Is This The Real Midlife Crisis?

By David Wall/Getty Images

By Leslie Price

Women in midlife are in crisis. Yes, there have been headlines on this topic – specifically concerning the pandemic’s deleterious effect on our careers. But this is an issue that predates the pandemic, and many of us aren’t even fully aware of its scope or ramifications. 

There are hints of it in the media. Last month, The Wall Street Journal published a story asking why so many women in middle age are on antidepressants. “For years,” they write, “middle-aged women have had some of the country’s highest rates of antidepressant use…The figures are drawing increasing attention from scientists and doctors. Many are alarmed at how high depression rates were among midlife women even before the pandemic.” They’re concerned, in part, because even though these drugs can be effective, they don’t address underlying hormonal issues – that “antidepressants [may be] overprescribed for menopausal symptoms.”

This week, we spoke with Jayashri Kulkarni, a Professor of Psychiatry at the Alfred Health and Monash University and the founder of the Monash Alfred Psychiatry Research Center in Australia. She’s been studying how our hormones influence mental health for decades, with a focus on estrogen treatments for severe mental illness. We discussed why women are more at risk for depression in midlife, the role that SSRIs may or may not play in treatment, and more.

How are women to know if they are experiencing hormone-induced mental health issues? If I say I'm experiencing a lot of anxiety or sleep disturbances, but also I'm in a stressful situation right now, and I’m under a lot of pressure – what's going on? Is it perimenopause, or is it just my life?

Look, it can be really difficult. You ask a woman to trust her instincts, because she has a pretty good idea by the time she gets to the mid forties of what makes her unable to cope. And so you look for that. What's new? You've always been a bit of a perfectionist, you've always been very hard on yourself. But that’s been a constant. And then all of a sudden, there's this new thing. Sometimes you look for the fluctuation as well, like in the person who still has menstrual cycles, it's often that she's feeling worse suddenly, particularly in the premenstrual period.

I look for the sudden onset. I also look for a sudden offset. So you're looking for fluctuation, you're looking with your patient to trust her instinct. She will tell you often, "This is weird, this is new, this isn't me. I've handled stress before, but something's not right." All of these cues need to be picked up and listened to. You really are looking for that change in functionality. But yes, it can be really difficult.

You have studied suicide in women in perimenopause. What predated this work?

The research that I was doing was [based upon] having noticed that there is a deep rise in the incidence and prevalence of women with depression as they approach midlife. All the data bears that out as well. There is data from the Harvard mood studies and so on. One of the things I wanted to do was to actually look at new treatments for this depression that women at this age have, and to consider the factors for why the depression rates are so high, why they escalate. Clearly menopause and hormonal factors are a big part of that. We've been doing a number of studies looking at new hormone treatments. Well, they're not new, but they're treatments that are hormones in the depression field. And, along with depression, is the rapidly rising suicide rate, which again, mirrors what's going on in depression. So in Australia (I know the Australian data well, I think the US is pretty similar), there is a rise in completed suicide in middle-aged women.

And in Australia, in fact, the rise is such that middle-aged women are the second largest group of completed suicides – [second to] men over the age of 85.

We need something different. So most of my focus has been to develop new hormone treatments that are effective, and then to educate both the general community as well as the health community, because the concept of menopause affecting the mental state has not really been taken very seriously at all. And so many times women present to their primary healthcare practitioners and will be prescribed the standard antidepressant treatment. It's not wrong, but it doesn't have the same effect that a hormone treatment can have.

There was recently a story about the number of women in this age demographic that are on antidepressants.

Yes. Because there is an increase in depression, and there's almost this kind of knee-jerk response.

And it does have side effects. If we worry about the weight gain and the difficulties of people coming off, the SSRIs are not that simple. Patients [can] get stuck on SSRIs for a long time, which has been another whole problem. And it doesn't actually treat the symptoms particularly well. It treats it partially, but not completely.

This article on perimenopausal depression has a list of symptoms. The thing that struck me is how many could be symptoms of pandemic anxiety. How do you think women in perimenopause are handling the pandemic?

Well, in short, very badly. Because again, we never think of just one factor that's creating mental ill health. It is always a combination of factors. And we take into account the factors such as the woman's past history, including any trauma that she's experienced in her early life, [and] add that to any current traumas. We know that the pandemic has created economic disabilities for women; [that] being in lockdown with a violent partner has huge ramifications; [and also there are a] number of fears about the virus itself, particularly in older populations. Then you throw in the third factor, which is the biology upheaval, and it's a perfect storm.

We use the phrase biopsychosocial for a reason because there are biological factors, psychological factors, and social or environmental factors that are at play here. But for the perimenopausal woman, she really doesn't need one other X factor. 

Why do you think that suicide is becoming more common in this age group? And why do you think that women in this age group are more likely to be experiencing depression and anxiety?

I don't know if it's “more,” I think we are just more aware of it. It's not a coincidence that at midlife, there are the biological hormone factors. There is also the middle of life. I'm at the crossroads, what am I doing? Marriage, work, children, death of a parent or parents; there are all these social pressures that come to bear. But nonetheless, we mustn't forget the biology in all of this. That is the thing that often gets overlooked.

I don't know whether it's new [because] I haven't been able to go back and have a look at, say the 1960s compared to now, and there would be discrepancies in the way that data was collected. We're much better at collecting suicide data and depression data now than back there.

A few years ago, you co-authored an article about contraception and links to depression. There has been more conversation around hormonal contraception and mental health. Do you think that we will start talking more openly about perimenopausal mental health and if so, what do you think it would take?

I do think there is a greater conversation going on, but to my liking, it's not enough. We need to accelerate this conversation. Often the talking is between women, and that's great, because that can be a supportive environment. But the conversation that goes lacking is between the woman and her primary healthcare practitioner, particularly a male primary healthcare practitioner. That's a difficulty because that's where the prescriptions for standard antidepressants start to happen. And that's when she starts to give up because she's not seeing an improvement, there becomes a demoralization and a sense that nothing is ever going to improve. And that plays into the hopelessness, which then can be expressed in suicidality. So conversations are happening, but we need more and we need to educate medical and health professionals on this whole topic, particularly mental health professionals.

Is there anything that you're studying right now in this area that you think would be helpful for women, or maybe surprising for women who are in this age demo?

The point I always try to get out is that menopause occurs in the brain well before the body. Which is why it's tricky to diagnose, because once the hot flushes hit, then everyone can be wise about what's going on. But the difficulty is that it can present with depression, anxiety, and brain fog like five years before the body changes occur – even menstrual cycle changes and all the rest of it. That is a really difficult perimenopausal time that many women struggle with, so we need to get that message out there. If you see in yourself, or your patient sees in herself, a change in functionality at about 43 onwards, it may well be that she's beginning the menopausal changes in the brain before the body.

A lot of the stereotypes women have been told about menopause are related to the physical piece of it. I’m not sure if people understand that the physical changes could come after mental-health shifts.

Yes and we still struggle a little bit with the dismissal of the mental-health changes. It's “weepy and a bit irritable,” or even “grouchy old bag.” All that is really understating the fact that there is a major depressive condition going on here. The other thing I've often heard is, well, you don't have to worry about treating it because it's a temporary issue. The menopause process will pass and then she'll be fine. The thing is, the transition process is 10 to 15 years. It's a long time to expect somebody to just cope.

And we can't afford to lose women in the productivity sense and in the parenting sense and in the partnership sense, as well as her own enjoyment of life. That's really unfair.

Is there anything else that you have found in your research that has surprised you?

Constant surprises, but I guess I am very careful because I'm certainly not trying to pathologize menopause or make out that women are just pathetic creatures at the whims of their hormones. On the other hand, we must do what we can to support the women who struggle badly through menopause mental-health changes.=

I get accused by feminists of, "what are you doing to us?" And I'm a feminist, so it's all bit difficult, but it's actually saying, "no, we want each woman to be able to fulfill her life and to be happy. So if this is bringing her undone, there are solutions and we need to pursue those solutions so that she is happy and fulfilled."

One of the surprises is that I kind of got attacked from my own base, if you like.

It's interesting, the idea of a “natural menopause” is kind of like the idea of “natural birth.” That is to say, just buckle up. It's going to be a bumpy ride...

Plus, for some women it's not. A significant percentage of women effortlessly make the transition, and there are no problems. 

So again, with our hormone strategies, we're very careful to make sure that we are developing a number of different ones to tailor the treatment to meet the needs of the individual woman – taking into account her physical health, as well as her mental health needs, as well as the social needs. Tailoring treatment for women's needs is really critical.

And where do you see women going for this sort of support? I ask because here in the US, it seems a little bit confusing. Every specialty is kind of on its own, so you can go see a gynecologist, which is different from your primary care doctor, which is different from a psychiatrist – and they might not talk to each other. It feels like it crosses across a lot of providers. And here, there's a relative lack of specialists for women in menopause.

And that's the problem. No specialty owns menopause, it's an orphan. So that does make it really difficult. I think cross-disciplinary work is really critical, as you said. In my clinic, we do have collaborative sessions. In fact, sometimes an endocrinologist and I will see a patient together, sometimes we'll have a gynecologist in the room. There's quite an array of disciplines and a willingness of the specialists to learn from each other. That's a really fulfilling way to work, but it's unusual.