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Menopause and Depression: The Importance of Finding Relief
Jules Washington
Medically reviewed on 11/16/2020 by
Dr. Geoffrey Grammer
Chief Medical Officer
Most people know that menopause is associated with physical symptoms like hot flashes, but there's a link between menopause and depression, too—one that's often under-recognized. During perimenopause—the years leading up to menopause—estrogen levels decrease. One study found that depression is 2.5 times more likely at this time of life than in the years before or after. However, perimenopausal depression is frequently missed, partly because physical symptoms receive more attention and partly because many depression symptoms overlap with those of menopause. Symptoms shared by both depression and menopause include low energy, changes in libido, trouble concentrating, sleep disturbances, and weight changes. The reassuring news is that treating the mental health symptoms of menopause can help with the physical ones, too. Taking a little time to understand the link between menopause and depression can be a meaningful first step along the road to better health.
Why Does Perimenopausal Depression Occur?
Three broad factors link menopause and depression: hormones, sleep disturbances, and life stressors.
Hormone Changes. Hormonal fluctuations are an integral feature of perimenopause. During these years, people experience fluctuating and decreasing levels of estrogen. Estrogen plays a key role in the manufacture, efficiency, breakdown, and regulation of chemical messengers such as serotonin and norepinephrine. These chemical messengers (neurotransmitters) influence mood and behavior: Normal levels contribute to feelings of wellness, calm, happiness, and contentment. Decreased or fluctuating estrogen levels in perimenopause can disrupt the normal functioning of serotonin and norepinephrine in some women, which in turn can lead to depression.
Sleep Disturbances. Sleep disturbances are a notable symptom of depression, and perimenopause is similarly associated with sleep-related issues. A third of perimenopausal people report sleep difficulties, often related to uncomfortable night sweats, and those transitioning to menopause are up to 3.5 times more likely to report severe sleep difficulties than their premenopausal counterparts. This is likely related to a perimenopausal decline in certain hormones that influence sleep patterns—estrogen, progesterone, melatonin, and growth hormone. Other non-menopausal factors can also affect sleep in midlife, including chronic illness and a natural age-related change in our sleep patterns.
Life Stressors. Menopause frequently arrives at a time when people are already experiencing significant shifts in their lives (95 percent of people have their last period between the ages of 45 and 55). The following factors, often associated with midlife, are also associated with an increased risk of depression:
- Caregiver stress: Those in midlife often must act as caregivers for their own aging parents. This can be stressful, and stress can contribute to depression. Being a caregiver also limits the amount of time you have to connect with friends, and low social support is a risk factor for perimenopausal depression.
- Career changes: For many, midlife is a time for career changes, the stress of which can contribute to depression.
- Personal aging: Shifts in familial dynamics, poorer overall health, and coming to terms with a loss in fertility are stressors that naturally come with aging. The stress of coping with such drastic changes may contribute to depression in some. (Older studies suggested that depression arose from children leaving home—known as "empty-nest syndrome"—but this has been disproven.)
Although midlife can be a time of seismic change, it's also a time where some feel especially empowered to reach out for the treatment they deserve. Finding the right treatment choice for you is the next step.
Perimenopausal Depression Treatment
Depression isn't something you simply have to accept in your perimenopausal years. Untreated perimenopausal depression exacerbates heart disease, diabetes, and osteoporosis, so it's important to seek depression treatment early. Talk therapy and medications help many people with depression. Selective serotonin reuptake inhibitors (SSRIs) can also relieve some of the physical symptoms of menopause, such as hot flashes and insomnia.
Menopausal hormone therapy can also soothe the physical symptoms of menopause (hot flashes, night sweats, and sleep disturbances). Some studies suggest that estrogen replacement therapy can help mood and enhance the effects of antidepressants. There are two caveats about the above drug-based treatments. First, hormone therapy may not be suitable for you if you are a smoker, have high blood pressure, or have a history of breast cancer, blood clots, or active liver disease due to increased risk of adverse effects. Second, up to a third of people with depression don't respond to antidepressants.
If you don't respond to antidepressant medications, there are non-drug options you can try, including Transcranial Magnetic Stimulation (TMS). TMS applies highly focused magnetic pulses to brain regions that are crucial in the regulation of mood. TMS is a non-invasive treatment that has been cleared by the FDA for the management of Major Depressive Disorder when one medication hasn't been effective (though typically covered by insurance after two). TMS can help to relieve some or even all of the symptoms of depression in many patients and is suitable for people with depression related to perimenopause. The symptoms of menopause have long been viewed as inevitable or inescapable. Thankfully, times have changed, and effective treatments are helping people with perimenopausal depression live the lives they deserve.
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Starting any medical treatment for the first time can leave you with questions, especially if you’re looking forward to the benefits it may bring. It’s no different when you’re preparing for your nasal esketamine treatment. Your previous mental health treatments may have consisted solely of taking antidepressants at home or visiting a therapist’s office for cognitive behavioral therapy (CBT), so nasal esketamine is probably a new treatment experience for you. If you're wondering what it's like to start nasal esketamine and get ready for your first session, keep reading. Getting Started with the Nasal Esketamine Treatment As with any new treatment, you’ll first talk to your primary care provider or psychiatrist about whether nasal esketamine is a good fit for you. Alternatively, you can schedule your esketamine nasal spray consultation with a treatment center (such as Greenbrook) that has certification by the FDA’s Risk Evaluation and Mitigation Strategy (REMS). At Greenbrook's REMS-certified nasal esketamine treatment centers, our Greenbrook-affiliated psychiatrists and psychiatric nurse practitioners will review your medical history and also conduct our own assessment to help determine whether nasal esketamine treatment is right for you. Certain conditions, including blood vessel disease and a history of psychosis, may make treatment a risk for you. Make sure you discuss all previous and present conditions with your doctor or nasal esketamine provider before beginning treatment. If the medication is deemed a good fit, you’ll receive your prescription from the Greenbrook-affiliated provider. Your Greenbrook Care Team will put together a personalized care plan for the weeks and months to follow. Keep in mind that you will need to take a standard (oral) antidepressant along with your nasal esketamine treatment. There are two important regulations to note when it comes to preparing for treatment: Each treatment is followed by a mandatory two-hour observation period. This means you will need to plan to stay at the center for at least two hours following your self-administration of the esketamine nasal spray. You cannot drive during the rest of the day after treatment and must arrange for transportation. These regulations are mandatory. It may be helpful to sit down and plan out several weeks’ worth of transportation once you know your treatment schedule. In addition, if you’re wondering what to bring for the treatment, we recommend entertainment such as an audiobook or playlist of favorite songs and a pair of headphones. You may want them during the two-hour observation period. What to Expect During Nasal Esketamine Treatment On the day of treatment, you’ll need to stop eating any food two hours before your appointment and stop drinking all fluids 30 minutes before you come in. Your Greenbrook Care Team will confirm that you are prepared for the two-hour observation period and that you have a ride home. You’ll get the opportunity to practice using a “trainer sprayer” that mimics the real nasal esketamine sprayer but does not release any medication. The Care Team will encourage you to use the restroom and set up your preferred environment in your private treatment bay or room. Some patients like reduced lighting, for example, while others don’t request light adjustments. You’ll complete a depression scale before each treatment session. Your Greenbrook provider will confirm that the dose kit is yours, show you how to administer it, and then hand it to you. Each sprayer contained 28mg of Spravato esketamine nasal spray. Patients usually start with two sprayers (56mg) and soon increase to 84mg (three sprayers) per treatment. But, your dosage maybe vary. Should you be left with a metallic taste by the spray, the Care Team will offer suckers to help make the flavor dissipate. After your dose, you’ll be encouraged to lie back in your comfortable recliner. While most patients enjoy a quiet setting, Greenbrook is prepared to accommodate patients with a more animated reaction to the medication. You may feel sleepy, dizzy, mildly dissociated, and/or nauseated during treatment. Greenbrook's Care Team is readily available if you need assistance. How to Prepare for after your Nasal Esketamine Treatment Most side effects begin to wane in the second hour of observation, but if you’re wondering, “Is it safe to drive immediately after nasal esketamine treatment?” the answer is a resounding no. In addition to the mandatory ride home, you will need to block off time to rest and let side effects fully dissipate. This extended rest period is especially important in the first weeks of treatment when you’ll have treatment twice a week. Do not drive or operate machinery of any kind until the day after treatment. Just take it easy, relax, and take care of yourself. If you’re unsure what activities you can do or should avoid during this time, talk to your Care Team for more information. While side effects tend to dissipate completely after a good night’s sleep, many nasal esketamine patients begin feeling relief from depression symptoms within hours of their treatment. Other Tips in Preparing for Your Nasal Esketamine Treatment At Greenbrook, we make every effort to schedule your treatment in the afternoons or whenever it is most convenient for you. We encourage you to see each treatment session as an opportunity to relax and take care of your mental health. If you have any questions or concerns, talk to your doctor or the Greenbrook Care Team. At Greenbrook, we’ll help you feel at ease when preparing for each treatment session. Schedule A Free Consultation To get started with nasal esketamine, schedule your free consultation today.
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