TUCSON, ARIZ. — When a female patient presents with hot flashes, consider screening her for depression, Dr. Marlene Freeman advised at a psychopharmacology conference sponsored by the University of Arizona.
The risk of depression is known to increase during perimenopause, and epidemiologic studies have shown that women in early perimenopause have greater rates of persistent mood symptoms (15%–18%) than do premenopausal women (8%–12%).
But a recent study found that the onset of perimenopausal depression was associated only with hot flashes, and not with many of the risk factors that are conventionally suspected, such as parity, previous depression, family history, smoking, duration of perimenopause, endocrine measures, vitamin or mineral supplements, exercise, or medical illnesses (Am. J. Psychiatry 2004;161:2238–44).
“We don't know if all women are going to have a tough time during perimenopause, but for some it can be an exquisitely high-risk time,” said Dr. Freeman, director of the Women's Mental Health Program at the University of Arizona, Tucson.
In general, history of major depressive episodes is important to predict future episodes, because some patients with depression have patterns of recurrence. But psychosocial factors—such as aging parents, children leaving home, marital issues, and the individual woman's feelings about growing older and leaving the reproductive years—also may factor into whether a woman experiences depressive symptoms or episodes, Dr. Freeman said.
Selective serotonin reuptake inhibitors are an attractive potential option for mood and somatic symptoms of perimenopause, particularly given the controversy surrounding the use of hormone therapy.
Dr. Freeman and her colleagues recently conducted a small, open-label, 8-week study in which 20 perimenopausal women with major depression were treated with escitalopram (Lexapro) 10 mg/day for 2 weeks, with the option of either decreasing the dosage or increasing to a maximum of 20 mg/day. Side effects caused two patients to drop out of the study, which was supported by Lexapro maker Forest Pharmaceuticals Inc.
An intent-to-treat analysis of 18 patients showed that 16 patients experienced a 50% or greater decrease in scores on the Hamilton Rating Scale for Depression, and 13 experienced a 50% or greater decrease in scores on the Greene Climacteric Scale used to quantify somatic symptoms. Paired t tests showed that the differences in pre- and posttest scores were significant for both of the primary measures.
Other studies have shown that extended-release paroxetine (Paxil) and venlafaxine (Effexor) have been successful in reducing hot flashes in women, she said. Open-label data showed that citalopram (Celexa) was efficacious as a monotherapy for perimenopausal and postmenopausal women with depression, and as an adjunct therapy for women who had remained depressed after 4 weeks of estrogen therapy with estradiol (J. Clin. Psychiatry 2003;64:473–9).