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Perimenopausal Depression

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We interview Ruta Nunacs on perimenopausal depression, and our word of the day – processomania – brings us into the crosshairs of politics and psychiatry.

Published On: 10/18/20

Duration: 24 minutes, 42 seconds

Article Referenced: Mood and Menopause,” The Carlat Psychiatry Podcast, October 2020

Rough Transcript:

Dr. Aiken: Women have twice the risk of depression as men. But what can we do about it during the perimenopausal years? Welcome to The Carlat Psychiatry Podcast, keeping psychiatry honest since 2003. I’m Chris Aiken, the editor in chief of the Carlat Report.

Kellie: And I’m Kellie Newsome, a psychiatric NP and a dedicated reader of every issue.

Dr. Aiken: Many cities have psychiatrists and psychiatric nurse practitioners who claim to specialize in women’s mental health. I’ve always been curious about that – because in the average outpatient practice the majority – 60% – of the patients are women. So if there’s something special to know about treating women – we ought to all be in on it.

That’s why we interviewed Ruta Nunacs on hormones and depression this month. Dr. Nunacs is a psychiatrist at Harvard’s Mass General Hospital’s Perinatal and Reproductive Psychiatry Clinical Research Program. 

There are four times in a woman’s life when they are uniquely vulnerable to hormone-related mood problems. The onset of menses, the luteal phase of the menstrual cycle – that’s the 2 week period between ovulation and menstruation; the peripartum period around pregnancy and just after delivery; and the perimenopausal period. The rate of depression shoots up 2-4 fold during the transition to menopause, and even 70% of women have symptoms of depression during the perimenopausal time even if they don’t have the full episode.

On the other hand just because something is caused by stress it doesn’t mean the cause is not hormonal – I mean stress affects cortisol and the HPA axis and that might be how it causes mental illness. But the hormonal changes of stress can cause just about every mental illness – cortisol disruption has been linked to insomnia, PTSD, bipolar disorder, depression, panic, schizophrenia…. Why is it that we only talk about depression when we talk about menopausal hormones?

Kellie: Vortioxetine has two trials that looked at cognitive symptoms in perimenopausal depression. One found benefits and the other did not, but both were small observational studies that were neither randomized nor included a placebo group. In our online interview Dr. Nunacs discussed the role of hormone replacement therapy in perimenopausal depression, and though we’ve included prescribing directions for the exact hormones used in the research trials she recommends having the OBGYN step in at that point.

Although estrogen based hormone replacement therapy is generally beneficial to mood in perimenopausal women, and improves well being in non-depressed women, Dr. Nunacs does not recommend it first line, and in the online interview she detailed when you would and would not recommend hormone replacement therapy.  As she spoke I realized there’s a paradox here – that while estrogen is beneficial in the perimenopausal years, it can disrupt mood and even increase suicidality when given to younger women in the form of birth control pills.

Young women with depression and bipolar disorder often ask me which contraceptive pills are the least likely to make their mood worse, and we’ve listed the best and the worst in a handy table in the online edition of this interview. 

Ruta Nonacs practices psychiatry at Massachusetts General Hospital’s Perinatal and Reproductive Psychiatry Clinical Research Program. She has published original research on peripartum mood disorders and is the author of A Deeper Shade of Blue: A Woman’s Guide to Recognizing and Treating Depression in Her Childbearing Years

And now for the word of the day…. Processomania

Mania is a psychiatric disorder, and we try to diagnose it based on generalizable signs and symptoms – like rapid tangential speech – rather than on the specific content of the mania. But the term “mania” has also been applied to people with obsessive interests who may or may not have actually mania. So there’s Beatlemania, Pyromania, and today’s term Processomania – also known as litigious mania – which is an undue proclivity to sue people for every conceivable infraction. You might see it in people with paranoid personality disorder or delusional disorder who feel easily slighted, or in actual mania. I recall a case where – I’ll change the details as always – a man had brought dozens of lawsuits against his family and friends, most of which were thrown out of court. I asked him to share the details of his case and he pulled out a large box of greeting cards – he had saved every birthday card that his siblings had sent him. Read this here – it says “Happy Birthday George – Love always, Dianne.”  You see that – it says “love always”  Well, he and Dianne were no longer on speaking terms, and he was now suing her for breaking her promise of “love always.”

Courts have a term for this behavior – Vexatious litigants – which refers to people who bring repetitive law suits against others solely to harass or subdue their enemies. California even maintains a public list of Vexatious litigants who are not allowed to bring cases to court without a judge’s permission.  The list has several thousand people on it, including corporations like a towing company, an evangelical church, a composer of theme songs from 1980’s television shows – and a handful of political groups – anti-Trump organization, and the “Occupy LA” movement which was a cousin of Occupy Wall street.

And that’s where things start to get dicey. In America the courts make no reference to mental illness when designating someone a Vexatious litigant, but China has a different history. In post Maoist China, political dissidents have been institutionalized for questionable psychiatric disorders made by state appointed psychiatrists, and the two most common diagnoses evoked to justify this incarceration are “Political mania” and “Litigious mania,” presumably because they bring law suits against the Communist party. 

Chinese psychiatric texts describe these dissidents as “disturbing the public order” by “writing reactionary letters, placing slogan-banners in public places, or shouting those slogans amidst crowds of people.” Here’s a translation from a 1994 textbook of forensic psychiatry from Beijing:  “The content…

Another writer focused on the lack of self-preservation:  

Many political dissidents have no mental illness, and some probably have real psychiatric disorders that are unrelated to their political views. But there’s a third possibility – sometimes meaningful political change can spring from what we call psychopathology. Martin Luther King, Abraham Lincoln, and Mahatma Ghandi all had suicidal episodes in their early adulthood. Those men are icons today but were not widely popular in their own time.

Fast forward to October 11 2016. A small band of environmental activists attempted to stop 15% of US crude oil imports but shutting down major oil pipelines. One of those activists, Ken Ward, was diagnosed with bipolar disorder and placed on lithium when he first started to take extreme positions on climate change. Ken now contests that diagnosis – and the unsettled story is captured in a documentary film: The Reluctant Radical. 

Kellie: Send your feedback and questions to  We do read those and use them to make these podcasts – recently we’ve gotten some questions on how to use lamotrigine in bipolar disorder and we’ll have a feature on that coming up in the next few months. You can read the full articles and earn CME credits at

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