A growing body of research indicates that the menopausal transition is a period of increased vulnerability to depressive illness.  Some women have experienced episodes of major depressive disorder (MDD) earlier in life and experience recurrent illness during the menopausal transition.  Other women, however, experience first lifetime-onset of MDD during this transition.  The identification of  specific risk factors for depression could improve depression screening and facilitate earlier intervention in this population of women.

To identify potential risk factors, researchers recruited perimenopausal women as part of  the Study of Women’s Health Across the Nation (SWAN).  For this cohort of 443 women, aged 42–52 years, psychiatric interviews were carried out at baseline to obtain information regarding lifetime history of  psychiatric illness, and interviews were repeated annually to document occurrences of MDD. Information regarding psychosocial factors and health-related data were collected annually.

During this 13-year prospective cohort study of midlife women, the researchers observed that a significant proportion of women (39%) experienced an episode of MDD during follow-up. Women without a lifetime history of MDD at baseline had a lower risk of developing MDD during the menopausal transition than those with a prior MDD history (28% v. 59%).  In addition, the researchers observed that these two groups have different risk factors for depressive illness.  

For women without a history of MDD, having a chronic medical condition prior to midlife, encountering limitations due to physical problems during midlife, and experiencing vasomotor symptoms (VMS) predicted first-onset of depression, but these factors did not predict recurrent depressive illness.

For women with lifetime histories of MDD, the risk factors predicting recurrence of MDD during midlife included psychological factors (i.e., stressful life events) and history of anxiety disorder.

The relationship between anxiety symptoms and depressive illness is interesting.  Another study looking at women in the SWAN cohort observed that anxiety symptoms emerging during the menopausal transition were predictive of subsequent episodes of MDD in midlife women.  Higher levels of anxiety symptoms were associated with a significantly higher adjusted odds of developing an episode of MDD at the subsequent annual visit [odds ratio (OR) 1.47, p=0.01].  This was true specifically for women with recurrent episodes of MDD but non-significant for first episodes of MDD.

These studies highlight the heterogeneity of women who experience depressive symptoms.  Given the high prevalence of depressive symptoms in this population, providers caring for midlife women must screen for the onset or recurrence of depression during the menopausal transition.  These studies also suggest that it may be helpful to screen for anxiety symptoms or history of anxiety disorder in this population of women.

Ruta Nonacs, MD PhD

Bromberger JT, Kravitz HM, Chang Y, Randolph JF Jr, Avis NE, Gold EB, Matthews KA. Does risk for anxiety increase during the menopausal transition? Study of Women’s Health Across the Nation (SWAN).  Menopause. 2013;20:488–495.

Bromberger JT, Schott L, Kravitz HM, Joffe H.  Risk factors for major depression during midlife among a community sample of women with and without prior major depression: are they the same or different?  Psychol Med. 2015 Jun;45(8):1653-64.

Kravitz HM, Schott LL, Joffe H, Cyranowski JM, Bromberger JT.  Do anxiety symptoms predict major depressive disorder in midlife women? The Study of Women’s Health Across the Nation (SWAN) Mental Health Study (MHS).  Psychol Med. 2014 Sep;44(12): 2593-602.