Depression in Middle Age: A Mid-Life Crisis or a Mid-Life Depression?

October 15th, 2018

As the baby boomers are moving into the geriatric population, and the Generation Xers are heading into their middle-age years, we are seeing depression rise in the offspring of the baby boomers. This may be attributed to the slowly decreasing stigma surrounding mental health disorders, paving the way for more people to seek and accept the help of mental health services. There still is a consistent trend of women seeking services more often than men, but women are also more susceptible to developing depression due to increased sensitivity from hormonal changes. These levels can begin to fluctuate at age 35.


It is well established that estrogen provides vasomotor and cognitive protection and falling levels of estrogen as seen before and during menopause can trigger symptoms of hot flashes, insomnia, and low energy. These symptoms are typically what brings the female patient to seek medical advice. Women suffering from the symptoms associated with menopause can have a double struggle due to coinciding depression symptoms that are often amplified by the physical symptoms.


In the Melbourne Women’s Mid-Life Health Project, feelings of downheartedness and sadness, as well as nervous tension were among the six most common complaints. An ongoing longitudinal study, the Harvard Study of Moods and Cycles, reported on the long-term, prospective evaluation of 1000 women who were premenopausal (36 to 44 years of age) at the time of enrollment. They received periodic hormonal, psychiatric, and quality-of-life assessments, and the results were controlled by factors that are commonly investigated in depression, such as body mass index, smoking, marital status, and occupational status.


The data from this study indicated that peri-menopausal women were two times more likely than premenopausal women to develop new-onset severe depression. In addition, the risk was exacerbated in those who developed vasomotor symptoms during perimenopause.  However, women are not the only group to experience significant physical and emotional changes during mid-life.


Unfortunately, there is overwhelmingly more data collected on women and depression than men, and the role of estrogen as a common biochemical pathway for depression. Men are also prone to hormonal changes during the middle-age years. In men, testosterone secretion affects neurobehavioral functions such as sexual arousal, aggression, emotional tone, and cognition. The prevalence of low levels of total serum testosterone is approximately 20% in individuals younger than 50 years, and 50% in those younger than 80 years. Beginning at approximately age 50, men secrete progressively lower amounts of testosterone; about 20% of men over age 60 have lower-than-normal levels. The psychiatric sequelae are poorly understood, yet there is evidence of an association with depressive symptoms.


In 1999, Seidman and Walsh collected data from observational studies and treatment studies and suggested that some depressed older men may have state-dependent low testosterone levels. Common symptoms of TDS include low libido, decreased vitality, fatigue, mood changes, insomnia, anemia, flushes, erectile dysfunction, decreased muscle mass, increased visceral body fat, ejaculatory dysfunction, and loss of concentration. The overwhelming culmination of these symptoms alone can be enough to trigger a depressive episode for a man, but again, as seen in estrogen, there may be a coinciding biochemical pathway shared between testosterone and depression, not simply a triggered event by these physical and quality-of-life changes.  


Treatment options as related to the hormonal fluctuations in men and women mid-life would suggest that hormone replacement therapy (HRT) would be beneficial. In 2002, the Women’s Health Initiative (WHI) study suggested that hormone replacement therapy had no protective effect against cardiovascular events among postmenopausal women using HRT. As a result, physicians became more reluctant to prescribing estrogen, even for younger, middle-aged symptomatic women. The prescription rate of HRTs decreased in the year following the published results of the WHI study, and the prescription rate of antidepressants significantly increased during the same time. This suggests that women developed psychological symptoms as they stopped using estrogen, or that antidepressants were being used to treat menopause-related symptoms.


Likewise, a study by Jung and Shin, as published in the World Journal of Men’s Health in 2016, says use of testosterone replacement therapy (TRT) effectively improved total serum testosterone levels as well as cognitive performance and depression scores in men with testosterone deficiency, suggesting that TRT may indeed improve some aspects of depression and cognitive ability in such patients. Therefore, TRT may be considered for men with depression or cognitive impairment in addition to low testosterone levels.


Men and women may also present with differing symptoms. Women may report more crying spells and men likely experience more anger outbursts. Women might have more emotional outbursts or what would be described as “meltdowns,” and men might be more withdrawn from family and friends. Though both men and women can experience decreased sexual desire or low libido as a result of depression, men are more likely to voluntarily verbalize this to a health care provider more than women. However, for the most part, both genders experience overlapping symptoms, including: loss of interest, appetite fluctuations, anxiety, lack of motivation and difficulty concentrating. Hormonal fluctuations in men and women is only one piece of the mid-life depression versus mid-life crisis puzzle.  


Middle-aged men and women typically experience various life changes during the phase. The younger, middle-aged population are experiencing a household with teenagers. The older, latter half of the Generation X parents, or the new “empty-nesters” may have a very difficult time with letting go of their adult children, as they begin to find their own independence. The feeling of loneliness coupled with a lack of “control” of their children’s choices may be unsettling.


However, societal and economic changes in the current era have also affected this age group. The divorce rate has increased significantly, and it is well known that marital struggles greatly impact mood.  Job loss, parental death, financial struggles all can have a negative impact on a person’s identity, playing into one’s self-esteem and sense of worth, potentially triggering a depressive episode. Communicating any struggles and coping with these changes is a necessary step towards getting help and is part of the treatment.


The bottom line is that various changes, both biological and environmental, can elicit symptoms of depression in both men and women. Quality-of-life is of the utmost importance to protect. Treatment is available, whether in the form of talk therapy, hormone replacement, antidepressants, non-medication treatments, or any combination of the above.


No matter what way, middle-aged men and women both have many options for getting relief from the symptoms.  With new advancements in depression treatment and the continued fight against the stigma of mental health conditions, there is new hope for this population to treat their depression, which in turn, will improve the chances of their children, the future generation, seeking help.


Need help? Contact SuccessTMS for the best treatment for depression in Broward and Martin Counties, FL at 561-240-0194.