Depression is a leading cause of disability and health-related costs in Australia and worldwide [1, 2], and affects between 4 and 14% of the population at any point in time . The prevalence of depression is consistently higher in women than in men across the reproductive lifespan, with an increase in the prevalence of clinically significant depressive symptoms noted during the years that overlap with the menopausal transition (MT) [3–6]. The prospective midlife Study of Women’s Health Across the Nation (SWAN) in the United States indicated that nearly one in every four women experience clinically significant depressive symptoms at this time . This, together with further confirmatory studies, led the National Institute of Aging to propose in 2010 that active screening of depressive symptoms should become an integral part of the assessment of all women going through the MT .
What is the menopausal transition?
All ageing women with intact ovaries go through the MT, which is triggered by low ovarian follicular reserve that leads to elevated follicle-stimulation hormone, fluctuating oestradiol and reduced progesterone levels . The MT commences at around age 47 and lasts 4 to 7 years . The ‘menopause’ is the final menstrual period and occurs at a mean age of 51 years, and by age 55 nearly all women are postmenopausal . Symptoms typically associated with the MT include irregular menstrual cycles, vasomotor symptoms (hot flushes and night sweats), sleep disturbances, vaginal dryness and dyspareunia, decreased libido, urinary symptoms, muscle and joint pains, and mood disturbance . Importantly, typical symptoms associated with the MT (for example, hot flushes and night sweats) are amenable to change by means of biological or behavioural interventions [12, 13].
Why is the prevalence of depressive symptoms high during the menopausal transition?
The reasons for the increased vulnerability to depression during the MT are not fully understood. Women with past history of depression are nearly five times more likely to have a recurrence of depressive illness during the menopausal transition, whereas women with no history of depression are two to four times more likely to report depressed mood compared with premenopausal women [6, 14, 15]. In some studies, the changing hormonal milieu has been associated with depressive symptoms during the MT [16, 17], but other factors may be as important, such as prolonged hot flushes, weight gain, comorbid diseases, poor social support, changing psychosocial roles, anxiety and perceived loss of control [18–21].
Can we prevent depression during the menopausal transition?
Despite growing recognition that the MT is a period of high vulnerability to depression, no previous studies have attempted to prevent this happening. The spectrum of physiological, psychological and social changes that women undergoing the MT have to negotiate indicate that effective preventive strategies must be multifaceted (in the same way that strategies to reduce the prevalence of cardiovascular events have greater chance of success when multiple risk factors are targeted simultaneously, such as hypertension, diabetes, dyslipidaemia, physical activity, diet, alcohol use and smoking). Moreover, past history of depression increases the risk of postmenopausal depression, cardiovascular events, substance abuse and mortality [22, 23], the successful prevention and treatment of depression during the MT is expected to have long-term beneficial consequences for our ageing population. Clinical recommendations on managing the MT promote a broad approach to prevention and management of depression , including education, lifestyle changes (diet, exercise, smoking, and alcohol consumption), optimisation of general health and social support, minimisation of vasomotor symptoms, problem solving strategies and, if depression is prominent (that is, major depressive episode or dysthymia), antidepressant treatment and/or psychotherapy . Oestrogen-containing hormone therapy is recommended for women with moderate to severe vasomotor symptoms without other contra-indications , and preliminary evidence suggests that it may also improve mood . As the origin of depression during the MT is most likely multifactorial, its optimal management and prevention should target multiple factors, which is consistent with the results of successful interventions designed to decrease the prevalence of depression and suicide ideation in later life .
Women undergoing the menopausal transition require a targeted health promotion intervention
The MT affects all ageing women with intact ovaries. Marked physiological and psychosocial changes characterise this unique period of a woman’s life, including symptoms such as hot flushes and night sweats, remodelling of body shape, shifting social roles (for example, children moving away from home), and onset of chronic illnesses (such as diabetes and hypertension). All these factors may interact to facilitate the development of depressive symptoms during the MT. As depression and poor lifestyle practices in mid life have been associated with poor health outcomes in older age [11, 27–29], developing health promotion interventions that are relevant to women in the MT seem not only desirable, but a necessity.
In summary, published observational data suggest that women undergoing the MT are at increased risk of clinically significant depressive symptoms and highlight numerous health and behavioural factors that might potentially mediate such increased risk. We have designed a health promotion intervention that seeks to address these risk factors systematically and to enhance behaviours associated with good mental health outcomes. More specifically, this study will aim to address the following:
determine the efficacy of a telephone-medicated health promotion intervention, compared with usual care, in decreasing the 12-month incidence of clinically significant symptoms of depression in women undergoing the menopausal transition who do not have clinically significant symptoms of depression or mental disorders at the time of entry into the study,
determine the efficacy of a telephone-mediated health promotion intervention in decreasing the 12-month incidence of major depressive episodes in women undergoing the menopausal transition, compared to usual care,
measure the effect of a telephone-mediated health promotion intervention in decreasing the severity of depressive symptoms over 12 months compared to usual care,
ascertain the prevalence of clinically significant symptoms of depression among community-dwelling Western Australian women undergoing the menopausal transition.