Consenso. Parte I Guías para evaluación y tratamiento de depresión perimenopausica: recomendaciones / Consensus. Part I Guidelines for evaluation and treatment of perimenopausal depression: recommendations

Hay una nueva apreciación de la perimenopausia, definida como las etapas de transición temprana y tardía de la menopausia, también como la posmenopausia temprana, como una ventana de vulnerabilidad para el desarrollo de síntomas depresivos y episodios depresivos mayores. Sin embargo, las recomendaciones clínicas sobre cómo identificar, caracterizar y tratar la depresión clínica están faltando. Para abordar esta brecha, se convocó un panel de expertos para revisar sistemáticamente la literatura publicada y desarrollar lineamientos sobre la evaluación y manejo de la depresión perimenopáusica. Las áreas abordadas incluyeron: 1) epidemiología; 2) presentación clínica; 3) efectos terapéuticos de los antidepresivos; 4) efectos de la terapia hormonal; y 5) la eficacia de otras terapias (por ejemplo, psicoterapia, ejercicio y productos naturales para la salud). En general, la evidencia sugiere que la mayoría de las mujeres de mediana edad que experimentan un episodio depresivo mayor durante la perimenopausia han tenido un episodio previo de depresión. La depresión de la mediana edad se presenta con síntomas depresivos clásicos comúnmente en combinación con síntomas de la menopausia (es decir, síntomas vasomotores, trastornos del sueño) y problemas psicosociales. Los síntomas de la menopausia se complican, coexisten y se superponen con la presentación de la depresión. El diagnóstico implica la identificación de la etapa menopáusica, la evaluación de los síntomas psiquiátricos y de la menopausia (los cuales son concurrentes), apreciación de los factores psicosociales comunes en la mediana edad, diagnósticos diferenciales y el uso de pruebas de detección con instrumentos validadas. Las opciones terapéuticas probadas para la depresión (es decir, antidepresivos, psicoterapia) son la primera línea de tratamientos para la depresión perimenopáusica. Aunque la terapia con estrógenos no está aprobada para tratar la perimenopausia, existe evidencia de que tiene efectos antidepresivos en mujeres perimenopáusicas, particularmente en aquellas con síntomas vasomotores concomitantes. Los datos sobre estrógeno más progestina son escasos y no concluyentes.

There is a new appreciation of the perimenopause ­ defined as the early and late menopause transition stages as well as the early postmenopause - as a windowof vulnerability for the development of both depressive symptoms and major depressive episodes. However, clinical recommendations on how to identify, characterize and treat clinical depression are lacking. To address this gap, an expert panel was convened to systematically review the published literature and develop guidelines on the evaluation and management of perimenopausal depression. The areas addressed included: 1) epidemiology; 2) clinical presentation; 3) therapeutic effects of antidepressants; 4) effects of hormone therapy; and 5) efficacy of other therapies (eg, psychotherapy, exercise, and natural health products). Overall, evidence generally suggests that most midlife women who experience a major depressive episode during the perimenopause have experienced a prior episode of depression. Midlife depression presents with classic depressive symptoms commonly in combination with menopause symptoms (ie, vasomotor symptoms, sleep disturbance), and psychosocial challenges. Menopause symptoms complicate, co-occur, and overlap with the presentation of depression. Diagnosis involves identification of menopausal stage, assessment of co-occurring psychiatric and menopause symptoms, appreciation of the psychosocial factors common in midlife, differential diagnoses, and the use of validated screening instruments. Proven therapeutic options for depression (ie, antidepressants, psychotherapy) are the front-line treatments for perimenopausal depression. Although estrogen therapy is not approved to treat perimenopausal depression, there is evidence that it has antidepressant effects in perimenopausal women, particularly those with concomitant vasomotor symptoms. Data on estrogen plus progestin are sparse and inconclusive.

Long-term risk of myocardial infarction and stroke in bipolar I disorder: A population-based Cohort Study.

OBJECTIVES: To estimate the risk of fatal and non-fatal myocardial infarction (MI) and stroke in patients with bipolar I disorder compared to people without bipolar I disorder. METHOD: Utilizing a records-linkage system spanning 30 years (1966-1996), a population-based cohort of 334 subjects with bipolar I disorder and 334 age and sex-matched referents from Olmsted County, Minnesota, U.S. was identified. Longitudinal follow-up continued until incident MI or stroke (confirmed by board-certified cardiologist/neurologist), death, or study end date (December 31, 2013). Cox proportional hazards models assessed the hazard ratio (HR) for MI or stroke, adjusting for potential confounders. RESULTS: There was an increased risk of fatal or non-fatal MI or stroke (as a composite outcome) in patients with bipolar I disorder [HR 1.54, 95% confidence interval (CI) 1.02, 2.33; p=0.04]. However, after adjusting for baseline cardiovascular risk factors (alcoholism, hypertension, diabetes, and smoking), the risk was no longer significantly increased (HR 1.19, 95% CI 0.76, 1.86; p=0.46). LIMITATIONS: Small sample size for the study design. Findings were not retained after adjustment for cardiovascular disease risk factors. Psychotropic medication use during the follow-up was not ascertained and was not included in the analyses. CONCLUSION: This study in a geographically defined region in the U.S. demonstrated a significant increased risk of MI or stroke in bipolar I disorder, which was no longer significant after adjustment for cardiovascular risk factors.