Treatments For Postpartum Depression
Q: Introduction
Sex hormones have profound effects on the neurotransmitter systems
involved in psychiatric disorders. In general, estrogen decreases
monoamine oxidase activity, facilitates neurotransmission, enhances
mood, and has trophic effects on the synapse. Progesterone's actions
often oppose the actions of estrogen. Progesterone increases monoamine
oxidase activity, inhibits neurotransmission, destabilizes mood, and has
a dismantling effect at the synaptic level. At the 153rd annual meeting
of the American Psychiatric Association, Patricia L. Paddison, MD,[1] of
Virginia Mason Medical Center in Seattle, Washington, discussed the
relationship between estrogen and psychiatric disorders.
A:Estrogen and Mood
Estrogen has complex interactions with the serotonergic (5-HT) system,
which probably helps to explain its mood-enhancing properties and its
relationship to an increased risk for depression. Estrogen enhances 5-HT
reuptake and facilitates 5-HT2 down-regulation. The highest risk for
menopausal-related depression is not in the postmenopausal period, but
during the perimenopausal period (5 years before and after menopause;
generally ages 45-55). Women with a history of depression are
particularly at risk, as are women who have surgically induced
menopause. The use of hormone replacement therapy (HRT) as the primary
treatment for depression during this period is controversial.
Dr. Paddison suggested that HRT alone may be appropriate if the
perimenopausal woman has depressed mood (but not major depressive
episodes), no psychiatric history, and prominent vasomotor symptoms. If
the symptoms do not remit, she suggests adding an antidepressant.
Several investigators have demonstrated augmentation of serotonin
selective reuptake inhibitor (SSRI) response with the addition of
estrogen. This augmentation strategy might be considered in the
perimenopausal woman who is not responding to antidepressant therapy.
When using HRT in the perimenopausal period, Dr. Paddison suggests the
use of low-dose progesterone/estrogen (birth control regimen). The use
of unopposed estrogen is not recommended because of the associated
increased risk for breast cancer, endometrial cancer, and abnormal blood
clotting. The more selective estrogen replacement therapies (raloxifene
and tamoxifen) may have a role here that is currently under
investigation.
Estrogen and Cognition
Estrogen can facilitate neurotransmission, increase cerebral blood flow,
and is involved in the gene regulation of ApoE, a protein involved in
Alzheimer's disease. All these actions may hypothetically contribute to
an effect on cognition. Although estrogen replacement therapy can
improve mood and cognitive function in postmenopausal women, it did not
slow the progression of Alzheimer's disease in a recent study published
in JAM
A: [2] Estrogen and Postpartum Syndromes Women with previously diagnosed affective disorder are at substantial risk for the development of depression during the postpartum period. During pregnancy, women have extremely high progesterone and estrogen levels, which drop to a very low level after birth. This may be one of the pathologic mechanisms involved in postpartum depression. Several recent studies have investigated the use of estrogen in women with postpartum depression with some success.