Transcript Women`s Mental Health Issues

Women’s Mental Health Issues
Dr. Raafea Malik
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Disclosure
The content of this presentation does
not relate to any product of a
commercial interest; therefore, there
are no relevant financial relationship
to disclose.
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Disclaimer
 The
Missouri State Medical Association
cannot and does not provide legal advice.
 This
presentation is informational in nature
and may not be relied upon for legal advice.
 Medical
practices should contact their legal
counsel for assistance.
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Women’s Mental Health Issues

Unipolar Depression
 Dysthymia
 Bipolar Disorder
 PMDD
 Pregnancy
 Seasonal Affective Disorder
 Effects of Oral contraceptives on Mood
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Epidemology
 Women
use more health care
resources:
More visits to doctors office than men
Fill more prescriptions
Have more surgeries and occupy over
60% of all hospital beds
Spend 2 of every 3 health care dollars
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EPIDEMOLOGY (cont.)
 Sex
Difference in Mood Disorder ECA
Study
NCS (National Co morbidity Study)
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Factors Affecting
Gender Differences
in Psychiatric Disorders
Neuroanatomic
Hormonal
Psychosocial
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Neuroanatomical
Sex Differences
 Differences
in brain anatomy
 Glucose metabolism in the brain
 Functional organization of the
brain
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Baseline – before depletion of the plasma tryptophan
After depletion of the plasma tryptophan
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Hormonal
 Estrogen
mostly causes
antidopaminergic and serotonin
enhancing effects
 Progesterone causes modulation of
gama GABA receptors by its
metabolites
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Psychosocial

Rapid social change

New role expectations

Higher rate of poverty and victimization
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UNIPOLAR
DEPRESSION
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Depression in Women
 Genetic
Loading
 Sensitivity to Hormonal Changes
 Reproductive–related Transitions
 Developmental Issues
 Traumatic History
 Child Bearing Responsibilities
 Negative Self-Image
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Psychotherapy
 Poor
response if neurobiological
disturbance is marked
 Effectiveness with both CBT & IPT
 IPT more effective in acute phase
combined
 Combined IPT and pharmacotherapy
most effective.
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Pharmacotheray
TCA’s
Imipramine
Amitriptyline
Nortriptyline
SNRIs
Effexor
Cymbalta
SSRIs
Prozac
Zoloft
Paxil
Lexapro
Celexa
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DYSTHYMIA
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Prevalance
3
– 6 % of adult population
 36%
of patients in psychiatric outpatient
 75%
comorbidity with anxiety and
substance abuse
 40%
have coexisting major depression
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Risk Factors
Biological
Psychological and Social Cultural
Balancing of roles
Parenting
Less than high school education
Unemployment
Young children at home
Past history of sexual abuse
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Treatment
Pharmacotherapy
SSRI vs. TCA’s
Psychotherapy
Interpersonal
Cognitive behavior therapy
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BIPOLAR
DISORDER
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Bipolar Disorder
 Lifetime
prevalence of mania 1.7% in
women and 1.8% in men
 Rapid cycling is 3 times more common in
women
 More likely to have dysphoric than euphoric
manic
 More likely to experience depression
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Why is rapid cycling more
common in women?
1.
2.
3.
Possibly due to the increase use of
antidepressants as they present with
predominantly depressive symptoms
Increase incidence of hypothyroidism in
women
Effects of fluctuating gonadal steroids on
neurotransmitters
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Genetics and Gender

Adoption and twin studies show a genetic
component
 1% in general population and 9% in a child with
one parent with bipolar disorder
 There are at least four genetic mechanisms that
account for difference in parent-of-origin
 X linkage
 Genomic imprinting
 Mitochondrial inheritance
 Trinucleotide repeat expansion
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Treatment

Considerations
1. Side effects can determine
compliance
2. Women in child-bearing age
3. Mood stabilizing vs. atypical antipsychotics
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PMDD
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Premenstrual Dysphoria






80 – 90% of women complain of at least one
symptom
10 – 20% have moderate to severe. 3 – 8% have
severe
Highest risk age 25 – 35 years
Causes major impairment in personal relationships
High axis I Co morbidity
70% report combination of emotional and physical
symptoms, while 14% only reported emotional
and 9% report physical symptoms
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Diagnostic Criteria for PMS
Affective Symptoms
Somatic Symptoms
 Depression
 Breast Tenderness
 Angry
 Abdominal
Outburst
 Irritability
 Anxiety
 Confusion
 Social Withdrawal
Bloating
 Headaches
 Swelling of
Extremeties
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Risk Factors
Increase nicotine use
Poor overall health status
Postpartum depression
Family history of PMDD or depression
Mood changes with OCP’s
 Independent genetic
factors from depression
 No association between cycle length or
dysmenorrhea
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Burden of Illness
 Relationship
problems with negative effects
on marriage (83%), children (61%), friends
(41%)
 Interference with work (27%), household
chores (45%) and 15% reporting more than
6 days of work missed per year
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Etiology
 Mostly
multifaceted
 Abnormalities in gonadal hormones and
interaction with certain neurotransmitters
 Abnormalities in Serotonin, GABA,
dopamine and acetylcholine
 Environmental vulnerability to PMS include
childhood abuse, poor support system,
interpersonal difficulties, lack of paternal
warmth, recent stressful event
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Diagnosis
 Clinical
symptoms
 Daily symptom diaries
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Treatment
 Hormonal Treatment
Suppression of ovulation by GnRH agonists
with a decrease in estrogen and progesterone
Oral contraceptives with estrogen, progestin
combination
Progesterone only during luteal phase
Bilateral salpingo-oophorectomy with
hysterectomy
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Treatment

Psychotropic treatment of PMDD
 SSRI’s are the first line treatment for severe PMDD
 Efficacy rate 60 – 70%
 Lower doses than are required for treatment of
depression
 Serotonergic agents are all effective
 Prozac, Zoloft, Paxil are all approved for it
 Contraceptives and intermittent dose strategies are
available
 Anti anxiety agents including Buspar and Benzodiapins
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Dietary Supplements
and Vitamins
 Vitamin
B6
 St. John’s Wort
 Black cohosh
 Kava
 Primrose oil
 Calcium
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Complementary and
Alternative Treatments
 91%
of women have tried these
 Vitex agnus castus
 Biofeedback
 Massage
 Reflexology
 Chiropractic
 Manipulation
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Lifestyle Modifications
 Reduction
of Caffeine
 Reduction of refined sugar
 Decrease Alcohol
 Decrease Salt
 Decease Red meat
 Increase Complex carbohydrates
 Increase aerobic exercise
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Other Treatments
 Cognitive
Behavioral Therapy
 Psychoeducational support groups
 Peer support
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MOOD DISORDERS
IN PREGNANCY
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Psychopharmacology
during Pregnancy
 General principles
All agents cross placenta and exposure to
fetus can depend on dose, route of
administration, length of exposure
FDA Recommendations
Risks associated with pregnancy
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Guidelines for Treatment
of Pregnant Women





Antidepressants should be tapered prior to
attempts at conception, if symptoms are not as
server and no prior history of episodes
Drug therapy should be avoided during first 10
weeks
ECT is an option if there is a risk to fetus or
mother
Fluoxetine is well-studied and does not produce
a risk of birth defects or neurodevelopmental
defects
If TCAs are appropriate, nortriptyline is
preferable
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TCA
 No
evidence of iatrogenesis
 Long-term follow up studies up to 7 years do
not show any neurobehavioral abnormalities
 Toxicity and withdrawals
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Neonatal Behavioral Syndrome

Symptoms:
 Cyanosis
 Tachypnoea
 Tachycardia
 Irritability
 Hypotonia
 Tremor
 Feeding difficulties
 Urinary retention
 Bowel obstruction
 Profuse sweating
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SSRI
 Safety
of use
 Risks of toxicity and withdrawal
 Long-term follow-up
Prozac
Zoloft
Paxil
Lexapro
Celexa
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Lithium





It should be discontinued at delivery
One month lithium levels during first half and
once a week later on should be kept at 0.9
Ebstein anomaly 4 -12% compared to 2 – 4% in
general population
No behavioral teratogenicity
Neonatal lithium toxicity include poor sucking
and cyanosis
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Anti-convulsants
 These
include Depakote, Lamictal, and
Carbamazepine
 Important to monitor serum levels
 First-term exposure increase birth defects
specially spina bifida
 Provide counseling to individual
 Ultrasound, fetal echo 16 – 18 weeks, with
serum or amniotic fluid and fetoprotein
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Anti-convulsants (cont.)
 Taper
anticonvulsants 1 week before
delivery to minimize neonatal
 Consider tapering over the last 2 weeks
to avoid a high ratio of recurrence
 Spina Bifida in general population is
0.03% and with Depakote increase 15
fold to 1 – 5% and 0.5 – 1.0% in
carbamazepine
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Antipsychotics
 Some
association between anomalies and
phenothiaine but no association with new
atypical antipsychotics
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Benzodiazepines
 Duration
should be minimum
 Infrequent use is not associated with
neonatal difficulties
 Anxiety should be treated with anti
depressants
 Lorazepam is drug of choice due to
decrease rate of placental transfer, and no
active metabolites
 withdrawal syndrome can occur
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Seasonal Affective Disorder
 Women
are 6 times more likely
 Symptoms
 Atypical presentation
 Treatment including light therapy and
pharmacotherapy
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Oral Contraceptives and
affect on mood
 Types
of OCP’s
 Estrogenic progestrone and androgenic side
effects
 High-risk population
 Management
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