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INTRODUCTION

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Depression is more common in women than in men during the reproductive years, particularly in association with reproductive transitions and several common gynecological conditions. In the first part of this chapter, we review specific evidence supporting an association of mood disturbance with puberty in girls, across the menstrual cycle, with polycystic ovary syndrome, with infertility, and during the transition to menopause. Because of the prevalence of depression in women during the reproductive years, there are some important implications for pharmacologic treatment. Some psychotropic medications can have adverse effects on the hypothalamic–pituitary–gonadal (HPG) axis, which manifest in menstrual dysfunction, as well as potentially disruptive interactions with both endogenous and exogenous reproductive hormones. In the second part of this chapter, we review what is known about the effect of psychotropic medications on the HPG axis, and discuss important interactions with reproductive hormones. Given that women of reproductive age comprise a large proportion of psychiatric patients, knowledge about these special considerations will improve treatment outcomes for a large number of women.

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DEPRESSION AND PUBERTY IN GIRLS

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Case illustration: Marta is a 13-year-old girl brought to see you by her mother, who is concerned because Marta has appeared listless, sad, and withdrawn. Marta had been a straight. A student until a couple of months ago, when she lost interest in school and had difficulty focusing on homework. Developmental history reveals that Marta's mother has had recurrent episodes of major depression, with a particularly severe, prolonged episode while pregnant with Marta. Marta was born with low birth weight. Within her first 2 years of life, she caught up and exceeded normal weight for height. Early developmental milestones were normal. Family life is characterized by frequent verbal altercations between Marta's parents. Marta tends to brood a lot after hearing these; by contrast, her older brother tends to distract himself. Marta began showing breast development by age 9, with menarche at age 11. Two months ago, Marta's best friend rejected her in favor of a more socially popular set of friends. Marta confides in you that she feels “fat and ugly,” which makes her feel hopeless about ever being socially desirable. She eats for comfort even when not hungry, and then feels guilty. She has had thoughts about killing herself by overdosing on pills from the medicine cabinet, but says she would never actually do that because it would be a sin.

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EPIDEMIOLOGY

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One of the most striking aspects of the epidemiology of depression is the marked increase in prevalence in girls, but not boys, which arises in mid-puberty. In prepubertal children, studies consistently show that rates of depressive disorder are either similar in boys and girls, or slightly higher in boys.1 Beginning at about age 13, the prevalence of depressive disorders in girls rises to about twice that in boys. In the National Comorbidity Survey – Adolescent Supplement, a nationally representative face-to-face survey ...

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