SAN FRANCISCO — Recognizing some important differences between women and men can help in treating depressed women, Dr. Holly A. Swartz said at Perspectives on Women's Health sponsored by OB.GYN. NEWS.
When treating women with depression, physicians should increase their attention to psychosocial stressors, work on strengthening social support, and treat comorbid anxiety or phobic symptoms. Psychotherapy may be especially helpful, said Dr. Swartz.
In the selection of pharmacotherapy, a selective serotonin reuptake inhibitor (SSRI) would be the first choice for younger women or postmenopausal women on hormone therapy, while a tricyclic antidepressant may be more effective in men and older women not taking hormones, said Dr. Swartz of the University of Pittsburgh.
“Atypical” depression with somatic symptoms and fatigue, sleep disturbance, and overeating or carbohydrate craving is more common in women than in men, who are more likely to have typical vegetative symptoms and low appetite when depressed. Comorbid anxiety also is more common in depressed women than in depressed men.
Interactions between an individual's underlying biology or genetics and events in the external environment play important roles in the causes and manifestations of depression.
It is theorized that women evolved to be more focused on affiliative behaviors, child rearing, and maintenance of social bonds, compared with men. It is believed that, in general, a disruption in interpersonal relationships is more stressful to women than to men, while a threat to social status is more upsetting to men than to women.
“In treating depression in women, you need to attend to the interpersonal context,” Dr. Swartz said.
Depression-specific psychotherapies can be as helpful as medication for depressed women and may have more lasting effects, she added.
Women are nearly twice as likely as men to develop major depression—21% vs. 13%, data suggest (Arch. Gen. Psychiatry 1995;52:1048). Approximately one in five women will have major depression at some point in their lifetimes.
Among people who develop major depression, 59% also will be diagnosed with an anxiety disorder, and in 86% of cases, the anxiety disorder precedes the depression. Depressed patients with comorbid anxiety are more likely to be severely suicidal and are less likely to respond to therapy, be it medication or psychotherapy. The risk for recurrent depression is higher in patients with untreated anxiety.
“If you're not paying attention to the anxiety, you're not doing the patient a service,” Dr. Swartz said.
People with high-anxiety levels typically are very somatically preoccupied, either with hyperalgesia (increased sensitivity to pain) or increased attention to sensations. When you treat highly anxious patients with antidepressants, “in practical terms, they'll get every side effect in the book, and then some,” she said.
High anxiety levels also may cause these patients to avoid treatment altogether.
Considering that depressed women often have comorbid anxiety, it's advisable to acknowledge their high degree of sensitivity and explain that this is hard-wired behavior that probably was adaptive at some point but has gone awry. Help them anticipate side effects to treatment, and assure them that side effects are transient and that they will reach a point where the treatment is tolerable.
Start with a low dose of an antidepressant and increase the dosage slowly, but forewarn the patient that she probably will need a high dose to achieve full remission. “It's typically a long process. I like to tell my patients about this up front,” she said.
Physicians who are not comfortable prescribing tricyclics might consider such dual agonists as venlafaxine or duloxetine, which have receptor effects similar to those of older tricyclics, she said.
Dr. Swartz is a consultant for Novartis and a speaker for Bristol-Myers Squibb Co. and Pfizer Inc. and has given continuing medical education presentations for Astra Zeneca. All these companies make psychotropic medications.
OB.GYN. NEWS is published by the International Medical News Group, a division of Elsevier.
A disruption in interpersonal relationships is more stressful to women than to men. DR. SWARTZ