I was on the phone yesterday having an urgent consultation with a woman we have worked for 15 years. She has had a pretty straight forward history of depression and anxiety that we’ve treated primarily with antidepressants
and cognitive behavioral therapy. She’s had a good response to this treatment approach. The two things about her depression that are a little unusual are that she has a strong family history of bipolar depression, although she herself has had only depressive episodes, and after the birth of her first child, she had a very unusual period of depression and anxiety but associated with a lot of agitation and, after she had not be able to sleep for a couple of nights, even some paranoia.
This responded very well to treatment with an estrogen patch and some medication to help her sleep. But I have often wondered about the possibility that she has a very small tendency to bipolar because people with postpartum psychosis definitely have a higher likelihood of having bipolar moods.
She started to go into menopause a couple of months ago (she developed hot flashes and irregular menstrual cycles), and at almost exactly the same time, seems to have experienced her first clearly hypomanic episode. This started us thinking about what we know about menopause and mood episodes.
There is an increased incidence of depression around the time of menopause. However, many studies have tried to identify correlations between levels of female hormones and these depressive episodes, without much success. Current thinking is that it’s not so much the absolute level of estrogen as the fluctuations in estrogen that take place in the menopausal period. These fluctuations are much greater than those that take place during a normal menstrual cycle. There are times when estrogen levels are relatively normal, but these are followed by times when estrogen levels fall well below those values.
The up and down fluctuations seem to be what are associated with mood episodes. In a similar fashion, it may be the sudden and dramatic drop in estrogen hormone levels after the birth of a child that is the trigger for postpartum mood episodes. Certainly the period right after the birth of the child is a time of very high risk for women who have any kind of genetic predisposition to depression, or bipolar.
And many woman who otherwise never experience psychotic symptoms can have those symptoms right after the birth of a child.
The good new in terms of menopause is that once the change is complete and a woman is solidly in the post menopausal state, depression seems to significantly taper off.