Guidelines for the Evaluation and Treatment of Perimenopausal Depression: Summary and Recommendations
Perimenopause, or transitional menopause, is defined as the early transition stages into menopause as well as the early post-menopause stage. It is a particularly vulnerable time for depressive symptoms and major depressive episodes in women. The following are the guidelines on evaluation and management of perimenopausal depression developed by NAMS in collaboration with the National Network of Depression Centers Women and Mood Disorders Task Group expert panel. The guidelines address an approach to depressive symptoms and depressive disorders in midlife women.
Epidemiology and Risk Factors
Risk increased for both depressive symptoms and major depressive episodes (MDE) during the perimenopause
Risk for depressive symptoms is elevated in the perimenopause even without previous history
Prior MDD | Current use of antidepressants | Anxiety | Premenstrual depressive symptoms
Sociodemographic factors (e.g., black race, high BMI, younger age)
Psychosocial factors (e.g., upsetting life events and social isolation)
Menopausal symptoms (sleep disturbance)
Limited and/or inconclusive data
Data suggests increased risk following hysterectomy with and without oophorectomy | Premature Ovarian Failure
Literature review can be found in the full open access guideline paper (‘Primary Sources – Learn More’ below)
Assessment and Diagnosis
The guidelines state
Depression during midlife presents with classic depressive symptoms, commonly in combination with menopause specific symptoms (ie, VMS, sleep disturbance) and psychosocial challenges.
Diagnostic Criteria (DSM-5)
MDD aka ‘Depression’
Discrete episodes of Major Depressive Episodes (MDE)
≥2 weeks’ duration (most longer) with significant changes in at least 5 of the following
Altered Affect (depressed mood) | Cognition | Impaired concentration | Diminished interest in pleasure | Weight and appetite changes | Sleep disturbance | Restless or slowed down | Fatigue | Feeling worthless or guilty | Thoughts of death or suicidal ideation with or without a plan
MDE must include either depressed mood or loss of interest in pleasure
Symptoms are present every day throughout the episode
Significant effect on daily living, including social and occupational interactions
No other explanation for the situation (e.g., medical disorder, such as a stroke)
Determine the specific menopause stage
Assess psychosocial risk factors and overlapping menopause and psychiatric symptoms
Identify women with
Past major depressive disorder
Severe depressive symptoms
Differential during menopausal transition includes
MDD | Subsyndromal depression | Adjustment disorder | Psychological distress | Bereavement | Bipolar Depression | General medical causes of depression
Most women who experience a MDE are likely experiencing a recurrence
Note: Refer women with past MDEs and severe depressive symptoms for as professional evaluation for the presence of mood disorder
There is no specific ‘menopause’ mood disorder screening tool
There are a variety of validated general screening tools that can be used including
PHQ-9 (see ‘Learn More – Primary Sources’ below)
To clarify contribution of menopause-related symptoms, consider the use of the following Quality of Life (QoL) tools (see ‘Learn More – Primary Sources’ below)
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