Depression: Tailoring treatment to life stage

Concomitant depression and anxiety. Depression accompanied by anxiety is common in women. The relationship between the two can be complex but does not usually alter choice of drug therapy, since the most commonly used agents are effective for both conditions.

TABLE 2

Mnemonic for major depression: SIG E CAPS(S)

Management strategy

The principles for managing depression are the same regardless of whether a patient has a major depressive episode or another depressive disorder. Treatment usually begins during the acute phase of an episode and varies with symptom severity.

Assessing symptom severity. This can be judged by the degree to which symptoms interfere with the patient’s usual activities:

• Mild symptoms cause some difficulty functioning in social, occupational, or school settings, but the patient is generally doing well.
  
• Moderate symptoms make daily tasks more arduous.
  
• Severe symptoms cause dysfunction in 1 or more areas of normal activities (social, occupational, or school), and the patient may have suicidal ideation. Suicidal or homicidal ideation always indicates severe depression, regardless of ability to function.⁵
  

• Psychotherapy and antidepressant medications are equally effective for women with mild to moderate symptoms. Therefore, patient preference should be the determinant.
  
• Women with mild to moderate seasonal symptoms concentrated in the winter months may need only bright-light therapy.⁷
  
• Exercise alleviates a broad spectrum of depressive illnesses, so treatment plans should always include initiating or increasing physical activity.⁸
  

• Psychotherapy alone is inadequate; antidepressant medication must be included at the start of treatment.
  
• Concurrent use of psychotherapy may be helpful.
  
• Exercise also is beneficial, though many women with low motivation and low energy cannot initiate physical activity until some improvement occurs.
  

When to refer for psychiatric care

Since the treatment of depressive disorders must be based on accurate diagnosis, the Ob/Gyn should consider referral to a mental health professional when the diagnosis is uncertain or response to initial treatment is inadequate.

Comorbid mental illness, such as posttraumatic stress disorder (PTSD) or personality disorder, can cause both diagnostic confusion and treatment resistance. Consultation with a psychiatrist therefore may be necessary. Patients with PTSD probably account for most of the “treatment failures” seen by generalists (TABLE 3).⁹ These women will benefit from antidepressant therapy initiated by their Ob/Gyns, but also need treatment by psychotherapists with experience managing PTSD.

In patients with comorbid personality disorders, meanwhile, the emergence of self-harming behavior is high. These patients—and any women at high risk for self-harm—should be referred to a psychiatrist for initiation of therapy.

Likewise, patients with a history suggestive of bipolar disorder should be referred to a psychiatrist for treatment.

TABLE 3

Traumatic events and risk for posttraumatic stress disorder*

Initiating drug therapy

TABLE 4 lists most antidepressant medications prescribed by generalists. It is normally unnecessary to change to a different drug class if an antidepressant fails, or if depressive symptoms recur. Unlike antibiotic treatment, in which failure with 1 agent predicts failure with other drugs in the same class, there is considerable variation within classes of antidepressants. Thus, changing to another drug in the same class is likely to be successful.

Side effects. Medications vary in their side-effect profiles. Nefazodone and buproprion are less likely than other agents to cause sexual side effects. Fluoxetine and sertraline, meanwhile, are less likely to cause weight gain in the first few months of treatment (although long-term data are less reassuring). Buproprion has not been associated with weight gain.

Specific subsets of patients. TABLE 5 lists some factors to consider when selecting antidepressant medications for women of reproductive age; women who have and who have not previously taken antidepressants; and women with premenstrual symptom exacerbation, obsessive-compulsive symptoms, an eating disorder, or specific symptom patterns (such as sleep disturbance, anger, low energy, or poor concentration).

In a patient with prominent anxiety symptoms, the prescribed medication should be initiated at half the usual starting dose, with gradually increasing doses. All selective serotonin reuptake inhibitors and serotonin/norepinephrine reuptake inhibitors are effective treatments for anxiety disorders. Because these women are less likely to tolerate buproprion than other agents, starting at a low dose and advancing therapy slowly is especially important with this treatment.