# 2003 Taylor & Francis
International Journal of Psychiatry in Clinical Practice 2003
Volume 7
Pages 269 /272 269
Major depressive disorder and response to citalopram treatment in women attending menopause clinic ˝ 1, KITTY KISS1, NO´RA BELSO ´ ZOLTAN RIHMER1, NA´NDOR TU¨ZKO˝2, SA´NDOR JA´NOS TO´TH2 AND FERENC PAULIN3
The authors investigated the prevalence of depressive disorders and response to citalopram among perimenopausal women visiting menopause clinics.
INTRODUCTION:
One hundred and eighty-five consecutive outpatients were screened using the short Beck Depression Inventory. A psychiatrist investigated persons who showed medium or severe Beck depression. In the case of DSM-IV major depressive episode, a 6-week open trial with citalopram (20 40 mg daily) was started. The 17-item Hamilton Depression Rating Scale (HDRS) measured the severity of depression at baseline and at weeks 3 and 6. The primary outcome measure was the rate of responders at weeks 3 and 6 (more than 50% drop in the total HDRS score at weeks 3 and 6 compared to baseline).
METHOD: 1
National Institute for Psychiatry and Neurology, Budapest 27, Pf. 1. 1281 Hungary; 2 St. Margit’s Hospital, Department of Obstetrics and Gynaecology, Budapest, Hungary; 3II Department of Obstetrics and Gynaecology, Semmelweis Medical University, Budapest, Hungary
/
Of the 185 consecutive outpatients screened, 48 (26%) have experienced medium or severe Beck depression, and 37 of them (20%) had DSM-IV major depression. Citalopram was started in 30 patients (daily doses ranged from 20 to 40 mg) and 21 (70%) finished the trial. The rate of responders at week 3 was 7/22 (32%) and at week 6 was 13/21 (62%).
RESULTS:
Correspondence Address Dr No´ra Belso˝, National Institute for Psychiatry and Neurology, Budapest 27, Pf. 1. 1281, Hungary Tel: /(361) 3915353 Fax: /(361) 2000770 E-mail: [email protected]; [email protected]
Depressive disorders are common among perimenopausal women visiting menopause clinics, and the majority of those with depression respond well to citalopram. Interdisciplinary cooperation is the key point of the detection and follow up of these patients. (Int J Psych Clin Pract 2003; 7: 269 272)
CONCLUSIONS:
/
Received 22 January 2003; accepted for publication 24 July 2003
Keywords citalopram major depression SSRI treatment
INTRODUCTION
D
epression is highly prevalent, mainly recurrent or chronic illness.1 In spite of its high lifetime and point-prevalence, depression remains underdetected, underdiagnosed and undertreated.2,3 Epidemiological studies conducted since 1980 have shown that the point prevalence of depressive disorders (including either severe or milder forms) is around 6%, while the lifetime prevalence rate is more than 30% in the general population.1 Depression rarely occurs as a single episode, and in the majority of the cases it
perimenopause menopause clinic
is a recurrent illness, indicating the need not only for acute but also for long-term prophylactic therapy.4 6 Although depression is a psychiatric illness, psychiatrists on their own only treat a small minority of patients (probably the most severe cases). Depression is one of the most common disorders in primary care, with a reported pointprevalence of between 6 and 26% of consecutive primary care attenders but, unfortunately, approximately half of such cases remain unrecognised or misdiagnosed.3,7,8 Particularly, depressions with predominantly somatic symptom presentation and with significant physical comorbidity remain DOI: 10.1080/13651500310003183
270
N Belso˝ et al
unrecognised.8,9 Other professionals, such as general physicians, cardiologists and neurologists, also frequently see depressed patients. The point prevalence of major depression in cardiovascular disease, stroke, Parkinson’s disease, diabetes mellitus, etc., has been reported as being between 20 and 50%, a figure well in excess of the point prevalence rate for the general population.10,11 In spite of the fact that the prevalence of depressive disorders does not seem to increase markedly during the menopause, either in the clinical setting or in the community,11,12 gynaecologists, and particularly those who work at menopause clinics, frequently see depressed patients.13,14 In a recent study by Novaes and Almeida,5 the authors reported a high prevalence (49.5%) of psychiatric morbidity among 101 endocrinologically confirmed perimenopausal women attending a menopause clinic (age 40 /58 years) and about one-third (29%) of them met criteria for a depressive disorder (15% for major depression, 14% for minor depression or dysthymia). The objective of our present study was to investigate the prevalence of DSM-IV major affective disorders and response to SSRI (citalopram) treatment among perimenopausal women visiting two menopause clinics in Budapest, Hungary. Moreover one of the most important aims of our investigation was to call the Hungarian gynaecologist’s attention to the problem of depression in woman in midlife and to begin an interdisciplinary collaboration with them. This trial was approved by the Medical Research Ethics Committee of the Semmelweis Medical University Budapest, Hungary.
METHODS One hundred eighty-five consecutive outpatients who visited one of two menopause clinics (Department of Obstetrics and Gynecology, St. Margit’s Hospital, Budapest and 2nd Department of Obstetrics and Gynaecology, Semmelweis University, Budapest) between 1 June and 28 November 2000 were screened using the Hungarian version of the shortened (nineitem version) Beck Depression Inventory.16 Persons with medium or severe Beck-depression (i.e. subjects with 19 or more total score) were examined and interviewed by a psychiatrist. Data on past depressive and hypomanic episodes were also collected. In the case of a DSM-IV major depressive episode,17 and after giving an informed consent, a 6-week open trial with citalopram (20 /40 mg daily) was started. The severity of depression was measured by the 17item version of the Hamilton Depression Rating Scale (HDRS)18 at baseline and at weeks 3 and 6. The primary outcome measure was the rate of responders at weeks 3 and 6 (more than 50% drop in the total HDRS score compared to baseline). The possible side-effects of citalopram therapy was investigated using a 17-item symptom checklist, listing the most frequently reported adverse events on citalopram therapy.19 For statistical comparison, two-tailed Student t test was used.
RESULTS One hundred and eighty-five consecutive patients, visiting one of the two menopause clinics mentioned, were screened. Forty-eight (26%) have experienced medium or severe Beckdepression, and 37 of them (20% of the original sample) met the criteria for diagnosis of DSM-IV major depressive episode at the time of the investigation. SSRI (citalopram) treatment was started in 30 patients and 21(70%) finished the trial. The mean age was 51.8 years (range 45 /65 years) and in the case of nonresponse (decrease of HDRS score lower than 50%) at week 3, the dose was increased to 40 mg. The mean and SD of the daily dose at the end of the trial was 28.579/7.93. All patients received psychoeducation before the start of the trial, but no specific psychotherapy (interpersonal or cognitive therapy) was administered during the study. The follow-up visits included supportive discussions. Eleven patients received concomitant psychotropics: four received alprazolam 1 mg daily dose for anxiety, three received 0.5 mg alprazolam at bedtime for sleeping problems, two received 1.0 mg clonazepam daily for anxiety and two received zopiclone (7.5 mg at bedtime) for insomnia. No other psychotropic drugs were used in our trial. At the end of the 6.weeks, only four patients (two on alprazolam, one on clonazepam and one on zopiclone) continued the concomitant therapy. Table 1 shows the main clinical characteristics of the patients studied, and Table 2 displays the clinical data and treatment response of those patients who participated in the 6-week open citalopram treatment. More than two-thirds of the patients enrolled (21/30, 70%) finished the 6-week open citalopram trial. The main reasons for drop-out were Table 1 Description of the sample Consecutive patients screened Persons with medium or severe Beck-depression Patients with DSM-IV major depressive episode Enrolled into a 6-week open SSRI trial First episode Recurrent
185 100 48 26 37 20 30 16 12 40 18 60
Table 2 Treatment responses of the 21patients who finished the 6-week open citalopram treatment Rate of responders At week 3 7/22 (32%) At week 6 13/2 (62%) Mean (9/SD) total HDRS scores At baseline 21.739/5.61 At week 3 14.509/6.53 At week 6 9.909/5.41
range 15 /31 range 2 /23 range 1 /19
Statistical comparisons (Student-t test): Baseline vs . week 6, t / 6.94, P B/0.001; Baseline vs . week 3, t /3.40, P B/0.001; Week 3 vs . week 6, t /0.02, ns.
Major depressive disorder and citalopram in the menopause
side effects in four patients (nausea in two, headache in one, gastrointestinal problems in one), with non-compliance in five patients. No serious side effects were observed during the trial. All but one of the nine drop-out events happened in the first 3 weeks of the study. The rate of responders at week 3 was 32% and at week 6 it was 62%. The mean total HDRS score at baseline was 21.73, and this decreased significantly at week 3 (14.50) and week 6 (9.90) (Table 2). It should be noted that more than half (18/30) of the perimenopausal women with DSM-IV major depressive episode who participated in the 6-week SSRI trial had at least one distinct previous depressive episode in the past, but only two of them were previously diagnosed (and treated) for depression. There was only one bipolar (Bipolar II) patient (3%) among the 30 major depressives enrolled. Collaboration with the gynaecological staff included the personal discussion of cases, witch seemed to be very useful for all concerned. In our experience, the perimenopausal women who took part in this study were open and cooperative. These patients received multidisciplinary health support in the menopause clinic, which strengthened and confirmed their trust and compliance.
DISCUSSION The main finding of this study was that 20% of perimenopausal women visiting a menopause clinic have had a DSMIV major depressive episode, and in more than half of these cases (60%) the present depression was a new episode of a recurrent depressive disorder. Our findings also show that screening for depression using the shortened version of the Beck Depression Inventory,16 which could be easily implemented within the non-psychiatric setting is quite helpful. The high rate of major depression among perimenopausal women visiting the menopause clinic, and the fact that past major depression is a significant predictor of perimenopausal depression found by us, is in good agreement with previous reports.13,15 On the other hand, however, the fact, that more than half of our major depressives have had at least one distinct major depressive episode in the past, indicates that ‘perimenopausal depression’ is frequently the new episode of a recurrent depressive illness in the perimenopausal age. The low rate of bipolar disorder (3%) among our perimenopausal patients with major depression suggests that major depressive disorder occurring during menopause belongs primarily in the unipolar spectrum. Since it is well-known that more than half of major depressives respond well to the first-choice antidepressant,4 6 our patients’ good responses to citalopram is an expected result. Moreover our finding, that the rate of responders at weeks 3 and 6 were 32 and 62%, respectively, is in good agreement with the report of Amsterdam et al,20 who reported a similar response rate on 20 mg open
271
fluoxetine treatment in menopausal women with DSM-III-R major depression. Of the 21 depressed patients who completed the 6-week open citalopram treatment, six were on estrogen-replacement therapy (ERT) at the time of the study (estrogen alone, three patients; estrogen and progesterone combination, three patients). The ERT started at least 3 months before the citalopram treatment (range 3 months /6 years; mean 1.9 years). Three of the six patients on ERT were responders at weeks 3 and 6, respectively, and the other three were nonresponders either at week 3 or at week 6. It is interesting to note that, in contrast to previous reports suggesting that ERT may enhance antidepressant activity,21 Amsterdam et al20 found the same, with a similarly good response rate to fluoxetine in menopausal women with and without ERT on a much larger sample of patients. The high prevalence of major depression among perimenopausal women underlines the fact that recognition of depression by obstetricians and gynaecologists is very important, because they are often the only physician who has contact with women, and depressed perimenopausal women frequently seek treatment from their gynaecologist only for symptoms of the menopause.14 Therefore cooperation between gynaecologists and psychiatrists, and screening and follow-up of depression among women visiting menopause clinics is of crucial importance in the heath support of this patient population. In spite of the open nature of the present study, our results suggest that citalopram (like fluoxetine20 and possible other SSRIs) can be an effective and safe antidepressant in the treatment of major depression among perimenopausal women.
ACKNOWLEDGEMENTS This study was supported by Lundbeck Hungaria Kft., Budapest, Hungary.
KEY POINTS . Major depression is quite common among perimenopausal women attending menopause clinics . Recognition of depression by obstetricians and gynaecologists and subsequent interdisciplinary collaboration is very important . Like fluoxetine, in this open study citalopram also seems to be an effective and safe antidepressant in the treatment of major depression among perimenopausal women
272
N Belso˝ et al
REFERENCES 1.
Wittchen H-U, Knauper B, Kessler RC (1994) Lifetime risk of depression. Br J Psychiat 165 (Suppl. 26): 16 /22. 2. Rihmer Z (2001) Can better recognition and treatment of depression reduce suicide rates? A brief review. Eur Psychiatry 16: 406 /9. 3. Lecrubier Y (1998) Is depression under-recognised and undertreated? Int Clin Psychopharmacol 13 (Suppl 5): 3 /6. 4. Goodwin FK, Jamison KR (1990) Manic Depressive Illness . New York: Oxford University Press. 5. Kasper S (1993) The rationale for long-term antidepressant therapy. Int Clin Psychopharmacol 8: 225 /35. 6. Montgomery SA, Kasper S (1998) Depression: a long-term illness and its treatment. Int Clin Psychopharmacol 13 (Suppl 6): 23 /6. 7. Christensen O, Bundgaard S, Bech P (2001) Prevalence of clinical (major) depression in general practice using the DSM-IV. version of PRIME-MD. Int J Psych Clin Pract 5: 49 /54. 8. Rihmer Z (1997) Recognition of depression and prevention of suicide: the role of general practitioners and general physicians. Int J Psych Clin Pract 1: 131 /4. 9. Freeling P, Tylee A (1992) Depression missed or mismanaged in primary care. In: Montgomery S, Rouillon F (eds) Long-Term Treatment of Depression . Chichester: John Wiley and Sons: 15 /31. 10. Cunningham LA (1994) Depression in the medically ill: choosing antidepressant. J Clin Psychiatry 55 (Suppl 9): 90 /7. 11. Stefanis CN, Stefanis NC (1999) Diagnosis of depressive disorders: a review. In: Maj M, Sartorius N (eds) Depressive disorders . Chichester: John Wiley and Sons: 1 /51.
12.
13.
14. 15. 16. 17. 18. 19.
20.
21.
Sza´do´czky E, Rihmer Z, Papp Zs, Vitrai J, Fu¨redi J (2002) Gender differences in major depressive disorder in a Hungarian community survey. Int J Psych Clin Pract 6: 31 /7. Harlow BL (1999) Prevalence and predictors of depressive symptoms in older perimenopausal women. Arch Gen Psychiatry 56: 418 /24. Yonkers KA, Chantilis SJ (1995) Recognition of depression in obstetric/gynecology patients. Am J Obstet Gynecol 173: 632 /8. Novaes SC, Almeida OP (2001) Depression during the perimenopause. Arch Gen Psychiatry 58: 306. Kopp M, Skrabski A (1992) Magyar lelkia´llapot (in Hungarian). Ve´geken Alapı´tva´ny, Budapest (in Hungarian). American Psychiatric Association (1994) DSM-IV. American Psychiatric Association Press, Washington DC. Hamilton M (1960) A rating scale for depression. J Neurol Neurosurg Psychiatry 23: 56 /62. Keller MB (2000) Citalopram therapy for depression: a review of 10 years of European experience and data from the U.S. clinical trials. J Clin Psychiatry 61 (12): 896 /908. Amsterdam J, Garcia-Espana F, Fawcett J, Quitkin F, Reimherr F, Rosenbaum J, Beasley C (1999) Fluoxetine efficacy in menopausal women with and without estrogen replacement. J Affect Disord 55: 11 /7. Zweifel JE, O’Brien WH (1997) A meta-analysis of the effect of hormone replacement therapy upon depressed mood. Psychoneuroendocrinology 22: 189 /212.
International Journal of Psychiatry in Clinical Practice 2003
Volume 7
Pages 269 /272 269
Major depressive disorder and response to citalopram treatment in women attending menopause clinic ˝ 1, KITTY KISS1, NO´RA BELSO ´ ZOLTAN RIHMER1, NA´NDOR TU¨ZKO˝2, SA´NDOR JA´NOS TO´TH2 AND FERENC PAULIN3
The authors investigated the prevalence of depressive disorders and response to citalopram among perimenopausal women visiting menopause clinics.
INTRODUCTION:
One hundred and eighty-five consecutive outpatients were screened using the short Beck Depression Inventory. A psychiatrist investigated persons who showed medium or severe Beck depression. In the case of DSM-IV major depressive episode, a 6-week open trial with citalopram (20 40 mg daily) was started. The 17-item Hamilton Depression Rating Scale (HDRS) measured the severity of depression at baseline and at weeks 3 and 6. The primary outcome measure was the rate of responders at weeks 3 and 6 (more than 50% drop in the total HDRS score at weeks 3 and 6 compared to baseline).
METHOD: 1
National Institute for Psychiatry and Neurology, Budapest 27, Pf. 1. 1281 Hungary; 2 St. Margit’s Hospital, Department of Obstetrics and Gynaecology, Budapest, Hungary; 3II Department of Obstetrics and Gynaecology, Semmelweis Medical University, Budapest, Hungary
/
Of the 185 consecutive outpatients screened, 48 (26%) have experienced medium or severe Beck depression, and 37 of them (20%) had DSM-IV major depression. Citalopram was started in 30 patients (daily doses ranged from 20 to 40 mg) and 21 (70%) finished the trial. The rate of responders at week 3 was 7/22 (32%) and at week 6 was 13/21 (62%).
RESULTS:
Correspondence Address Dr No´ra Belso˝, National Institute for Psychiatry and Neurology, Budapest 27, Pf. 1. 1281, Hungary Tel: /(361) 3915353 Fax: /(361) 2000770 E-mail: [email protected]; [email protected]
Depressive disorders are common among perimenopausal women visiting menopause clinics, and the majority of those with depression respond well to citalopram. Interdisciplinary cooperation is the key point of the detection and follow up of these patients. (Int J Psych Clin Pract 2003; 7: 269 272)
CONCLUSIONS:
/
Received 22 January 2003; accepted for publication 24 July 2003
Keywords citalopram major depression SSRI treatment
INTRODUCTION
D
epression is highly prevalent, mainly recurrent or chronic illness.1 In spite of its high lifetime and point-prevalence, depression remains underdetected, underdiagnosed and undertreated.2,3 Epidemiological studies conducted since 1980 have shown that the point prevalence of depressive disorders (including either severe or milder forms) is around 6%, while the lifetime prevalence rate is more than 30% in the general population.1 Depression rarely occurs as a single episode, and in the majority of the cases it
perimenopause menopause clinic
is a recurrent illness, indicating the need not only for acute but also for long-term prophylactic therapy.4 6 Although depression is a psychiatric illness, psychiatrists on their own only treat a small minority of patients (probably the most severe cases). Depression is one of the most common disorders in primary care, with a reported pointprevalence of between 6 and 26% of consecutive primary care attenders but, unfortunately, approximately half of such cases remain unrecognised or misdiagnosed.3,7,8 Particularly, depressions with predominantly somatic symptom presentation and with significant physical comorbidity remain DOI: 10.1080/13651500310003183
270
N Belso˝ et al
unrecognised.8,9 Other professionals, such as general physicians, cardiologists and neurologists, also frequently see depressed patients. The point prevalence of major depression in cardiovascular disease, stroke, Parkinson’s disease, diabetes mellitus, etc., has been reported as being between 20 and 50%, a figure well in excess of the point prevalence rate for the general population.10,11 In spite of the fact that the prevalence of depressive disorders does not seem to increase markedly during the menopause, either in the clinical setting or in the community,11,12 gynaecologists, and particularly those who work at menopause clinics, frequently see depressed patients.13,14 In a recent study by Novaes and Almeida,5 the authors reported a high prevalence (49.5%) of psychiatric morbidity among 101 endocrinologically confirmed perimenopausal women attending a menopause clinic (age 40 /58 years) and about one-third (29%) of them met criteria for a depressive disorder (15% for major depression, 14% for minor depression or dysthymia). The objective of our present study was to investigate the prevalence of DSM-IV major affective disorders and response to SSRI (citalopram) treatment among perimenopausal women visiting two menopause clinics in Budapest, Hungary. Moreover one of the most important aims of our investigation was to call the Hungarian gynaecologist’s attention to the problem of depression in woman in midlife and to begin an interdisciplinary collaboration with them. This trial was approved by the Medical Research Ethics Committee of the Semmelweis Medical University Budapest, Hungary.
METHODS One hundred eighty-five consecutive outpatients who visited one of two menopause clinics (Department of Obstetrics and Gynecology, St. Margit’s Hospital, Budapest and 2nd Department of Obstetrics and Gynaecology, Semmelweis University, Budapest) between 1 June and 28 November 2000 were screened using the Hungarian version of the shortened (nineitem version) Beck Depression Inventory.16 Persons with medium or severe Beck-depression (i.e. subjects with 19 or more total score) were examined and interviewed by a psychiatrist. Data on past depressive and hypomanic episodes were also collected. In the case of a DSM-IV major depressive episode,17 and after giving an informed consent, a 6-week open trial with citalopram (20 /40 mg daily) was started. The severity of depression was measured by the 17item version of the Hamilton Depression Rating Scale (HDRS)18 at baseline and at weeks 3 and 6. The primary outcome measure was the rate of responders at weeks 3 and 6 (more than 50% drop in the total HDRS score compared to baseline). The possible side-effects of citalopram therapy was investigated using a 17-item symptom checklist, listing the most frequently reported adverse events on citalopram therapy.19 For statistical comparison, two-tailed Student t test was used.
RESULTS One hundred and eighty-five consecutive patients, visiting one of the two menopause clinics mentioned, were screened. Forty-eight (26%) have experienced medium or severe Beckdepression, and 37 of them (20% of the original sample) met the criteria for diagnosis of DSM-IV major depressive episode at the time of the investigation. SSRI (citalopram) treatment was started in 30 patients and 21(70%) finished the trial. The mean age was 51.8 years (range 45 /65 years) and in the case of nonresponse (decrease of HDRS score lower than 50%) at week 3, the dose was increased to 40 mg. The mean and SD of the daily dose at the end of the trial was 28.579/7.93. All patients received psychoeducation before the start of the trial, but no specific psychotherapy (interpersonal or cognitive therapy) was administered during the study. The follow-up visits included supportive discussions. Eleven patients received concomitant psychotropics: four received alprazolam 1 mg daily dose for anxiety, three received 0.5 mg alprazolam at bedtime for sleeping problems, two received 1.0 mg clonazepam daily for anxiety and two received zopiclone (7.5 mg at bedtime) for insomnia. No other psychotropic drugs were used in our trial. At the end of the 6.weeks, only four patients (two on alprazolam, one on clonazepam and one on zopiclone) continued the concomitant therapy. Table 1 shows the main clinical characteristics of the patients studied, and Table 2 displays the clinical data and treatment response of those patients who participated in the 6-week open citalopram treatment. More than two-thirds of the patients enrolled (21/30, 70%) finished the 6-week open citalopram trial. The main reasons for drop-out were Table 1 Description of the sample Consecutive patients screened Persons with medium or severe Beck-depression Patients with DSM-IV major depressive episode Enrolled into a 6-week open SSRI trial First episode Recurrent
185 100 48 26 37 20 30 16 12 40 18 60
Table 2 Treatment responses of the 21patients who finished the 6-week open citalopram treatment Rate of responders At week 3 7/22 (32%) At week 6 13/2 (62%) Mean (9/SD) total HDRS scores At baseline 21.739/5.61 At week 3 14.509/6.53 At week 6 9.909/5.41
range 15 /31 range 2 /23 range 1 /19
Statistical comparisons (Student-t test): Baseline vs . week 6, t / 6.94, P B/0.001; Baseline vs . week 3, t /3.40, P B/0.001; Week 3 vs . week 6, t /0.02, ns.
Major depressive disorder and citalopram in the menopause
side effects in four patients (nausea in two, headache in one, gastrointestinal problems in one), with non-compliance in five patients. No serious side effects were observed during the trial. All but one of the nine drop-out events happened in the first 3 weeks of the study. The rate of responders at week 3 was 32% and at week 6 it was 62%. The mean total HDRS score at baseline was 21.73, and this decreased significantly at week 3 (14.50) and week 6 (9.90) (Table 2). It should be noted that more than half (18/30) of the perimenopausal women with DSM-IV major depressive episode who participated in the 6-week SSRI trial had at least one distinct previous depressive episode in the past, but only two of them were previously diagnosed (and treated) for depression. There was only one bipolar (Bipolar II) patient (3%) among the 30 major depressives enrolled. Collaboration with the gynaecological staff included the personal discussion of cases, witch seemed to be very useful for all concerned. In our experience, the perimenopausal women who took part in this study were open and cooperative. These patients received multidisciplinary health support in the menopause clinic, which strengthened and confirmed their trust and compliance.
DISCUSSION The main finding of this study was that 20% of perimenopausal women visiting a menopause clinic have had a DSMIV major depressive episode, and in more than half of these cases (60%) the present depression was a new episode of a recurrent depressive disorder. Our findings also show that screening for depression using the shortened version of the Beck Depression Inventory,16 which could be easily implemented within the non-psychiatric setting is quite helpful. The high rate of major depression among perimenopausal women visiting the menopause clinic, and the fact that past major depression is a significant predictor of perimenopausal depression found by us, is in good agreement with previous reports.13,15 On the other hand, however, the fact, that more than half of our major depressives have had at least one distinct major depressive episode in the past, indicates that ‘perimenopausal depression’ is frequently the new episode of a recurrent depressive illness in the perimenopausal age. The low rate of bipolar disorder (3%) among our perimenopausal patients with major depression suggests that major depressive disorder occurring during menopause belongs primarily in the unipolar spectrum. Since it is well-known that more than half of major depressives respond well to the first-choice antidepressant,4 6 our patients’ good responses to citalopram is an expected result. Moreover our finding, that the rate of responders at weeks 3 and 6 were 32 and 62%, respectively, is in good agreement with the report of Amsterdam et al,20 who reported a similar response rate on 20 mg open
271
fluoxetine treatment in menopausal women with DSM-III-R major depression. Of the 21 depressed patients who completed the 6-week open citalopram treatment, six were on estrogen-replacement therapy (ERT) at the time of the study (estrogen alone, three patients; estrogen and progesterone combination, three patients). The ERT started at least 3 months before the citalopram treatment (range 3 months /6 years; mean 1.9 years). Three of the six patients on ERT were responders at weeks 3 and 6, respectively, and the other three were nonresponders either at week 3 or at week 6. It is interesting to note that, in contrast to previous reports suggesting that ERT may enhance antidepressant activity,21 Amsterdam et al20 found the same, with a similarly good response rate to fluoxetine in menopausal women with and without ERT on a much larger sample of patients. The high prevalence of major depression among perimenopausal women underlines the fact that recognition of depression by obstetricians and gynaecologists is very important, because they are often the only physician who has contact with women, and depressed perimenopausal women frequently seek treatment from their gynaecologist only for symptoms of the menopause.14 Therefore cooperation between gynaecologists and psychiatrists, and screening and follow-up of depression among women visiting menopause clinics is of crucial importance in the heath support of this patient population. In spite of the open nature of the present study, our results suggest that citalopram (like fluoxetine20 and possible other SSRIs) can be an effective and safe antidepressant in the treatment of major depression among perimenopausal women.
ACKNOWLEDGEMENTS This study was supported by Lundbeck Hungaria Kft., Budapest, Hungary.
KEY POINTS . Major depression is quite common among perimenopausal women attending menopause clinics . Recognition of depression by obstetricians and gynaecologists and subsequent interdisciplinary collaboration is very important . Like fluoxetine, in this open study citalopram also seems to be an effective and safe antidepressant in the treatment of major depression among perimenopausal women
272
N Belso˝ et al
REFERENCES 1.
Wittchen H-U, Knauper B, Kessler RC (1994) Lifetime risk of depression. Br J Psychiat 165 (Suppl. 26): 16 /22. 2. Rihmer Z (2001) Can better recognition and treatment of depression reduce suicide rates? A brief review. Eur Psychiatry 16: 406 /9. 3. Lecrubier Y (1998) Is depression under-recognised and undertreated? Int Clin Psychopharmacol 13 (Suppl 5): 3 /6. 4. Goodwin FK, Jamison KR (1990) Manic Depressive Illness . New York: Oxford University Press. 5. Kasper S (1993) The rationale for long-term antidepressant therapy. Int Clin Psychopharmacol 8: 225 /35. 6. Montgomery SA, Kasper S (1998) Depression: a long-term illness and its treatment. Int Clin Psychopharmacol 13 (Suppl 6): 23 /6. 7. Christensen O, Bundgaard S, Bech P (2001) Prevalence of clinical (major) depression in general practice using the DSM-IV. version of PRIME-MD. Int J Psych Clin Pract 5: 49 /54. 8. Rihmer Z (1997) Recognition of depression and prevention of suicide: the role of general practitioners and general physicians. Int J Psych Clin Pract 1: 131 /4. 9. Freeling P, Tylee A (1992) Depression missed or mismanaged in primary care. In: Montgomery S, Rouillon F (eds) Long-Term Treatment of Depression . Chichester: John Wiley and Sons: 15 /31. 10. Cunningham LA (1994) Depression in the medically ill: choosing antidepressant. J Clin Psychiatry 55 (Suppl 9): 90 /7. 11. Stefanis CN, Stefanis NC (1999) Diagnosis of depressive disorders: a review. In: Maj M, Sartorius N (eds) Depressive disorders . Chichester: John Wiley and Sons: 1 /51.
12.
13.
14. 15. 16. 17. 18. 19.
20.
21.
Sza´do´czky E, Rihmer Z, Papp Zs, Vitrai J, Fu¨redi J (2002) Gender differences in major depressive disorder in a Hungarian community survey. Int J Psych Clin Pract 6: 31 /7. Harlow BL (1999) Prevalence and predictors of depressive symptoms in older perimenopausal women. Arch Gen Psychiatry 56: 418 /24. Yonkers KA, Chantilis SJ (1995) Recognition of depression in obstetric/gynecology patients. Am J Obstet Gynecol 173: 632 /8. Novaes SC, Almeida OP (2001) Depression during the perimenopause. Arch Gen Psychiatry 58: 306. Kopp M, Skrabski A (1992) Magyar lelkia´llapot (in Hungarian). Ve´geken Alapı´tva´ny, Budapest (in Hungarian). American Psychiatric Association (1994) DSM-IV. American Psychiatric Association Press, Washington DC. Hamilton M (1960) A rating scale for depression. J Neurol Neurosurg Psychiatry 23: 56 /62. Keller MB (2000) Citalopram therapy for depression: a review of 10 years of European experience and data from the U.S. clinical trials. J Clin Psychiatry 61 (12): 896 /908. Amsterdam J, Garcia-Espana F, Fawcett J, Quitkin F, Reimherr F, Rosenbaum J, Beasley C (1999) Fluoxetine efficacy in menopausal women with and without estrogen replacement. J Affect Disord 55: 11 /7. Zweifel JE, O’Brien WH (1997) A meta-analysis of the effect of hormone replacement therapy upon depressed mood. Psychoneuroendocrinology 22: 189 /212.
