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. In one unpublished case series, women with a high vulnerability to postpartum depression were treated prophylactically with estrogen therapy at delivery. None suffered postpartum depression. However, it appears that estrogen replacement has no effect on postpartum psychosis. Clinical Implications * Obtain a thorough menstrual history from all women presenting for treatment. * Defer the treatment of perimenopausal symptoms with HRT to an obstetrician-gynecologist or primary care physician. * Develop collaborative relationships with local obstetrician-gynecologist physicians. * Become comfortable with the use of estrogen therapy.

Treatments For Postpartum Depression

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