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The Real WMDs: Clinic Advises on Women's Mood Disorders

News from the Johns Hopkins Department of Psychiatry and Behavioral Sciences

Drs. Karen Swartz and Jen Payne

If you tuned into the “Today” program last September, you might have caught several bright, articulate women — depression survivors, all — telling how they slipped into the disorder’s darkness.  One young mother’s joy at childbirth dissolved as the “nasty person,” the depression that had occasionally visited her life, returned without warning.  Another woman, in her late 40’s, spoke of keeping her family intact by denying her bleak-mood until it became like ignoring an oncoming train.

All were part of a "Today" series with Hopkins psychiatrists Karen Swartz and Jennifer Payne aimed at highlighting gender differences in mood disorders.  The TV interest reflects how the field is growing, so much so that the two specialists spend much of their time on related clinical and basic research.  The rest they spend on their new Hopkins clinic (column, right) dedicated to treating mood disorders in women.

“We’ve long been aware that major depression is nearly twice as common in women as in men,” says Payne, “and there’s no doubt that some women experience serious, debilitating premenstrual or postpartum mood changes.” The gonadal hormones—such as estrogen– are surely involved, she says.

Look, for example, at how the rate of depression in boys and girls is identical until puberty, then doubles and stays elevated in women throughout their reproductive years.

Yet the underlying pathology is murky.  And until it’s clear, questions such as why some women become psychotic after childbirth while others are fine go unanswered.  More important, truly targeted therapies—the sort with few side effects, the sort patients stick with—likely won’t come without that understanding.

Last year, Payne combed through studies on women with major depressive disorders (MDD), bipolar disorder or premenstrual dysmorphic disorder (PMDD) - a monthly depression serious enough to require medical care.  Postpartum depression, the rarer postpartum psychosis and menopause –linked depression also came into her survey.  What surfaced was what the women who already have mood disorders typically do worse during times of hormonal flux.  But a more surprising trend was that a small subset appears particularly undone by shifts in hormones. 

“I believe there’s a distinct group of women with unusual sensitivity to normal hormone fluctuations,” she says.  “And their problems aren’t tied to actual hormone levels so much as to changes in those hormone levels.”

Payne suspects genes underlie such sensitivity.  Her recent work, for example, suggests that postpartum depression runs in families.  And a good place to start a search , she says, is to look at genes turned on or off by estrogen.  Among others, she’s eyeing the gene for BDNF, a nerve-stimulating molecule newly tied to bipolar disorder.  That gene’s switch is likely estrogen-activated.

“We think we’ll ultimately show that what’s broken in, say, premenstrual depression, differs somehow from what goes wrong in major Depression.  But there should also be an overlap,” she says, “and then it will get interesting.”

More Than PMS

“Oh, you’re just being emotional”

Psychiatrist Karen Swartz, M.D., has stopped counting female patients who’ve told her their doctors have dismissed them with some version of that phrase, “It not only does them a disservice,” says Swartz.  “But writing off what may be serious mood disorders as ’just hormones’ is also dangerous.”  Swartz  has added that to her cogent reasons for starting Hopkins’ new Women’s Mood Disorders Center, which opened last fall.

The new clinic, which offers women initial evaluations and second-opinion consultations, centers on the common ground between hormones and mood disorders, namely, premenstrual dysphoria disorder (PMDD), postpartum depression and psychosis, menopause-related depression and mood disorders during pregnancy.  Women with major depression or bipolar disorder — both marked by gender differences — are also seen by Swartz or colleague Jennifer Payne, M.D., who co-directs the Center.  Psychiatrist Susan Lehmann, M.D., specializes in older patients. 

Some of the Center’s reasons for being are sociological.  “Many women, for example, are less likely than men to acknowledge depression because they feel whole households depend on them,” says Swartz.

Mostly, however, the women’s clinic is good medicine.  Swartz, for instance, has seem patients told they have PMDD.  “Sure, their mood does drop before a period,” she says.  “But take a proper psychiatric history, and you see mood cycling though-out the month — unrecognized bipolar disorder.  Treating them for PMDD could send them into a full-blown mania.”  And dealing with depression during pregnancy is dicey.  Some women you just monitor, Swartz says.  For others, not treating depression puts them and their babies at risk — low birth weight or other problems.  “We walk a fine line,” says Swartz.

More information can be found at Women’s Mood Disorders Center

Find other Hopkins Newsletter articles from past issues.