ReviewMenopause and depression: Is there a link?
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.
References (45)
- et al.
Even minimal symptoms of depression increase mortality risk after acute myocardial infarction
Am J Cardiol
(2001) - et al.
Sex and depression in the National Comorbidity Survey I: lifetime prevalence, chronicity and recurrence
J Affect Disord
(1993) - et al.
The epidemiology of depression: an update on sex differences in rates
J Affect Disord
(1984) - et al.
From menarche to menopause: exploring the underlying biology of depression in women experiencing hormonal changes
Psychoneuroendocrinology
(2008) - et al.
Depression and midlife, Are we overpathologising the menopause?
J Affect Disord
(2012) - et al.
Relationships between psychological symptoms, somatic complaints and menopausal status
Maturitas
(1986) - et al.
Psychological well-being, mid-life and the menopause
Maturitas
(1994) - et al.
Depressive symptoms during the menopausal transition: the Study of Women's Health Across the Nation (SWAN)
J Affect Disord
(2007) - et al.
A longitudinal analysis of the association between menopause and depression. Results from the Massachusetts women's health study
Ann Epidemiol
(1994) Bilateral oophorectomy versus ovarian conservation: effects on long-term women's health
J Minim Invasive Gynecol
(2010)
The reciprocal relationship between menopausal symptoms and depressive symptoms: a 9-year longitudinal study of American women in midlife
Maturitas
Basal plasma hormone levels in depressed perimenopausal women
Psychoneuroendocrinology
Estrogen replacement in perimenopause-related depression: a preliminary report
Am J Obstet Gynecol
The impact of attitudes towards the menopause on women's symptom experience: a systematic review
Maturitas
A meta-analysis of the effects of cognitive therapy in depressed patients
J Affect Disord
Fact Sheet 369: Depression
Depression and cancer mortality: a meta-analysis
Psychol Med
Executive summary of the Stages of Reproductive Aging Workshop+ 10: addressing the unfinished agenda of staging reproductive aging
Climacteric
The contexts of midlife in women
Menopause: A Mental Health Practitioner's Guide
The CES-D scale a self-report depression scale for research in the general population
Appl Psychol Meas
Screening for depression in primary care clinics: the CES-D and the BDI
Int J Psychiatry Med
Psychologic distress and natural menopause: a multiethnic community study
Am J Public Health
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