Anxiety and Depression in Women

Many women suffer with both major depression and anxiety. Here's why and the difficulties that come with treating comorbid anxiety and depression in women.

1. Major depression in women is twice as common as in men - lifetime prevalence 21% for women. At age 10, the incidence difference begins to differ between the sexes, and peaks by mid to late adolescent.
2. Women are more likely to have an increase in stressors prior to the depression diagnosis than men. Anxiety, panic, somatic complaints, increased appetite, weight gain, guilt, and decreased sexual desire are more apt to be seen in women that men. Comorbid psychiatric disorders are more common. Women attempt suicide more often than men but men are more apt to be successful with the attempt.
3. Why is depression more common in women than men? May be due to genetic transmission or difference in brain structure. Depression is also associated with reproductive function. There are many psychosocial risk factors. Lack of work outside the home may be a risk factor, along with marital conflict (women three times more apt to be depressed in an unhealthy marriage than men) and the presence of young children in the home.
4. Depression and anxiety together usually results in more treatment difficulties - often with the need for higher med dosing with longer duration of med use.
5. Women with anxiety have much more panic and phobia problems than men. Posttraumatic stress disorder in women is more common along with a history of sexual abuse in women with PTSD.
6. Tricyclic antidepressants can have significant side effects once at therapeutic doses to treat depression. The lethal potential is greater than with the SSRI's as well.
7. Panic disorder in women is associated with a more frequent relapse when the meds are discontinued. SSRI's are effective as this is most thought to be due to a serotonin deficiency. Starting at low dose and then titrating up to the mid or higher end of the dosing schedule for any given ssri is the recommended way to go. Beginning a benzodiazepine with the SSRI initially can be acceptable, but it is important to let the patient know that this is a temporary medication.
8. Cognitive therapy is a valuable adjunct to medication use and should not be forgotten.
9. Premenstrual dysphoric disorder (PMDD) - premenstrual and cyclical with mood symptoms (irritability is the hallmark), along with other typical depressive symptoms. Women with postpartum depression, history of mood changes when on bcp's have a higher incidence of PMDD. The theory of this is that there is a decrease in serotonin function. There is also serotonergic dysregulation.
10. Treatment of PMDD - one a day multivitamin plus calcium, diet modification with smaller and more frequent meals with higher carbohydrates and less fat, nsaids can be effective for the dysmenorrhea, and consideration for SSRI medications. The SSRI's work "immediately" to treat the PMDD as they effect serotonin levels immediately. Some may already be on an SSRI and can "bump up" the dose for the one to two weeks of PMDD symptoms. The low dose of an SSRI may be all that is needed to treat the PMDD especially if there is no other comorbid condition such as anxiety or depression
11. Postpartum depression (PPD) can also be well treated with SSRI's. Treatment for a minimum of one year is suggested. There can be an increase in conduct disorders and depression in children of women with untreated postpartum depression. Women with a previous history of PPD do better when given meds prophylactically shortly after the birth or even before birth (ssri's are category C, however -so one must weigh the risks and benefits) if the mother has a history of the depression beginning before the child is born. Minimal case reports of problems noted in babies breastfeeding whose mothers are on an SSRI medications.
12. Depression during the perimenopause: commonly seen together. Early menopause is risk factor, as is surgical menopause.

The Concise Guide to Women's Mental Health is a book that can be obtained from the American Psychiatric Association to get additional advise in medication prescribing in breastfeeding or pregnant women.

Source: Annette Smick, M.D. (Marquette General Hospital), Feb. 2001

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