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Guidelines for the evaluation and treatment of perimenopausal depression

summary and recommendations

Maki, Pauline M., PhD1,*; Kornstein, Susan G., MD2,*; Joffe, Hadine, MD, MSc3; Bromberger, Joyce T., PhD4; Freeman, Ellen W., PhD5; Athappilly, Geena, MD6; Bobo, William V., MD, MPH7; Rubin, Leah H., PhD8; Koleva, Hristina K., MD9; Cohen, Lee S., MD10; Soares, Claudio N., MD, PhD, MBA11 on behalf of the Board of Trustees for The North American Menopause Society (NAMS) and the Women and Mood Disorders Task Force of the National Network of Depression Centers

doi: 10.1097/GME.0000000000001174
Consensus Recommendations

There is a new appreciation of the perimenopause – defined as the early and late menopause transition stages as well as the early postmenopause - as a window of vulnerability for the development of both depressive symptoms and major depressive episodes. However, clinical recommendations on how to identify, characterize and treat clinical depression are lacking. To address this gap, an expert panel was convened to systematically review the published literature and develop guidelines on the evaluation and management of perimenopausal depression. The areas addressed included: 1) epidemiology; 2) clinical presentation; 3) therapeutic effects of antidepressants; 4) effects of hormone therapy; and 5) efficacy of other therapies (eg, psychotherapy, exercise, and natural health products). Overall, evidence generally suggests that most midlife women who experience a major depressive episode during the perimenopause have experienced a prior episode of depression. Midlife depression presents with classic depressive symptoms commonly in combination with menopause symptoms (ie, vasomotor symptoms, sleep disturbance), and psychosocial challenges. Menopause symptoms complicate, co-occur, and overlap with the presentation of depression. Diagnosis involves identification of menopausal stage, assessment of co-occurring psychiatric and menopause symptoms, appreciation of the psychosocial factors common in midlife, differential diagnoses, and the use of validated screening instruments. Proven therapeutic options for depression (ie, antidepressants, psychotherapy) are the front-line treatments for perimenopausal depression. Although estrogen therapy is not approved to treat perimenopausal depression, there is evidence that it has antidepressant effects in perimenopausal women, particularly those with concomitant vasomotor symptoms. Data on estrogen plus progestin are sparse and inconclusive.

1Departments of Psychiatry, Department of Psychology, University of Illinois at Chicago, Chicago IL USA

2Department of Psychiatry and Institute of Women's Health, Virginia Commonwealth University, Richmond, VA USA

3Connors Center for Women's Health and Department of Psychiatry, Brigham and Women's Hospital and Dana Farber Cancer Institute/Harvard Medical School, Boston, MA, USA

4Department of Epidemiology, Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA

5Departments of Obstetrics & Gynecology, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA

6Edith Nourse Rogers Memorial Veterans Hospital, Bedford MA; Harvard Medical School, Boston MA USA

7Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA

8Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD USA

9University of Iowa Carver College of Medicine, Iowa City, IA USA

10Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA USA

11Department of Psychiatry, Queen's University School of Medicine, Ontario CA.

Address correspondence to: Pauline M. Maki, PhD, Department of Psychiatry, Neuropsychiatric Institute, MC913, 912 S Wood St., Chicago IL 60612. E-mail:

Received 25 May, 2018

Revised 13 June, 2018

Accepted 13 June, 2018

Funding/support: None.

Financial disclosure/conflicts of interest: Dr. Maki has received speaking honoraria from Mylan. Dr. Kornstein has research support from Marinus Pharmaceuticals, Palatin Technologies, Pfizer, and Takeda Pharmaceuticals, as well as consulting fees from Alkermes, AMAG Pharmaceuticals, Lilly, and Marinus Pharmaceuticals. Dr. Joffe has received grants from Merck and Pfizer, as well as consulting fees from KaNDy, Merck, and Sojournix. Dr. Cohen has received Research Support from the National Pregnancy Registry for Atypical Antipsychotics, Alkermes Biopharmaceuticals, Forest/Actavis Pharmaceuticals, Otsuka Pharmaceuticals, Sunovion Pharmaceuticals, Inc, Teva Pharmaceuticals, the Brain & Behavior Research Foundation, JayMac Pharmaceuticals, SAGE Therapeutics, and Takeda/Lundbeck Pharmaceuticals, as well as consultant fees from Alkermes Biopharmaceuticals. Dr. Soares has received honoraria as a consultant for Bayer, Lundbeck, Otsuka and Pfizer. He has also received grants from the Ontario Brain Institute (OBI) and the Ontario Ministry of Technology, Innovation and Science. Drs. Bromberger, Freeman, Athappilly, Bobo, Rubin, and Koleva have no conflicts to disclose.

This article is being co-published in Journal of Women's Health and Menopause: The Journal of the North American Menopause Society.

© 2018 by The North American Menopause Society.