The prevalence for major depression in 16 to 65-year-old women in the UK is 25 per 1,000 and if the less specific category of ‘mixed depression and anxiety’ is included, the figure rises dramatically to 124 in 1,000. There are also several depressive conditions that are specific to women, including postnatal depressive disorder (PND) and premenstrual dysphoric disorder (PMDD).
Socio-economic factors such as deprivation and poverty are associated with depression. This makes women particularly vulnerable, because they represent two thirds of the adults living in the poorest UK households.
Depression is also associated with social isolation. Women are at risk of isolation for several reasons including lone parenthood, longer life expectancy and fear (many women fear going out alone at night).
Women’s mental health is also likely to be adversely affected by the greater risk of domestic violence and abuse, both in childhood and adulthood, although this is rarely disclosed during consultations.
Depression is characterised by low mood, loss of interest and enjoyment in daily activities, reduced energy and impaired daily functioning (see box).
Women are particularly prone to somatic symptoms and associated physical complaints such as headaches, which may impede diagnosis of underlying depression.
Sleep disturbance is strongly associated with depression. Characteristic changes include early morning waking and difficulty falling asleep. Women are more likely to suffer sleep disorders and experience daytime sleepiness. Pregnancy and hormonal changes during the menstrual cycle or peri-menopause may also disrupt sleep.
Effective management of depression should actively address any sleep problems.
NICE recommends a stepped approach that involves both pharmacological and psychological treatments. All depressed patients should be assessed for their risk of suicide.
Most depressed patients benefit from general advice on managing sleep and anxiety. It is helpful to remind patients to take better general care of themselves, perhaps by eating healthily and relaxing more.
The health professional often plays a key role in giving the woman ‘permission’ to take time for herself.
Regular exercise has been shown to alleviate depressive symptoms. NICE recommends a structured exercise programme, but any increase in activity is likely to be helpful.
Walking is easily accessible, free and can be carried out in short bursts and gradually built up. Playing with children is another excellent way to get exercise as well as imp-
roving family relationships.
Several psychological approaches can be useful for depression, including counselling, problem-solving therapy and cognitive behavioural therapy (CBT). Guided self-help or computerised CBT may also be beneficial. Simple CBT-based approaches can be incorporated into routine primary care consultations.
Encourage women to increase activity levels despite tiredness or lack of motivation. Activities should be enjoyable and planned in advance.
Encourage the patient to focus on small, achievable goals and to give herself positive feedback for each step forwards.
Boost self-esteem by asking women to keep a daily ‘positive’ diary of things that went well, any compliments received and evidence of their own positive qualities. Ask the woman how she might encourage a friend in the same situation, and whether she could apply that advice to her own life.
There is evidence for the use of antidepressant medication in moderate-to-severe depression. First-line treatment is with an SSRI such as fluoxetine. SSRIs may also be of benefit in PMDD and PND.
When prescribing, bear in mind that certain side-effects such as weight gain may be of particular concern to women. Sexual dysfunction (female anorgasmia) can be another troublesome side-effect of SSRIs. Patients should be given sufficient information to make informed decisions about choices of medication.
Discuss common side-effects and reassure the patient that most will subside after the first one to two weeks of therapy, and reassure patients that antidepressants are not addictive.
Most patients should be seen after two weeks and then followed up regularly to assess their response to treatment and any problems or side-effects of treatment.
Continuing antidepressants for at least six months after remission of a depressive episode can greatly reduce the risk of relapse.