Identifying A Mood Disorder

Mood disorders are classified broadly as being either depressive disorders or bipolar disorders ( Table 1 ). Identifying a mood disorder would entail certain fundamentals.

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  Suspect an unrecognized mental health problem, notably depression, during a “wellness” clinic visit.

  
  
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  Ask about symptoms of a mood disorder (eg, depression, mania) at the first clinic visit.

  
  
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  Take a history of any prior mental illness in the patient or her family.

  
  
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  Inquire about the use of any psychoactive medications, prior abuse (sexual, physical, or emotional), or substance use.

  
  
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  Use validated screening tools ( Table 2 ), since symptom or risk-based screening alone may be insufficient.

  
  
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  Attempt to distinguish between a mild or severe form of a mood disorder to determine whether to refer the patient to a psychiatrist.

  
  
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  Appreciate that a mood disorder is more common in women and most often during reproductive age.

  
  
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  Ask about the possibility of pregnancy for any woman with a known or suspected mood disorder.

Principles of Mood Management

Screening for mood disorders alone is often insufficient without appropriate subsequent treatment. OB/GYNs must appreciate the principles of management when assisting a patient with a known or suspected mood disorder.

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  Identify the specific mood disorder to determine whether the patient should be treated by the OB/GYN or referred to a mental health provider.

  
  
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  Appreciate that ensuring adequate care can be problematic.

  
  
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  Know that intervention for mood disorders includes many resources (see Table 2 ), such as home visits, telephone-based peer support, and interpersonal psychotherapy by other mental health team members.

  
  
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  Understand that barriers for patients not to pursue further care include difficulties with access to care, personal perception of a mood disorder, and societal stigmata.

  
  
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  Know about first-line medications to prescribe, especially among women of reproductive age who are susceptible to pregnancy ( Tables 3 and 4 )

  
  
  
  

  Table 3

  
  

  Examples of first-line therapies for depressive disorders

  
  

  Ferguson 2001, Edinoff 2021, Scotton 2019, Glickman 2006, Strong 2009, Data from the National Library of Medicine 2024, Stahl 2021

  
  

  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  

  Class/Therapy	Medication	Dosage, mg/day a	FDA Approved Indications a	Side Effects/Drug Interactions	Clinical Pearls
  Psychotherapy		Frequency of visits is determined by the patient and their therapist	Not regulated by the FDA but helpful for mood disorders, anxiety disorders, OCD, panic disorder, PTSD, and SAD.		Make contacts with local therapists for referrals
  Selective serotonin reuptake inhibitors			Different for individual SSRIs, but many are used off-label for other indications	Class commonly causes GI symptoms (nausea, GI upset, diarrhea, constipation) the first few days taking the medication and dissipate with time; sexual dysfunction is common; SIADH can occur, especially in the elderly; can rarely cause serotonin syndrome; do not use with MAOIs and wait for five half-lives before starting MAOI	Medications take 4–6 wk for full effect; discontinuation syndrome, when suddenly stopping medication can occur with symptoms including “brain zaps;” monitor patients for activation of suicidal ideation, especially children and adolescents
  	Fluoxetine (Prozac)	Starting: 10–20 Typical: 20–80	MDD, OCD, PMDD, Bulimia nervosa, panic disorder bipolar depression (in combination with olanzapine [Symybax]), TRD (in combination with olanzapine [Symybax])	SE include: dry mouth, insomnia, somnolence, sweating; do not use if patient is taking: thioridazine, pimozide, tamoxifen	Weight gain is uncommon but can occur in 2%; best to take in the AM as it can be activating; good for patients with fatigue and low energy; can increase anxiety in the short term, but improves it in the long term; long half-life 4–6 d
  	Sertraline (Zoloft)	Starting: 25–50 Typical: 100–200	MDD OCD, panic disorder, PTSD, SAD, PMDD	SE include: nausea, diarrhea, sexual dysfunction, and somnolence; do not use if patient is taking: thioridazine, pimozide, disulfiram	Higher rates of GI side effects; better to use for anxiety at higher doses; can be taken at night if sedating
  	Escitalopram (Lexapro)	Starting: 5–10 Typical: 10–20	MDD, GAD	SE include: nausea and insomnia; do not use if patient is taking: pimozide	May have less sexual dysfunction than other SSRIs
  	Citalopram (Celexa)	Starting: 10–20 Typical: 20–40	MDD	SE include: dose-dependent QQTprolongation, dry mouth, nausea, somnolence, insomnia; do not use if patient is taking: thioridazine, pimozide	Take at night if daytime sedation; may have less sexual dysfunction than other SSRIs
  Serotonin and norepinephrine reuptake inhibitors				In addition to SSRI side effects can also cause hypertension and tachycardia; do not use if patient has uncontrolled angle-closure glaucoma
  	Duloxetine (Cymbalta)	Starting: 20–30 Typical: 30–120	MDD, diabetic peripheral neuropathic pain, fibromyalgia, GAD, chronic musculoskeletal pain	SE include: nausea, dry mouth, and somnolence; do not use if patient: has uncontrolled alcohol use or is taking thioridazine	Beneficial for chronic pain, especially at higher doses
  	Venlafaxine (Effexor)	Starting: 37.5–75 Typical: 75–225	MDD, GAD, social anxiety disorder, panic disorder	SE include: nausea Dizziness, somnolence, sexual dysfunction, increased sweating	Discontinuation syndrome when stopping can be particularly challenging; may be more helpful for vasomotor symptoms; XR formulation improves tolerability
  Norepinephrine and dopamine reuptake inhibitors	Bupropion (Wellbutrin SR, Wellbutrin XL)	Starting: 100 bid (SR, 150 (XL) Typical: 200–450, divided dose (SSR 300–450 (XL)	MDD; SAD (XL); smoking cessation (SR)	SE include: dry mouth and tremor; do not use in patients with history of seizures, patients with anorexia or bulimia, recent head injury, nervous system tumor, is taking thioridazine; if patient is abruptly discontinuing alcohol, sedatives, or anticonvulsants	XL dosing is preferred; less helpful for anxiety; less likely to produce hypomania than other antidepressants; dose qAM due to activating properties; reduces hypersomnia and fatigue; infrequent sexual dysfunction
  Noradrenergic and specific serotonergic antidepressant	Mirtazapine (Remeron)	Starting: 7.5–15 Typical: 15–45	MDD	SE include: drowsiness and weight gain; do not use with MAOIs and wait for five half-lives before starting MAOI	Dose QHS due to sedation; helpful for stimulating appetite; does not affect CYP450 system; infrequent sexual dysfunction
  Bright Light Therapy		Starting: 30 min Typical: 30–60 min	Not regulated by the FDA but helpful for SAD, MDD, bipolar depression	In persons with bipolar depression, can lead to a switch to mania or hypomania.	Sit under lamp each morning about 12–18 inches from face but not directly in eyes; type of light is bright white light; light intensity must be 10,000 lux; larger light boxes are more effective; can take 2–4 wk to start working

   
  

  Abbreviation : FDA, US Food and Drug Administration; GAD, generalized anxiety disorder; GI, gastrointestinal; MAOI, monoamine oxidase inhibitor; MDD, major depressive disorder; OCD, obsessive compulsive disorder; PMDD, premenstrual dysphoric disorder; PTSD, post-traumatic stress disorder; SAD, seasonal affective disorder; SE, side effects; SIADH, syndrome of inappropriate antidiuretic hormone secretion; TRD, treatment resistant depression.

  
  

  a Unless otherwise noted.

  
  
  
  

  Table 4

  
  

  Medications approved by the Food and Drug Administration for bipolar disorder

  
  

  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  

  Mania	Depression	Maintenance
  Quetiapine	Quetiapine	Quetiapine
  Valproic Acid	Valproic Acid	Lamotrigine
  Cariprazine	Cariprazine	Lithium
  Lithium	Lamotrigine	Olanzapine
  Olanzapine a	Lurasidone a	Aripiprazole
  Aripiprazole	Lumateperone a	Ziprasidone
  Ziprasidone	Olanzapine/Fluoxetine
  Haloperidol
  Clozapine
  Aripiprazole
  Risperidone a
  Chlorpromazine
  Carbamazepine
  Asenapine a

   
  

  a FDA approval for use as monotherapy or adjunctive.

  
  
  
  
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  Prescribe antidepressants and anti-anxiety medications that have been commonly used in the past.

  
  
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  Discuss the need for contraception and planning for any future childbearing.

Major Depressive Disorder

Depression is a complex and common mental disorder that can manifest in a variety of different ways that seem contradictory at first glance: an increase or decrease in sleep and an increase or decrease in appetite can all be symptoms. Depression is heterogeneous and not a “one-size-fits-all” condition. Factors such as genetic predisposition, environmental influences, and co-occurring disorders contribute to the unique ways that depression can manifest differently.

The 12-month prevalence in women is 6.9%, and the lifetime prevalence is 17.1%. The mean age of onset for women is 30.4, with a mean of 4.8 episodes in their lifetime. Thoughts of wanting to die occur in 46.6% of affected women. A suicide attempt occurs in 9.3% of women, and 35.5% will often think about suicide. Only 65.5% of these women are treated, with the mean age of first treatment being 33.5 y old.

Much thought has been given as to why the prevalence of major depressive disorder (MDD) is higher in women. Before puberty, boys and girls have similar rates of depression. As puberty sets in, a notable shift occurs, particularly among females aged 14 to 25 who have a doubled likelihood of experiencing depression. This heightened vulnerability places young women at the forefront of global statistics for major depression and various mental health disorders. It has been noted that the increased prevalence of depression correlates with the ages at which women have hormonal changes such as puberty, pregnancy, and perimenopause, leading to the suggestion that hormonal change (eg, estrogen, progesterone) may trigger or play some role in depression.

Persistent Depressive Disorder (Dysthymia)

This condition has similar diagnostic criteria to MDD but with some crucial differences. The depressed mood must be present for most days for at least 2 y. The patient, while depressed, only needs to have 2 of the following symptoms for Dysthymia: poor appetite or overeating, insomnia or hypersomnia, low energy or fatigue, low self-esteem, poor concentration or difficulty making decisions, or feelings of hopelessness. Given that Dysthymia requires 2 y of symptoms and the symptoms are fewer than MDD, this can be an easy diagnosis to miss, and many patients may not even report symptoms. If someone presents with these symptoms for less than 2 y, a more apt diagnosis might be “Other Specified Depressive Disorder,” as described further on. Fortunately, the treatment choices for Dysthymia mirror those available for MDD.

Premenstrual Syndrome and Premenstrual Dysphoric Disorder

Premenstrual syndrome (PMS) manifests as moderate to severe physical, emotional, and behavioral symptoms that start in the luteal phase and alleviate with the onset of menstruation. These symptoms must occur during most menstrual cycles. This condition is not found in the DSM but is widely recognized as a shared experience affecting 30% to 40% of reproductive-age women.

Premenstrual dysphoric disorder (PMDD) affects around 3% to 8% of reproductive-age women. While the symptoms align temporally with those of PMS, individuals with PMDD experience notable distress or disruptions in daily functioning at a specific time of the menstrual cycle. This interference extends to work, school, regular social activities, and relationships, significantly compromising their overall quality-of-life and well-being.

PMS and, especially, PMDD are linked to increased rates of suicidality compared to women without these diagnoses. Treatment options for PMDD align with MDD.

Depressive Disorder Due to Another Medical Condition

An important consideration that can sometimes be overlooked is it is important to remember is that medical conditions can cause or be associated with depressive disorders. Typically, there will be evidence of this in the history, physical examination, or laboratory findings. Examples of medical conditions that cause depressive disorders include hypothyroidism, human immunodeficiency virus, systemic lupus, anemia, polycystic ovaries, and endometriosis. ^,

Unspecified Depressive Disorder

This diagnosis may apply when the patient has clinically significant distress or impairment, but the physician determines that the specific criteria for another diagnosis are not met. This diagnosis is often used when there is insufficient information for a more specific diagnosis. Listing this diagnosis can be helpful when a mood disorder is identified; however, there is not enough time to thoroughly investigate it. These situations include emergencies or when a patient mentions depressive symptoms when presenting with a different complaint. This diagnosis gives the basis for a follow-up appointment or referral.

Bipolar Disorders

Bipolar disorder is the most critical condition to rule out when assessing a patient for depressive disorders because the treatments for depressive disorders can exacerbate symptoms of bipolar disorder. Among females, the 12-mo prevalence of bipolar disorder is 2.8%, with a lifetime prevalence of 4.5%. ^, A bipolar disorder is commonly mistakenly equated with mere “mood swings,” but the diagnosis hinges on more than fleeting changes. This condition involves episodes of mania (or hypomania) and depression. It is essential to know that a patient cannot have both a bipolar illness and a unipolar depressive disorder, although they mistakenly report both. Substance use at a time of increased energy and decreased need for sleep as substances can confuse the clinical picture.

Generalized Anxiety Disorder

GAD commonly coexists with mood disorders, each potentially exacerbating the others, underscoring the importance of screening when evaluating someone for a mood disorder. GAD is particularly prevalent in women, with 7.1% lifetime prevalence, according to the National Comorbidity Study. Criteria for GAD include experiencing excessive and difficult-to-manage anxiety on most days for at least 6 mo. A concise description is feeling excessively worried about various matters for most of the day, leading to significant distress or impairment in functioning. Fortunately, the therapeutic approaches for MDD frequently align with those for GAD. Treating bipolar disorder with comorbid GAD is trickier since first-line treatments for GAD may activate manic symptoms. Those women may be best treated by referral to a psychiatrist.

Borderline Personality Disorder

While Borderline Personality Disorder affects only about 1% of the general population, individuals with this disorder can create a significant presence in a clinic. It is commonly associated with mood disorders, with rates ranging between 80% and 96%. Borderline personality disorder is characterized by a persistent pattern of interpersonal, self-image, and affective instability, along with marked impulsivity, typically starting in early adulthood. This diagnosis is challenging to make. However, during routine visits or discussions, they may observe symptoms or behaviors suggestive of borderline personality disorder. Signs could include erratic emotions, impulsive behaviors, relationship instability, or self-image difficulties. “Splitting” of staff, rapidly alternately idealizing and devaluing various healthcare team members, may also occur. If the OB/GYN suspects borderline personality disorder, they may recommend the patient consult with psychiatry for further evaluation and management so they may have a collaborative approach to patient care.

Attention-deficit/Hyperactivity Disorder

Between 9% and 16% of individuals with depression also experience comorbid attention-deficit/hyperactivity disorder (ADHD). ADHD is characterized as a persistent pattern of inattention and hyperactivity-impulsivity that interferes with functioning or development. Despite the perception that ADHD is less prevalent in women or that they tend to exhibit inattentive symptoms predominantly, the data do not support this notion. Females with ADHD are less likely to be referred for treatment. ADHD encompasses multiple criteria, making it challenging to address such a considerable number of symptoms. A careful evaluation is encouraged because there is significant overlap with ADHD, anxiety, and trauma. For example, someone with GAD can have difficulty sustaining attention, difficulty relaxing, procrastination, restlessness, and impulsivity. Utilizing a patient questionnaire, the “Adult ADHD Self-Report Scale” can aid in assessment (see Table 2 ). Given the difficulty of this diagnosis, these patients may be best served by a referral to a pediatrician or psychiatrist for a comprehensive evaluation.

Substance Use Disorders, Substance-Induced Mood Disorders

Substance use disorders are under-recognized and can significantly contribute to or are the cause of mood symptoms. A key challenge lies in distinguishing whether mood symptoms stem from chronic substance use, intoxication, withdrawal, independent depressive disorders, or a combination of both. For example, alcohol is a known depressant and can induce anxiety and insomnia during withdrawal. Mood elevations from stimulants like cocaine may mimic mania and lead to dysphoria and restlessness upon withdrawal. Those with an alcohol use disorder are 2.3 times more likely to have recently experienced MDD and 1.7 times more likely to have Dysthymia in the last year.

To ascertain if a mood disorder is substance-induced, the use of the substance must cease. Since patients are often not willing to do this, the optimal approach is to treat both substance use and depressive disorders concurrently. When an individual is at risk of or has a substance use disorder, OB/GYNs can utilize Screening, Brief Intervention, and Referral to Treatment (SBIRT) (see Table 2 ). SBIRT is a 3-step process that involves: (1) utilizing a validated tool to screen patients to assess the severity of an individual’s substance use; (2) providing a brief intervention when indicated by screening and clinical judgment; and (3) referring to appropriate treatment if warranted.

Social Determinants of Mental Health

Social determinants of mental health refer to the various environments in which individuals are born, live, learn, work, play, and age. These factors play a significant role in shaping mental health outcomes. For instance, adverse neighborhood environments are strongly linked to depressive symptoms, with living in impoverished areas potentially contributing to the onset of MDD within a year. Additionally, numerous other factors such as age, socioeconomic status, social support, financial strain, food insecurity, education, employment status, living arrangements, marital status, race, childhood experiences including conflict and bullying, exposure to violent crime, abuse, discrimination, stigma, ethnicity, migrant status, working conditions, significant life events, literacy levels, environmental factors, job strain, and the social structure of the environment all influence mental health outcomes. Recognizing and addressing these determinants is crucial for promoting mental well-being and reducing the burden of mental illness in communities.

What Constitutes an Adequate Medication Trial?

Patients often report having “tried” a particular medication that did not yield desired results, but it is essential to delve deeper with follow-up questions. Inquire about the duration of medication use and the dose-titrated. It does not indicate a treatment failure if they discontinue the medication after a few days to a week. A sufficient trial of an antidepressant generally spans 4 to 6 w at optimal dosing. Patients need education that antidepressants require several weeks at a particular dose to reach maximum effectiveness, often necessitating dose adjustments and multiple trials over several months. It is essential to give antidepressants adequate time to work.

Selecting First-line Medications

Choosing first-line therapies for mood disorders can seem daunting due to the variety of options within each medication class. This article aims to simplify this process by focusing on common first-line treatment and therapy options for mood disorders (see Table 3 ). These medications are frequently chosen by their side effect profile, patient concerns (weight gain, concern for libido loss), and past medication trials. Simply, we treat depressive disorders with antidepressants, and we treat bipolar disorders with antipsychotics and mood stabilizers.

Adolescents

Menarche is often the precipitating event for women to present to their OB/GYN for the first time. While an equal number of males and females experience mood disorders in childhood, adolescence brings significant mood changes, with depression rates jumping from around 1% in childhood to 8% to 11% during the teenage years. ^, This period also sees the development of a sexually dimorphic pattern in mood disorders. The ratio of women to men with depression is roughly 2:1 in adolescents and remains consistent through adulthood. ^, More adolescents than adults may be diagnosed with premenstrual exacerbation of mood, given the more significant hormone fluctuations.

Menstrual Cycle

Disturbances around the menstrual cycle are a common reason for visits to OB/GYNs due to their regularity throughout a woman’s reproductive life. Between 80% and 90% of women experience unwanted emotional or physical symptoms premenstrually. A smaller portion of women, 12% to 25%, experience functional impairment from these symptoms and would meet the criteria for PMS. ^, Approximately 4% to 5% of women meet the criteria for the most disabling form, PMDD.

Both SSRI antidepressants and hormonal contraceptive pills have consistently been shown to alleviate mood symptoms associated with the menstrual cycle. ^, Since this issue often arises in the OB/GYN office initially, it is reasonable to start with either an SSRI or hormonal birth control that the provider is familiar with, as there is no consistent evidence regarding the superiority of specific medications. SSRIs may be taken either throughout the entirety of the menstrual cycle or just for the days during the luteal phase when a woman is symptomatic before menstruation.

While data on whether premenstrual mood disturbances increase the risk for peripartum mood disorders is inconsistent, there may be some overlap in pathophysiology between the 2 processes. Therefore, screening these women more regularly late in pregnancy and during the first few months after birth may be beneficial.

Contraception

Contraception is a significant reason why women seek consultations with OB/GYNs. Despite anecdotal reports of hormonal birth control (such as pills, injections, intrauterine devices, or patches) affecting mood, more extensive studies have not consistently supported this claim. ^, Some research has suggested that sensitivity to specific progestins might influence mood, ^, leading to studies where drospirenone preparations are more frequently used to address mood symptoms of PMS. ^,

However, many studies have not shown a predictable impact on mood from various estrogen or progestin preparations. Distinguishing any positive impact on underlying depression is challenging to tease out from the benefits that may come from improving PMS symptoms. ^, Thus, while consistent evidence regarding the influence of hormonal contraception on mood is lacking, it is crucial to consider this factor alongside any potential mood effects of an unintended pregnancy.

Pregnancy and Postpartum

This issue features articles dealing with the importance and impact of mental health during pregnancy, particularly anxiety and depression. Pregnancy is a significant life event that can precipitate or exacerbate mood disorders, notably depression and comorbid anxiety. Postpartum unipolar depression is receiving more attention in peer-medical journals with new drug therapies (eg, allopregnanolone, esketamine/ketamine) for the first time or recurrent episodes.

Bipolar disorders are less frequent than depression and not more prevalent during pregnancy. Treatment of bipolar disorder in pregnancy is complex and is ideally managed alongside a psychiatrist, underscoring the importance of collaboration. Postpartum psychosis, involving women exhibiting manic symptoms within a few days after delivery, is rare unless there is a history of bipolar disorder.

Many of the medications for mood disorders, such as SSRIs for depression, are typically continued during pregnancy in the lowest effective doses. While fetal risks are unlikely, ultrasound assessments are helpful for accurate gestational dating, fetal growth assessment, and detailed fetal anatomy, especially with views of the heart. Exposed neonates need to be observed for withdrawal symptoms or pulmonary hypertension. Benzodiazepines are best used cautiously and sparingly, on an as-needed basis, especially during the third trimester, to avoid a neonatal withdrawal syndrome that can persist for several days.

Breast or Gynecologic Cancer

A cancer diagnosis can be devastating for any person. Insomnia, depression, and anxiety are often seen in women affected by breast or ovarian cancer. Significant functional impairment is seen more often than with cervical cancer. There can be significant distress in body image and sexual function from surgery, as well as impact from hormonal fluctuations. Given that treatments often precipitate menopause, these women need to be screened for associated mood issues associated with menopause, as well as requiring more screening for cognitive changes.

Perimenopause/Menopause

The menopausal transition can be emotionally complex for many women, affecting various aspects of their lives, such as home dynamics, social roles, body image, and health conditions. Perimenopause, in particular, sees a high prevalence of depressive symptoms, with up to two-thirds of women experiencing them. A younger age of onset, vasomotor symptoms, menopause-related sleep disruption, history of mood disorders, and limited support are some of the significant risk factors for developing or worsening depression.

SSRIs and serotonin and norepinephrine reuptake inhibitors remain the standard of therapy for depression in perimenopause, with data supporting citalopram, escitalopram, duloxetine, venlafaxine, mirtazapine, vortioxetine, and desvenlafaxine. ^, These medications also show evidence for reducing concomitant vasomotor symptoms. ^{, ,} Use of hormone replacement therapy has had mixed evidence primarily due to methodological differences, but remains a viable option for treating mood symptoms.

Elderly

In the elderly population, depression tends to be a chronic condition, although its rate for older adults tends to be lower than the general population. While the treatment options for older women are essentially the same, OB/GYNs must take into consideration more significant amounts of medical comorbidities and a higher likelihood of adverse medication reactions and medication interactions. The American Geriatric Association’s 2015 Beers Criteria is a helpful guide for looking at potentially inappropriate medications in these populations, including vigilance for particular anticholinergic effects of various antidepressants.