Dear Doctor,
I struggled with depression in high school, but got treatment that worked for me, and felt pretty solid ever since. However, in the past year or so, it feels like all my old symptoms have come back with a vengeance — I’m exhausted all the time, I find myself lashing out at my family, and I feel like I don’t enjoy anything about my life anymore. I know all about hot flashes, but is depression a symptom of perimenopause, too?
Dr. Sonali Sharma, MD, MSc, and Women's Health Advisor, Psychiatry at Evernow:
We experience numerous hormonal changes throughout our lives, like during puberty, pregnancy, or postpartum. Each of these changes brings with it a a risk of mood shifts, anxiety shifts, sleeping shifts, and stress shifts.
During perimenopause, we are at increased risk for anxiety, and sleep issues, because there's a biological change our hormone levels — our estrogen and progesterone are dropping. In addition, in midlife, our melatonin levels are declining too.
There’s a high risk of depression, during this time. In fact, the studies that I've seen and reviewed actually show that there's a two to fourfold increased risk for depression.
Two things can happen during this phase: people with pre-existing anxiety and depression, or who have experienced anxiety and depression in the past, can re-experience it, or experience it with a severity that they hadn't previously had. And people who've never had it before can experience anxiety and depression for the first time in their lives.
The good news is that this change isn’t permanent. In my experience, when menopause happens, and then one year after that, I see things stabilize a little bit more. But during perimenopause, it’s important to pay attention.
What is depression?
Feeling sad is a healthy emotion. Depression is not just feeling sad — it’s when you feel either low mood, loss of energy, or the inability to feel pleasure from things you’d normally enjoy. These feelings last for at least a couple of weeks, and you're experiencing it almost every day.
When I speak to patients, here are the things I look at as key indicators of depression:
- Whether or not their sleep has started to change or be disrupted. This can be sleeping too much or sleeping too little, or waking up much earlier than you’d planned to.
- If they’re not able to concentrate or show up for work and relationships.
Some other common indicators of depression can be:
—Guilty ruminations. This is having an overactive mind, constantly thinking the same thoughts over and over to the point where it’s affecting your daily mental health.
—Irritability, which can present as anger.
—Loss of energy, or a sudden change in energy. So that can mean energy going up, leaving you feeling more agitated, or energy going down, leaving you feeling fatigued.
—Change in concentration. You may feel a lack of focus and difficulty focusing on tasks at work or at home.
—Changes in appetite. You may find yourself eating more or less than usual.
—Unusual physical feelings, like feeling heavy in your body, as though it’s hard to move or get out of bed. Or, alternately, feeling uncomfortable or physically agitated.
More serious symptoms of depression can include feeling gloomy and hopeless, thinking that life is not worth living, even experiencing suicidal thoughts.
If you’re in perimenopause and you’ve experienced depression in the past
If you’ve experienced depression or anxiety before perimenopause, you are more likely to have symptoms reappear or get worse. In my practice, I see that sometimes people who've been well-controlled during those years leading up to menopause are suddenly feeling a worsening of symptoms.
Changes to your hormones can cause what we call “breakthrough symptoms” — that’s when you've been well controlled for a while, either with treatment or without, and you haven't had symptoms of anxiety or depression for some time., And then all of a sudden, with no clear or obvious stressor in your life, you have resurgence of symptoms.
When I see a patient whose medication has worked for them for years suddenly stops working, I've had to make switches or adjustments.
It’s important to note that just because you’ve struggled with depression in the past, it doesn’t mean you will have breakthough or severe symptoms. I like to say that risk is there but it’s something to keep an eye on rather than something to anticipate.
If you're feeling depression symptoms for the first time during perimenopause
The first thing I’d want to do if you a patient suddenly started reporting feeling severe fatigue, extended feelings of anxiety and sadness, or loss in energy is to speak to your primary care doctor to rule out a medical causes first.
However, if you're feeling hopeless, gloomy, and your feelings seem different from every day sadness, you may want to go to a psychiatrist to get an evaluation — and one that does comprehensive care and can do some lab work for you and just rule out the medical causes, as well.
If you’re able to, it may be worth considering asking your mom if she experienced depression during perimenopause and menopause. But there are people who have no family history of depression and anxiety and who have not experienced themselves in the past, that do experience it during perimenopause.
How is depression in perimenopause treated?
If you find yourself struggling with depression in perimenopause, there are a lot of treatment options, from talk therapy to hormone therapy to SSRIs and SNRIs (Paxil, an SSRI, is also used for the treatment of hot flashes and night sweats). Your doctor will treat your depression on a case by case basis, and your care team have to determine what the best treatment is.
Just know that there are treatment options available — there’s no need to suffer any severe perimenopause symptoms on your own. As long as we arm ourselves with knowledge, we're prepared to find the right treatment and care so that we can make it easier on ourselves.
If you’ve had a history of anxiety or depression and you’re worried about a recurrence in perimenopause, making sure that you’re connected with care — licensed mental health providers, like a psychiatrist or therapist — is a way to get ahead of that risk and the possibility that symptoms can flare up.
