Understanding Depression at Midlife
By Cheryl Platzman Weinstock
Six years ago, Ruth White woke up in the middle of the night with an overwhelming urge to smother her 7-year-old daughter and then kill herself.
"I called a girlfriend from another part of the house because I was too scared to go back in the bedroom, where my daughter had been sleeping beside me," recalls Ruth, now 46 and a professor of social work at Seattle University. "I stayed on the telephone with my friend most of the night. She said if things got crazy she would call 911. Luckily, she didn't have to. I got myself together enough to drop off my daughter at school the next morning and then went straight to my therapist's office and broke down."
Ruth's therapist diagnosed her with bipolar disorder, a type of depression characterized by periods of manic "highs" and depressed "lows" also known as manic depression. She immediately started on medication and agreed to enlist friends and family to help care for her and her daughter until she was stable. "I had recently moved to Seattle and begun a new, demanding career, and my 12-year relationship [with my daughter's father] was on the rocks," says Ruth. "There was evidence of my illness before-most dramatically, after my daughter was born, I had serious postpartum depression. But I went to counseling and got through it. This time, I think the stress of so many changes broke me."
During the months that followed, Ruth struggled through treatment and was even hospitalized for a week, but since then she's been doing well. (She has been symptom-free for the past two years and recently wrote a book, Bipolar 101.) Her case may sound extreme, but being diagnosed at midlife (usually defined as ages 40 to 64) with a mental health problem-depression in particular-is not uncommon. Research shows that the odds of being diagnosed with depression peak at age 44, and more than 15 percent of women ages 45 to 64 experience frequent depression, according to the United States Department of Health and Human Services. And experts think that in reality, that number could be even higher, because many cases go unreported. Even scarier is the fact that people ages 45 to 54 now have the highest rates of suicide, according to the Centers for Disease Control and Prevention.
Indeed, with all the changes we face at midlife-sending our kids to college, caring for ailing parents and possibly dealing with health issues ourselves-it makes sense to experts that this is a time when depression tends to crop up. It's also a period when many of us have concerns about relationships (divorce rates spike at middle age), finances (it's harder to recoup from a late-career layoff, and retirement age is near) and our general plans for the rest of our lives, says psychologist Dan Gottlieb, PhD, host of the Philadelphia radio show "Voices in the Family."
Certainly not everyone who faces these issues will develop depression, a disorder that scientists believe has to do with problems in the brain circuitry and possibly an imbalance of mood chemicals. One thing that increases your risk substantially: family history. "Genetics is a major risk factor for developing a psychiatric disorder," explains Shari I. Lusskin, MD, director of reproductive psychiatry at New York University School of Medicine. That means if a parent or sibling had a mental health issue, you're at higher risk yourself.
Family history almost certainly played a role when depression hit Susan Polis Schutz, now 65, five years ago. The Boulder, Colorado, resident, a successful author known for her poetry and greeting cards, was a "positive, take-charge person" for most of her life. Although her father and many of his relatives suffered from depression, she was surprised to be facing it herself. "After years of working intensely and actively raising three children, I was very tired mentally. I had just finished my autobiography, which I had worked on for 10 years, and once it was over I was left with a sense of emptiness. Under normal conditions, I think it would've bounced right off me, but probably because of my strong genetic predisposition, my foundation cracked. I went to bed and stayed there for three months," she says. "Fortunately, therapy, medication and support from my family helped me get better, but I realized that most depressed people feel so little hope. That's why I wrote Depression and Back-to let others know that depression is an illness and they're not alone in facing it."
But a predisposition to depression can put you at risk at any time in your life, so why are so many women being diagnosed at middle age? Part of the reason is that more women feel comfortable speaking up and are being diagnosed since more celebrities like Brooke Shields and J.K. Rowling (of Harry Potter fame) have publicly spoken about their battles with depression. The fact that antidepressants are now so heavily advertised has perhaps helped lift some of the stigma, too: As we hear about depression in the context of having a tangible treatment, it's easier to understand that it's a real physical disease. But there are other factors at play.
How Hormones Put Women at Risk
Although the average age of menopause is 51, perimenopause-the period of several years leading up to it, when estrogen and progesterone levels start to decrease-is actually considered riskier for mental health problems. Recent research, including some conducted by Peter Schmidt, MD, a psychiatrist and head of the behavioral endocrinology program at the National Institute of Mental Health, suggests that hormonal fluctuations may increase a woman's vulnerability to depression.
"When estrogen levels fluctuate, brain chemicals that regulate mood- serotonin, dopamine and norepinephrine-also get disrupted, which can in turn lead to depression," explains Stephen Stahl, MD, PhD, adjunct professor of psychiatry at the University of California San Diego.
Of course, some women are at greater risk than others. "Women who've had depression or hormone-related mood issues before, like postpartum depression or premenstrual mood changes so severe they interfere with daily functioning [also called premenstrual dysmorphic disorder or PMDD], are at higher risk for depression during perimenopause," says Gail Saltz, MD, associate professor of psychiatry at New York Presbyterian Hospital.
Changing hormones may have been the main trigger for Cindy Lail's depression. Cindy, 55, of Lawrenceville, Georgia, remembers how awful she began feeling at 41. "Around the time that my periods started being irregular, I got really down," she recalls. "I didn't enjoy anything anymore, but I didn't know what was happening. I just wanted to stay in bed and I got irritated very easily," she says. One day, during a routine checkup, Cindy broke down crying and told her doctor everything she had been feeling.
Fortunately, Cindy's doctor prescribed an antidepressant, and also referred her to a psychiatrist for therapy sessions and to monitor her medication. But many women delay treatment because they mistakenly think it's temporary fluxes in hormones that will resolve on their own. If your symptoms are severe or persistent, whether or not you're nearing menopause, it's worth talking to your doctor or a mental health professional who can help you figure out how to feel better.
The Stress Factor
Stress can be a problem at any age, but for women in their 40s and 50s who are saddled with responsibilities for both young children and aging parents, it can become overwhelming. Part of the so-called "sandwich generation," many women today are in roles that weren't typical for their own mothers, since they also have careers outside the home, says Katherine Muller, PsyD, director of psychological training at Montefiore Medical Center in New York. "When you're tense, levels of the stress hormone cortisol go up," explains Pam Peeke, MD, MPH, author of Body for Life for Women. When chronically elevated, "cortisol affects the balance of mood chemicals in the brain in such a way that you're more susceptible to depression."
Although depression and other mental health problems can't always be prevented, nurturing yourself can help reduce the risk. "Start small," says Dr. Muller. "It could be as simple as taking 10 minutes alone to listen to music or reading a book while you're waiting to pick up your kids from soccer practice. You just need some downtime to put your mind in another space."
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Trying to gain some control over the stressful situation is also important. "It's not just the stressor per se that causes depression but the perceived inability to do anything about it," says Alice D. Domar, PhD, a psychologist and executive director of the Domar Center for Mind/Body Health in Massachusetts. "So if you could, say, take turns with your siblings to care for your parents, you would be less likely to become depressed."
Dr. Peeke agrees: "A good caregiver is a healthy caregiver. That might mean arranging for someone to watch your mother while you go for a run, or even finding a good facility for her instead of caring for her at home."
Thinking Too Hard?
Another issue that crops up at midlife is the tendency to evaluate and analyze "life so far," says Dr. Muller. It's natural to do some navelgazing, but in some cases it can lead people to evaluate themselves too harshly. "Midlife is when we face that our youthful dreams may not all come true," says Dr. Domar. It's also a time when other life events- sending kids off to college, dealing with our own aging body, or losing a parent or spouse-prompt us to look at things in a different light.
"We start to question what has or hasn't happened in our lives," says Dr. Gottlieb. "We wonder, 'Is this the marriage or career I want? I might live another 40 years; what am I going to do with that time?' In my practice I find that men often act on their emotions (hence the stereotypical guy buying a sports car) and think about why after, whereas women spend more time analyzing how they feel. For some, these thoughts inspire change, but for others they lead to hopelessness, which can turn into depression."
When facing these kinds of big questions six years ago, Linda Nagamine, 60, slipped into a deep depression. "I worked in the airline industry but wondered if I should be doing something different with my life, and I felt like my marriage was in jeopardy," recalls the Honolulu resident. "It seemed like I was losing control." The perceived stigma almost kept her from getting the help she needed. "I thought maybe I would be treated differently if anyone knew, so I sneaked in the side entrance of my employee assistance program office so no one would see me." Linda was referred to a psychiatrist and took medication for four months, which helped her feel well enough to work on her marriage (she just celebrated her 34th wedding anniversary) and make new career goals. She became an inventor and created a handbag accessory called the Fun Key Finder.
Of course, thinking about life and what you want out of it can be positive and useful. "It's when it turns into rumination-when you keep harping on 'Why did I do that?' or 'Why didn't I do that?' and you don't take action-that it becomes a problem," says Dr. Peeke. Ruminating can provoke anxiety and raise levels of stress hormones, which, in vulnerable people, can lead to depression. "When you find yourself ruminating, give yourself a little talk," says Dr. Peeke. "Tell yourself, 'Stop right now; this is getting me nowhere.'" Break down your problems and concerns one by one. If you can't do that on your own, or if you think your worries have already escalated into depression, seek help as soon as possible.
Getting Help
If there's one thing experts emphasize, it's that depression is very treatable. For many people, a combination of therapy and medication (which can take 4 to 6 weeks to kick in) works. Some people do get better solely from talk therapy, which is helpful because it allows you to voice your feelings and get guidance as you work through them. One type, cognitive behavioral therapy, focuses on changing harmful patterns of thinking.
If you do take antidepressants, know that you may have to try a few before finding one that works-and you won't necessarily need to take them forever. "Some people need medication for a limited time to get through a rough period, but others may need it throughout life," says Dr. Clayton. Most of the popular drugs fall into two categories: SSRIs (selective serotonin reuptake inhibitors) like Paxil and Prozac increase the availability of the brain chemical serotonin. SNRIs (serotonin-norepinephrine reuptake inhibitors) like Effexor and Pristiq boost levels of serotonin and norepinephrine, another mood-boosting chemical.
Several small studies have suggested that hormone therapy (HT)-and low-dose estradiol (a form of estrogen) in particular-can treat depression in perimenopausal women, says Dr. Schmidt. However, it's not officially approved for this purpose, and using it could raise breast cancer and stroke risk. Women who are at risk for breast cancer or clotting disorders should be extremely cautious about using HT, and anyone who chooses to use it should do so for the shortest amount of time possible.
Original article appeared on WomansDay.com.
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