Do ‘reproductive depression’ exist? Is there evidence for oestrogen therapy in psychiatry?:BJP:Jan.2013

25.01.2013

It has been suggested that a subgroup of women are at  high risk for developing depressive symptoms at times of sex hormone fluctuation  (PMDD, Post natal depression, perimenopausal depression) referred to as “reproductive depression“.Does it exist? What do evidence suggest ?

Michael C. Craig reviews the wider role of oestrogen in psychiatry in this article.

In support of reproductive depression : PMDD (premenstrual dysphoric disorder)  has high heritability (50%).Unipolar non psychotic post partum depression has heritability of 40%. Women with postnatal depression reports recurrence of symptoms following ovarian suppression and treatment with high dose oestrogen and progesterone. Acute hormonal fluctuations like this do not cause recurrence in those without history of postpartum depression.Incidence of unipolar depression is reported to be twice and admissions triple in the post partum period. Women with PMDD are more likely to get depressed at other times of hormonal fluctuation. The suggestion here is that PMDD, Post partum depression and perimenopausal depression are occurring probably in the same set of women.

Is there evidence for oestrogen therapy in mental disorders?

Post partum unipolar depression: One RCT (Gregoire et al 1996) showed significantly larger reduction in Edinburgh Postnatal Depression Scale scores when randomised to oestrogen therapy compared with placebo, at 3 and 6 months. Currently there is not enough evidence to recommend the use.

Peri and post menopausal  depression: Studies show mixed results.Two short duration  RCTS  (Schmidt  et al 2000, Soares et al 2001) show significant benefits in mood. several studies showed no benefit over placebo.

PMDD: Royal colleges guidelines (2007) state that  there is‘insufficient evidence to recommend the routine use of progesterone or progestogens for women with PMS’. However,  The third generation contraceptive pills (progesterone plus antimineralocorticoid) if prescribed continuously, in low dose perhaps, is shown to be effective in small trials.SSRI improve symptoms in 60-90% of patients with PMDD.CBT is also associated with excellent outcome.

Bipolar disorder: Recurrence risk is 1/4 during post partum.This doubles in those with history of severe postpartum psychosis and a family history of post partum psychosis. only 3 open label pilot studies of oestrogen in preventing recurrence.largest study showed no benefit. Author observes that prescribing of oestrogen therapy to women with postpartum psychosis cannot be supported at the present time.

Schizophrenia: More relapses reported around the time of menopause and postpartum.Meta-analysis of four small RCTs  (Chua et al  2005)  concluded that, overall, oestrogen therapy did not have a significant beneficial effect as a sole treatment or adjunctive therapy. Kulkarni et al 2008  ( RCT, 28 dys only) reported  benefit of adding 100 mg of transdermal 17b-oestradiol to antipsychotics.

Alzheimer’s disease: current evidence suggests that oestrogen therapy does not have a significant beneficial effect in treating Alzheimer’sdisease.

Summary of the article:

Should psychiatrists be prescribing oestrogen therapy to their female patients?Craig MC. Br J Psychiatry. 2013 Jan;202:9-13

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