Evaluation and management of depressive and anxiety symptoms in midlife

Objectives Evaluation and management of anxiety and depression during the menopausal transition are complicated by the overlap between some symptoms of affective disorder with those of menopausal symptoms, and also by inconsistencies in the literature regarding the relationship between the menopausal transition and affective disorders. Methods We have reviewed key studies over the past three decades addressing depression and anxiety during the menopause transition, in order to present a practical, clinical approach to the evaluation and management of anxiety and depressive symptoms at midlife. Results Symptoms of anxiety and depression are common at midlife and may coincide with menopausal symptoms. Some menopausal symptoms are also symptoms of anxiety and/or depression. Management should include treatment of troublesome menopausal symptoms, providing strategies to deal with psychosocial stressors, and exclusion of clinically significant anxiety and depressive disorders. Interventions such as exercise and cognitive behavior therapy may improve mood and general health at menopause, and a multifocal approach is recommended. Depression of greater than moderate severity requires treatment with an antidepressant. Some selective serotonin reuptake inhibitors and serotonin–norepinephrine reuptake inhibitors may also improve vasomotor symptoms and these should be considered in women with both affective disorder and vasomotor symptoms. Conclusions There is no clear evidence that the menopause transition alone increases the risk of clinically significant affective disorders, except in women with risk factors such as psychosocial stressors, severe and prolonged vasomotor symptoms and a previous history of affective disorders. Nevertheless, anxiety and depression are common in women and clinicians should be alert to the symptoms of these conditions at all encounters.