic and other antidepressants and 2) hypothyroidism. Women, compared with men, show an increased
incidence of both drug-induced rapid cycling and hypothyroidism (122).
Drug-Induced Rapid Cycling
Of patients whose rapid cycles of mania and depression
have been induced by tricyclics, women predominate. Wehr and Goodwin (120) found that five patients, in whom rapid cycles developed,
represented all but one of the bipolar women who had been maintained on antidepressant
drugs. Rapid cycles did not develop
in either of two bipolar male patients who were maintained on tricyclics.
Wehr and Goodwin speculated that the female reproductive neuroendocrine
axis, a generator of physiologic rapid cycles, may have been instrumental in
the expression of drug-induced cycling. Reproductive
hormonal disturbances and treatments may have been predisposing factors in their
patients' illnesses; all but one (four of five) of the women in their sample
had irregular menses, amenorrhea, history of estrogen or progesterone treatment,
or onset of the illness in the postpartum period.
In Kukopulos' (56) longitudinal study of the patients who developed rapid cycles after tricyclics, 70 percent
were women. According to Kukopulos,
"female sex, middle age, and menopause, along with anti-depressant drugs,
contributed to the establishment of rapid cyclicity." Of the patients in
his longitudinal study whose course of illness changed to rapid cycling, 87
percent were women, and in a third (25 of 77) of these women, the change in
course coincided with menopause. Kukopulos
also noted that the patients with depression and hypomania (bipolar II) were
those most prone to rapid cycling.
Wehr and Goodwin (120) concluded that women have a higher risk of drug-induced
mania and drug-induced rapid cycling than do men. In contrast, Kupfer et al
(57) report that women with recurrent depression are not
more likely to switch into hypomania than men, and Coryell et al (18) de-emphasize the effects of drug-induced rapid cycling.
Hypothyroidism and Rapid Cycling
In addition to female gender and antidepressant
drugs, thyroid impairment may be associated with rapid cycling (19,122), and women are prone to thyroid disease. Studies that document sex differences indicate
that almost all patients on lithium who develop hypothyroidism are female.
In studies by Transbol et al (114), and Cho et al (15), 90 to 100 percent of bipolar patients with lithium-induced
hypothyroidism were women.
As shown by Cowdry et al (19), abnormalities of the thyroid axis, some of which may
become apparent only during treatment with LiCO3, are associated with rapid
cycling. Overt hypothyroidism was found in 12 (51%) of 24 rapid cycling patients
and in none of the nonrapid cycling patients. Elevated TSH levels were present (and higher)
in 92% of the rapid cycling group as compared with 32% of the nonrapid cycling
group. In this sample, women represented
83% of the rapid cycling group and 53% of the nonrapid cyclers.
In an mood disorder clinic population, Cho et al
(15) found postlithium thyroid medication use was significantly
higher among rapid cycling women (32.2 %) than nonrapid cycling women (2.1 percent).
Furthermore, thyroid dysfunction was primarily limited to women. Of those patients taking thyroid medication in addition to lithium,
92% were women. Five out of seven women
with hypothyroidism had rapid cycling.
In a study by Wehr et al (122), 47% of women with rapid-cycling and 39% of women with
nonrapid cycling bipolar illness developed thyroid disease. Of those patients with thyroid disease, the
thyroid disease emerged after the onset of affective illness in 90% of the patients
and in the majority of cases it emerged during lithium treatment.
Transbol et al (114) evaluated the prevalence of hypothyroidism in lithium-treated
manic-depressive outpatients and found elevated TSH levels in 25% of the patients.
Of these patients, 95% were women over 40 years of age.
None of the men had elevated TSH levels. Rapid cycling and nonrapid cycling subgroups were not reported separately.
In a medication-free sample, abnormalities of the
thyroid axis may not be as apparent. Post et al (81) found no significant differences in thyroid hormone
levels for rapid cyclers and non-rapid cyclers across gender.
Similar to rapid cycling, mixed states for bipolar
disorder predominate in women. As compared with manic or depressive states,
a mixed state indicates a simultaneous occurrence of manic and depressive symptoms.
Chang et al (14) found elevated TSH levels and low thyroxine levels
in patients with mixed mania compared with pure mania for both men and women;
there was a trend toward a greater proportion of women in the mixed group. There
were no significant differences in previous lithium exposure.
Reproductive status may affect the appearance of
thyroid disease. There is a common appearance
of goiter during puberty, pregnancy, and menopause. Women are particularly prone to develop hypothyroidism
during the postpartum period (4). This type
of hypothyroidism may represent an autoimmune phenomenon, as the extent of postpartum
hypothyroidism correlates with traces of microsomal antibodies early in pregnancy
(48, 59). Women with
isolated gonadotropin deficiency have blunted basal TSH, and TSH responses to
TRH (106). Administration
of estrogen restores the TSH response to that of normal controls, and cessation
of estrogen treatment reduces the amount of releasable TSH.
In hypogonadal men, TSH response to TRH is similar to normal men but
increases with estrogen treatment. Oral contraceptives increase the TSH response
to TRH (86). Thus, estrogens
seem to be required to maintain, and may enhance, the normal TSH response to
TRH in the female.
In summary, cyclic affective disorder in the form
of rapid cycling manic-depressive illness is more prevalent in women. Treatment with antidepressant drugs often precipates
rapid mood cycles, particularly in women with bipolar II illness.
Thyroid impairment, more prevalent in women, also is associated with
the rapid cycling form of the illness. The predominance of these disorders in
women suggests that abnormalities in reproductive hormones, and other neuroendocrine
systems, may exacerbate mood cyclicity. There is very little information available
on the course of rapid cycling bipolar illness in men.
Clinical
Psychopharmacological Treatment
Thyroid Treatment
Thyroid hormone has been used to treat both cyclic
and noncyclic forms of affective disorders. Gjessing first used Hypermetabolic thyroid treatment in the 1930s
to treat periodic catatonia and rapid cycling affective disorder. Stancer and Persad (107) reported treatment of intractable rapid cycling manic-depressive
illness with levothyroxine. Five of
the seven women, who developed rapid cycling bipolar disorder with an onset
during the postpartum or involutional period, responded to hypermetabolic doses
of thyroid hormone. The effect of thyroid
hormone had differential effects in men and women: The treatment was unsuccessful
in two men and one adolescent girl, which further indicate that female reproductive
hormones may be important in the development of mood cyclicity.
Prange et al (83) reported triiodothyronine enhanced the antidepressant
effect of imipramine in women but not in men. Men responded to initial doses of imipramine
in a shorter period of time than women. Women
treated with imipramine and thyroid supplement responded as rapidly as men treated
with imipramine alone. Later, Goodwin
et al (34) demonstrated that among tricyclic nonresponders, men
benefited from the addition of T3 as often as women.
The mechanisms for thyroid-enhancement of responses
to antidepressants may be as Whybrow and Prange (131) suggest, relating to the capacity of thyroid hormone
to alter the ratio of alpha to beta adrenergic receptors and their sensitivity
to noradrenergic neurotransmitters. Depressed
women appear to be uniquely responsive to thyroid hormone.
Women also are uniquely vulnerable to thyroid impairment. Therefore,
changes in hormonal axes are likely to play an important role in altering the
course of mood disorders.
Estrogen
Women also are sensitive to other hormonal treatments.
Estrogen also has been used as a treatment in refractory depression.
Klaiber et al (54) used 5 to 25 mg of oral conjugated estrogen in cyclic
doses to treat pre- and postmenopausal women. With estrogen, as compared with placebo, there was a significant
drop in Hamilton scores, which correlated with reduction in previously elevated
monoamine oxidase (MAO) levels. With
inconsistent results, Prange (83) gave 25 mg and 50 mg estradiol to depressed patients
already treated with imipramine. The
higher estrogen dose was toxic. The
lower dose was associated with reduction of Hamilton scores and improved sleep.
A meta-analysis of 26 studies on the effect of hormone replacement therapy on
depressed mood in menopausal women found that estrogen significantly reduced
depression, progesterone blunted the antidepressant effect of estrogen, and
that androgens increased the antidepressant effect of estrogen (143).
Estrogen may also induce rapid cycling or at least
predispose to tricyclic-induced rapid cycling as reported by Oppenheim (70). Interestingly,
Parry and colleagues (unpublished observations)
observed one male rapid cycling patient who had low testosterone secondary to
mumps orchitis. Progesterone, on the
other hand, may suppress rapid cycles of mood (45).
The mechanism by which estrogen exerts its possible
antidepressant effect is unknown, but work by Kendall et al (52) showed estrogen is needed for reduction of serotonin
receptor binding during imipramine treatment.
Ovariectomy blocked the effect of imipramine on serotonin receptors,
and estrogen treatment reinstituted it. In postmenopausal women, estrogen can
augment reduced serotonergic activity and some norepinephrine-related processes
(38). In depressed, perimenopausal women, there is a greater
magnitude of treatment effect when estrogen is used as an adjunct to a selective
serotonin reuptake inhibitor (SSRI) (fluoxetine) than using fluoxetine alone
or estrogen alone (111).
Estrogen also appears to play an important role
in the maintenance of internal circadian rhythm synchronization. Wise et al.
(134) suggested that menopause may be associated with an
age-related deterioration or fragmentation of multiple circadian rhythms. In
ovariectomized rats, estrogen implants reduce the degree of rhythm desynchrony
by enhancing the coupling between component oscillators (112). Evidence linking
disrupted circadian rhythms to affective disorders is extensive and will be
discussed in more detail below.
Besides improvement in mood, estrogen has been
posited to improve memory and cognitive functioning in postmenopausal women
and in women with Alzheimer’s Disease (44). However, these findings are equivocal and have been
a source of controversy. Conflicting results may be due to methodological issues,
such as: failure to define criteria for menopausal status, failure to assess
for mood or physical disturbance as a confounding factor, wide variation in
the type of neuropsychological instruments used, and considerable variability
in the type, dosage, and route of hormone replacement therapy. For these reasons, the authors (44) concluded that until randomized, controlled trials
are conducted, there is inadequate evidence to support the conclusion that estrogen
replacement therapy improves cognitive functioning.
Preliminary
findings in imaging may provide additional information on the effects of estrogen
on the brain. Resnick et al. (88) studied fifteen women on estrogen replacement therapy
(ERT) compared with seventeen nonusers on positron emission tomography (PET)-regional
cerebral blood flow (rCBF) activation patterns. Activation patterns differed significantly
across groups on figural and verbal memory tasks. More specifically, task-associated
changes in rCBF pertaining to memory components occurred in the parahippocampal
region and right frontal regions. ERT users also performed better on neuropsychological
figural and verbal memory tasks. These findings lend further support to hypotheses
by Sherwin and colleagues (102) that ERT may preserve some aspects of verbal memory.
In a PET activation study by Berman et al. (9), they also demonstrated that reproductive hormones
are likely to have a modulating role on executive functioning. The authors found virtually no activation of
the prefrontal cortex while performing an executive functioning task in the
absence of gonadal steroid hormones (ovarian suppression induced by a gonadotropin-releasing
hormone agonist). With estrogen or progesterone, the rCBF pattern normalized.
There also is considerable evidence from the animal
literature suggesting that estrogen significantly affects physiologic systems
involved in learning and memory. For example, estrogen induces the formation
of excitatory synapses in the CA1 region of the hippocampus and has activational
effects on cholinergic function in the central nervous system (62). For example, estrogen protects against an age-related
decline of cholinergic function in the basal forebrain projections to the frontal
cortex (103).
Seasonal
Affective Disorder
Like rapid cycling affective disorder, seasonal
affective disorder (SAD) is a cyclic mood disorder that occurs predominately
(80%) in women. Thus, it also may serve
as a model to understand the contribution of reproductive hormones to affective
illness in women.
Patients with SAD who have recurrent winter depressions,
have symptoms of major affective disorder with characteristic "atypical"
features (such as hyperphagia, hypersomnia, and lethargy), which begin to develop
each year in association with shortening of the daylength.
A majority of these patients respond to high intensity (2500 lux) light
treatments, which artificially extend the daily photoperiod. More recent work
suggests that using higher intensity (10,000 lux) light treatments for a shorter
time period (30-45 minutes) (58; see also Biological
Rhythms in Mood Disorders) also may be safe and effective. Initially, bright light was thought to act
in seasonal depression by suppressing melatonin, a hormone that is centrally
involved in seasonal reproductive cycles in animals. This hypothesis since has been brought into question and a multitude
of other hypotheses proposed (92,121). Increasing evidence has indicated that the serotonin
system may be disturbed in SAD (101, 50) and is likely to play a role in the mechanism of action
of light therapy (68).
A large proportion (70%) of women with SAD also has mood changes in association with the menstrual cycle. In a recent study, 38% of women diagnosed with late luteal phase dysphoric disorder also met criteria for SAD (60). Some women with seasonal affective disorder report improvement in their premenstrual symptoms with light therapy. Parry and colleagues (78) identified a woman with a family history of bipolar illness who developed severe premenstrual depression with suicidal ideation only during the fall and winter and was relieved of premenstrual symptoms during the spring and summer. Light was an effective treatment for this patient with seasonal PMS and that its therapeutic effect could be blocked by the simultaneous administration of melatonin. Light also increased this patient's TSH. Propranolol and atenolol, beta blockers that inhibit the synthesis of melatonin, had a therapeutic effect similar to light. Light therapy also may benefit women with non-seasonal premenstrual syndrome (74, 77), which will be discussed in more detail below.
In patients with seasonal affective disorder who
have summer depression and winter hypomania, Wehr et al (123) reported that eight of 12 patients were women and suggested
that temperature may influence these patients' clinical state.
Women with major depression and bipolar illness
may also experience cyclic, seasonal recurrences. Suhail and Cochrane (110) measured seasonal variations in psychiatric admissions
over a period of one year for a psychiatric hospital in Birmingham. They found
that admissions for depression and mania showed a statistically significant
seasonal pattern only among women (depression highest in the winter and mania
in the summer), which suggests that women may have a specific vulnerability
to variations in light and temperature. Interestingly, none of the subjects
in this study (402 women) were diagnosed with SAD.
It appears that certain women with genetic vulnerability
for mood disorders may be at risk for developing other cyclic affective disorders
such as seasonal premenstrual disorders.
Applications
of Rapid Cycling and Seasonal Affective Disorder to Postpartum and Premenstrual
Affective Illness
Rapid cycling bipolar illness and SAD are examples
of cyclic forms of mood disorders that predominate in women. The interaction of reproductive hormones, particularly
with thyroid hormones in rapid cycling affective disorder and with melatonin
in seasonal affective disorder, may provide clues to the pathogenesis of reproductive-related
depressions. The increased incidence
of hypothyroidism occurring postpartum (4) or in winter may in part account for rapid cycling
mood disorders and depression that may occur at these times, respectively. Another cyclic mood disorder
that can be viewed as a form of rapid cycling is recurrent premenstrual depression
in which thyroid and melatonin disturbances also have been implicated (72, 78). Melatonin
may play a role not only in the pathogenesis of seasonal premenstrual syndrome
(78), but also in nonseasonal forms of this disorder (72, 73). Recent studies
demonstrate that patients with premenstrual depression have circadian disturbances
of melatonin secretion compared with normal controls and may respond to light
treatment (72, 74, 77, 73). Similar studies
of melatonin in postpartum mood disturbances are currently underway.
Pregnancy
and Postpartum Mood Disorders
The relative risk for developing a major psychiatric
illness or psychosis requiring hospitalization is highest during the postpartum
period (53), and may recur during pregnancy. First episodes of
manic-depressive illness in women often have their onset in the postpartum period
(31, 87). Reich and
Winokur (87) observe that not only is there a special risk for female
manic-depressive patients to develop mania or depression in the postpartum period,
but having a postpartum affective episode appears to predispose to subsequent
postpartum affective episodes (an increased risk of 50%). Furthermore, a woman's
initial risk for a postpartum psychosis is 1 in 500 (34) to 1 in 1000 (117). Once a woman
has had a postpartum psychosis, her risk for psychosis following a subsequent
pregnancy is one in three (53). Thus, in postpartum
depression and psychosis, a previous episode sensitizes a woman to the development
of future episodes with subsequent pregnancies.
Clinical Psychopharmacologic Treatment
Before discussing specific treatment modalities,
it needs to be emphasized that at this early stage of recognition of postpartum
psychiatric syndromes by American Psychiatry, a rational treatment plan for
postpartum depression and psychosis cannot be developed from double-blind, placebo-controlled
crossover trials of pharmacologic or psychotherapeutic interventions. Because these illnesses can be so devastating
to the individual and her family, treatment approaches have utilized whatever
interventions have been immediately useful and available. In the literature, the majority of the more
scientifically rigorous treatment studies are confined to studies that utilize
patients with maternity blues, i.e., those individuals without severe disorders,
as their study subjects. Therefore,
by necessity, suggested treatment approaches discussed in this chapter reflect
clinical experience more than information derived from research investigations.
There are several important principles of treating
postpartum depression and psychoses. The
first principle of treatment is that organic illnesses must be ruled out.
An initial presentation of postpartum psychiatric illness may be due
to an underlying Sheehan's syndrome, thyrotoxicosis (if presenting as an acute
psychoses in the first month after delivery), or as hypothyroidism (if presenting
as major depression in the 4-5th month postpartum).
All too often these medical emergencies are overlooked, with disastrous
consequences. Thus, one of the first crucial steps in the
initial evaluation and treatment of postpartum disorders, as in other medical
and psychiatric disorders, is a thorough history, physical and laboratory examination.
The other important principle guiding treatment
is that the earlier the symptoms are recognized and treated, the better. For example, postpartum psychosis may initially
present with symptoms of depersonalization: the patient may feel distant from
her child and from the situation at hand. She may feel as though she is just being an
onlooker (as portrayed in the film "Rosemary's Baby"). This phenomenon may be interpreted as a "failure
to bond" but more likely represents the initial presentation of an emerging
psychosis. Patients then may develop
strange and bizarre sensations described as though their, or that of their child's
head, is separate from their body. If treatment is instituted with small doses of an antipsychotic
medication, these symptoms may resolve within a few days to a week. However, if not recognized and treated in its
initial stages these symptoms may rapidly progress to paranoid delusions and
a frank agitated psychosis which may become more severe, more refractory to
treatment, and more likely to recur over the next 6 months to a year. Without
aggressive management and early detection, the symptoms may extend into the
second and third year postpartum.
It also must be stressed that because of the changing
nature of postpartum psychiatric illness, different treatments at different
stages of the illness are indicated. For
example, an early presentation of psychosis would best be treated with neuroleptic
medication. However, this psychosis
may resolve and the patient may develop symptoms of major depression later in
the course of the illness that may require antidepressant medication.
Furthermore, the initial presentation of the depression may appear in
an agitated form with many anxious features and insomnia.
Thus, treatment with an antidepressant that may have some anticholinergic
features (e.g., imipramine, nortriptyline) that induce more sedative side effects
or affect specific receptor subtypes that do not tend to elicit anxious, agitated
side effects would be indicated. Later,
the patient may present with symptoms of a retarded, anergic depression with
possible obsessive compulsive features; a compound that may have activating
qualities (e.g., desimpramine, fluoxetine) may be indicated. As Post (82) suggests in the treatment of affective illness and
psychosis, different treatment modalities may have differential effects and
efficacies depending upon when in the course of the illness these treatments
are administered.
• See Table
1
Specific issues related to the treatment of first
postpartum psychosis and then postpartum depression are discussed below.
Postpartum Psychoses
One of the most important aspects of management
of the postpartum psychoses are that the earlier they are recognized and treated,
the more likely they are to respond to treatment and be associated with a more
positive outcome and prognosis. Since
most postpartum psychoses have an acute onset within the first two weeks postpartum
(generally not until after the 3rd postpartum day), and 80% of them occur within
one month postpartum, clinicians should be on the alert for early signs of depersonalization,
delusional thinking, mania or bizarre behavior.
Women with a previous history of postpartum psychiatric illness or affective
illness are at particularly high risk. The
clinician should have a low threshold for hospitalization in any patient with
symptoms of an impending postpartum psychosis.
Early hospitalization can prevent infanticide or suicide that may occur
when mothers at risk are left at home alone to care for their infants, a frequent
occurrence in modern culture. Often
small (2-5 mg) doses of neuroleptics such as haloperidol (or if it contributes
to extra-pyramidal symptoms, perphenazine or loxapine) may decrease the symptomatology
and prevent the development of a more severe psychosis. Further research is
needed to investigate the efficacy of newer atypical antipsychotics for postpartum
psychosis; however, clinical observations and anecdotal reports (B. Parry, personal
communication) suggest that atypical antipsychotics, though effective for some
other types of schizophreniform psychoses, do not appear to be as effective
as the typical neuroleptics for the affective psychoses manifested in postpartum
psychiatric illness, perhaps due to relative selectivity of dopamine receptor
subtypes.
Neuroleptic medication also is efficacious in treating
the symptoms of a postpartum psychotic depression (see below), without incurring
the risks of tricyclic antidepressants. In the potentially hypothyroid postpartum state, antidepressants
may induce rapid cycling and are not recommended in breast feeding women. Risk
factors for antidepressant-induced rapid cycling include being female, being
in the postpartum state, and being hypothyroid.
If the symptoms of an emerging postpartum psychosis
are recognized and treated early, they may resolve within a week.
Cases in which the symptoms are not recognized and treated in their initial
stages may become much more refractory to treatment and take much longer to
resolve. In general however, the postpartum psychoses
have a good prognosis, resolve in 2-3 weeks, and are amenable to treatment. Unfortunately postpartum psychosis is the condition
under which women are most likely to commit infanticide. Of those women with postpartum psychoses, 4%
may commit infanticide (31). This consequence
generally does not occur unless the patient is psychotic. The tragedy of this occurrence is made all
the more poignant by the recognition that this disorder is otherwise so amenable
to treatment and thereby preventable.
Although dosages of neuroleptics can be reduced
after the initial episode of psychosis is resolved, this process should be done
gradually and cautiously. Women remain
at risk for recurrences, particularly in those women with a previous history
of psychiatric illness, for at least 6 months, and often up to 12 months postpartum.
Data from a large scale epidemiological study in Edinburgh (53) suggest that there is an increased risk for psychiatric
admissions for up to two years postpartum. Videbech and Gouliaev (117) found that 60% of women with postpartum psychosis had
recurrences after 7-14 years; most were of the nonpuerperal type (42%).
Although it is not necessary to leave a patient on neuroleptic medication
for this length of time, it is wise for the clinician to be on the alert for
early signs of recurrence and to bear in mind that a patient who initially presents
with symptoms of a postpartum psychosis within the first few weeks after delivery
may develop symptoms of a postpartum depression later in the course of her illness
(i.e., four-five months postpartum). For
an early onset of psychoses, patients should probably remain on neuroleptics
for at least six weeks postpartum. The
concentrations of different antipsychotic drugs vary greatly in the breast milk.
Overall, given the amount of data available, the typical neuroleptics are relatively
safe (compared with the risks of untreated psychiatric illness) during pregnancy
and lactation. In contrast, risperidone
is not recommended in breast-feeding women (115).
As in other psychiatric illnesses, psychopharmacologic intervention is most effective when combined with psychotherapeutic interventions. Particularly with regard to postpartum psychoses, pharmacologic intervention is urgent to prevent the mother from becoming increasingly psychotic and potentially committing infanticide. At this point the patient cannot be cognitively and emotionally available to participate in a psychotherapeutic interaction until the medications help to reduce the hallucinations, delusions, and agitated behavior. However, as most clinicians and even psychotic patients appreciate, medications are most likely to be received and taken willingly when some sense of rapport, trust, and support is perceived by the patient and her family as coming from the physician.
Postpartum Depression
In contrast to postpartum psychosis in which there
is an acute onset occurring early in the postpartum period, postpartum depression
generally has a more insidious onset that occurs later, i.e., 4-5 months postpartum.
Its severity may range from mild to moderate dysthymia and anxiety disorders
to major melancholia. As with the postpartum
psychoses, organic abnormalities need to be ruled out, particularly hypothyroidism,
which occurs in 10% of women postpartum and has a peak incidence at 4-5 months
postpartum (48). Transient
hyperthyroidism may actually appear earlier in the postpartum course. Indications for the use of antidepressant medication
are similar to those for other affective illnesses, and include the presence
of neurovegetative signs. It is necessary
to bear in mind that the course of affective illness over time, and that of
postpartum illness being no exception, is that untreated episodes tend to become
more severe, more frequent and often more refractory to treatment.
These depressive episodes should be treated aggressively with both pharmacologic
and psychotherapeutic strategies early in the course to prevent untoward biological
and psychological consequences, which can include a disruption of maternal bonding
with the newborn child.
Since many of the depressions may appear with obsessive-compulsive
features, implicating serotonergic mechanisms, recent clinical experience suggests
the efficacy of the serotonergic antidepressants, such as fluoxetine, sertraline
and paroxetine. However, side effects
particularly of agitation from fluoxetine (24) or the potential induction
of mania in bipolar patients need to be monitored closely. Although some evidence
has shown that fluoxetine is effective for postpartum depression (3), it may not be the best first line of treatment in
the anxious depressions often seen early in the postpartum state.
If agitated depressive symptoms occur early in
the postpartum state, small doses of neuroleptics can be beneficial. Anxiolytics are best avoided because of their
risk for the development of physiologic dependence, withdrawal, paradoxical
exacerbation of agitation, and their inadvisability of use in breast feeding
women. With the use of antidepressant
medication, it is best to collaboratively consider the risk-benefit analysis
of breast-feeding, as some studies indicate that small amounts may be excreted
into the breast milk. If the mother
is reluctant to give up breast feeding, and her depressive symptoms are severe
enough to warrant pharmacologic treatment, research suggests that antidepressants
such as amitriptyline, nortriptyline, desipramine, clomipramine, dothiepin,
and sertraline are at low risk for adverse effects—especially with infants older
than 10 weeks. In nursing infants, higher serum levels and adverse effects were
reported with doxepin and fluoxetine (136). The clinician
is advised if administering antidepressant drugs to a postpartum patient, to
rule out hypothyroidism, to follow closely the course and timing of the mood
changes of the patient, and to discontinue antidepressant medication if there
is evidence of drug-induced rapid cycling.
Recently, estrogen skin patches have been reported
to be beneficial in severe postpartum depression. For postpartum dysphoria, Dalton (21) has recommended progesterone treatment (100 mg IM for
the first postpartum week and then 400 mg bid by suppository for two or more
months postpartum). However, some clinicians
and investigators find that progesterone may actually exacerbate depression.
For severe or psychotic postpartum depression or mania refractory to
pharmacotherapy, electroconvulsive therapy (ECT) remains the treatment of choice.
Sleep deprivation has therapeutic efficacy in a majority of patients
with major depressive disorders. The
efficacy of sleep deprivation in postpartum non-psychotic depression currently
is under experimental investigation (Parry et al, unpublished observations). The relapse that may occur with recovery sleep
after postpartum sleep deprivation potentially may be averted with lithium,
in non-breast feeding women.
Since the experience of a postpartum depression
or psychoses can be very disruptive cognitively and emotionally for the woman
and her family, these disorders, like other psychiatric disorders, are best
treated with a combination of pharmacologic and psychotherapeutic management
with the aim of providing education, support, and cognitive structuring whereby
these patients and their families can attempt to gain "some method out
of the madness" which stems from this very confusing, disorienting, and
emotionally traumatic cataclysm in their lives. Preliminary studies have indicated
significant decreases in depressive symptoms using interpersonal psychotherapy
during pregnancy (105), cognitive-behavioral counseling or fluoxetine for
postpartum depression (3), and group treatment with educational, supportive,
and cognitive-behavioral components for postnatal depression (61). Further research with standardized, empirically-validated
therapeutic approaches is necessary in this area.
Anthropological studies indicate that other cultures
have rituals allowing for 40-day rest periods for the mother after the birth
of a baby in which to "mother the mother." During this time period,
the focus is on allowing the mother time to rest, recuperate, eat and sleep.
Female relatives come to the home to prepare meals, do housework and
care for the infant. Thus, social support, education, child care
services, and social recognition of the new motherhood status is ensured. Previously, a week hospital stay for the mother
after delivery was required. Now, in
modern cultures, the mother usually goes home a day after delivery, and often
without extended family or neighbors to help with infant care.
In this isolated environment, there are not the supportive therapeutic
factors available that would otherwise help to mitigate against the development
or exacerbation of the spectrum of non-psychotic depressions. In addition, demographic
risk factors, such as an unplanned pregnancy, not breast-feeding, unemployment
after childbirth, and being head of the household may place additional strain
upon the mother and increase the likelihood of postnatal depression (118).
Maternity Blues
The maternity blues is not considered a disorder
since it occurs in 50-80% of women and because of the absence of major symptomatology.
It is best treated with reassurance that the symptoms occur in a majority
of women, and that they generally improve spontaneously within a week to ten
days. In rare instances the symptoms may progress
to a more severe postpartum disorder, which stresses the necessity of making
frequent follow-up visits. However,
this progression is the exception rather than the general rule. In contrast to postpartum psychosis, pharmacologic
intervention generally is not warranted for the maternity blues.
Instead, psychotherapeutic intervention in the form of education, support
and reassurance, has more import.
Prophylaxis
Given that there is a high recurrence rate for
both postpartum psychosis (initial risk 1/500; subsequent risk 1/3) and postpartum
depression (initial risk 1/10; subsequent risk 1/2), prophylactic treatment
for women, particularly for those who have a previous history of affective illness,
is an integral part of the management of these disorders. Patients with a previous
history of nonpuerperal affective illness are three times more likely to develop
postpartum mood disorders, particularly mania.
Thus, one of the most effective prophylactic interventions in this group
is lithium. Although lithium dosage should be halved about one week before delivery
because of marked fluid and electrolyte changes occurring then, it can be restarted
shortly thereafter. Lithium is contraindicated
in breast-feeding women. Clinicians particularly should be on alert
for lithium induced hypothyroidism in postpartum women, since 90% of patients
who develop hypothyroidism on lithium are women (15) and the postpartum period presents a particular risk
factor for the development of hypothyroidism (4). Furthermore,
this condition, i.e., postpartum hypothyroidism, can induce rapid mood cycling.
Patients with a previous history of affective disorders
may have an exacerbation of their illness during pregnancy. Although lithium is contraindicated during
the first trimester because of the infant's risk for Ebsteins anomaly of the
heart, in severe cases lithium may be administered cautiously, checking particularly
for fluid and electrolyte changes, during the third trimester.
For mania occurring during pregnancy, neuroleptics (with careful monitoring)
or ECT can be given without undue risk to the fetus. To date, there have been
few published reports assessing the efficacy of the anticonvulsants on manic
symptoms in the puerperium (17, 135); the majority of work on teratogenicity of anticonvulsant
drugs are based on women with epilepsy. Carbamazepine and valproate may expose
the fetus to a substantial risk of congenital malformation and/or developmental
delay (100, see also Lithium
and the Anticonvulsants in Bipolar Disorder). Because
of the risk of neural tube defects with anticonvulsants, lithium treatment is
preferable. More data needs to be gathered
to determine whether anticonvulsants are safe for breastfeeding; sodium valproate
appears to be relatively safe. Valproate concentrations are smaller as compared
with carbamazepine; at the same, valproate has been associated with an increased
risk of hepatotoxicity in young children (5, 135). The World
Health Organization and American Academy of Pediatricians suggest that valproate
may be safer than carbamazepine.
Another prophylactic treatment which has received
attention, although is controversial, is progesterone (100 IM after labor, daily
for 7 days, then progesterone suppositories for two months or until the return
of menstruation) (21). Since progesterone
is essentially an anesthetic in animals, its use in humans is probably more
effective for the agitated rather than the depressive symptomatology of postpartum
psychiatric syndromes. It also may exacerbate
depressive symptomatology.
Additional information contributes to the hypothesis
that postpartum illnesses are unique and organic in etiology. There has been successful use of three different
substances for prophylaxis in high-risk patients, i.e., patients who have had
previous postpartum psychosis or depression. Administration of long-acting parenteral estrogen or progesterone
has seemed to ward off recurrences.
In summary, the severity and recurrence of postpartum
psychiatric disorders deserve early, aggressive and innovative treatment approaches.
Their presentation is often episodic and fluctuating, with different
presentations of symptoms being more related to different stages of the illness
than to different categories of the illness.
Treatment requires longitudinal follow-up care. Because postpartum psychiatric disorders appear
to exhibit a pattern consistent with a model of kindling and behavioral sensitization
(as opposed to a model of tolerance), it is crucial in treatment strategies
to interrupt this cycle using early and aggressive treatment and prophylactic
management whether it is by ECT, lithium, hormonal or chronobiologic interventions
such as sleep deprivation or phototherapy.
Premenstrual
Depression
One clinical model for studying the relationship
of gonadal hormones to affective illness is the affective changes associated
with the menstrual cycle. Historically
referred to premenstrual syndrome (PMS), this condition has been more rigorously
defined as late luteal phase dysphoric disorder (LLPDD) in the DSM-III-R and
as premenstrual dysphoric disorder (PMDD) in the DSM-IV under mood disorders.
For purposes of familiarity, the term PMS will be used in this chapter.
In PMS, the mood and behavioral changes are recurrent and predictable
and thus can be studied prospectively and longitudinally. Similar to winter in SAD, and the postpartum
period in affective illness, the late luteal phase of the menstrual cycle is
a vulnerable time for the development of depressive mood changes. Therefore,
medication discontinuation and/or modification should consider changes in therapeutic
levels as a fluctuation of menstrual cycle phase; this may prevent mood relapse
at a vulnerable time.
Studies indicate that PMS may be related to major
depressive disorders. In support of
this hypothesis, patients with PMS and affective disorders, in contrast to patients
with anxiety disorders (93), respond to sleep deprivation: Total and late-night
partial sleep deprivation temporarily alleviate symptoms in a majority of patients
with major affective disorders (95). Eighty percent
of patients with premenstrual depression responded to a night of total sleep
deprivation and that late-night partial sleep deprivation (in the second half
of the night) was more effective than early-night partial sleep deprivation
(in the first half of the night) (80). In a follow-up
study, PMS subjects responded equally well to both early and late night partial
sleep deprivations, but only after a night of recovery sleep (75). Sleep deprivation
lowers prolactin (71) and increases TSH (96) although at least in one of the studies (51) these hormonal changes did not correlate with clinical
response. An effective intervention
with total or partial sleep deprivation in patients with PMS would be consistent
with current theories that implicate prolactin and thyroid disturbances in the
pathogenesis of PMS. Sleep reduction
also may serve as a final common pathway in the genesis of mania in postpartum
psychiatric illness (124). Thus, the
interaction of sleep with a sensitive circadian phase of thyroid or prolactin
secretion may be a common predisposing factor for the development of affective
illness, premenstrual depression, and possibly postpartum mood disorders.
Clinical psychopharmacologic treatment
Nutritional Supplements
Vitamin B6 (pyridoxine) has been used
to treat premenstrual mood symptoms because of its purported efficacy in treating
oral contraceptive induced-depressions (79). This effect
is related to observations that estrogen may increase tryptophan metabolism
via the kynurenine-niacin pathway and thus increase the requirements for B6. A slight decrease in the excretion of tryptophan
metabolites in women suffering from PMS symptoms has been found, although plasma
levels of pyridoxal phosphate generally are not different in women with and
without premenstrual symptoms. Controlled
studies suggest mixed results for pyridoxine; some find B6 to be
better than placebo whereas other controlled studies find it no better than
placebo. Some of the studies affirming
efficacy are confounded by women taking concomitant hormones, psychotropics,
or diuretics, or by reported improvements not being specific to the premenstrual
phase. Pyridoxine may have weak effects
on global ratings, behavior, and social activities (132), although a significant amount of physical and mood
symptomatology may remain. High and
prolonged doses of pyridoxine may be associated with neurological toxicity.
In PMS studies very few of these symptoms have been noted in controlled
studies. There has been no dose response relationship evident for B6
in reported studies; significant improvements have been reported at doses as
low as 50 mg.
The evidence supporting vitamin E's efficacy over
placebo is not presently convincing. Vitamin
E has been studied for the treatment of premenstrual symptoms, with improvements
in motor coordination reported. Significant improvements in premenstrual anxiety and depression
found in earlier studies of women with fibrocystic breast disease, have not
been replicated. For vitamin A, early
uncontrolled studies are encouraging but no placebo controlled studies are available
to support its use.
One recent controlled study indicates that oral
magnesium is effective in relieving premenstrual mood changes (27). Magnesium
deficiency may activate premenstrual symptoms through various means. Significant magnesium deficiency in red blood
cells of PMS patients initially reported warrant further follow-up. Although magnesium supplements have been recommended,
consistent reports linking treatment of low blood magnesium levels with reduction
of premenstrual symptoms have not been found.
Hormones
Theories of PMS often attribute symptoms to fluctuations
of ovarian steroid hormones. Thus, several
studies have tested hormonal treatments. Although some studies support low luteal progesterone,
high estrogen, or low progesterone-estrogen ratios being etiologic, other studies
do not implicate high estrogen levels relative to progesterone.
Some studies support the possibility of an asynchrony between declining
rates of progesterone and estrogen, early ovulation, or decreases in progesterone
over time relative to estrogen.
Consistent with the studies suggesting that estrogen
is high relative to low progesterone, several investigators have treated PMS
symptoms with progesterone or other progestin compounds. However, efficacy claims for the progestins
are based primarily on uncontrolled studies. Dalton (20) reported good results with open progesterone administration,
and Dennerstein et al (23) found beneficial trends during the first but not second
month in a controlled study of oral progesterone. In a double-blind, placebo
controlled trial, Baker et al. (7) found that administration of vaginal progesterone suppositories
may alleviate some symptoms of anxiety and irritability in women with moderate
to severe premenstrual syndrome. Symptom improvement was noted only in a subcategory
of questions relating to guilt and self-image. No differences were found on
several instruments measuring dysphoria (e.g. Hamilton depression and anxiety,
Beck depression inventory, etc.), and the researchers did not use standardized
diagnostic criteria to screen subjects.
Other studies have not found progesterone to be
superior to placebo (28). Furthermore, administration of the menses-inducing,
progesterone antagonist mifepristone altered neither the severity nor the timing
of symptoms in women with prospectively diagnosed PMS (99). These findings
suggest that hormonal events during the late luteal phase are not the direct
cause of mood disturbance. The authors
hypothesized that mood disturbances may be synchronized, or linked, with the
reproductive cycle, but not caused by the hormonal changes of the cycle itself.
With synthetic progestins, several open or single
blind trials report improvement rates of 50-82%. When compared to placebo, however, the synthetic
progestins are not found to be effective over placebo, including ethisterone,
norethisterone and, with some exceptions, medroxyprogesterone acetate, when
given short of inhibiting ovulation. Ylostalo
and colleagues (138) found norethisterone effective for breast tenderness.
Most of the evidence does not support either natural
or synthetic progestins as effective treatments of premenstrual mood symptoms.
It appears that the improvements attested to this treatment are likely
attributable to a placebo effect, except perhaps where given in a manner sufficient
to induce anovulation.
Ovarian steroid treatment studies using oral contraceptives
also have yielded inconsistent results. Several studies suggest that premenstrual moodiness,
irritability, fatigue, and depressed mood may be less commonly reported in women
using various oral contraceptives than in women not using them.
However, other studies have found little difference in premenstrual symptoms
between oral contraceptive users and non-users.
The results suggest that suppression of ovulation is not curative of
PMS, when gonadal steroids are yet present from exogenous administration.
Given that steroids have psychological effects, it can be difficult to
predict individual responses in different women. Some data, for example, suggest that the estrogen-dominated pills
may adversely affect women with premenstrual irritability, whereas progesterone-dominated
pills adversely affect women with premenstrual depression.
More research is necessary to determine whether specific identified subgroups
would reliably benefit from oral contraceptive treatment of premenstrual mood
symptoms.
Gonadotropin
Releasing Hormone
At a more central level, interruption of hypothalamic-pituitary-ovarian
cyclicity may relieve premenstrual symptoms, when amenorrhea is induced.
Gonadotropin releasing hormone agonists (GnRH), which with chronic administration
down-regulate pituitary gonadotropin secretion, have been used with some success
in several studies. Muse and colleagues reported that a GnRH agonist robustly
attenuated both behavioral and physical symptoms in 7 women over a 3 month period
compared to placebo (67). In this study,
GnRH effectively interrupted the menstrual cycle (reversibly) during a three
month administration, with amenorrhea induced during the second and third cycles.
There were no significant differences in behavioral symptoms between
GnRH and placebo during the first cycle, although physical symptoms improved
during the first cycle.
Two subsequent studies have since used the intranasally
administered form of GnRH agonist, buserelin. Bancroft et al (8) found a total daily dose of 600 mg of buserelin prompted
improvement in bloating and breast tenderness with less clear effects on mood
in 10 of 20 women studied openly. The
other 10 women suffered adverse effects such as a worsening of their symptoms.
Hammarback and Backstrom (42) found GnRH to be better than placebo for mood, swelling
and breast tenderness, although 3 of 26 women experienced worsening of their
symptoms at 400 mg per day.
In a double-blind, placebo-controlled study, West
and Hillier (129) administered goserelin, a GnRH agonist analogue, to
27 women diagnosed with premenstrual tension. Over the course of three months,
they found that the GnRH analogue significantly reduced physical symptoms, such
as breast discomfort and swelling. Statistical trends also suggested that goserelin
may dampen cyclical fluctuations of anxiety and reduce irritability. Less consistent
improvement was noted with depressive symptomatology. The authors also noted
a substantial placebo effect.
The GnRH agonist, leuprolide acetate, has also
been found to be effective in treating premenstrual mood disturbances. Brown et al. (10) administered the depot leuprolide intramuscularly for
three consecutively cycles in 25 women with late luteal dysphoric disorder.
Depot leuprolide was ineffective for women with severe premenstrual depression
and associated with adverse events. For women with less-severe symptoms, depot
leuprolide was well-tolerated and effective in reducing symptoms. The authors
speculated that severity of symptoms may be indicative of diagnostic subtypes;
women with severe premenstrual depression may have a more sensitive hypothalamic-pituitary-ovarian
feedback system.
Freeman et al. (30) compared women with PMS, as documented by daily mood
ratings, and women with dysphoric symptoms throughout the cycle who experience
premenstrual symptoms. They found that depot leuprolide was significantly more
effective than placebo for subjects with PMS but not for subjects with premenstrual
exacerbations of dysphoric disorders. The reduction in dysphoric symptoms for women with PMS did not occur
until the third cycle. The authors suggested that the differential responses
to the GnRH agonist may indicate that premenstrual depression has mechanisms
different from those of other dysphoric mood disorders.
For eight weeks, Schmidt and colleagues (98) administered leuprolide or placebo to 20 women with
premenstrual syndrome in a double-blind, crossover design. Leuprolide treatment
in women with prospectively documented PMS was associated with a significant
reduction in symptoms as compared with placebo and baseline values. When given
leuprolide plus estradiol or progesterone, the women with PMS had a significant
recurrence of symptoms; normal women given the same regimin experienced no changes
in mood. According to Schmidt and colleagues
(98), these findings suggest that normal plasma concentrations
of gonadal steroids may trigger a disruption of mood in susceptible women.
This form of treatment may be considered a medical
ovariectomy (67) and the potential hazards for long term use, such as
increased cardiovascular morbidity and mortality, and osteoporosis, have not
been clarified. Estrogen supplementation
will not reverse the effects (66).
Danazol
Danazol is another antigonadotropin which causes
hypothalamic pituitary-gonadotropin suppression, as a synthetic androgenic derivative
of ethisterone. Preliminary reports
indicate that this steroid is better than placebo for negative affect, pain,
and behavioral change at doses of 100-400 mg per day. Double-blind studies (97, 119, 37) indicate that danazol compared with placebo significantly
lowers premenstrual symptoms of lethargy, irritability and anxiety in the premenstrual
phase. Side effects of nausea, giddiness,
skin rash, flushing, vaginitis, musculoskeletal and breast pain, decreased breast
size, weight gain, mild hirsutism, and depression have been reported.
Thus treatment with danazol should be considered only after other treatments
fail, and when symptoms are severe. It
should not be considered in women contemplating pregnancy or nursing. As such, danazol's usefulness may be limited
because of its androgenic properties in women of childbearing age. As a trend in these studies, the 200 mg/day
dose appears to be better tolerated. Its
efficacy is comparable to the 400 mg/day dose in most patients.
Prolactin
Inhibition with Bromocriptine
Several studies have tested bromocriptine for treatment
of premenstrual symptoms because of the observed increases in prolactin levels
during the luteal phase. Although most
studies do not find abnormalities in prolactin levels in women with premenstrual
symptoms, most, but not all studies indicate bromocriptine to be effective primarily
for the treatment of mastodynia.
Significant improvements in mood, depressive symptoms
(25), and irritability (138) have been sporadically reported, in double-blind, and
single-blind placebo-controlled studies, respectively. Limiting side effects have been noted in approximately
20% of women treated with bromocriptine; side effects can include nausea, headache,
vomiting, dizziness, fatigue and paroxysmal tachycardia.
Salt
and Water Balance
Diuretics have been studied related to the observations
that fluctuations in capillary filtration rate and permeability to plasma proteins
occurs premenstrually. Women with premenstrual
symptoms also have been found to have a higher luteal body water/potassium ratio
than controls. Early uncontrolled studies of diuretics indicated satisfactory results
with various compounds, including ammonium chloride, chlorothiazide, chlorthalidone,
and quinethazone. However, neither chlorthalidone
nor potassium chloride has been found to be better than placebo in double-blind
placebo studies. For bloatedness, two studies (69, 116) suggest the superior efficacy of spironolactone over
placebo.
The sulfuramide diuretic, metolazone, 1-5 mg daily,
was found to be effective for irritability, tension, depression, headache and
water retention symptoms (128) in a placebo-controlled diuretic study that included
only women with premenstrual weight gain. Excessive
diuresis and weakness occurred occasionally, with the 5 mg dose. Thus, some
evidence supports diuretic or antimineralocorticoid efficacy.
The efficacy of such interventions, however, may be limited to subgroups
of women with premenstrual weight gain.
Prostaglandin
System
Women with premenstrual symptoms have also been
treated experimentally with compounds affecting prostaglandin metabolism. Prostaglandins are known to mediate dysmenorrheic
somatic complaints, and also have been investigated in women with premenstrual
mood complaints. Linoleic acid, the
main precursor for PGE-1, was elevated in women with premenstrual symptoms in
one study (11) whereas the PGE-1 product was lower in these women
in another study (47). One interpretation
is that the conversion of linoleic acid to PGE-1 is impaired in symptomatic
women.
Mefenamic acid, a prostaglandin synthesis inhibitor,
has been found more
effective than placebo for mood symptoms in some
studies (64, 137), although Gunston (35) found no significant benefit on mood for mefenamic
acid over placebo. In this study, there
were improvements in gastrointestinal symptoms. Budoff (12) suggests that mefenamic acid improves breast tenderness,
ankle swelling and abdominal bloating with little effect on mood symptoms of
tension, lethargy and depression. Overall,
the effects of mefenamic acid on mood have been inconsistent in comparison to
its effects on pain. Many of its effects
on affective symptoms have been obscured by the inclusion of dysmenorrheic women
in study populations. One methodologically
sound study (64) however, that excluded dysmenorrheic subjects, did
find positive effects on mood of active drug over placebo. Significant decreases in premenstrual water
retention and "arousal" symptoms have been reported with a diet low
in fat that reduces the availability of prostaglandin precursors (49).
Efamol (evening primrose oil), a prostaglandin
synthesis precursor (containing linoleic acid precursors, gamma linoleic acid,
and vitamin E) also has been tried as a strategy to augment PGE-1 from administration
of these essential fatty acid precursors. Although more effective than placebo for depressive
symptoms in one study (85), another study was unable to find significant differences
between placebo and Efamol (13). Again, the
results of the treatment effects on premenstrual mood symptoms, distinct from
dysmenorrhea, are complicated by inclusion of women with dysmenorrheic symptoms.
Psychotropics
Because of the complex effects of the hypothalamic-pituitary-gonadal
axis and CNS neurochemistry, some treatment studies have aimed to influence
neurotransmitters, or neuromodulators more directly.
The central alpha-2 adrenergic presynaptic autoreceptor agonist properties
of clonidine have been theorized to compensate for a putative excess of central
noradrenergic activity via presynaptic noradrenergic inhibition.
One placebo comparison of clonidine (32) indicated efficacy over placebo in reducing premenstrual
psychiatric rating (BPRS) scores. Clonidine
can decrease plasma renin activity and promote aldosterone secretion, and has
been used for the treatment of opiate withdrawal. The promising results from this initial controlled
trial deserve further study in order to determine which specific symptoms may
respond best to stimulation of this inhibitory autoreceptor that governs the
release of serotonin as well as norepinephrine.
In a double-blind crossover study (16), naltrexone
was recently employed in an attempt to discover whether an opiate antagonist,
given before an expected midcycle rise and fall of B-endorphin, would inhibit
the effects of a putative premenstrual endogenous opioid withdrawal. The naltrexone treatment was modestly but significantly
better than placebo, with the largest improvements found in concentration difficulties,
behavioral changes, and negative affect. It was given only on days 9-18 of the cycle,
such that patients may have been in an opiate antagonist withdrawal state during
the late luteal phase. These results
suggest that either an increased luteal opiate receptor sensitivity or a blockade
of midcycle agonist occupancy may be therapeutic for premenstrual dysphoria.
More work is needed to determine replicability and if the dose or schedule
could be optimized to augment the benefit or decrease the side effects of nausea,
decreased appetite and dizziness.
Lithium has been tried for premenstrual mood symptoms
because of the thymoleptic action of the compound observed in patients with
affective disorders. Rubinow and Roy-Byrne
(94) reviewed lithium treatment in premenstrual tension,
citing three open trials with positive results which were not confirmed in two
subsequent double-blind, placebo-crossover studies. For recurrent suicidal depressions, or rapid cycling mood disorders
linked to the menstrual cycle, lithium may well be the treatment of choice.
Other authors have suggested that patients who respond to lithium may
be those who meet diagnostic criteria for cyclothymic disorders.
Glick and Stewart (33) reported lithium to be effective in open trials of
three schizophrenic patients with premenstrual exacerbations of schizophrenia.
However, even at low doses (600-900 mg/day), most patients may detect
significant lithium-related side effects. Lithium's
teratogenecity, of course, indicates caution in women of childbearing potential.
Alprazolam also has been found in two published
reports to be more effective than placebo for mood symptoms and global improvement
(43, 104). The agreement between studies is encouraging and suggests
that alprazolam may indeed be a useful treatment for premenstrual mood symptoms,
although, some questions remain as to whether there is attribution secondary
to the subjective effects of alprazolam. Longer term studies now are needed to determine whether dependence
or withdrawal symptoms would be problematic over a longitudinal intermittent
treatment regimen of luteal alprazolam and follicular drug withdrawal.
Given the overlap of premenstrual mood symptoms
with that of depression or anxiety, recent studies have focused on the use of
antidepressants. Open studies have indicated
encouraging results with nortriptyline, clomipramine, fluoxetine, nefazodone,
and paroxetine (2, 139). Double blind
trials indicate that fluoxetine, sertraline, paroxetine, clomipramine, imipramine,
and phenelzine may be effective (2, 26). Currently, SSRIs, such as fluoxetine and sertraline
are the treatment of choice for premenstrual dysphoria. In large-scale, double-blind
studies (109, 140), both have been found to be effective, compared with
placebo, when given continuously throughout the cycle. Preliminary studies (40, 108, 142, 29) have indicated that women with PMDD who respond to
continuous sertraline or fluoxetine treatment also respond to treatment restricted
to the luteal phase. Larger controlled trials are necessary to confirm these
findings. Intermittent treatment may
have advantages in reducing side effects and increasing medication compliance;
at the same time, an irregular dosing schedule may increase the likelihood of
forgetting to take medications as prescribed. The efficacy of the SSRIs in treating this
disorder is predicated upon the documented differences in serotonergic activity
between women with PMDD and normal controls (41). Although several lines of evidence suggest luteal
fluctuations of MAO activity, there is little information available on MAOI
trials. Antidepressants may be indicated
for the more severe PMS mood symptoms, although premenstrual dysphoric changes
and irritability may continue despite effective antidepressant treatment (141).
The 5-HT1A partial agonist, buspirone, has also
been used in the treatment of premenstrual mood symptoms. Rickels and colleagues (90) have shown that buspirone was significantly more effective
than placebo for irritability, fatigue, pain and social functioning in 34 patients
treated with a mean daily dose of 25 mg 12 days prior to menstruation.
Buspirone can cause lightheadedness, headache, or gastrointestinal distress
primarily when the dose is first being adjusted, but lacks apparent dependence
potential. It is not known whether the therapeutic effects
reported for fenfluramine, nortriptyline, clomipramine, fluoxetine and buspirone
might all be mediated through 5-HT1A receptor mechanisms.
Chronobiologic
Manipulations
Some nonpharmacologic experimental treatments for
PMDD include sleep deprivation and light therapy. The efficacy of these types
of treatment are based on a chronobiologic model of depression; this model posits
that affective disorders may arise due to disruptions in circadian rhythms or
a desynchronization of the oscillator regulating these rhythms with the sleep-wake
cycle, each other, or the environment.
One night of total sleep deprivation during the
symptomatic premenstrual phase of the menstrual cycle was found to alleviate
PMS symptoms. Follow-up studies suggest
only one night of partial sleep deprivation (sleep 9 PM - 1 AM or 3 AM to 7
AM) may be beneficial (80). Light therapy involves sitting in front of a box of
lights 2 hours a day for one week. Although early studies suggested superior
efficacy of evening (7-9 PM) bright light (>2500 lux, 5 times brighter than
room light) (74), subsequent trials showed equal efficacy of bright
evening, bright morning (6:30-8:30 AM) and dim (10< lux) red evening light
administered in the premenstrual phase to PMS patients (77). Although these
treatments may show promise, further trials are needed before these interventions
can be recommended for general clinical usage. These findings are interesting in comparison
with recent evidence suggesting a seasonal variation in PMS with approximately
70% of the women experiencing fewer symptoms during the summer when the photoperiod
is naturally longer.
• See Chart
1
RELATIONSHIP
BETWEEN REPRODUCTIVE-RELATED DEPRESSIONS
A depression occurring in association with the
reproductive cycle may sensitize a woman to future depressions. A previous history of psychiatric illness or
of affective changes during pregnancy may predispose to oral contraceptive-induced
depressions (79). Severe premenstrual depression may predispose a woman
to postpartum depression and, like affective illness, premenstrual depression
may have its onset or be exacerbated after a postpartum depression.
Alternatively, a major affective disorder may be exacerbated or precipitated
during a premenstrual period. There
are anecdotal reports that after treating cycles of bipolar illness with lithium,
premenstrual and seasonal mood cycles persist or become more prominent. Price et al (84) report patients with rapid cycling disorders have an
increased tendency to have more severe forms of PMS, although Wehr et al (122) found no convincing relationship between manic-depressive
cycles and menstrual cycles in their patients with rapid cycling disorders.
Thus, the cyclicity of affective disorders in the
form of rapid cycling bipolar illness or SAD may be compounded by periodic affective
change occurring in association with the premenstruum, with pregnancy and the
postpartum period, and with altered reproductive hormonal milieus induced by
oral contraceptives or gonadal hormone treatments.
MECHANISMS
OF REPRODUCTIVE RELATED DEPRESSIONS:
With the kindling model of depression in mind (82), one wonders whether such periodic reproductive-related
depressions may sensitize women to future affective episodes.
Most longitudinal studies to date have not specifically focused on gender-related
differences in course of the illness. Sex
differences in depression begin to appear after the onset of puberty in adolescence
(126). There is a
marked increase in major depression in female children at approximately 16 years
of age, a time of major change in the neuroendocrine reproductive axis.
In contrast, male children exhibit a gradual increase in depression across
all ages, with considerably lower absolute rates than in female children.
Furthermore, the onset of major depression is earlier (12 to 13 years
of age) in both male and female offspring of depressed probands (125), and the risk for depression appears to be increasing
with time (36, 125, 127).
How cyclic depressions related to reproductive
events may affect other forms of cyclic affective disorders is unknown, but
a relationship does seem to exist. Work
in animals may provide models and possibly shed light on the mechanisms involved.
For example, the predisposition of women with thyroid impairment to cyclic
forms of depression has a parallel in an animal model. Richter (89) produced abnormal cycles of motor activity experimentally
in female animals, but not male animals, by partial thyroidectomy.
As in rapid cycling patients, treatment with thyroid extract abolished
the abnormal behavioral cycles, which returned after cessation of treatment. Richter hypothesized that the abnormal, regular cycles of activity
were produced by the effect of thyroid deficiency on homeostatic mechanisms
controlling luteotropin (prolactin) release (possibly related to the effect
of TRH on prolactin). He induced similar
cycles by daily subcutaneous injections of prolactin. Such cycles were also produced by inducing
pseudopregnancy. This condition stimulates
pituitary secretion of prolactin, which acts on the ovary to produce persistent
corpora lutea and the secretion of progesterone. Ovariectomy abolished running activity; estrogens
increased it. Giving the rats anhydrohydroxy
progesterone produced longer abnormal activity cycles. As occurs in affective illness, the abnormal
activity cycles become shorter with time. Of
relevance here is our clinical work demonstrating higher baseline prolactin
levels (Parry et al, unpublished observations) and increased prolactin response
to TRH in women with rapid cycles of mood related to the menstrual cycle (PMS)
(76).
Reproductive hormones modulate hormonal, neurotransmitter,
and biologic clock mechanisms that have each been the focus of hypotheses about
the pathophysiology of affective disorders. Estrogen and progesterone can alter the biosynthesis,
release, uptake, degradation and receptor density of norepinephrine, dopamine,
serotonin, and acetyleholine (63). The gonadal
steroids also modulate other hormonal mechanisms (thyroid, cortisol, prolactin,
and opiates) that also affect neurotransmitter systems.
Gonadal hormones affect biologic clock mechanisms, which also have been implicated in the pathophysiology of affective disorders. Estrogen shortens the period of circadian activity in ovariectomized hamsters and rats (1, 65). The onset of activity occurs earlier on days of the estrous cycle when endogenous titers of estradiol are high in intact hamsters. Progesterone delays the onset of activity in intact rats by antagonizing the effect of estrogen (6). Estrogen, in addition to shortening the free-running period and altering the phase relationship of the activity rhythm to the light-dark cycle, increases the total amount of activity and decreases the variability of day-to-day onsets of activity. These findings parallel clinical work by Wever (130) who found that the mean free-running period of the sleep-wake cycle is significantly shorter in women than in men (28 minutes). The wake episode is shorter (1 hour 49 minutes) and the sleep episode longer (1 hour, 21 minutes) in women compared with men. Thus, the fraction of sleep is longer for women than men. The circadian temperature rhythm was similar in both sexes. According to Wirz-Justice et al (133), women sleep longer than men at all times of the year. When in free-running conditions, women, compared with men, tend to become internally desynchronized, particularly in the summer, by shortening the period of their sleep-wake cycle.
Estrogen also serves to enhance coupling between
different circadian pacemaker components (1). Ovariectomized
female rodents develop rhythm desynchronies. Replacement with estrogen restores the normal
coupling relationship between these disparate rhythms. This factor may be involved in some of its
therapeutic effects.
Thus, the decline of ovarian hormones common to
the premenstrual, postpartum and menopausal periods, and their inherent cyclicity,
may destabilize or sensitize neurotransmitter, neuroendocrine, and biologic
clock mechanisms, and thereby set the stage for the development of cyclic affective
disorders.
Although the cyclicity of the endocrine milieu
may increase the vulnerability to episodic depressions in women, it may protect
against the development of many chronic illnesses, which are more characteristic
in men. Mood cyclicity may contribute to longevity by enhancing homeostatic
mechanisms. Indeed, work on hamsters has shown that longevity increases with
the restoration of synchronous high amplitude circadian rhythms (46). The investigation of hormonal contributions to affective
illness in women and the examination of the way in which the course of these
illnesses is affected by reproductive events of the life cycle may increase
our understanding of affective illness and potentially provide alternative treatment
strategies.
Women are at higher risk than men to develop depressive
episodes during the reproductive years. Furthermore, women are vulnerable to depressions associated with
oral contraceptives, abortion, the premenstrual period, the puerperium, and
menopause. The phenomenology and the
biologic mechanisms involved in these illnesses perhaps should be viewed in
the context of other manifestations of the link between depression and female
reproductive functions. For example,
women are especially vulnerable to a rapid cycling form of affective illness
and to hypothyroidism, an associated factor for this form of affective disorder.
The postpartum period also is associated with impaired thyroid function,
and there are reports of the induction of rapid cycles of mood following the
termination of pregnancy. Thus, alterations in thyroid hormones may be
a feature of both postpartum and rapid cycling forms of affective disorder in
women.
A previous history of a postpartum depression places
a woman at a high risk for the development of a subsequent puerperal episode.
Also, difficulties during pregnancy may predispose a woman to the development
of other reproductive-related depressions.
The role reproductive hormones play in this possible sensitization phenomenon
needs to be examined in order to understand the relationship of depression to
the female reproductive cycle. Appropriately
timed clinical psychopharmacologic interventions may serve to inhibit this sensitization
phenomenon and benefit long term prognosis.
published 2000