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The Context of A Womans Life: Does It Affect the Treatment of Her Depression?Joyce A. Spurgeon, MDNovember 2015So, today I have been asked to speak with you about women and depression. I thought it might be interesting to approach this talk a little differently. I can sit up here and spout statistics to you and review some of the pharmacology that has been studied. We will do a little of both these things. However, I am going to ask you to bear with me and allow me to do something frankly that I have wanted to do for a long time. Indulge me if you will.I want to talk to you not only about the facts of treating depression in women but also about some of the things that I have learned about treating women just bywell, by doing it.

1OutlineDefine the problemReview Eriksons stages of psychosocial developmentReview specific time periods in womens life with unique risks involvedThe 3 Cs of development

The outline of todays talk is pretty simple. We are going to define the problem. I am going to review a few of Eriksons adult states of development because the concept of psychosocial development very much interests me. In this context some of Eriksons ideas are helpful in trying to make sense of what I am trying to say. We are going to then walk through a womans life cycle pausing to identify and explore briefly some of the unique experiences to women. Finally I plan to share a concept that a good friend of mine introduced me tohe gave me permission to talk to you about it because I warned him that he should probably write a book about it before he allowed me to steal it! It resonates with me in a way that I am hoping might bring some of Eriksons ideas into a more current world framework for us.2A Problem?Number of non-institutionalized people 12 or older with depression in any 2 week period from 2007-2010- 8%Number of visits to PCP in 2009-10 with depression as the primary diagnosis- 8 millionNumber of suicide deaths in 2010- 38,364Suicide deaths per 100,000 in 2010- 12.4Before we can do anything we have to look at the problem. So, this first slide is simply a stats slide.I dont know that we need to establish that depression is a problem in this group of people, but I thought I would at least give you a few numbers to ponder. These stats are all from the CDC3MorbidityDepression is the leading cause of medical disability in people ages 14-44.Depressed people lose 5.6 hours of productive work every week that they are depressedIn any 30 day period, depressed workers have 1.5-3.2 more short term disability daysFor those people who make all the decisions about policy, you also have to prove that depression costs money if not treated so I included a few little stats on loss of productivity associated with depression. I dont think that we need to belabor these points. I also cant imagine that I need to talk to this audience how depression devastates more than just the economics of a persons life- it is destructive to all aspects of a persons life.4Depression RatesGirls and boys before puberty and after menopause have the same rates of depressionAfter menarche, girls develop depression 2 times the rate of boysThis rate holds true through numerous studies including ECA and NCSThe WHO gathered data from 14 countries and it was consistent with 2:1I do want to focus a little bit on the difference between men and women with depression. Again, this always sort of makes me want to giggle and say men and women are different.REALLY? Sometimes stating the obvious is fun! In reviewing the literature there are suggestions that the accepted rate of depression being 2:1 women:men is only true after menarche and through menopause. So, before puberty and after menopause (for those of you who are still thinking at this point- this is the time when the sex hormones play a much smaller role in womens lifes) girls and boys and women and men have the same incidence of depression. This rate holds true across a lot of the big studies like the epidemiological catchment study (ECA) and the National Comorbidity Survery (NCS). The World Health Organization also studied this ratio in 14 different countries to try to evaluation if there were cultural differences with this presentation and the data held up that the ratio is 2:1.5Presentation differenceWomen are more likely to show reverse neurovegatative signs of depressionWomen have more co-morbid diagnosis like GAD, panic, phobias, eating disordersMen are more likely to have substance abuse issues as co-morbid issuesThere are also some differences in presentation of depression in women and men. Women are more likely to have reverse neurovegatative signs like weight gain and increased sleep compared to men. The co-morbid diagnoses also tend to be different.6Erikson slidesEgo identity- the conscious sense of self that we develop through social interactionsThis changes through new experiences and information we acquire through social interactionEpigenesis- the stepwise process by which genetic information, as modified by environmental influences, is translated into the substance and behavior of an organismSo, we have established that depression in women is a problemnow lets dabble for a bit into some of the things that we can learn from Erik Erikson. For those of you who were undergrads in psychology or love studying the history and theories of human behavior.forgive me in advance.I am going to do a quick review so that we can all start on the same page. For those of you who are trying to remember who Erikson is and whether you can remember any of those stages this is for you!Erikson was a follower of Anna Freud. The main element of his theory and part of what makes his ideas fit so well in this talk is that he was very interested in the development of ego identity. He believed that ego identity was the conscious sense of self that we develop through social interaction. This is obviously a constantly changing thing because it must adapt and integrate new experiences and information that we acquire through social interaction. Eriksons earlier stages follow closely with Sigmund Freuds except without the sexual bent. We arent going to review the earlier stages today. I want to review a few of Eriksons stages that are pertinent to our talk today.I have included the biological definition of epigenesis.the concept of epigenesis from a behavioral theorist view is that basically all things unfold in a process of stages- these stages all have relationship with one another. Most of us would agree that people who struggle with earlier stages show signs of these struggles even when they might have progressed to a later stage. He also worked hard to look at both the internal and external things that affect development- I think this concept is why I am trying to integrate his theory into my talk today. The longer that I am a psychiatrist the more I see demonstrated through patients that rarely is a disease strictly biologic or strictly psychosocial stressors. It is almost always a combination of the two. Add some of the existential crises that people experience and you have a set up for ending up in a psychiatrists office. 7Identity versus Role ConfusionAges 13-19 years oldWhat role am I going to play as an adult?Concept of fidelity the ability to sustain loyalties freely pledged in spite of the inevitable contradictions and confusions of value systemsPsychosocial moratorium I included this stage because I think that as society has changed this stage really does extend a little later in life and thus affects some of the people that we are going to be talking about. The question of this stage is reallyWhat role am I going to play as an adult? This stage is the idea of bridging the gap between childhood and adulthood. The success of this stage leads to the concept of fidelity or the ability to commit ones self to others based on accepting others even when there are ideological differences. Erikson also introduced the concept of a psychosocial moratorium which is the idea that people must have enough time and space to freely experiment and explore enough to emerge with a firm sense of identity and the depth of awareness of who and what she wants to be. I like this concept because without exploration of ones self there is little depth of understanding. I still believe that if people understand what makes them respond the way that they do, they are more likely to be able to make some changes if needed to that response.8Intimacy versus IsolationAges 20-39Can I love?Distantiation: the readiness to isolate and if necessary to destroy forces and people whose essences seems dangerous to our own and whose territory seems to encroach on the extent of ones intimate relationsThe next stage is intimacy vs. isolation- the age ranges on this one start to get a little wider. It goes from 20-39. The real question is.Can I love? Intimacy in this case does not necessarily mean sex. It really is about finding lasting deeper relationship whether it be with a partner or with friends. As you might imagine, this stage depends on a person having fully completed the last stage so that they can be ready to enter an intimate relationship as a full already established identity in their own right. Well, at least that is the idea in a perfect world!There is also a counterpoint to the concept of intimacy in this stage. Distantiation is the readiness to isolate and if necessary to destroy forces and people whose essence seems dangerous to our own and whose territory seems to encroach on the extent of ones intimate relations. Obviously, this would lead to extreme isolation. 9Generativity versus StagnationAges 40-64Can I make my life count?Central Tasks:Express love through more than sexMaintain healthy life patternsDevelop sense of unity with mateNo longer center figure in childrens livesReverse roles with parentsAchieve responsibility in all aspects of lifeAdjust to the physical changes assoc. with agingThe last stage that we are going to look at is generativity vs. stagnation which runs from age 40-64. The main existential question in this stage is..can I make my life count? Generativity is primarily the concern in establishing and guiding the next generation. There are several tasks that are listed on this slide that are all things that are supposed to be accomplished during this stage.

So this completes the quick and dirty review of Eriksons stages.we will be revisiting some of these topics as we go through our list of issues. Again, I am asking you to think about Erikson this morning as we progress through the life cycle because understanding the developmental stage that a person is struggling with sometimes gives you some clues on what is going on in their head as well as their heart and soul. Now we are going to transition into some of the different conditions for us to consider that are unique to a womans life.10PMS75% of women with a normal menstrual cycle experience some symptoms of PMSWomen in the US tend to show more affective symptomatologyWomen in other countries are more likely to complain of physical symptomsWomen with higher educational levels are more likely to have heightened severity of complaintsWe are going to talk about Premenstrual Dysphoric Disorder. However it is difficult to talk about PMDD without first touching on the idea of PMS. When I taught a lecture about women to the PGY-2 residents this is where a collective groan and eye rolling occurred. The guys quickly realized that they could say nothing right on this topic and the girls were already starting to collectively share empathetic looks with each other. So, PMS affects about 75% of all women who are having normal periods. I think it is interesting that there are cultural differences in the presentation of PMS. US women are more likely to talk about irritability, mood swings, and feelings of tension. While women in other countries are more likely to complain about swelling, breast tenderness and back pain. Again, PMS is normally something that is an irritating factor in a womans life but not something that makes her non-functional.11PMDDIn the majority of menstrual cycles, at least 5 symptoms must occur in the final week before the onset of menses, start to improve within a few days after menses starts, and become minimal of absent in the week post-mensesOne of the following symptoms must be present: (Criterion A)Marked affective labilityMarked irritability or anger or increased conflictMarked depressed moodMarked anxiety, tension, or feelings of being on edgeDSM 5 definition of PMDD12PMDD, continuedOne or more of the following must be present to reach a total of 5 symptoms when combined with aboveDecreased interest in usual activitiesSubjective difficulty in concentrationLethargy, easy fatigability, or marked lack of energyMarked change in appetiteHypersomnia or insomniaA sense of being overwhelmed or out of controlPhysical symptoms such as breast tenderness or swelling, joint or muscle pain, a sensation of bloating or weight gain13PMDD, contMust cause significant distressDistress is not merely an exacerbation of another disorderShould confirm Criterion A by prospective daily ratings during at least two symptomatic cyclesNot due to substance abuse or a medical conditionI think that the criteria that distress not merely being an exacerbation of another disorder is interesting because it is not uncommon for women with other disorders to notice that their symptoms are worse during the luteal phase. Some would argue that these women should be diagnosed with their primary illness and pmdd as well.14PMDD TreatmentPharmacologic: SSRIs have been extensively studied and all have been found to be effectiveLimited studies of SNRIs show efficacyLuteal phase dosing effective and may be the treatment of choice initallyConsider birth control pills/ patch in consultation with OB/GYNAugmentation of SSRIs for any residual symptoms

Treatment of PMDD can be tricky at times. I will tell you that the diagnosis is the key in my opinion. You need to be very clear that the onset of symptoms is very defined when it comes to diagnosis. The people that I have had to respond best to pharmacological treatment have been the ones who have the real onset within 5-6 days before their period starts and the symptoms remit with the beginning of menses. The criteria suggested that you have the woman chart her mood and menses over 2 months time. If you can get them to do this, it can provide you with some really helpful information. Woman who have symptoms a lot of other times during the month are less likely to feel better on the medication as we sometimes use it. So, for clear PMDD cases you should be able to treat with a SSRI in the luteal phase which is normally considered day 14 until menses. There is limited data on SNRIs in PMDD. I rarely use them because if a SSRI doesnt work then I normally consider hormone treatment of some kind as the next best step.or sometimes it is a step we do in addition to the SSRI treatment if there is a partial response. Most people have heard of Yaz which was the only FDA approved OCP for PMDD at one point (there might be more now). There have been some good studies that show low dose contraceptive pills usually the ones that have a combination of ethyinyl estradioal and drosperinone can be helpful in treating PMDD. Some other options for women who are really struggling for functioning during that time is to use a form of birth control that stops menses and ovulation all together. I am definitely not professing to be an OB/GYN but my patients who have been the sickest with this have really benefitted from having an OB/GYN who would listen to them and help them try to decrease the number of days per month that they are impaired. 15Nutritional and Lifestyle Modifications in the Treatment of PMDDCalcium supplementation 1200 mg/day has been shown to improve some symptomsExercise has been shown to decrease symptomsLimit caffeine and alcohol intakeStress reduction techniques are helpful

There are also some lifestyle changes that should not be overlooked particularly for those people who do not like to take medications. There has been some evidence that these are helpful. I have to be honest that by the time someone gets to see me.these have usually already been tried and not been found to be helpful.

16Psychosocial IssuesIt is not uncommon for PMS to be a problem during adolescenceIt is not uncommon for my PMDD patients to be in their early 20sWhat does this time period hold for women?Trying to keep these illness within a psychosocial context is challenging.we have already reviewed some of the Erikson stuff. Young women are trying to figure out what they are going to be and who they are during this time. It is with the start of menses, that girl begins to the transition into womanhood. For some women this is a very difficult transition. There are all sorts of traumas and life experiences that make menses and its monthly occurrence something that is difficult. Add to the emotional effects of this the fact that physically they are uncomfortable and it seems like you have a formula for the perfect storm. Let me use a case to demonstrate.17CaseAJ is a 21 year old womanPresents with pretty typical PMDD which responds well to treatment with SSRIShe realizes that the PMDD symptoms are much better with treatment but wonders about some of the underlying sadness that she feelsSadness does not meet criteria for any of the mood disorders

18CaseShe keeps coming back because she feels like there should be something more that can be done for her because most of her friends do not feel this wayIn reviewing AJs history more in depth because she keeps asking is there anything we can do for the sadness. It becomes quite clear that some of the trauma of AJs past is interfering with her ability to figure out who and what she wants to be. She went away to college and feels like she separated appropriately from her parents. She doesnt feel like she has any more stress than the normal junior in college. Once her PMDD was adequately treated, she felt like she was functioning much better. However, if we had stopped treatment with just that, we would have missed a whole important part of her treatment. Once AJ got into treatment with a therapist, she was finally able to talk about some of the abuse that she suffered as a child. This abuse played a role in her PMDD because her monthly cycle was a reminder to her of how many times she had to count the days to make sure that she wasnt pregnant at a time in her life when she shouldnt have been worrying about such things. While she really felt like she had dealt with this trauma in the therapy she had as a kid, she realized over time that as she really transitions in her life stage to her adult self that some of those things that she thought she had sort of figured out had reared their ugly head again. In the treatment of women who have overcome traumas (as much as anyone overcomes them), it is interesting to note the AJ is not the first one that I have met that has to struggle to keep their trauma compartmentalized when there is a major life transition.AJ really viewed herself as finally becoming an independent woman at this stage of her life- she had decided on a major and a career path, was in a good relationship, and really felt like she had found her way out/away from the trauma of her childhood. I have learned and continue to learn a lot from her as she goes forward in her journey. The complexity of her case was not in treating the PMDD. She really did have all the basic good prognostic signs- symptoms started 5 days before her menses and completely resolved with menses. She responded well to the low dose of Prozac we gave her to treat thisshe only had to take it for about a week of each month. However, her otherwise untreated discontent for lack of a better word became something that she realized was impeding her life in multiple areas. Even more exciting for me was that she was willing to do something about it. For the first few sessions that she came to me because she thought since the Prozac worked so well that surely I had something else that could help her.I had to work really hard to convince her that what was going on with her wouldnt be solved by a pill. Once that sunk in, she decided that she was willing to do the work to discover what was going on with her. It really did come down to some of the transitions that were occurring in her life were stirring some of her old stuff but also challenging some of her new beliefs as well. We are still able to laugh about the fact that getting better sure is hard work and that if I could just develop that magic pill to end pain and suffering that I would be doing people a big service!!!

Next we are going to talk about pregnancy. This is my area of interest so I am going to try to stop myself from going overboard with information. 19Pregnancy10-20% of women will suffer depression during pregnancyStandard of care used to be- no treatment during pregnancyNew standard- do risk/benefit analysis on each patientWomen who discontinue their antidepressant before conception have a 68% recurrence rate of depression during pregnancyWomen who continue their medication have a 26% recurrence rate

I think the take home point that I really want you to have about treating women during pregnancy is that pregnancy is not a protect state!

According to Cohen et al. They did a longitudinal cohort of 32 women with a history of depression who were euthymic at conception on antidepressant therapy. All discontinued or tried to discontinue their medication when they found out that they were pregnant. 75% relapsed during pregnancy. 79% relapsed during the first trimester

20Pregnancy1/3 of pregnant women meet criteria for a psychiatric diagnosis, only 25% get treatmentThe estimates are that about 3% of pregnant women are exposed to antidepressantsOne study reported that there has been an increase in SSRI use in the US in pregnant women from 2.5% in 1998 to 8.1% in 2005Wisner, et al. in 2009 estimated of the 4,000,000 babies born in the US, 100,000 are exposed to SSRIs

Again more stats that make us at least look at the fact that this is a problem that is growing. Or, it might not be growing in real numbers but it is being recognized more readily.21

This is my favorite graph of all times on how to do a risk/benefit analysis of treatment during pregnancy! Go through a brief overview of the graph22Consequences of No TreatmentIncreased risk of preterm deliveryWomen are much less likely to seek appropriate prenatal careMore risky behaviors- smoking, drinking, etc.Some evidence of increased adverse obstetrical outcomesIncreased risk of postpartum mood disordersBecause people are quick to hold onto the risks of taking medications, it is always important to review that there are risks to no treatment as well. 23Case23 year old married, white female comes in at 14 weeks gestation.She has no significant psychiatric history although she identifies that she has felt sad a lot in her life but never treatedPlanned pregnancyHas lots of conflicts with her family of origin and is desperate to have things go differently for her baby24CaseShe cries through the entire interviewPt denies SI but describes inability to eat, poor concentration and attention to the point that she cannot do her job, feels guilty about exposing her baby to these feelings, energy level is poorHas some co-existing worry about how she let herself get this far down25CasePt. has good social support from her husband but has isolated from friendsSo, why is this case important? Again, I am trying to teach you a little about what I have learned from my journey with these women. This was a patient that I followed all through pregnancy and post-partum. In fact, you need to remember the basic facts from her case because we are going to talk about her again in the post partum time of this lecture. Through her pregnancy, this patient struggled mightily. She did not want to take medications because she was unable to accept any risk that the medications might have on her baby. At the beginning of treatment this was acceptable. She was depressed but seemed to be willing to work in therapy and really seemed motivated. This was a case in which I talked to her OB/GYN several times over the course of her pregnancy particularly about the fact that the patient did not seem to be gaining the appropriate amount of weight with her pregnancy. Her symptoms also seemed to escalate as her pregnancy progressed. She went from depression to developing a crippling anxiety where she was having panic attacks at the thought of interacting with anyone. Eventually as the symptoms progressed and her functioning declined to the point that she was not even able to drive herself to her appointments, her treatment team all decided that it was time for medication. She reluctantly agreed. I would love to say that she immediately got better but really she got a little more functional with the medication but she remained pretty depressed and quite anxious. Several months before she was to deliver her mother and father who she had a difficult relationship with anyway decided to move to Japan. While patient felt some relief to just have them out of the picture, this opened up a whole different process for her in that she felt totally rejected by them. Rejection had been a long term issue between she and her parents but this just put it up to an entirely different level. As a psychiatrist, all I could think is.really? We have to stir all that up now when we are trying to get this girl functioning????She was as stable as I could get her at delivery which essentially means that she wasnt crying every day and her panic attacks were more manageable. She was limitedly attending therapy but felt a greater attachment to me than to her therapist (which has good and bad points to it). Always remember though that a lot of times you can get women to do things for their unborn child that they wont do for themselves.it is bad that we have to use that card from time to time but when someone is really sick, use what you know to get them the treatment that they need!.of course, because the cards were never going to work out easy- she had a complicated delivery of a 6 lb baby. Pt. ended up needing a c-section and she just felt like all of it did not go well. Having talked to the OB/GYN who delivered her, some of it was just normal stuff that happens in deliveries but patients heightened anxiety and depression did not make this easy from her perception. And really when you are the treating therapist or psychiatrist her perception is usually all you have to work with.I bet many of you are thinking.hmmm.I bet the postpartum course was interesting.well stay tuned..we will get there.26Post Partum Blues50-85% of all new mothersSymptoms begin in first few days and last up to day 10Central feature: marked lability of mood which seems to have a heightened response to stimuliPresent in a large percentage of every cultureUp to 20% of women will go on to experience a depressive episode in their first postnatal year

So these are pretty easy to recognize in that these woman cry at everything and with every emotionthey are normally not just crying because they feel sad. 27Post Partum DepressionIn the DSM-V, this would be the diagnosis of major depression using the specifier with peripartum onsetMood symptoms occur during pregnancy or in the 4 weeks following delivery50% of postpartum episodes actually began prior to delivery28Post Partum DepressionApproximately 13% of women will suffer from postpartum depression500,000 women in the United States each year will struggle with this disorderThe risk for adolescent mothers is much higher with the rate being up to 26%12.5% of all admissions to psychiatric hospitals in women occur in the first year postpartum

29Risk Factors for Post Partum DepressionPersonal family history of a mood disorderPostpartum bluesPrevious episode of postpartum depressionPsychosocial issuesPovertyAdolescent motherDepression/anxiety during pregnancy

30CaseWe are going to continue the case from pregnancy- to see how her postpartum course wentComplicated pregnancy + Complicated delivery= ?

So, add a complicated delivery (per patient) to a complicated pregnancy and that equals a complicated post partum course!!!Pt. was seen 5 days post partum in my office.I must say that this is the earliest that anyone has ever come in after having a baby particularly by C-section. She wanted to tell me about the horrors of delivery which I listened to.but it was clear that she was struggling with something else. She kept saying that she loved her baby but there was something about the repetition that worried me. She finally admitted that she was doing all the things that she knew she was supposed to do for the baby but she didnt feel anything. She was mortified to tell me because she was afraid that it confirmed that she was going to be the same type of mother that her mother was- she was not going to be emotionally or even physically present for her baby. So, while I thought that this patient had made the separation between herself and her mom, there were obviously still some concerns in the patients mind that she was still part of her mother. To complicate things even more, it was like she had some issues with identity as well as some of the next stage of intimacy. She was fairly certain that her ability to maintain a loving relationship not only with her child but with her husband as well was completely flawed and was something above her capabilities. Add a newborn, a husband who works a lot to provide for the family, no family support, and all of these issues and you can probably already figure out that this was complicated. We decided at this point that her first therapist was not a good fit for her and worked on getting her in with someone who would be willing to see her more frequently and would allow her to bring the baby with her because she didnt have any childcare.

I will tell you that she is actually doing quite well now. It took some time to get there but she is definitely attached to the baby now in a way she missed out in the early months. She was able to do some of the practical things that can help with attachment even when the mom is not feeling it like baby massage and stuff. She was also very motivated to be okay because she knew in her heart that she loved this baby which helped keep her on track with her treatment.

One of the things that is most clear to me from treating a lot of women with postpartum issues is that this is a time of major role transition. Even if the woman has no major family dysfunctional issues (and really who doesnt have something/someone dysfunctional in their family??), this is a time when these relationships are all re-evaluated or re-defined within the context of the woman having a baby who is dependent on her. Some common questions that I get asked .When they handed me my baby, I realized that I loved him or her with my whole heart. It made me wonder why my mom didnt love me like that?

As I see how dependent babies are on their parents to take care of them, I wonder how my mom survived this without any help. I wonder if I can survive it.

I woke up the day after I had my baby and realized that this person is completely dependent on me to teach him/her about life. I am not sure based on my own life that I am ready/qualified for the job.

As you can imagine these questions can become all consuming particularly when we start thinking about the fact that the person thinking them are in a hormonal jumble time in their life as well as most probably sleep deprived and not feeling like their best selves..31Interpersonal TherapyInterpersonal Therapy targets 4 basic problem areas:Unresolved GriefRole disputesRole transitionsInterpersonal deficitsI just throw this slide in to remind us that interpersonal therapy plays an important role in the treatment of depression during pregnancy and post partum. I think that our case clearly outlines why a therapy with this type of focus might be particularly helpful in this population.

However, there is also some evidence that it prevents time to relapse.So for people who have had depression in the past and stop their medication to try to conceive. Median time to relapse without maintenance therapy is 21 weeksTime to relapse with maintenance ITP 54 weeks

This slide is also to remind us that there is more going on during any of these time periods than just the biological factors. It reminds us that maybe Erikson knew what he was talking about with his psychosocial theory!32MenopauseThere seems to be controversy whether there is an increased risk of depression in the women who are in menopausePerimenopause is the time period where women are particularly at risk8-15% of women will experience depression in the perimenopause timeSome of the controversy is because the flaws that have been found in research- lack of proper characterization of menopausal staging, intertwining psychological distress with depressive symptoms and clinical depression

There are some studies that suggest that the flucuation in the hormone level is more predictive than the hormone level itself.33Risk factors for perimenopausal depressionHistory of a mood disorderSurgical menopauseHistory of PMS or PMDDHistory of post partum depressionSmokerHas hot flashesHas sleep disturbancesCurrent stress level

There is also some evidence that treating with hormones might decrease the risk of depression during the perimenopausal time. The hormones might also help decrease the physical signs that also can be interfering with some basic biologic functions like sleep which obviously is helpful to treat depression. While there is a lot of controversy on the use of hormone replacement- it is important to note that this is not hormone replacement throughout the rest of the womans life- it is suggesting hormone replacement during the perimenopausal period.

34CaseKB is 48 year old femaleHx of OCD that was fairly well treated Started having hot flashes and signs of perimenopauseNoticed that depression was becoming a constant in her life even though she had not had a depressive episode since she was in her 20s

35CaseWas already on a maximum dose of Prozac for her OCDLots of sleep disturbances since starting having perimenopausal symptomsMenopause is time that marks the end of a womans child-bearing years. This is a major transitional time for most women whether they had or wanted children or not. It also occurrs in a time period in a womans life anywhere from 45-55 where they are beginning to think about what is going to be the next stage of life. KB was a patient that I have seen for quite some time. The beginning of menopause was very difficult for her because it was the end of several dreams for her. This was a patient with several traumas in her teenage years after losing her mother at a young age : she witnessed her brother being killed in a motorcycle accident and her sister died of some complications to a fairly routine procedure in the hospital. She was fairly emeshed with her father until his passing when she was in her late 20s. She came to treatment with me in her mid 30s because her old psychiatrist had retired. Her goal of treatment was to have an adult relationship with a man. She had never had any type of adult relationship in her life. She was embarrassed to say that she thought she might be the oldest virgin in the world- while the thought of sex was not her primary motivation- she really just wanted to have the companionship of a date. This was never achieved. She could not tolerate anyone getting too close to her. By the time that she entered perimenopause she was not only having symptoms but she was grieving what she felt like she never got the chance to have- a relationship with a man or children. Menopause became the transition where she viewed that these things were forever lost to her (nothing like a little catastrophic thinking). While the symptoms of menopause were difficult to treat, we were able to get her sleeping a little better with medication which did ease some of her depression. Yet, it seems like her depression was actually more of a difficulty in dealing with this major life transition particularly in light of many of the psychosocial issues that she was grappling with.

She never felt like she detached appropriately from her family of origin. To the ones who are left in her family, she remains the emotionally sick one even though she is actually functioning quite wellShe was never able to allow anyone into the intimacy that she so longed to experience with others. I can remember the day in my third year of residency after I had been seeing her weekly for a year and a half when she finally cried- it was a break through only in that she had finally allowed herself to express some of the emotion to me that she normally kept so shoved within herself.

Finally she was really asking how at this point she could make her life count.she wasnt sure and still is pondering how to answer the question to herself as to why she is here on this earth and what she is going to be able to leave behind.

I hope that these cases having illustrated to you how the biological factors are just one of the things that we have to deal with in patient care. The psychological factors are intimately intertwined within the therapeutic space. Understanding patients developmental stage issues can shed light into their current struggles even when sometimes it might appear that they are unrelated. 36The 3 CsCompetency (20-35 years old)Communion (35-50 years old)Creativity (>50 years old)I want to end with this.So this is a concept that a friend of mine has developed which actually mimics Eriksons in a lot of ways. This truly is another framework for psychosocial development.Competency occurs in your younger adult years. This is the time that you work on becoming who you are going to be.whether this be professionally or personally. You find your lifes path and you develop a certain amount of feelings of confidence about your achievements. Most people during this time have established a job/career path. It is common that people have had children if they want to or have found a partner in life.to achieve this stage you basically become comfortable with what you do in your day to day life.

Once you figure out how to be competent, your emotional energy begins to shift to communion. Communion is the desire to be in relationship with others. Once you have found the competence in your role, you can begin to explore your deeper emotional relationship with others. Who do you want to be in the lives of the people who you love? What kind of mother, wife, sister, friend do you want to be? Are you in relationships now that will sustain you as you move forward in your life? Who is the person that you see at the end of the day when you are stripped of your competence and are sitting in the silence with just the real you and the you everyone else sees? Is there symmetry to the two yous? Has that symmetry been shaken in your quest for competence?

Finally you end with creativity.I love this because there is such positivity to the process of aging. Once you have established your path.you then deepen your ties with those around you.this frees you to be your most creative, really you self.

The final thing that I would add to this concept is really going back to Eriksons idea of psychosocial moratorium.people must have the time and space to freely engage in this process. Finding this space is difficult for people to do. As we become more social media savvy, it appears that time and space to just think and be are cut down even further because everyone including ourselves expect instant answers, instant gratification. It is going to be interesting to see how society handles these issues as we go forward. I challenge each of you here today to think about your own ability to create your own psychosocial moratorium so that you can find the depth of who you are..37ConclusionThe complexity of treating women with depression across the life span continues to be an evolving field of practicePharmacological advances are very helpful in this pursuitTaking time to discover the psychological implications in a patients life is valuable- using a psychosocial model like Eriksons is just one tool38BibliographyAmerican Psychiatric Assocaiton: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013. Centers for Disease Control and Prevention. Fast Stats on Depression. August 2014. www.cdc.gov/nchs/fastats/depressionCherry, K. About.com Psychology. August 2014. psychology.about.com/od/psychosocialtheoriesCohen LS, Soares C, Vitonis A, Otto MW, Harlow BL. Risk for New Onset of Depression During the Menopausal Transition: The Harvard Study of Moods and Cycles. Arch Gen Psychiatry. 2006; 63(4): 385-390 doi:10.1001/archpsyc.63.4.385Cohen and Nonacs. Mood and Anxiety Disorders During Pregnancy and Postpartum. APA Publishing 2005.Cohen et al. Relapse of depression in pregnancy following antidepressant discontinuation: a preliminary prospective study. Arch Womens Ment Health 2004; 7(4) 217-24.Druss BG, Schlesinger M, Allen HM (2001). Depressive symptoms, satisfaction with health care, and 2 year work outcomes in an employed population. American Journal of Psychiatry, 158, 731-734.Freeman EW, Samuel MD, Lin H, Nelson D. Associations of Hormones and Menopausal Status with Depressed Mood in Women with No Hisotry of Depression. Arch Gen Psychiatry. 2006;63(4): 375-382. doi: 10.1001/archpsyc.63.4.375Stewart WF, Ricci JA, Chee E, Hahn SR, Morganstein P (2003). Cost of lost productive work among US workers with depression. Journal of American Medical Association, 289, 3135-3144.Tasman, Kay, Lieberman. Psychiatry, 2nd Edition. West Sussex, England, John Wiley & Sons. 2003.Yonkers YA, et al. Efficacy of low dose oral contraceptives with drospirenone in PMDD. Obstetrics and Gynecology. 2005; 106, 492-503.Wikipedia. August 2014. widipedia.org/wiki/Erikson%27s_stages_of_psychosocial_developmentWisner et al. Risk-benefit decision making for treatment of depression during pregnancy. American Journal of Psychiatry 2000; 157:1933-40. doi:10.1176/appi/ajp.157.12.1933

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