Mental pain may be less visible than physical pain, but in some cases it can be harder to bear—especially when the attempt to conceal it increases the sufferer’s burden and when there doesn’t seem to be any identifiable reason for persistent, insidious sadness. From the time a woman begins puberty until she completes menopause, she’s almost twice as likely as a man to experience an episode of major depression or to be diagnosed with an anxiety disorder. Reproductive transitions are especially fraught, as girls and women experience the physical, hormonal, and social transformations that accompany puberty, pregnancy (and/or miscarriage), and menopause.
There doesn’t seem to be any single culprit responsible, so physicians such as Dr. Helen Kim, director of the Hennepin Women’s Mental Health Program and the Mother–Baby Program at Hennepin County Medical Center, assess patients across a range of considerations. “Biological risk factors like genetics, hormonal changes, or physiological stress response explain part of the picture,” she says. “But psychological, social, and environmental factors also play a big role.”
Kim notes that some of the societal risk factors for depression—gender-based violence, income inequality, body-image issues, and responsibility for the care of others—disproportionately impact women. There are also differences in how men and women respond to stress. “Men have higher rates of externalizing behaviors [when dealing with emotional distress], such as alcohol abuse or aggressive and impulsive behaviors,” Kim explains, “while females exhibit more internalizing symptoms like depression and anxiety.”
While there seems to be a bundle of genetic, interpersonal, sociological, and hormonal factors that combine to increase the likelihood of a depression diagnosis, depression in women is most common between the ages of 40 and 59. The implication is that these heightened risks are most likely to converge around the time a woman enters menopause.
Dr. Chris Schoonover, an endocrinologist with Allina Health, confirms that a woman is two-and-a-half times more likely to be diagnosed with depression during the transition to menopause than before or after it. “The brain in women has been shown to be an estrogen target organ,” says Schoonover. “And the neuroprotective effects of estrogen are directly associated with mood management.”
Women experiencing estrogen fluctuations, whether from PMS, postpartum blues, or menopause, share many symptoms, including irritability, anxiety, and memory and cognitive dysfunction. Schoonover adds, “Whenever brain estrogen levels fall below the minimum requirement, there’s risk of brain center dysfunction.”
Add to that the sociological changes women undergo as they transition out of their reproductive years and the interpersonal challenges of being sandwiched between two generations needing care and attention, and it’s not surprising that a menopausal woman’s sense of emotional well-being may be tenuous.
Depression carries health implications that range beyond psychological symptoms, too. “Divisions between physical illness and psychiatric illness are artificial and too simplistic,” says Kim. She notes that untreated depression affects inflammatory processes in the body that can lead to or exacerbate such health conditions as heart disease and diabetes.
Depression can also decrease a patient’s ability to participate in the treatment of other conditions or maintain a healthy lifestyle, explains Dr. Michaela Tsai, an oncologist with Minnesota Oncology. “When a cancer patient is suffering from chronic pain, depression, and sleep deprivation, it can be difficult for her to rally to come in for physical therapy or additional treatments,” she says.
Tsai offers her depressed patients non-Western therapy options, such as visualization, acupuncture, massage, and spiritual counseling, in addition to Western treatments, including cognitive behavioral therapy and pharmaceutical antidepressant medications.
Many experts today agree that the best treatment for depression is a combination of medication and psychotherapy, a holistic approach that focuses on our most current understanding of the factors at work. “The mind, brain, and body are connected,” Kim concludes—a reality crucial to grasping depression and alleviating its pain.