T re a tme nt o f Mo o d Diso rde rs in Midlife Disc lo sure s I - PDF document

10/5/2017 T re a tme nt o f Mo o d Diso rde rs in Midlife Disc lo sure s I HAVE NO DISCL OSURE S Wo me n K AY ROU SSOS-ROSS, MD U NI VE RSI T Y OF FL ORI DA DE PART ME NT S OF OBGYN AND PSYCHI AT RY T o da y’ s F o c us: Midlife Wo me n UNDE RST AND INCI DE NCE OF • MOOD DISORDE RS IN MIDL I F E WOME N  Midlife wo me n=Me no pa usa l tra nsitio n (MT )= Pe rime no pa use =Clima c te ric DISCUSS PAT HOPHYSIOL OGY •  I nc lude s time fra me b e twe e n full re pro duc tive func tio n a nd me no pa use OF MOOD DISORDE RS IN (De ll e t a l. Me no pa use a nd Mo o d. 2000) MIDL I F E WOME N Ob je c tive s  T ime fra me typic ally 4-8 ye a rs in le ng th IDE NT I F Y APPROPRIAT E •  T T RE AT ME NT OPT IONS OF ypic a lly o c c urs in 45-55 ye a r o ld wo me n MOOD DISORDE RS IN  Ave ra g e a g e 47 ye a rs o ld MIDL I F E WOME N 1

10/5/2017 E pide mio lo g y  Mo o d diso rde rs a re twic e a s c o mmo n in wo me n a s in me n  T his distinc tio n o c c urs in a do le sc e nc e a nd e q ua lize s a fte r me no pa use  15-50% o f wo me n e xpe rie nc e de pre ssive sympto ms during the me no pa usa l tra nsitio n (MT ) (T o ffo l e t a l. Me no pa use . 2015)  15-30% me e t c rite ria fo r de pre ssive diso rde rs  T he re is a 2x inc re a se d risk o f a first e piso de o f de pre ssio n fo r wo me n in MT  SWAN study sho we d wo me n 2-4x mo re like ly to e xpe rie nc e MDD if the y we re pe rime no pa usa lo r e a rly po stme no pa usa l (Bro mb e rg e re t a l. Psyc ho l Me d. 2011)  Se a ttle midlife Wo me n’ s He a lth Study fo und a do ub ling o f the ra te o f de pre ssive sympto ms in la te MT (Wo o ds e t a l. Me no pa use . 2008) E xe c utive Summa ry o f the Sta g e s o f Re pro duc tive Ag ing Wo rksho p + 10: Addre ssing the Unfinishe d Ag e nda o f Sta g ing Re pro duc tive Ag ing . Ha rlo w e t a l. J Clin E ndo c rino l Me ta b . 2012 Risk F a c to rs fo r Mo o d Diso rde rs in Pa tho physio lo g y o f Mo o d Diso rde rs in Midlife Midlife  Prio r de pre ssive e piso de *  Do mino the o ry  E spe c ia lly if re la te d to prio r re pro duc tive e ve nt (So a re s. Me no pa use . 2014)  Va so mo to r sympto ms trig g e r de pre sse d mo o d due to disruptio n in sle e p a nd func tio nal impairme nt (Go rdo n e t a l. Curr Psyc h Re p. 2014)  Sig nific a nt va so mo to r sympto ms  Ho t flushe s pro vo ke sle e p d isturb a nc e whic h a ffe c ts mo o d  Psyc ho so c ia l stre sso rs  E mpty Ne st Syndro me  F ina nc ial stre ss  Wo me n b e c o me mo re a wa re o f the ir lo ss o f fe rtility a nd the ir ma te rna l ro le  Cha ng e s in wo rk-life  Psyc ho so c ia l stre sso rs: Cha ng e s in fa mily dyna mic , c ha ng e s in wo rk life ,  Divo rc e , Childre n le a ving fo r c o lle g e , Ca ring fo r e lde rly pa re nts c ha ng e s in fina nc ial se c urity o c c ur a t the sa me time a s MT a nd ma y c a use de pre ssive sympto ms  He a lth re la te d issue s 2

10/5/2017 Pa tho physio lo g y o f Mo o d Diso rde rs in Pa tho physio lo g y o f Mo o d Diso rde rs in Midlife Midlife   Ho rmo na l fluc tua tio n Ab rup t c ha ng e s in ho rmo ne le ve ls ma y a lte r the e q uilib rium o f ne uro tra nsmitte rs fo und in the b ra in thus inc re a sing risk o f mo o d diso rde rs  E vide nc e o f wo rse ning o f mo o d diso rde rs during time s o f ho rmo na l fluc tua tio n  E ST ROGE N  Re la te d to me nse s (o nse t o f me nse s, pre me nstrua l d yspho ric d iso rd e r-PMDD)  Re la te d to pre g na nc y o r po stpa rtum  Re la te d to me no pa usa l tra nsitio n  Histo ry o f PMDD a nd / o r po stpa rtum d e pre ssio n a re risk fa c to rs fo r d e pre ssio n d uring me no pa usa l tra nsitio n (Wo o d s e t a l. Me no pa use . 2008, F re e ma n. Arc h Ge n Psyc h. 2004)  E vide nc e tha t inc ide nc e o f de pre ssio n in po stme no pa usa l a g e d wo me n is simila r to tha t o f me n  Altho ug h e stro g e n le ve ls a re lo w, the le ve ls o f e stro g e n a re sta b le a nd no t fluc tua ting Ro le o f E stro g e n in T re a tme nt o f Mo o d Dia g no sis o f Ma jo r De pre ssive Diso rde r Diso rde rs in Midlife Wo me n DSM V Dia g no stic Crite ria (5 sympto ms fo r 2 we e k pe rio d )  Mo dula te s se ro to nin a nd no re pine phrine  De pre sse d mo o d o r a nhe d o nia *  I nc re a se s GABA a c tivity  - Cha ng e s in sleep  De c re a se s a c tivity o f MAO (invo lve d in se ro to nin de g ra da tio n)  - L o ss o f inter est / ple a sure  I nc re a se s trypto pha n hydro xyla se (invo lve d in se ro to nin synthe sis)  - Guilt / wo rthle ssne ss  Se le c tive ly inc re a se s se ro to nin re c e pto r de nsity in b ra in  - F a tig ue / lo ss o f ener gy  - De c re a se d fo c us o r concentr ation  Pro mo te s NE a va ila b llity  – Cha ng e s in appetite o r we ig ht  I nvo lve d in inc re a sing NE hydro xyla tio n fro m do pa mine  – Cha ng e s in a c tivity ( psychomotor ) (So a re s. Me no pa use . 2014)  – T ho ug hts o f d e a th/ suicide 3

10/5/2017 T re a tme nt Optio ns fo r Wo me n in MT T he ra py  Co g nitive -Be ha vio ra l T he ra py (CBT )  Antide pre ssa nts  Psyc ho the ra py  CBT o ffe rs impro ve me nt in ho t flushe s a nd nig ht swe a ts b y c ha ng ing the  SNRI  Co g nitive -Be ha vio ra l c o g nitive a ppra isa l o f sympto ms (No rto n e t a l. Me no pa use . 2014) T he ra py  SSRI  T e le pho ne g uide d se lf he lp CBT impro ve d sympto ms o f ho t flushe s a nd nig ht swe a ts (Ste fa no po ulo u e t a l. Ma turita s. 2014)  Co mple me nta ry  E stro g e n me dic ine  Ora l  Ac upunc ture  T ra nsde rma l Co mple me nta ry Me dic ine Antide pre ssa nts  Ac up unc ture  Antid e pre ssa nts  Sid e E ffe c ts (15-20% o f pa tie nts)  No c le a r e vide nc e o f impro ve me nt o f va so mo to r sympto ms o r mo o d in  SNRI  GI sympto ms (na use a ) pe rime no pa usa lwo me n (Cho e t a l. Me no pa use . 2009, Do din e t a l. Co c hra ne  Dulo xe tine (20-60 mg )  Se xua l dysfunc tio n (20%) Da ta Ba se Syst Re v. 2013)  Ve nla fa xine (37.5-225 mg )  He a d a c he  SSRI  Sle e p d isturb a nc e  F luo xe tine (10-40 mg )  Se rtra line (50-150 mg )  Cita lo pra m (20-40 mg )  Sho uld se e impro ve me nt in sympto ms within 1 mo nth  E sc ita lo pra m (10-20 mg )  Pa ro xe tine (20-50 mg ) 4