Female Gender, Mood Disorders Are Historically Related

Mood disorders and their impact on women and their families was the topic of a half-day conference held at New York City's Algonquin Hotel;, former haunt of the famous-and depressed- writer Dorothy Parker, who made at least one suicide attempt there in the early 1900s.

Called "Portraits: Looking at Women and Mood Disorders Over a Lifetime," the seminar was the eighth such event in the Wyeth-Ayerst Women's Health Update Series, an ongoing educational program started in 1993 by Wyeth-Ayerst Laboratories.

The first of three speakers was Kay Redfield Jamison, Ph.D., professor of psychiatry at Johns Hopkins University School of Medicine, who gave an overview of women and mood disorders and discussed the relationship of manic-depression with creativity.

Jamison, who wrote the best-selling book An Unquiet Mind in addition to Touched With Fire: Manic Depressive Illness and the Artistic Temperament, said she herself was struck by manic-depression at the age of 17. "It was a horrifying experience," she recalled. "I was suicidal, paralytic and totally lacking in energy. But the good news is, I was an example of someone for whom treatment worked very well."

Today, Jamison is committed to studying and educating society about mood disorders. "I'd had no preparation for madness," she said. "But the more we can prepare people for the possibility of having mood disorders the better, because mood disorders are one of, if not the major health problem for women. They're painful, costly and lethal illnesses, but they're almost as treatable as they are serious."

Jamison alluded to 15 studies that showed there are much higher rates of mood disorders in highly creative people like writers and artists. In fact, recent studies have shown that poets and writers are four times more likely than others to suffer from affective disorders, particularly manic-depression.

"Their emotional range goes from deep despair to an ecstatic going-around-the-cosmos experience," she said. "We ask our artists and writers to go to the edge for us, to do things we can't do ourselves."

Jamison said that almost 20% of untreated manic-depressives will commit suicide.

"This is an extremely high death rate," she said. "If you were a cardiologist, you wouldn't tolerate that."

Kimberly A. Yonkers, M.D., assistant professor of psychiatry and director of the Reproductive Mood Disorder Program at the University of Texas Southwestern Medical Center, said major depression goes undiagnosed in 50% of cases and, even when detected, undertreatment occurs in two-thirds of patients.

She called major depression the "most common medical illness a doctor will see," with 20% of women having at least one episode.

"Depressive disorders occur twice as often in women as in men," she said, adding that the ratio is found globally across cultures. "Underlying psychosocial risk factors and biological differences may affect vulnerability to depression at different points of a woman's life. "

Yonkers, who is also an assistant professor of obstetrics and gynecology, noted the association of depression with reproductive function, pointing out that it's around the age of puberty that rates for men and women begin to diverge, beginning to converge again after the age of menopause.

Regarding psychosocial contributions to depressive vulnerability in preadolescent girls, Yonkers discussed gender stereotypes and socialization that encourage girls to be helpless, dependent and concerned with appearance rather than competent, powerful and confident.

"Given what's in your toolbox to support yourself, the toolbox given to little girls is not as good as what's given to little boys," she said.

Yonkers also noted that while clinical criteria for diagnosing the illness are the same for men as for women, depressed women are more likely than depressed men to experience guilt, decreased sexual interest, increased appetite, panic with phobia and hypersomnia.

She then discussed the differences between major depressive disorder (MDD), premenstrual dysphoric disorder (PMDD), premenstrual syndrome (PMS) and postpartum depression.

"PMDD is a newer clinical entity," she said, explaining that unlike PMS, which affects about 70% of menstruating women and doesn't necessarily affect mood, PMDD occurs in about 3% of women, with at least one symptom being a mood symptom. And whereas functional impairment is not necessarily a feature in PMS, PMDD symptoms do cause functional impairment at work or with interpersonal relationships, she said.

In fact, PMDD, which has an age of onset in the late 20s and probably worsens with increasing age, will cause 1,400 to 2,800 symptomatic days over the course of an afflicted woman's lifetime. "This is four to eight years if you run it consecutively," Yonkers said. "So this is really nontrivial and needs to be treated."

Regarding the relationship between PMDD and MDD, Yonkers said that about 30% of women with PMDD have a previous history of MDD, and women with PMDD are at greater risk for developing a future episode of MDD.

Yonkers next discussed depression during and after pregnancy, stating that mood disorders may predate or occur during pregnancy.

"About 10% of pregnant women will have a mood disorder during pregnancy," she said. "Risk factors include financial difficulties, troubled relationship with partner, prior psychiatric illness and a concurrent general medical illness."

Postpartum disorders include "maternity blues," which is common and requires no treatment; postpartum depression, which includes MDD without psychosis and minor depression; and the very serious emergency of postpartum psychosis, which includes MDD with psychosis, mania and brief reactive psychoses.

Yonkers said that contrary to myth, most women do not become depressed during older age. However, depressive symptoms are more likely during the four-year period before or after the last menstrual period, and women with previous episodes of depression or surgical menopause may be at risk for recurrence during the perimenopause, she said.

Linda S. Austin, M.D., associate professor of psychiatry and director of the Project for Public Education and Mental Health at the Medical University of South Carolina, talked about the impact of mood disorders on the family.

"Mood is a filter that goes over all your perception," she said. "If your mood is off even a little bit, it can have a profound effect on your life, career and family. It's like sailing... if you're off [course] by a few degrees, you may end up in Africa."

Austin said that if a woman is depressed, she is disengaged, intrusive, less warm, negative, unresponsive and unsupportive. Spouses typically respond with anger; infants respond with anger, reduced activity, low mood, social withdrawal and depressive behavioral styles outside the mother-infant interaction. Children and adolescents respond to maternal depression by feeling insecure and developing avoidant behavior.

"Children need the parent to be a safe harbor from which they sail out," said Austin. "If Mom can't get out of bed or is three sheets to the wind, how safe is that child going to feel in the world?"

Furthermore, the marital discord found in families with a depressed mother may have a larger negative impact on the child than the parent's mood disorder, she said.

Austin next reviewed a study of 92 children of mothers who had a mood disorder, medical ailment or no illness. Children of women with mood disorders fared most poorly: half had a mood disorder by age 19, 32% had a conduct disorder, 23% had a substance abuse problem and 18% had an anxiety disorder.

To lessen the impact of a mood disorder on children, Austin said, conflict in the family should be explained to them and parents should stress that the children are not to blame. Additionally, children should get into counseling and support groups.

In conclusion, Austin noted potential pitfalls of depressed women seeking help from a family doctor or ob/gyn rather than a psychiatrist. One concern is that the family doctor or ob/gyn might prescribe antidepressants without first taking a complete history.

"Antidepressants can initiate mania with disastrous consequences," she cautioned. "Another concern is lack of follow-up. Depression is an illness with 20% mortality; you can't just say 'oh, try this [pill]' and not follow up."