Elsevier

Maturitas

Volume 79, Issue 2, October 2014, Pages 142-146
Maturitas

Review
Menopause and depression: Is there a link?

https://doi.org/10.1016/j.maturitas.2014.05.014Get rights and content

Abstract

Aim

Depression is common and may have significant implications for the individual, their families and work and for the health care system. The menopause transition (MT) may be an ‘at risk’ time for the development of depression. This review aims to explore the relationship between depression and MT and the complex interaction between the biological, psychological and social factors that inform it.

Methods

The literature on depressive disorders and MT is reviewed.

Results and conclusions

Longitudinal studies have demonstrated an association between the menopause transition (MT) and an increase in depressive symptoms. A trend towards higher rates of depressive disorders during the MT, has also been shown, although not always reaching statistical significance. Risk factors for the development of depressive symptoms and depression in the MT include the presence of vasomotor symptoms (VMS), a personal history of depression (particularly depression that is related to pregnancy or hormonal changes through the menstrual cycle), surgical menopause, adverse life events, and negative attitudes to menopause and ageing. A treatment approach to depression during the MT exploits the biological as well as the psychosocial factors that are likely to be contributing in an individual.

Introduction

Depression is the most common illness worldwide, with around 350 million people affected [1] and the burden of depression is rising globally. It can have detrimental effects on an individual's relationships, capacity to work in or outside the home, financial status as well a risk of self-harm and suicide. In addition to the impact on the psychosocial wellbeing, depression has serious implication for physical health. Morbidity and mortality associated with ischaemic heart disease, and cancer are increased in individuals diagnosed with concurrent depression [2], [3].

Depression is around twice as common in women as in men [4], [5], and it has been widely suggested women may be at increased risk during periods of hormonal change such as puberty, pregnancy and the menopause transition [6]. While a clear association between specific hormonal changes and depression has not been established, these observations suggest that these are times of “risk” during a woman's life.

The menopause transition (MT) is the period from infrequent and irregular periods until the final menstruation, this marking the beginning of the post-menopausal period [7]. The MT lasts for 3–9 years and is characterised by fluctuations in sex steroid levels, vasomotor symptoms (VMS), vaginal dryness and loss of libido. It coincides with the Midlife, generally defined as between the age of 45 and 55 years [8] which may be associated with increasing physical health concerns, changing social, work and family roles [9]. As a result, the MT has long been considered a time of physical as well as psychological and social change. More recently there has been increasing interest in prevention of depression, emphasising the importance of knowing which women are at increased risk for depression at menopause so that targeted prevention interventions could be developed. In combination with an ageing population in Australia and many other resource-rich countries, it is important to establish whether the menopause transition is a period of vulnerability to depression, and if so what are the personal and environmental factors that contribute to risk. Further, it is important to know whether the increased risk of depression is confined to the MT or whether it persists in postmenopausal women. This review aims to explore this relationship between MT and depression and the biological, psychological and social factors that inform it.

Section snippets

Sources and selection criteria

We searched Medline and Pubmed, used personal archives of references, and consulted with other experts to inform this manuscript. When available, data from systematic reviews and randomised controlled trials were used. We also used expert guidelines [9].

Depressive symptoms and menopause transition

Depressive symptoms, measured using depression scales such as the CES-D, have been widely studied as a surrogate for the relationship between MT and depressive disorders [10]. They differ in the duration, severity and impact on function. More widely, the CES-D scale is used as a screening tool for individuals who may have a depressive disorder and require further assessment [11]. As a result, depressive symptoms encompass depressive disorders as well as depressive symptoms, which do not

Menopause transition and depression

Three large longitudinal studies all in the United States of America (USA), addressing the relationship between the menopause transition and depressive disorder have reached conflicting conclusions [19], [22], [23]. Bromberger et al. applied structured clinical interviews to diagnosis depressive disorders in 221 woman, from one site of the SWAN study – a multicultural longitudinal cohort study of women transitioning the menopause [22]. Demographics, a history of depressive disorders, and other

Menopausal symptoms and depression

A number of studies have demonstrated an association between the presence of VMS and depressive symptoms during the MT [19], [21], [23], [30]. Sleep disturbance has also been associated with depressive symptoms during the MT [30] and in one treatment study, improvements in sleep, but not reduction in VMS, predicted improved mood [29]. One study found an association between depressive symptoms and painful intercourse [30] however other urogenital symptoms such as vaginal dryness have not been

Hormonal changes and depression (biological factors)

One common factor in the relationship between MT, menopausal symptoms and depression is the hormonal changes that occur during this period. The findings of an association between MT and depression independent of psychosocial factors suggest that at least in part there is a biological basis for this relationship. A relationship between hormonal changes, VMS and sleep disturbance was demonstrated in a study by Joffe et al., who used a GnRH induced model of menopause to demonstrate that

Psychosocial factors

MT coincides with the midlife, a time of social and personal change for many women. There may be changing roles at home and at work, grown up children living at home or moving away, increasing responsibilities and working hours. A decline in physical health, libido, and reproductive potential, as well as negative attitudes to ageing may all negatively impact on mood. A number of studies have demonstrated an association between these psychosocial events of midlife with development of depressive

Treatment

As we have seen, the development of depression during the MT is multifactorial and therefore its treatment requires a bio-psychosocial approach that reflects this. In managing patient with both depression and menopausal symptom during the MT and post-menopause period, clinicians should be aware of the overlap in symptoms between menopause and depression, the potential for depression to exacerbate the impact of menopausal symptoms, and of the bidirectional nature of sleep disturbance and

Conclusion

Depression is a leading cause of morbidity and mortality in our community, both directly and indirectly through its impact on the health outcomes of other diseases. Most women do not develop depression through the MT. However, there is increasing evidence from longitudinal studies that this is a period of risk for new onset or recurrent depression for some women [19], [22], [23]. Further longitudinal studies are needed to characterise this at risk population. The National Institute of Mental

Contributors

Josephine Vivian-Taylor and Martha Hickey: They declare that they have participated in the researching and writing of the manuscript and that they have seen and approved the final version.

Competing interest

The authors have no conflicts of interest.

Funding

There was no funding provided to complete this research.

Provenance and peer review

Commissioned and externally peer reviewed.

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