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Treating Depression in Women

Treatment Principles

In addition to confirming the diagnosis of depression and evaluating suicide risk, the physician should identify any relationship between depression and menstruation, pregnancy, the postpartum period or the perimenopausal period. A possible relationship between depression and medications such as birth control pills or agents used in hormone replacement therapy must also be explored. If there is a link to any treatable cause of depression, it should be addressed first. If the patient's depression does not respond to this intervention, further treatment is required.

Psychosocial and pharmacologic treatments may be considered. Psychosocial therapies should address issues that particularly affect women, such as competing roles and conflicts. Commonly used treatments include psychotherapy to correct interpersonal conflicts and to help women develop interpersonal skills; cognitive-behavioral therapy to correct negative thinking and associated behavior; and couples therapy to reduce marital conflicts. In patients with mild to moderate depression, psychosocial therapies may be used alone for a limited period, or they may be used in conjunction with antidepressant medication.

The pharmacokinetics of antidepressant drugs differ somewhat in men and women (Table 5). Thus, standard pharmacotherapy may have to be modified for use in female patients. Currently, little is known about these pharmacokinetic differences because many more men than women have participated in investigational drug studies. Nonetheless, certain gender-related differences merit consideration.

Absorption of antidepressants may be enhanced in women because they secrete less gastric acid than men. In addition, gastrointestinal transit time may be slower in women, especially during high progesterone phases of the reproductive cycle. This slower transit time may also enhance the absorption of antidepressant medications. Another difference is the higher ratio of body fat to muscle in women; this ratio becomes even greater with age and increases the volume of distribution for many drugs. Finally, progesterone increases microsomal and monoamine oxidase enzyme activity, whereas estrogen decreases this activity; these actions affect monoamine neurotransmitters and drug metabolism.

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Because of these biologic differences, antidepressant plasma concentrations may be higher in women. Thus, female patients with depression may require lower dosages of antidepressants than their male counterparts. Women may also experience drug side effects more frequently. Although women frequently experience sexual side effects, they generally do not report these effects unless specifically asked.

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