Gender, Depression, Anxiety, and Insomnia

1. Gender, Depression, Anxiety, and Insomnia Rosaly Correa-de-Araujo, MD, MSc, PhD Director, Office of the Americas Office of the Secretary, Office of Global Health Affairs Former Director, Women’s Health & Gender-based Research, Agency for Healthcare Research & Quality MD ACP Women In Medicine Month Baltimore, MD – September 23, 2006

2. Depression

3. Major Depression • 1 in 5 women vs. 1 in 10 men • Hypothesis • Artifact • Biologic • Psychologic

4. Depression • Clinical syndrome • Depressed mood extended over time • Decreased activity • Adverse functional changes • Self-Reported Instruments • Beck depression inventory • Center for epidemiologic studies depression scale (CES-D) • Diagnostic interview schedule

5. Symptoms of Major Depression • Depressed mood most of the day, nearly every day • Markedly ↓ interest or pleasure in all, almost all activities, most of the day, nearly every day • Weight loss or gain while not dieting, ↓ or ↑ appetite nearly every day

6. Symptoms of Major Depression • Insomnia or hypersomnia nearly every day • Psychomotor agitation or retardation nearly every day • Fatigue or loss of energy nearly every day • Worthless or excessive or inappropriate guilty nearly every day

7. Symptoms of Major Depression • ↓ ability to think or concentrate, or indecisiveness, nearly every day • Recurrent thoughts of death, suicidal ideation w/out specific plan, or a suicide attempt or a specific plan

8. The Depression Continuum Bad day Long-term Sadness Negativism Low self-steem Frequent day symptoms affecting function Sadness Loss Moodiness Increasing severity Dysthymic disorder Depressive Disorder not otherwise specified Transient Adjustment disorder w/ depressed mood Major depressive episode

9. Developmental Stressors • Marriage • Lesbian relationships • Family issues • Single parenting • Miscarriage & infertility • Divorce • Midlife & menopause • Older women • Occupational stress

10. Anti-cancer Psychotropics Benzodiazepines Neuroleptics Cardiovascular Alpha-methyldopa Propranolol Clonidine Thiazide diuretic Digitalis Others Cocaine Amphetamines L-dopa Cimetidine, ranitidine Hormones Oral contraceptives ACTH & glucocorticoids Anabolic steroids Anti-inflammatory or anti-infective NSAID Ethambutol Disulfiram Sulfonamides Baclofen Metoclopramide Medications Possibly Associated w/ Depression

11. AIDS Cancer CHD Chronic fatigue Chronic renal failure Dementia Diabetes Fibromyalgia Lyme disease Stroke Substance abuse Thyroid disease Medical Conditions Associated w/ Depression

12. Depression & Hypertension • Depression and anxiety predicting self-reported, treat, incident hypertension • Strongest association in Black women

13. Depression & CHD • Relative risk of depression for onset of CHD: 1.64 • Depressive symptoms associated with increased risk for both cardiac events and cardiac mortality in older women • Major depression prevalence 3X more in CHD persons • Women more often clinically depressed than men

14. Depression & CHD • Rate of risk of cardiac mortality among those w/ or w/out heart disease and major depression twice that of those w/ minor depression • Women higher rates of depression prior to cardiac surgery • Women higher rates of depression post MI not related to age or medical status

15. Depression & Heart Failure • Women w/ HF more likely tan men • Depression risk factor for HF to be depressed • Older adults more likely to be unmarried, functional disability, hypertension and diabetes, 50% chance of developing HF • Significant in women

16. Depression & Rehabilitation • 25% reduction in CV mortality for both women and men • Women less likely to referred, enroll • Hinder efforts to preventing CHD

17. Depression & Breast Cancer • Depression ins survivors significantly higher – chemotherapy • Effect of tamoxifen still debated • Younger women more at risk for depression from chemotherapy

18. Perinatal Depression • Major depression • 30 studies on prevalence • 3.1 to 4.9% at different times in pregnancy • 1 to 5.9% at different times during 1st postpartum year • Not significantly different from non-childbearing women of similar age

19. Perinatal Depression • Major depression • 10 studies on incidence • Screening for postpartum appears feasible, data precluded optimal screener or threshold screening • Screening instruments generally good for major depression alone

20. Perinatal Depression • Major depression • No data on screening improving outcomes • Interventions no consistent superior outcomes • Psychological interventions, significant improvement in postpartum depression • Pharmacologic interventions, conflicting results

21. Perinatal Depression • Depression is one of the most common perinatal complications • Screening is feasible, fairly accurate • Studies with larger samples, greater racial/ethnic mix needed • Still to be determined if screening leads to better access to treatment and improved outcomes

22. Anxiety

23. Anxiety • Rates of panic disorder worldwide are twice as common in women • Lifetime prevalence is women is 5% • Highest prevalence in women between 25 and 44 • Greater elevation in agoraphobia in women at 2 to 4 times the rate in men

24. Gender Differences in Symptoms • Women, greater agoraphobic avoidance • Women, more catastrophic thoughts and greatre fear of physical sensations • Women, higher rates of comorbid social anxiety disorder and post-traumatic stress disorder • No specifc gender differences I for depression or panic attacks

25. Gender Differences in Outcomes • Equivalent rates of remission at 5 years: 395 • Greater rate of relapse in women (82%) than men 951%) during 5 year period, independent of agoraphobia • Panic disorder commonly has chronic and recurrent course for both men and women

26. Specific Issues In Anxiety • Menstrual fluctuations and premenstrual syndrome • Pregnancy and postpartum • Menopause

27. Anxiety in Hypertension & CVD • Anxiety associated with sudden death, but study did not included women • Anxiety disorders more common in women than men • Ventricular arrhythmias • Decreases in heart rate

28. Insomnia

29. Insomnia • Significant inability to fall asleep or stay asleep Sleep deprivation Interference with day time functioning. • 30-35% of adults • 2 to 3 times more women Short-term: < 1 week Transient: > 1 but < 3 months Chronic: > 3 months

30. Causes of Insomnia Insomnia may precede relapse of known depression • Physical • Physiologic • Psychological • Psychiatric • Pharmacologic Drug Interactions Hypertension drugs

31. Insomnia • Treatment • Multifactorial • Education • Symptoms, health status, other medications, social support, responsibilities, age • Short-term: short-acting sedatives • Long-term: sleep centers • Sleep restriction • Stimulus control

32. Good Sleep Hygiene • Regular wake time • Limit time in bed to hour of sleep • Bedroom quiet, safe, dark • Use bedroom only for sleep • Limit alcohol, tobacco • Worry book: worry well in the afternoon • Stress-reducing routines before bedtime

33. THANK YOU! rosaly.correa@hhs.gov (301) 443-7291