Mood disorders and fertility in women: a critical review of the literature and implications for future research

Mental health and access to services among US women of reproductive age

OBJECTIVE

The objective of the study was to estimate prevalence of depression and serious psychological distress (SPD) and mental health service receipt among reproductive-age women.

STUDY DESIGN

We used 2006-2007 nationally representative data to estimate the prevalence of depression and SPD among nonpregnant women aged 18 to 44 years. Using logistic regression, we individually examined predictors of depression and SPD and characteristics associated with clinical diagnosis and current treatment.

RESULTS

More than 14% of women had current depression and 2.7% had current SPD. Risk factors for major depression and SPD included older age, less education, being unmarried, inability to work/unemployed, and low income. Among depressed women, 18-24 year-olds, nonwhite women, those with children, the employed, and urban women had lower odds of clinical diagnosis. Among women with SPD, Hispanic, employed, and those without health insurance had lower odds of receiving treatment.

CONCLUSION

Mental health conditions are prevalent among women of reproductive age and a substantial proportion goes untreated.

Up-regulated monoamine oxidase in the mouse uterus during the peri-implantation period

PURPOSE

Monoamine oxidases (MAO), functioning as the metabolism of neuroamines, have been reported to be required for endometrial receptivity recently. The aim of this study was to examine the expression patterns of the two subtypes, MAOA and MAOB, during the peri-implantation period and to investigate whether MAOA or MAOB is a useful marker for receptivity.

METHODS

A total of 30 uteri were collected from females of gestational day 0, 2, 4, 6, 8, and mRNA and protein expression of MAOA/B were examined by real-time PCR, Western blot analysis and Immunohistochemistry analysis, respectively.

RESULTS

We found that the mRNA of MAOA expressed in the uteri at all stages of peri-implantation and began to rise on day 4 with a continuous increase up to day 8 of pregnancy, consistent with the changes of MAOA protein expression. The summit of MAOB mRNA and protein level was observed on day 4. Immunohistochemistry analysis revealed that both of MAOA and MAOB were mainly localized in the glandular and luminal epithelium cells, as well as their intense staining signals observed in the trophoblast cells on day 6 and 8.

CONCLUSIONS

Both MAOA and MAOB were up-regulated in the uteri during the peri-implantation period, which could play a role in mouse embryo implantation and endometrial receptivity; the temporal and spatial marked increase of MAOs may be traced as a useful marker for mouse endometrial receptivity; the expression mode of mouse MAOs should pave a way for further study.

The neurobiology of preovulatory and estradiol-induced gonadotropin-releasing hormone surges

Ovarian steroids normally exert homeostatic negative feedback on GnRH release. During sustained exposure to elevated estradiol in the late follicular phase of the reproductive cycle, however, the feedback action of estradiol switches to positive, inducing a surge of GnRH release from the brain, which signals the pituitary LH surge that triggers ovulation. In rodents, this switch appears dependent on a circadian signal that times the surge to a specific time of day (e.g., late afternoon in nocturnal species). Although the precise nature of this daily signal and the mechanism of the switch from negative to positive feedback have remained elusive, work in the past decade has provided much insight into the role of circadian/diurnal and estradiol-dependent signals in GnRH/LH surge regulation and timing. Here we review the current knowledge of the neurobiology of the GnRH surge, in particular the actions of estradiol on GnRH neurons and their synaptic afferents, the regulation of GnRH neurons by fast synaptic transmission mediated by the neurotransmitters gamma-aminobutyric acid and glutamate, and the host of excitatory and inhibitory neuromodulators including kisspeptin, vasoactive intestinal polypeptide, catecholamines, neurokinin B, and RFamide-related peptides, that appear essential for GnRH surge regulation, and ultimately ovulation and fertility.

Early-onset Major Depressive Disorder in men is associated with childlessness

METHODS

The self-reported number of children was compared for men and women from the National Epidemiologic Survey of Alcoholism and Related Conditions Survey (NESARC). Subjects with a diagnosis of major depressive disorder or bipolar disorder were compared to those without an axis I disorder. The effect of age, gender, marriage and diagnostic status on number of children was completed using multivariate analyses.

RESULTS

Men with a history of major depressive disorder but not bipolar disorder reported higher rates of childlessness and lower mean number of children. This reduced number of children was related to an early age of onset of MDD. Thirty percent of men with an age of onset of MDD before 22 were childless compared to only 18.9% of men without an axis I disorder (Odds ratio=1.82, 95% CI=1.45-2.27). No effect of mood disorder on number of children was found in women with major depression or bipolar disorder.

DISCUSSION

This study suggests that an early age of onset of major depressive disorder contributes to childlessness in men.

Depressive symptoms related to infertility and infertility treatments

This article reviews depressive symptoms in women as they relate to infertility and infertility treatments. Common causes of infertility in women are discussed and the literature on depressive symptoms before and during various infertility treatments is presented. Recommendations are made from a psychiatric perspective regarding how to manage depressive symptoms in women in the context of infertility.

Effects of estradiol on learned helplessness and associated remodeling of hippocampal spine synapses in female rats

BACKGROUND

Despite the fact that women are twice as likely to develop depression as men, our understanding of depression neurobiology in female subjects is limited. We have recently reported in male rats that development of helpless behavior is associated with a severe loss of hippocampal spine synapses, which is reversed by treatment with the antidepressant desipramine. Considering that estradiol has a hippocampal synaptogenic effect similar to those of antidepressants, the presence of estradiol during the female reproductive life might influence behavioral and synaptic responses to stress and depression.

METHODS

With electron microscopic stereology, we analyzed hippocampal spine synapses in association with helpless behavior in ovariectomized female rats (n = 70), under different conditions of estradiol exposure.

RESULTS

Stress induced an acute and persistent loss of hippocampal spine synapses, whereas subchronic treatment with desipramine reversed the stress-induced synaptic loss. Estradiol supplementation given either before stress or before escape testing of nonstressed animals increased the number of hippocampal spine synapses. Correlation analysis demonstrated a statistically significant negative correlation between the severity of helpless behavior and hippocampal spine synapse numbers.

CONCLUSIONS

These findings suggest that hippocampal spine synapse remodeling might be a critical factor underlying learned helplessness and, possibly, the neurobiology of depression.

The role of genetic variation in the causation of mental illness: an evolution-informed framework

The apparently large genetic contribution to the aetiology of mental illness presents a formidable puzzle. Unlike common physical disorders, mental illness usually has an onset early in the reproductive age and is associated with substantial reproductive disadvantage. Therefore, genetic variants associated with vulnerability to mental illness should be under strong negative selection pressure and be eliminated from the genetic pool through natural selection. Still, mental disorders are common and twin studies indicate a strong genetic contribution to their aetiology. Several theories have been advanced to explain the paradox of high heritability and reproductive disadvantage associated with the same common phenotype, but none provides a satisfactory explanation for all types of mental illness. At the same time, identification of the molecular substrate underlying the large genetic contribution to the aetiology of mental illness is proving more difficult than expected. The quest for genetic variants associated with vulnerability to mental illness is predicated upon the common disease/common variant (CDCV) hypothesis. On the basis of a summary of evidence, it is concluded that the CDCV hypothesis is untenable for most types of mental illness. An alternative evolution-informed framework is proposed, which suggests that gene-environment interactions and rare genetic variants constitute most of the genetic contribution to mental illness. Common mental illness with mild reproductive disadvantage is likely to have a large contribution from interactions between common genetic variants and environmental exposures. Severe mental illness that confers strong reproductive disadvantage is likely to have a large and pleiotropic contribution from rare variants of recent origin. This framework points to a need for a paradigm change in genetic research to enable major progress in elucidating the aetiology of mental illness.

An evolutionary hypothesis of depression and its symptoms, adaptive value, and risk factors

Major depression is an evolutionary paradox: it carries great disadvantages for survival and reproduction of both patients and their relatives, yet it is common and has significant heritability. We propose a new hypothesis to help explain many of depression's symptoms and its risk factors, most of them not explained by previous evolutionary theories. We hypothesize that the evolutionary costs of depression are offset by its benefits in combating existing infections and avoiding new ones. As our hypothesis predicts, depression can be elicited by various infections as well as by environmental stressors that compromise immune function. Moreover, many depressive symptoms tend to aid immune function and reduce exposure to new infections and stressors. The hypothesis makes many predictions about the epidemiology and physiology of depression that are supported by available evidence. The hypothesis also suggests that possible underlying infectious and immune factors deserve greater consideration in prevention and treatment of depression.

Short-term outcomes of mothers and newborn infants with comorbid psychiatric disorders and drug dependency

OBJECTIVES

The aim of the present study was to determine the characteristics and short-term outcomes of mother-infant pairs with comorbid drug dependency and psychiatric disorders.

METHODS

A population-based retrospective chart review was carried out of 879 drug-dependent mother and infant pairs in New South Wales (NSW) and the Australian Capital Territory (ACT) who delivered between 1 January and 31 December 2004.

RESULTS

Psychiatric comorbidity (dual diagnosis, DD) was identified in 396 (45%) of the 879 drug-dependent women. DSM-IV depression (79%), followed by anxiety (20%), was most prevalent. DD women were more likely to use amphetamines (29% vs 18%, p < 0.05), less likely to use opiates (42% vs 51%, p < 0.05) and to have had no antenatal care (24% vs 8%, p < 0.05). They also had more previous pregnancies (4, range = 2-5 vs 3, range = 2-5, p < 0.05) and domestic violence (29% vs 14%, p < 0.05) was more common. DD infants were less likely to be admitted to a nursery (47% vs 55%, p < 0.05). Withdrawal scores were similar (maximum median Finnegan scores = 4 (interquartile range = 3-8) vs 10 (interquartile range = 7-12, p = 0.30) but fewer needed withdrawal medication (19% vs 27%, p < 0.05). Maternal psychotropic agents did not worsen the severity of neonatal withdrawal.

CONCLUSIONS

Psychiatric comorbidity, especially depression, is common and affects almost half of drug-using mothers. Antenatal care, drug use and social outcomes are worse for DD mothers and their infants. It is recommended that all drug-using women be assessed antenatally for psychosocial disorders so that timely mental health intervention can be offered, if required.

Risk factors for psychiatric disorders in infertile women and men undergoing in vitro fertilization treatment

OBJECTIVE

To identify risk factors associated with depression and anxiety in infertile women and men undergoing in vitro fertilization (IVF).

DESIGN

Prospective study.

SETTING

A university hospital in Sweden during a 2-year period.

PATIENT(S)

825 participants (413 women and 412 men).

INTERVENTION(S)

Primary Care Evaluation of Mental Disorders (PRIME-MD), based on the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), as the diagnostic tool for evaluating mood and anxiety disorders, and fertility history and outcome of IVF treatment collected from the patients' medical records.

MAIN OUTCOME MEASURE(S)

Risk factors associated with depression and anxiety disorders.

RESULT(S)

A negative pregnancy test and obesity were the independent risk factors for any mood disorders in women. Among men, the only independent risk factor for depression was unexplained infertility. No IVF-related risk factors could be identified for any anxiety disorder.

CONCLUSION(S)

A negative pregnancy test is associated with an increased risk for depression in women undergoing IVF, but no risk of developing anxiety disorders is associated with the pregnancy test result after IVF. Pregnancy test results were not a risk factor for depression or anxiety among men.

Prevalence of psychiatric disorders in infertile women and men undergoing in vitro fertilization treatment

BACKGROUND

This study was undertaken to determine the prevalence of psychiatric disorders in infertile women and men undergoing in vitro fertilization (IVF) treatment.

METHODS

Participants were 1090 consecutive women and men, 545 couples, attending a fertility clinic in Sweden during a two-year period. The Primary Care Evaluation of Mental Disorders (PRIME-MD), based on the Diagnostic and Statistical Manual of Mental Disorders, 4th edn (DSM-IV), was used as the diagnostic tool for evaluating mood and anxiety disorders.

RESULTS

Overall, 862 (79.1%) subjects filled in the PRIME-MD patient questionnaire. Any psychiatric diagnosis was present in 30.8% of females and in 10.2% of males in the study sample. Any mood disorder was present in 26.2% of females and 9.2% of males. Major depression was the most common mood disorder, prevalent in 10.9% of females and 5.1% of males. Any anxiety disorder was encountered in 14.8% of females and 4.9% males. Only 21% of the subjects with a psychiatric disorder according to DSM-IV received some form of treatment.

CONCLUSIONS

Mood disorders are common in both women and men undergoing IVF treatment. The majority of subjects with a psychiatric disorder were undiagnosed and untreated.