Transcript The Context of a Womans Life Meadows Conference

Joyce A. Spurgeon, MD
November 2015
Outline
 Define the problem
 Review Erikson’s stages of psychosocial development
 Review specific time periods in women’s life with
unique risks involved
 The 3 C’s of development
A Problem?
 Number of non-institutionalized people 12 or older
with depression in any 2 week period from 2007-20108%
 Number of visits to PCP in 2009-10 with depression as
the primary diagnosis- 8 million
 Number of suicide deaths in 2010- 38,364
 Suicide deaths per 100,000 in 2010- 12.4
Morbidity
 Depression is the leading cause of medical disability in
people ages 14-44.
 Depressed people lose 5.6 hours of productive work
every week that they are depressed
 In any 30 day period, depressed workers have 1.5-3.2
more short term disability days
Depression Rates
 Girls and boys before puberty and after menopause
have the same rates of depression
 After menarche, girls develop depression 2 times the
rate of boys
 This rate holds true through numerous studies
including ECA and NCS
 The WHO gathered data from 14 countries and it was
consistent with 2:1
Presentation difference
 Women are more likely to show reverse
neurovegatative signs of depression
 Women have more co-morbid diagnosis like GAD,
panic, phobias, eating disorders
 Men are more likely to have substance abuse issues as
co-morbid issues
Erikson slides
 Ego identity- the conscious sense of self that we
develop through social interactions
 This changes through new experiences and
information we acquire through social interaction
 Epigenesis- the stepwise process by which genetic
information, as modified by environmental influences,
is translated into the substance and behavior of an
organism
Identity versus Role Confusion
 Ages 13-19 years old
 “What role am I going to play as an adult?”
 Concept of fidelity “the ability to sustain loyalties
freely pledged in spite of the inevitable contradictions
and confusions of value systems”
 Psychosocial moratorium
Intimacy versus Isolation
 Ages 20-39
 “Can I love?”
 Distantiation: “the readiness to isolate and if
necessary to destroy forces and people whose essences
seems dangerous to our own and whose territory
seems to encroach on the extent of one’s intimate
relations”
Generativity versus Stagnation
 Ages 40-64
 “Can I make my life count?”
 Central Tasks:
 Express love through more than sex
 Maintain healthy life patterns
 Develop sense of unity with mate
 No longer center figure in children’s lives
 Reverse roles with parents
 Achieve responsibility in all aspects of life
 Adjust to the physical changes assoc. with aging
PMS
 75% of women with a normal menstrual cycle
experience some symptoms of PMS
 Women in the US tend to show more affective
symptomatology
 Women in other countries are more likely to complain
of physical symptoms
 Women with higher educational levels are more likely
to have heightened severity of complaints
PMDD
 In the majority of menstrual cycles, at least 5
symptoms must occur in the final week before the
onset of menses, start to improve within a few days
after menses starts, and become minimal of absent in
the week post-menses
 One of the following symptoms must be present:
(Criterion A)
 Marked affective lability
 Marked irritability or anger or increased conflict
 Marked depressed mood
 Marked anxiety, tension, or feelings of being on edge
PMDD, continued
 One or more of the following must be present to reach
a total of 5 symptoms when combined with above
 Decreased interest in usual activities
 Subjective difficulty in concentration
 Lethargy, easy fatigability, or marked lack of energy
 Marked change in appetite
 Hypersomnia or insomnia
 A sense of being overwhelmed or out of control
 Physical symptoms such as breast tenderness or
swelling, joint or muscle pain, a sensation of bloating or
weight gain
PMDD, cont
 Must cause significant distress
 Distress is not merely an exacerbation of another
disorder
 Should confirm Criterion A by prospective daily
ratings during at least two symptomatic cycles
 Not due to substance abuse or a medical condition
PMDD Treatment
 Pharmacologic:
 SSRIs have been extensively studied and all have been
found to be effective
 Limited studies of SNRIs show efficacy
 Luteal phase dosing effective and may be the treatment
of choice initally
 Consider birth control pills/ patch in consultation with
OB/GYN
 Augmentation of SSRIs for any residual symptoms
Nutritional and Lifestyle
Modifications in the Treatment of
PMDD
 Calcium supplementation 1200 mg/day has been
shown to improve some symptoms
 Exercise has been shown to decrease symptoms
 Limit caffeine and alcohol intake
 Stress reduction techniques are helpful
Psychosocial Issues
 It is not uncommon for PMS to be a problem during
adolescence
 It is not uncommon for my PMDD patients to be in
their early 20s
 What does this time period hold for women?
Case
 AJ is a 21 year old woman
 Presents with pretty typical PMDD which responds
well to treatment with SSRI
 She realizes that the PMDD symptoms are much
better with treatment but wonders about some of the
underlying sadness that she feels
 Sadness does not meet criteria for any of the mood
disorders
Case
 She keeps coming back because she feels like there
should be something more that can be done for her
because most of her friends do not feel this way
Pregnancy
 10-20% of women will suffer depression during
pregnancy
 Standard of care used to be- no treatment during
pregnancy
 New standard- do risk/benefit analysis on each patient
• Women who discontinue their antidepressant before
conception have a 68% recurrence rate of depression
during pregnancy
– Women who continue their medication have a 26%
recurrence rate
Pregnancy
 1/3 of pregnant women meet criteria for a psychiatric
diagnosis, only 25% get treatment
 The estimates are that about 3% of pregnant women
are exposed to antidepressants
 One study reported that there has been an increase in
SSRI use in the US in pregnant women from 2.5% in
1998 to 8.1% in 2005
 Wisner, et al. in 2009 estimated of the 4,000,000
babies born in the US, 100,000 are exposed to SSRIs
Consequences of No Treatment
 Increased risk of preterm delivery
 Women are much less likely to seek appropriate
prenatal care
 More risky behaviors- smoking, drinking, etc.
 Some evidence of increased adverse obstetrical
outcomes
 Increased risk of postpartum mood disorders
Case
 23 year old married, white female comes in at 14 weeks
gestation.
 She has no significant psychiatric history although she
identifies that she has felt sad a lot in her life but never
treated
 Planned pregnancy
 Has lots of conflicts with her family of origin and is
desperate to have things go differently for her baby
Case
 She cries through the entire interview
 Pt denies SI but describes inability to eat, poor
concentration and attention to the point that she
cannot do her job, feels guilty about exposing her baby
to these feelings, energy level is poor
 Has some co-existing worry about how she let herself
get this far down
Case
 Pt. has good social support from her husband but has
isolated from friends
Post Partum Blues
 50-85% of all new mothers
 Symptoms begin in first few days and last up to day 10
 Central feature: marked lability of mood which seems
to have a heightened response to stimuli
 Present in a large percentage of every culture
 Up to 20% of women will go on to experience a
depressive episode in their first postnatal year
Post Partum Depression
 In the DSM-V, this would be the diagnosis of major
depression using the specifier with peripartum onset
 Mood symptoms occur during pregnancy or in the 4
weeks following delivery
 50% of postpartum episodes actually began prior to
delivery
Post Partum Depression
 Approximately 13% of women will suffer from
postpartum depression
 500,000 women in the United States each year will
struggle with this disorder
 The risk for adolescent mothers is much higher with
the rate being up to 26%
 12.5% of all admissions to psychiatric hospitals in
women occur in the first year postpartum
Risk Factors for Post Partum
Depression







Personal family history of a mood disorder
Postpartum blues
Previous episode of postpartum depression
Psychosocial issues
Poverty
Adolescent mother
Depression/anxiety during pregnancy
Case
 We are going to continue the case from pregnancy- to
see how her postpartum course went
 Complicated pregnancy + Complicated delivery= ?
Interpersonal Therapy
 Interpersonal Therapy targets 4 basic problem areas:
 Unresolved Grief
 Role disputes
 Role transitions
 Interpersonal deficits
Menopause
 There seems to be controversy whether there is an
increased risk of depression in the women who are in
menopause
 Perimenopause is the time period where women are
particularly at risk
 8-15% of women will experience depression in the
perimenopause time
Risk factors for perimenopausal
depression
 History of a mood disorder
 Surgical menopause
 History of PMS or PMDD
 History of post partum depression
 Smoker
 Has hot flashes
 Has sleep disturbances
 Current stress level
Case
 KB is 48 year old female
 Hx of OCD that was fairly well treated
 Started having hot flashes and signs of perimenopause
 Noticed that depression was becoming a constant in
her life even though she had not had a depressive
episode since she was in her 20s
Case
 Was already on a maximum dose of Prozac for her
OCD
 Lots of sleep disturbances since starting having
perimenopausal symptoms
The 3 C’s
 Competency (20-35 years old)
 Communion (35-50 years old)
 Creativity (>50 years old)
Conclusion
 The complexity of treating women with depression
across the life span continues to be an evolving field of
practice
 Pharmacological advances are very helpful in this
pursuit
 Taking time to discover the psychological implications
in a patient’s life is valuable- using a psychosocial
model like Erikson’s is just one tool
Bibliography
•
American Psychiatric Assocaiton: Diagnostic and Statistical Manual of Mental Disorders,
Fifth Edition. Arlington, VA, American Psychiatric Association, 2013.

Centers for Disease Control and Prevention. Fast Stats on Depression. August 2014.
www.cdc.gov/nchs/fastats/depression
Cherry, K. About.com Psychology. August 2014. psychology.about.com/od/psychosocialtheories
Cohen LS, Soares C, Vitonis A, Otto MW, Harlow BL. Risk for New Onset of Depression During the Menopausal
Transition: The Harvard Study of Moods and Cycles. Arch Gen Psychiatry. 2006; 63(4): 385-390
doi:10.1001/archpsyc.63.4.385


•
•







Cohen and Nonacs. Mood and Anxiety Disorders During Pregnancy and Postpartum. APA
Publishing 2005.
Cohen et al. Relapse of depression in pregnancy following antidepressant discontinuation: a
preliminary prospective study. Arch Womens Ment Health 2004; 7(4) 217-24.
Druss BG, Schlesinger M, Allen HM (2001). Depressive symptoms, satisfaction with health care, and 2 year work
outcomes in an employed population. American Journal of Psychiatry, 158, 731-734.
Freeman EW, Samuel MD, Lin H, Nelson D. Associations of Hormones and Menopausal Status with Depressed Mood
in Women with No Hisotry of Depression. Arch Gen Psychiatry. 2006;63(4): 375-382. doi: 10.1001/archpsyc.63.4.375
Stewart WF, Ricci JA, Chee E, Hahn SR, Morganstein P (2003). Cost of lost productive work among US workers with
depression. Journal of American Medical Association, 289, 3135-3144.
Tasman, Kay, Lieberman. Psychiatry, 2nd Edition. West Sussex, England, John Wiley & Sons. 2003.
Yonkers YA, et al. Efficacy of low dose oral contraceptives with drospirenone in PMDD. Obstetrics and Gynecology.
2005; 106, 492-503.
Wikipedia. August 2014. widipedia.org/wiki/Erikson%27s_stages_of_psychosocial_development
Wisner et al. Risk-benefit decision making for treatment of depression during pregnancy. American Journal of
Psychiatry 2000; 157:1933-40. doi:10.1176/appi/ajp.157.12.1933