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Aging: Menopause Interventions for "The Change"
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Section 12
Depression During the Menopausal Transition

CEU Question 12 | CEU Answer Booklet | Table of Contents | Geriatric & Aging
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The perception that menopause leads to mood disturbances such as depression has a long history. How did these beliefs come about, and are they supported by the scientific literature? This article reviews the theories of menopause and depression Menopouse counselor CEUmenopause and depression, the scientific literature, and the implications of these findings for prevention and treatment. Epidemiologic studies of menopausal status and depression do not provide consistent evidence of an association between the menopausal transition and depression among the general population of women. Depression experienced by women transitioning through menopause may be attributed to factors unrelated to menopause. A subset of women, however, may be more vulnerable to the effects of hormonal changes. For some women, short-term estrogen replacement therapy to relieve vasomotor symptoms may be beneficial, although for others psychotherapy or antidepressants may be more appropriate. Additional research is needed to better understand the association between different stages of the menopausal transition and dysphoric mood or depression, and better identification of women potentially at risk for depression during the menopausal transition.

The belief that menopause leads to mood disturbances such as depression, increased irritability, and nervousness has a long history. Some of the earliest writings on menopause refer to psychological or mood characteristics of women at this time. In 1777, John Leake stated in his book Chronic or Slow Diseases Peculiar to Women that the cessation of menses led to “pain and giddiness of the head, hysteric disorders, colic pain and a mid-life female weakness.” He further stated that at this time women are sometimes affected with low spirits or melancholy. In 1887, Farnham summarized the relation between menopause and psychiatric disorder as “the ovaries, after long years of service … become irritated, transmit their irritation to the abdominal ganglia, which in turn transmit the irritation to the brain, producing disturbances in the cerebral tissue exhibiting themselves in extreme nervousness or in an outburst of actual insanity” (U.S. Congress, Office of Technology Assessment, 1992).

In 1896, the German psychiatrist Kraepelin introduced the concept of involutional melancholia as an agitated depression with hypochrondriac or nihilistic delusions that was more common in women than men and first appeared during middle age (Kraepelin, 1896). Although Kraepelin later conceded that involutional melancholia was not a separate clinical entity, but rather a form of manic-depression, other psychiatrists continued to argue that it was a distinct clinical entity. In 1980, the American Psychiatric Association concluded that a unique form of depression did not occur at middle age and subsumed involutional melancholia under the broader category of major depression in DSM-III (American Psychiatric Association, 1980).

The notion that women become depressed, irritable, and suffer from other mood disturbances at the time of menopause continues. This belief prevails among women in general (Avis, 1996) as well as among clinicians (Cowan, Warren, & Young, 1985; Roberts, 1985). In general surveys, high percentages of women believe that women become depressed and irritable at menopause (Avis & McKinlay, 1991; Koster, 1991; Lock, 1986). A recent review found a largely negative portrayal of menopause in the media that has actually increased over time (Gannon & Stevens, 1998).
How did these beliefs come about, and are they supported by the scientific literature? This article reviews the scientific literature on the association between the menopausal transition and depression, and the implications of these findings for prevention and treatment. First, theories proposed to explain a relation between menopause and depression are presented. Following a review of the scientific literature, the implications of these findings for prevention and treatment of women during the menopausal transition, informing health care policy, and future research that might lead to practical benefits for women with depression are discussed.

It is useful to begin by defining perimenopause. The standard epidemiological definition of natural menopause is 12 consecutive months of amenorrhea in the absence of surgery or other pathological or physiological cause (e.g., pregnancy, lactation) that would terminate menstruation (World Health Organization Scientific Group, 1996). Traditionally, the term perimenopause has been used to refer to that period of time immediately prior to the menopause, when the endocrinological, biological, and clinical features of approaching menopause commence, through the first year after the final menstrual period. It is characterized by increased variability in menstrual cycles, skipped menstrual cycles, and changes in hormone levels (World Health Organization Scientific Group, 1996). Operationally, however, the perimenopause has been inconsistently defined (Crawford, 2000). One frequently used epidemiological definition of perimenopause is menses occurring in the past 12 months but with changes in regularity or no menstrual cycle in the past 3–11 months (Brambilla, McKinlay, & Johannes, 1994; Cooper & Baird, 1995). The recently held Stages of Reproductive Aging Workshop (STRAW) determined that the term perimenopause was vague and recommended the use of the term menopausal transition instead and further recommended that this term be distinguished by early and late stages (Soules et al., 2001). Recent studies have also made a distinction between early and late perimenopause where early perimenopause is considered the time when menstrual bleeding becomes irregular and late perimenopause is defined as more than three months of amenorrhea (Dudley et al., 1998; Johannes, Crawford, Longcope, & McKinlay, 1996). In this paper, the term perimenopause will be used when referring to studies that specifically use this term in classifying women's menopausal status. Otherwise, the newly recommended term menopausal transition will be used.

Theories of Menopause and Mood
Prior to reviewing research on the menopausal transition and depression, it is useful to put this research in the context of proposed theories or hypotheses. Each theory has somewhat different implications for treatment. The first two theories are related to declining estrogen levels but differ in the directness of the effect. The first theory is the symptom or domino hypothesis which posits that depressed mood is caused by vasomotor symptoms and sleep disturbances associated with declining estrogen levels (Campbell & Whitehead, 1977; van Keep & Kelherhals, 1974). This theory has been referred to as the domino hypothesis in that vasomotor instability leads to chronic sleep deprivation, which in turn leads to irritability and depression (Schmidt & Rubinow, 1991). Based on this theory, estrogen therapy (or other treatment regimens that reduce vasomotor symptoms) would improve mood to the extent that symptoms are alleviated.

The second theory is the biochemical hypothesis that associates a decline in estrogen directly with biochemical changes in the brain that lead to depression. This hypothesis derives support from the similarity between the pathophysiology of depression and the neurobiologic effects of estrogen. The biochemical hypothesis differs from the symptom hypothesis in that it posits a direct association between estrogen decline or fluctuations and depression (Steiner, 1992; Stewart & Boydell, 1993). In terms of treatment, this hypothesis suggests that estrogen therapy would have a beneficial effect on depression regardless of whether or not a woman is experiencing vasomotor symptoms.

The third theory is the psychoanalytic view, which posits that onset of the menopausal transition is a critical event in the life of a mid-aged woman and is a threat to her adjustment and self-concept (Deutsch, 1945). In the 1940s, psychoanalytic writers such as Helen Deutsch and Theresa Benedek viewed menopause in terms of reproductive loss (Deutsch, 1945; Benedek, 1950). This hypothesis argues that the loss of fertility has a psychological effect that leads to depression and suggests that psychotherapy designed to help women adjust to this “event” is the best treatment approach.

The fourth theory is the social circumstances perspective that states that menopause per se is not associated with depression, but rather the various life events and circumstances coincidental with the menopausal transition are related to depression (Schneider, Brotherton, & Hailes, 1977; Winokur, 1973). This perspective views mid-life as a time of numerous changes in women's lives (e.g., children leaving or returning home, increased health problems, and illness and death of aging parents) that may increase a woman's risk for depression and other psychological disturbances. According to this hypothesis, psychotherapy or antidepressants are the most appropriate treatment for depression experienced by women during the menopausal transition.
- Avis, Nancy; Depression during the menopausal transition; Psychology of Women Quarterly; Jun 2003; Vol. 27; Issue 2.

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Personal Reflection Exercise #5
The preceding section contained information about depression during the menopausal transition.  Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 12
What is the psychoanalytic theory of depression in menopause? Record the letter of the correct answer the CEU Answer Booklet

 
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