Depression: Tailoring treatment to life stage
One in 4 women experiences at least 1 major depressive episode in her lifetime—almost invariably during the reproductive years. A psychiatrist and Ob/Gyn surveys the characteristic symptoms and appropriate treatment strategies specific to each age.
For perimenopausal women, consider concomitant therapy with estrogen and an antidepressant to maximize treatment response. Patients with prominent menopausal symptoms and no history of depression should be started on hormones prior to the initiation of antidepressant agents. Women with a history of depressive symptoms or treatment for depression, on the other hand, might respond better if started on the antidepressant first; hormonal therapy can be added as indicated.
TABLE 4
Common medications for major depression
| AGENT | TRADE NAME | CLASS | NEUROTRANSMITTER, INITIAL SIDE EFFECTS |
|---|---|---|---|
| Selective serotonin reuptake inhibitors | |||
| Citalopram/escitalopram | Celexa, Lexapro | C | Serotonin, activating |
| Fluoxetine | Prozac,* Sarafem, Prozac Weekly | C | Serotonin, activating |
| Fluvoxamine | Luvox | C | Serotonin, sedating |
| Paroxetine | Paxil Paxil-CR | C | Serotonin, sedating |
| Sertraline | Zoloft | C | Serotonin, activating |
| Other antidepressants | |||
| Buproprion | Wellbutrin* Wellbutrin-SR | B | Dopamine, activating |
| Mirtazapine | Remeron Remeron SolTab | C | Complex, sedating |
| Nefazodone | Serzone | C | Serotonin, mildly sedating |
| Venlafaxine | Effexor Effexor-XR | C | Serotonin, norepinephrine, mildly sedating |
| *Generic available | |||
Factors to consider in initiating antidepressant medications in women
| IF THE PATIENT HAS… | THEN CHOOSE OR CONSIDER… | SUCH AS… |
|---|---|---|
| Previously used an antidepressant medication | The same medication unless it was discontinued due to inefficacy or intolerable side effects. | |
| Never taken antidepressant therapy, but first-degree relatives have used a therapy successfully | The same medication used by the relative | |
| The potential for pregnancy and lactation | An agent that can be continued during pregnancy and lactation | All antidepressant medications |
| Anger and irritability as primary symptoms | A serotonergic agent | Fluoxetine, sertraline, paroxetine, citalopram/escitalopram, venlafaxine, nefazodone |
| Low energy and poor concentration as the primary debilitating symptoms | An energizing agent | Buproprion, fluoxetine,sertraline, citalopram/escitalopram |
| Severely disturbed sleep | An agent that has sedating side effects to be used at bedtime; these effects may be less welcome once the depression remits | Fluvoxamine, mirtazapine |
| Prominent premenstrual syndrome or | Serotonergic agent, intermittent dosing | Fluoxetine, sertraline, paroxetine, citalopram/escitalopram, venlafaxine, nefazodone |
| Premenstrual exacerbation of depressive symptoms | An agent that’s not an intermittent (luteal-phase) antidepressant; continuous treatment with increased premenstrual dosing, return to basic dose with onset of menses | |
| Obsessive-compulsive symptoms (counting, checking, or intrusive thoughts) or an eating disorder | Serotonergic agents as first choice; higher doses may be needed to control symptoms | Fluoxetine, sertraline, paroxetine, citalopram/escitalopram, venlafaxine, nefazodone |
Base treatment duration on episode pattern
Depression is usually a chronic condition marked by recurrent episodes. Thus, the duration of treatment is related to the number of recurrences the patient has experienced, and the aim of therapy is to prevent further episodes. If treatment has been incomplete, depressive symptoms often recur in the first few weeks following discontinuation.
- A woman experiencing depression for the first time has a 50% likelihood of recurrence. She should continue medication for 4 to 6 months after she feels well (that is, she feels fully back to her “usual self,” not just somewhat better).
- A woman with a second major depressive episode has about a 70% chance of recurrence and should remain on medication for 1 year after she feels fully well.
- A woman experiencing a third episode has more than a 90% chance of recurrence and probably should consider lifelong antidepressant therapy.
- For postpartum onset, psychiatrists often recommend a full year of antidepressant therapy even if it is the patient’s first depressive episode. This is because the stress and sleeplessness associated with care of an infant undermine recovery from a depressive disorder.
Ending treatment
Clinicians should terminate antidepressant treatment with a slowly tapering regimen. Abruptly discontinuing treatment may precipitate recurrent depressive symptoms that will require further management.
A common approach is to decrease from a high dose by halving it every 5 to 7 days. Once the patient reaches a lower dose, slow the drug tapering even further. Some women may need alternate-day dosing at the end of the taper to avoid rebound or discontinuation symptoms.
With history of PMS, taper only after menses. If a woman experienced PMS before her current depressive episode, consider using a very slow taper, decreasing doses after the onset of menses each month. Help the patient anticipate the reemergence of PMS and teach her to counter it with exercise, with calcium supplementation, and by restarting a serotonergic antidepressant, as indicated.
Taper SAD patients during their “best” season. In women with seasonal affective disorder (SAD), begin tapering antidepres sants during the season in which the patient is at her healthiest, psychologically. For a woman with winter dysphoric symptoms, do not consider reducing antidepressant medication until the days are lengthening in the spring, even if she has taken the drug for the recommended length of time.
Managing serotonin discontinuation syndrome. Abrupt discontinuation of serotonergic agents may lead to a constellation of symptoms called “serotonin discontinuation syndrome” (TABLE 6).10 Agents with a long half-life or multiple active metabolites (e.g., fluoxetine, sertraline) are less likely to cause discontinuation symptoms than agents with a short half-life or no active metabolites (e.g., paroxetine, venlafaxine).
Specific symptoms can be treated; for example, analgesics for headache, medication for sleep or anxiety. If the patient is experiencing dizziness or poor balance, take steps to protect her from secondary injury, such as a fall.
