Menopause Although menopause was assumed for many years to be associated with an increased incidence of depression, empirical studies led to conﬂicting results and controversy. Menopause appears to have mood effects in some women that can be differentiated from the secondary effects, such as hot ﬂashes interfering with sleep. Psychosocial studies indicate that some patients are upset by their loss of fertility or the departure of grown children from the home (empty nest syndrome), but many women find menopause liberating (98,99). For some women the return of adult children to the maternal home, or responsibilities for the care of grandchildren, seems to be a precipitating factor for depression. Patients who suffered PMS or postpartum depression may be vulnerable to a recurrence of depression at this new time of hormonal change. Patients with depression at the time of menopause should be assessed for psychosocial precipitants and domestic abuse. There are conﬂicting reports on the effectiveness of hormones for treatment of mood symptoms during menopause (100–105). Treatment with SSRIs may ameliorate hot ﬂashes (106).
Depression in elderly patients can cause a pseudodementia, characterized by decreased activity and interest and what appears to be forgetfulness. Unlike patients with genuine dementia, these patients report memory loss rather than trying to compensate and cover up for it. The early stages of dementia can precipitate depression as patients react to the loss of cognitive abilities (107).
Approach to the Patient The severity of depression is determined by the patient’s emotional pain and the degree of interference with her normal functioning. Depression is an agonizingly painful and disabling, but readily diagnosable and treatable, disease (108). Nevertheless, it shares the stigma of all psychiatric disorders. Patients and their families often attribute the signs and symptoms of depression to life circumstances or to a medical condition, either diagnosed or undiagnosed. The persistence of symptoms in the face of a pleasant life situation or the failure of the patient to respond to attempts at cheering, such as changes of scene, often exacerbate suffering by provoking guilt in the patient and frustration in her significant others. Some patients report low energy and general malaise rather than depressed mood. Physical symptoms are especially common in Asian and some other cultures and in the elderly (107). Some patients with severe depression continue to function and can appear normal and cheerful. The only way to rule out depression is by asking about symptoms and using the diagnostic criteria (108).
Management Both antidepressant medication and psychotherapy are effective treatments for depression. There is evidence that a combination of the two produces the best outcomes (109–111). Reports about the efficacy of alternative treatments, the most common of which is St. John’s wort, are conﬂicting, but mostly negative (112). Patients should be specifically questioned about their use of herbal and other preparations and encouraged to use those whose components are standardized. Transcranial magnetic stimulation is a promising research intervention (113,114).
There are many forms of psychotherapy. Those that were specifically studied for efficacy in the treatment of depression are cognitive-behavioral therapy and interpersonal therapy. These forms of therapy are focused on present thoughts, feelings, relationships, and behaviors. Therapy continues for a set number of sessions, usually no more than 16 weekly sessions, in a prescribed, predetermined progression (115). There is increasing evidence that supportive and psychodynamic psychotherapy is effective.