Year : 2015  |  Volume : 57  |  Issue : 6  |  Page : 239--245

Depression in women in Indian context


Neena Bohra1, Shruti Srivastava2, MS Bhatia2,  
1 Holy Family Hospital, New Delhi, India
2 Department of Psychiatry, University College of Medical Sciences, Guru Teg Bahadur Hospital, New Delhi, India

Correspondence Address:
Shruti Srivastava
Assistant professor, Department of Psychiatry, University College of Medical Sciences, Guru Teg Bahadur Hospital, New Delhi
India

Abstract

The estimate of the global burden of disease predicts that depression will be the second-leading cause of disability worldwide by 2020. Depression is widely prevalent in women in all age groups especially in India where 1.2 billion population lives. In the current scenario of underdiagnosed, untreated cases of females suffering from depression, the hurdles faced by Indian women include inadequate number of mental health professionals, lack of awareness, stigma, disadvantaged position of women, multiple roles, increased levels of stress, and domestic violence. The literature search included an electronic database, published materials, and standard textbooks. The authors have provided a brief overview of different types of depression in females. Epidemiology, etiology, clinical presentation, and management linked to the reproductive cycle of women have been covered. Awareness through public education, early detection, organized national mental health programs, comprehensive management, with judicious utilization of the limited resources would tackle the rising number of cases of female depression, in a cost effective manner, thereby preventing suicide.



How to cite this article:
Bohra N, Srivastava S, Bhatia M S. Depression in women in Indian context.Indian J Psychiatry 2015;57:239-245


How to cite this URL:
Bohra N, Srivastava S, Bhatia M S. Depression in women in Indian context. Indian J Psychiatry [serial online] 2015 [cited 2019 Nov 20 ];57:239-245
Available from: http://www.indianjpsychiatry.org/text.asp?2015/57/6/239/161485


Full Text

 Introduction



Depression is a serious condition that can impact every area of women's life. It affects social life, family relationships, career, and one's sense of self-worth and purpose. There are several factors that contribute to the unique picture of depression in women from reproductive hormones to social pressures to the female response to stress.

Major depressive disorder (MDD) is the most common psychiatric disorder. Unipolar depressive disorder is the fourth most common cause of disability in females, in all ages as per the Global Burden of Disease, 2000. [1] The lifetime prevalence of MDD is 10-25% for women, and 5-12% for men. [2] According to the World Health Organization (WHO), it is also the most important precursor of suicide and will be the second cause of Global Disease Burden by the year 2020, WHO states that the burden of depression is 50% higher for females than males and Indians are reported to be among the world's most depressed. The prevalence of depression is 9%, of major depressive episode is 36%, and the average age of onset of depression is 31.9 years, in India. [3]

Depressive disorders affect almost 10% of the United States population [4] with 2-3 times more females than males affected. [5] The prevalence rates of depression from India range from 1.5/1000 to 37.74/1000. [6] The higher rates of depression have been reported in the rural compared to the urban population. [6],[7]

Up to 20% of those attending primary health care in developing countries suffer from the often linked disorders of anxiety and depression, but the symptoms of these conditions are often not recognized. [8] The preponderance of female cases of depressive disorder is consistent finding from India. [6],[7] Women have the greatest risk for developing depressive disorders during their child-bearing years. Psychosocial events such as role stress, victimization, sex-specific socialization, internalization, coping style, disadvantaged social status, and perceived stigma of mental illness, more in females, [9] have all been considered to contribute to the increased vulnerability of women to depression. The prevalence of mental morbidity in married women from Mumbai was found out to be 27.2% using a self-reported questionnaire from WHO with higher reporting of somatic symptoms than emotional symptoms. [10]

In addition, depression is also an important consequence of domestic violence, which affects between one-quarter and over one-half of women at some point in their lives. [11] Routine screening of all female patients visiting general hospital settings for domestic violence should be made mandatory so as to prevent detrimental physical and mental health consequences. [12] Recently, there has been a growing trend in India of shifting the age-old status of women from homemakers to the working class, which offers them independence, financial and stability. In the study, released by the Associated Chambers of Commerce and Industry, working women in the age bracket of 21-52 years were surveyed. Sixty-eight percent of the women were afflicted with lifestyle ailments such as obesity, depression, chronic backache, diabetes, and hypertension. [13]

It is said that long hours of working under strict deadlines cause up to 75% of working women to suffer from depression or general anxiety disorder compared to women with lesser levels of psychological demands at work. Work pressure and deadlines have led 53% of the respondents to skip meals and go for junk food. Women employed in sectors that demand more time such as media, knowledge process outsourcing, and touring jobs are unable to take leave when unwell and force themselves to work mainly due to job insecurity, especially, during the current financial meltdown, the report said. Factors such exposure to industrial pollutants and environmental toxins, poor quality of sleep, lack of exercise, sunlight exposure, poor nutrition, excessive intake of alcohol, and drug abuse also cause depression.

The literature search included an electronic database, published materials, and standard textbooks. The keywords used were depression female, India.

 Types of Depression



Depression has been categorized in Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition-Text Revision (DSM-IV-TR). [14] Clinically, major depressive episodes often arise from a low-grade, intermittent, and protracted depressive substrate known as dysthymia. Likewise, many instances of bipolar disorders represent episodes of mood disorder superimposed on a cyclothymia. The term dysthymia according to the DSM-5 would be called persistent depressive disorder. [15] The symptoms of minor depression are similar to major depression and dysthymia, but they are less severe and/or usually have a shorter term. Seasonal affective disorder (SAD) is characterized by a depressive illness during the winter months when there is less natural sunlight. The depression generally lifts during spring and summer.

 Signs and Symptoms of Depression in Women



The symptoms of depression in women are the same as those for major depression laid down in DSM-IV-TR. [14] The bereavement exclusion in DSM-IV-TR has been removed from depressive disorders in DSM-5. [15] Although the signs and symptoms of depression are the same for both men and women, women tend to experience certain symptoms more often than men. For example, SAD - depression in the winter months, is more common in women. Furthermore, women are more likely to experience the symptoms of atypical depression. Women also have a higher incidence of thyroid problems. Since, hypothyroidism can cause depression; this medical problem should always be ruled out by a physician in women who are depressed. Depression in women may develop during different phases of the reproductive cycle (premenstrual dysphoric disorder [PMDD], depression during pregnancy, postpartum depressive conditions, and menopausal depression).

 Causes of Depression in Women



There is ongoing research on exploring potential causes and contributing factors to women's increased risk for depression. It is likely that genetic, biological, chemical, hormonal, environmental, psychological, and social factors all intersect to contribute to depression.

According to a study by Winokur et al., "depression spectrum disease" has been characterized relative to "pure depressive disorder" as follows: Relatively, early age of the onset of depression (typically under 40), greater incidence of familial affective disorder, significantly more female than male first-degree relatives with affective disorder, significantly greater familial alcoholism, and antisocial personality. [16]

Stressful life event such as trauma, loss of a loved one, a difficult relationship, or any stressful situation often triggers a depressive episode. Additional work and home responsibilities, caring for children and aging parents, abuse, and poverty also may trigger a depressive episode in women. [17],[18] Evidence suggests that women respond differently than men to these events, making them more prone to depression.

There are a number of medical and neurological causes of depression such as a cerebrovascular disease, epilepsy, infections including HIV, neoplasm, autoimmune disorders, and Myxedema Madness (MM), MM is more common in women. It presents as hypothyroidism associated with fatigability, depression, and suicidal impulses. MM may mimic schizophrenia when it presents with thought disorder, delusions, hallucinations, paranoia, and agitation.

 Treatment



The major depressive episodes are treatable in 70-80% of patients. The psychiatrists must integrate pharmacotherapy with psychotherapeutic interventions. Physicians view mood disorders as fundamentally evolving from psychodynamic issues. Their ambivalence about the use of drugs may result in a poor response, noncompliance, and probably inadequate dosages for too short a treatment period. Conversely, if physicians ignore the psychosocial needs of the patient, the outcome of pharmacotherapy may be compromised. The need of the hour is to create nationwide public awareness campaign through media, newspapers, radio programs, involvement of nongovernmental organizations, schools and colleges, and integrating distribution of public education materials with multipurpose workers so that early detection of depression is possible at the grass route level. Routine screening of all women visiting antenatal, postnatal, and geriatric clinics; primary health centers in addition to general outpatient psychiatric clinics for depression is recommended.

Pharmacological

A recent review of 35 clinical trials done in India on antidepressants has found antidepressants superior to placebo; tricyclic antidepressants had maximum effect. Electroconvulsive therapy was superior to antidepressants and active repetitive transcranial magnetic stimulation (rTMS) superior to sham rTMS. [19]

Psychological

Psychotherapy in conjunction with antidepressants is more effective than either treatment alone in the treatment of MDD. Recently, eye movement desensitization and reprocessing has also shown promising results in depression in Indian patients. [20]

 Specific Modifications of Treatment in Women



Biological differences between the genders should be addressed. Women should generally be started on lower doses of antidepressants than men. Women are also more likely to experience side effects, so any medication use should be closely monitored. Besides, women are more likely than men to require simultaneous treatment for other conditions such as anxiety disorders and eating disorders.

Estrogen therapy has been shown to improve both mood and vasomotor symptoms and remains a viable option for symptomatic mid-life women. Recent concerns involving the long-term safety of estrogen therapy have led clinicians to pursue non-hormonal treatment strategies. Low-dose antidepressant therapy has been shown to improve vasomotor symptoms, as well as depression, and may be the preferred alternative for women with depression who cannot receive estrogen. [21]

 Depression in Special Situations



Premenstrual dysphoric disorder

PMDD (premenstrual syndrome or ovarian cycle disorder) presents as recurrent physical and emotional symptoms restricted to the late luteal phase of the menstrual cycle and remitting within the 1 st day or two following the onset of menstruation. It is listed in DSM-1V-TR as a Mood Disorder, not otherwise specified. PMDD has been categorized separately in DSM-5. Although most women of child-bearing age experience some symptoms of PMDD over the course of their menstrual cycle, only 5-9% of child-bearing age women meet its criteria.

Kramp [22] defined "premenstrual" as the last 6 days of the luteal phase and first 2 days of menstruation. Dalton [23] defined paramenstruation as 4 days before and 4 days following the onset of menstruation.

Epidemiology

The pooled prevalence of PMDD from 17 studies in a meta-analysis was calculated to be 47.8%. [24]

The menstrual cycle not only influences mood, behavior, thinking, and somatic functioning, but is also influenced by their disorders. [22] Clinical studies [23],[25],[26],[27] have shown that various mood disturbances (depression, mania, anxiety neurosis etc.), disorders of thought (schizophrenia), behavioral disorders (personality and conduct disorders), and somatic diseases (fever, hormonal disturbances, bleeding disorders, drugs, vitamin deficiency, malnutrition etc.,) affect menses in about three-fourth of cases. Normal menstruation causes tension (a premenstrual syndrome) in about one-third to two-third of women.

Clinical picture

The different types [25] of symptoms attributed to premenstrual syndromes can be categorized as follows:

Affection (mood): Sadness, anxiety, anger, irritability, labile mood.Cognitive: Decreased concentration, indecision, suspiciousness, sensitivity, suicidal or homicidal ideation.Pain: Headache, breast tenderness, joint, and muscle pain.Psychological: Insomnia, hypersomnia, anorexia, craving for certain foods, fatigue, lethargy, agitation, libido change, hysteria, and even psychosis.Physical: Nausea, vomiting, diarrhea, sweating, palpitations, weight, gain, swelling over legs, bloating, oliguria.Dermatological: Acne, dry hair, rash.Neurological: Fits, vertigo, dizziness, tremors, numbness, clumsiness.Behavioral: Decreased motivation, Impulsivity, decreased efficiency, social withdrawal.

The syndrome of "pre, peri or paramenstrual tension" typically starts about 5-10 days before onset of menses and lasts till the end of menses. It affects both social and occupational functioning, leading to various degrees of maladjustment and decreased output. Women over age 30 have greater premenstrual problems, while younger women have more frequent menstrual symptoms, especially dysmenorrhea.

Etiology

Many hypothesis, [28],[29],[30] have been put forward to explain this group of syndromes. The most accepted ones are:

Ovarian: Altered ovarian activity (i.e., altered ratio of estrogen and progesterone; unopposed estrogen due to decreased renal and hepatic clearance or increased gonadotrophin secretion; and unopposed estrogen due to inadequate luteal phase activity with progesterone deficiency)Fluid and electrolyte (hormonal): Increased water and electrolytes retention by the body either due to decreased urinary output or increased absorption of electrolytes like sodium (due to hormonal effects of prolactin and angiotensin aldosterone, i.e., up prolactin leaves in 2 nd and 4 th week of menstruation)Other hormonal secretion of endometrial toxins: Vitamin B or magnesium deficiency; changes in glucose levels by alteration in its metabolism in premenstrual period; premenstrual change in endorphins and other peptide hormones, e.g., vasopressin, MSH; secretion of various, "brain chemicals" such as dopamine, acetylcholine, and prostaglandinsPsychological: Anxiety neurosis; prolonged or excessive stress, e.g., examination; divorce, marital disharmony; death or separation of a parent; depression, hysterical, inadequate or obsessive personalities, etc., can precipitate premenstrual syndromes in 50-75% of susceptible women. The disorders related to menstruation can alter the duration, symptoms and course of already existing physical or psychiatric illness.

Evaluation and diagnosis

Menstruation is a normal physiological process in females starting at the age of about 13 years (menarche) and lasts till the age of about 45 years (menopause). It is a cyclic phenomenon usually occurring every 21-30 days and includes uterine bleeding for about 3-7 days.

In 1968, Moos [31] devised a 47 item "Menstrual Distress Questionnaire" consisting of eight symptom groups focused on somatic, psychological, emotional, and behavioral changes. PMDD is best determined by prospective daily symptom ratings over a 2-month interval. The evaluation for PMDD includes a detailed psychiatric evaluation. Medical evaluation should rule out physical conditions (e.g., endometriosis, fibrocystic breast disease, migraine headaches). Family history of premenstrual symptoms and history of effective treatment in female relatives is useful to guide treatment in patients with PMDD.

Treatment

Exercise, relaxation therapy, and cognitive behavioral therapy are helpful. [32] Caffeine, salt, alcohol, and nicotine should be minimized during high-risk days, and difficult decisions are best avoided. The selective serotonin reuptake inhibitors (SSRIs), fluoxetine, sertraline, paroxetine, and citalopram have been found to treat effectively PMDD. [33],[34],[35] These medications should be given throughout the month, even though there is some success for administration during only the two premenstrual weeks (i.e., the luteal-phase).

Estrogen has been found to be effective in PMDD. [36] Calcium carbonate at a dose of 1200 mg/day appears to provide some improvement in symptoms by the second or third menstrual cycle. Other modalities include Vitamin B6, primrose oil, magnesium, and Vitamin E. Diuretics (e.g., tiaziden, spironolactone) are useful for the treatment of women with premenstrual edema and bloating. The use of prostaglandin inhibitors is effective for the treatment of premenstrual pelvic pain and headache. Other medications include atenolol, clonidine, and naltrexone.

The treatment of associated physical, mood, behavioral, or cognitive disturbances should also be treated with psychotherapy for a better outcome. It is equally important to identify the familial, social or occupational stresses and remove them.

Depression during pregnancy

The prevalence of depression during pregnancy was found to be 9.18% (range from 4% to 20%) based upon Beck Depression Inventory in 185 women in a cross-sectional survey carried out in Mumbai, [37] Depression during pregnancy is associated with poor prenatal care, inadequate nutrition, elevated risk of postpartum depression, suicide, greater incidence of preterm deliveries, and small for gestational age babies. [38]

Antidepressant medication should be withheld during the first trimester because major androgenesis occurs during this period. To date, the most extensively studied drug is fluoxetine. Other SSRIs such as citalopram, sertraline, paroxetine, and fluvoxamine during pregnancy are also safe and have found no link with congenital malformations. [39],[40],[41]

Postpartum blues

Up to 85% of mothers experience postpartum blues, [42] a temporary condition beginnings in the first 2-4 days after giving birth peaks between postpartum days 5 and 7, and dissipating by the end of the second postpartum week.

Clinical picture

The symptoms are transitory and are known as "postpartum blues." The women experience unfamiliar episode of crying, irritability, depression, emotional liability, feeling separate, and distant from the baby, insomnia, and poor concentration. This coincides with sudden weight loss, decreased thirst, and increased urinary sodium excretion.

Severe postnatal blues (in about one-third cases) may be linked to more serious psychiatric disorders. Postnatal depression is not only the most frequent, but also the most disabling neurotic disorder at this time. [43]

Etiology

The cause of postnatal blues is unknown, but increased levels of urinary cyclic adenosine monophosphate and reduced plasma levels of free tryptophan have been reported. No associations however, have been found so far with changes in the levels of estrogen or progesterone in the puerperium, although evidence of modification of platelet a 2 adrenoreceptor activity by estrogen may be a clue to the way in which sex hormones mediate their effects on central brain synapses.

There is evidence that depression and mood instability are maximal on the fifth postpartum day and that women with higher neuroticism scores are more likely to experience "the blues" although why this should be so is quite unknown.

Epidemiology

Within 6 weeks of childbirth, about 10-15% of mothers may develop a nonpsychotic depression, and if untreated this illness may last for 6 months or more and cause considerable family disruption. At least half of the mothers with severe depression remain depressed for a year and most of them had not received any sustained psychiatric treatment.

The onset is usually within the first postpartum month, often on returning home and usually between day 3 and day 14.

The main causes of missing this diagnosis are an assumption that all mood disorders in the puerperium are "just postnatal blues" (i.e., transitory); transfer from hospital to home at the time when the illness begins: The physician, family, or health visitor are most concerned with the physical health and developmental milestones of the baby; limited psychiatric training of general practitioners; and paramedical personnel or the mothers may not report their depressed mood to the general practitioner.

Predispositions

Postnatal depression is associated with increasing age, childhood separation from father; problems in relationship with mother and father-in-law; marital conflict; mixed feelings about the baby; physical problems in the pregnancy and prenatal period; a tendency to be more neurotic and less extroverted personalities; a previous psychiatric history; family distress; lower social class or a hereditary predisposition.

Etiology

Possible etiological factors include a postulated hormonal effect on tryptophan metabolism. Having a baby is an important life-event involving changes in financial, social, and marital status. Social and situational changes make the woman particularly vulnerable at this time, lack of support from husband or family may increase vulnerability to depression.

Clinical picture

The patient shows many symptoms, [42] which are often disguised as loneliness or worry about physical illness, are listed below:

Excessive anxiety about her baby's health that cannot be diminished by reassurance,Self-blame (the mother believes that she cannot live up to her own expectations; nor is she as competent as her own mother or someone in the neighborhood).Sad mood is not itself a common complaint though tears, and other depressive behavior can frequently be observed.Worry at her rejection of the baby and a reluctance to feed or handle it.Irritability and loss of libido leading to deterioration in the marital relationship.Sleep difficulty due to mood disturbance is common, but may be masked by the disruption of night feeds or by a noisy hospital routine.A fear that baby may not be hers, or could be seriously deformed.Suicidal thoughts or a fear of harming the baby.The other symptoms include feeling tired, despondent and anxious, poor appetite, and decreased libido.

Management

A psychiatric history (with particular reference to the symptoms) and mental state examination is necessary to diagnose the disorder. Premature discharge for a home should be avoided, and the medical personnel should be made familiar with this disorder. Postpartum blues resolve spontaneously. The treatment consists of counseling and antidepressant drugs. Breastfeeding is not contraindicated, but should be discontinued if treatment with lithium carbonate is maintained.

Most (90%) cases have this disturbance for less than 1-month every year without treatment. About, 4-5% of cases may have this disorder lasting longer than 1-year.

Depression in elderly

In India, increased life expectancy led to a rise in the older adult population between 2001 and 2011, expected to reach 324 million by 2050. Depression in the age group, more than 60, is associated with female gender and widowhood. [44]

 Conclusions



Depression is widely prevalent in women in India across all age groups. The multiple roles played by Indian women contribute to stress, thereby making her susceptible to depression, which is often under-reported due to stigma. The influence of female hormones during the reproductive years contributes to the premenstrual dysphoric syndrome, depression during pregnancy, postpartum depression. Emphasis should be on early detection at the primary care level, and routine screening of intimate partner/domestic violence should be made mandatory. The mainstay of treatment is the use of antidepressants which should be made available free of cost at all primary care levels. Adequate dose, sufficient duration of medication, along with consistent contact with mental health professionals brings good results. Combined role of nonpharmacological interventions including cognitive therapy gives the best results.

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