 This is Dr. Mishra. I am a practicing psychiatrist for 32 years. I have a special interest in the fields of mode disorder and depression. And it is this with this background I come and do this presentation today on a very timely topic. I have prepared some slides here which I will take about 40 45 minutes or so to complete that will leave us about 15 20 minutes time for Q&A or discussion session. I just want to say this thing that I will not be able to answer any specific treatment question for a person, because that is a decision between the patient and the doctor. But I will be very happy to answer any general questions related to depression and women at various stages and their treatment, etc. So without any further delay, I will start the presentation. First of all, let's talk about how common is depression. But first of all, I want to say that depression is very common both in men and women. And it is the leading cause of disability worldwide. But the depression is specially more common in women compared to men. Actually, it is twice as common in women compared to men. I can describe a term for prevalence. Prevalence means number of cases of a condition or disorder in a community over a timeframe or at a point of time. So, you will see here that lifetime in in their lifetime, women, 21% of women will develop depression compared to 12% of men. 12% of men developing depression is a high number, but women almost one quarter of women will develop depression during their lifetime. Now, in any given year, 13% of women will develop depression compared to 8% of men. And you can see here that chances of women developing depression are almost twice as high as compared to men. So now in the next couple of slides, we will be discussing that how depression occurs throughout the lifespan of a woman, so to say. We will start with childhood and early teenage years up until the menopause. So, if you look at the slide, you will see that up until 11 years of age, there are really no difference in rates of depression between boys and girls. But as soon as the girls read by the time the girls reach age 16, they're twice as likely than boys to have depression. So, right from there, the increased incidence starts occurring for depression and women, right from early teenage years. Next, we go to the reproductive phase of a woman's life, what happens then. And actually reproductive lifespan of women consists of multiple phases. One of that is a monthly cycle of menstruation. So, if you notice in this slide, you will see that around menstruation, mode symptoms are very common. And the commonest type of syndrome we see is mild premenstrual symptoms, which occurs in about three quarters of women going through menstrual cycle. While much more severe syndrome of premenstrual syndrome, which is called PMS or premenstrual syndrome occurs in about 20 to 40% of women. Now, these are uncomfortable symptoms, but not a diagnosable clinical entity. About 3 to 8% of women though, go through what we call premenstrual dysphoric disorder, which is a disabling condition. And it requires treatment by either the primary physician or a psychiatrist. So, as you can see, that during the reproductive phase of their lives, women have multiple syndromes which they can have around their menstrual cycle. And commonest one being premenstrual symptoms, mild nature compared to a fully diagnosable syndrome of premenstrual dysphoric disorder. Now, another phase during reproductive life of a woman is pregnancy. So, depression or mood disorder syndromes are very common around pregnancy. First of all, we'll discuss what is perinatal or peripartum. So perinatal period is basically all from the start of pregnancy up until 28 days after the childbirth is the period which is called peripartum or perinatal. So, around perinatal time, depression can occur at various stages. So, first thing is that depression can occur during pregnancy in the pre-trimastoral pregnancy at any time. And about 1 in every 7 to 10 women will have depression during pregnancy. Then the childbirth happens and about 8 out of 10 women will suffer what we call postpartum blues after giving birth to a child. The next syndrome which we encounter or mood symptoms syndrome is postpartum depression, which occurs after childbirth and it happens in 1 in every 5 to 8 childbirths. So, if you see that overall perinatal depression, meaning depression developing during pregnancy as well as after the childbirth, the rate is about 11.5%. So, it is pretty common. I just want to add one more thing that previously it was considered as if pregnancy is a protective factor against depression, but that exactly is not the case. Actually, a woman is as likely, almost as likely to develop depression during pregnancy or around pregnancy as compared to any other stages of her life. So, that leads us to the last syndrome which we encounter in the reproductive age, especially around pregnancy is what we call postpartum psychosis, which develops in 1 in 1000 childbirths. Now, it is fortunately uncommon condition, but it is extremely severe and dangerous both for mother and baby. It's treatable though, but it is very serious condition, which requires hospitalization. Then the last stage of reproductive cycle is menopause and depression can also develop in what we call perimenopausal duration or time. Why women are more likely to develop depression during menopausal time, perimenopausal again means just before, during and just after menopause. The risk is higher for women who already have history of PMS or have history of postpartum depression in previous pregnancies. So, those are the women who are more risk of developing this perimenopausal depression. Now, even if you have not had any episodes of depression, your risk of developing new onset depression in perimenopausal period is high compared to other times. Now, why a woman may develop depression around this time? An incubation part which may come to your mind is definitely hormonal care. You know that around menopause, there is reduction in sex hormones, especially estrogen. So, estrogen withdrawal may be the reason why women develop depression in perimenopausal period. But there's really no clear cause and effect relationship which we have found between the levels, hormonal levels in the blood auto system and development of depressed symptoms. So, actually, that can be definitely a cause or risk factor for developing depression, but there are many other things which also influence depression development around menopause time. And what are the factors which may be contributing? One is those uncomfortable, unpleasant menopausal symptoms such as sleep disturbance, heart flashes, sexual dysfunction, anxiety can themselves lead to depressive symptoms around this time. Also, this is the phase of life when social changes occur in a woman's life. For example, this is the time when kids start leaving home or kids have left home, leading to what we call, you know, emptiness syndrome. And around the same time, there are changes in your professional roles and social roles which can also lead to depression. In perimenopausal period, hormonal changes, social changes and facing uncomfortable and unpleasant menopausal symptoms. All three can have contributory factors, all can be contributory factors for development of depression in this perimenopausal period. This is again a slide. It is just to emphasize what we have already discussed. You can see that women are always throughout lifespan have increased rates of depression, but there are some peaks also which you can see right here, which we discussed like say in menopause, depression is much higher in women around that age compared to men. So far, we discussed that depression is common both in men and women. We discussed that depression is especially common in women. We also discussed that how depression presents itself across the lifespan of a woman. But now we will try to understand that why women have higher rates of depression compared to men. So we'll try to see what factors may be responsible for this increased expression of depression. So first thing is, we all must know that more disorders including depression are brain disorders. These are not some imagined things which women imagine more than men know. These are brain disorders with clear reasons why somebody develops depression. So first is that thing which we should understand. Second thing we should understand is that depression is not one, not the result of one single cause, so to say. It is depression occurs because of environment and genes makeup, the interaction of genetic makeup with the environment and that results in depression. So, as we noticed in the previous in our previous slides that depression is associated with the ovarian hormone changes throughout the life cycle like it happens in early teenage years when a girl must have just had the start of reproductive cycle, then we see depression with menstrual cycle, pregnancy, and during menopausal time. So, we know that ovarian hormone fluctuations have something to do with depression but as I said before, there's no direct relationship between hormonal levels and depressive symptoms which we have established. One more thing I want to make clear that, of course, depression occurs at higher frequency in women and occurs specially at the time of these hormonal transition. I just want to make sure that we all understand that majority of women will not experience depression or mood problems during reproductive transition. It happens in a very sizable number of women, but majority of women would go through their whole life cycle without developing depression, so I just want to put this point across. Now, so why some women develop depression in reproductive life compared to others? Probably because of their genetic, some women's genetic makeup making them more sensitive to fluctuations in hormone levels compared to others. A woman's genetic makeup may be such that sensitivity to fluctuations in hormone is higher compared to other women and therefore when these fluctuations happen, this woman develops depression. And again, it is not only hormone but because it is gene and environment interaction, some other psychosocial factors have to contribute also for a woman to develop depression during these fluctuations. So biologically you can say that depression is a brain disorder which occurs because of gene and environment interaction and some women are specially sensitive to fluctuations in their hormone levels and therefore these women develop depression around these transition phases while most others just navigate through these changes without developing depression. These are all the times when the hormones are fluctuating. So we can assume that there is some relationship but nobody has been able to establish direct relationship between hormone levels in the blood and depressive symptoms. But biologically, you can assume that changes of fluctuation hormone levels are one of the cause for developing depression at higher rates. Then basically, in general, we don't know exactly what causes depression and it is known that it is not a totally genetic or totally environmental in origin that depressive syndrome. It is the people develop depression because of environmental interaction with their genetic makeup. So this is how we can assume that some women have heightened sensitivity to these fluctuations in hormone levels. So I want to make one point here that majority of women go through these hormonal changes throughout their lifespan without developing depression. So most women do not experience depression or more problems during reproductive transitions as we discussed. But some do. So why these some women do develop around those times is probably the fact that because of their genetic makeup, they have heightened sensitivity to these fluctuations and that's why they develop depressive symptoms compared to other women who go through these changes without any problems. So biologically, we can say that it is gene environmental interaction and some people have increased sensitivity to fluctuation in hormone levels and those go on to develop depression at these various phases. But this is my opinion. I'm no authority on the subject, but this is my opinion. It is more important what happens in their social life, which is more causative of depression and women. So this slide tells you that women not only experience more types of stressors, but they face stress during their lifespan at increased frequency as well. Just for an example, up to six to three from six to 33% of women will suffer childhood sexual abuse. Now, about 15% of women will suffer adult sexual assault and male partner violence is estimated between 15 to 71%. So women go through these stressors much more often than men. So that trauma related to that increases the vulnerability. On top of that, women in general are less than men, which leads to chronic financial stress and poverty increase poverty rates and all associated problems which come with people who are in financial stress and live in poverty. On top of that, one more thing, which is a well known phenomenon is that women are more likely to react to stressor with depression compared to men. What I mean by that is that if a man and a woman both are exposed to similar level of stress or same type and intensity of stressor, it is more likely that women will react by getting depression compared to men. So, as you can see that they have this vulnerability, they respond to stressor with depression more often. But on top of that, they also have increased exposure to various different types of traumatic events in their lives, which I believe is more of the reason for increased rates of depression in women. So now we have tried to understand that depression is common, more common in women, and what may be the reason why they develop. Now let's see how to identify that a person is suffering from depression. These are DSM is our diagnostic manual, which gives us diagnostic criteria to diagnose psychiatric illnesses. And that says that depression in anybody is not related to only women, but in any person, depression can be diagnosed if they show five or more of these symptoms in the same two weeks period of time. So, and one more thing is their specification that one of those symptoms has to be either depressed mood or diminished stress. So suppose a person comes to me and has and report that he has been having he or she has been having for two weeks, five of these symptoms which are depressed mode, loss of pleasure, weight changes, sleep changes, psychomotor agitation fatigue, worklessness, difficulty concentrating and thoughts of death, or suicidalization. So if I find five of these symptoms, one of those should be either depressed mode or loss of pleasure, and these symptoms are going on for two weeks. I would be thinking that patient has major depression, but depression or any psychiatric disorder is diagnosed only when the symptoms result in significant distress or impairment in functioning so I will have to cross that hurdle also before diagnosing depression that not only patient is showing sufficient symptoms for sufficient time, but also these symptoms are resulting in psychosocial functional impairment. So just try to make a mental picture. This is the picture of depression, because more or less picture of depression remains the same in these syndromes with some additional symptoms around the lifespan, reproductive lifespan. So these are symptoms of major depression. Now we are going to discuss very briefly specific syndrome which we mentioned earlier but we'll go in a little bit more detail that how depression presents in women across their lifespan. So as we discussed that about three to 8% of women will have pre menstrual dysphoric disorder around their menstrual cycle. So what is that? Now first of all, let's discuss who is more likely to develop PMDD are people or women who have either personal or family of PMS with meaning pre menstrual syndrome, PMDD or depression in the family or themselves so they are likely to develop PMDD. Also lower educational level and smoking have been associated with development of PMDD. Symptoms of PMDD start about a week before menstruation and improve within few days of start of the cycle. So this is the typical presentation of PMDD. Symptoms last approximately 10 days, 10, 12 days every month in the later half of the cycle. Now what are the symptoms? Symptoms again as we discussed, depressed mood, loss of pleasure, sleep, appetite, changes, concentration problems and whatnot, as we discussed in previous slide. But they may also have resting illness, bloating and headache along with this. Now to be diagnosed as we discussed before, these symptoms should be severe enough to affect their functioning. Unfortunate thing is that symptoms of PMDD continue to increase throughout the reproductive cycle until menopause. And that's why it can become for a woman very troublesome to handle living with these symptoms for 10, 12 days every month. But so that is unfortunate part that generally symptoms tend to increase over the year until menopause, but good news is that very effective treatment is available. So one doesn't have to really suffer through these symptoms. The treatment of PMDD is basically changes in diet, regular things, which you would like to do regular exercise, stress management, vitamin supplements, anti-inflammatory medications for pain, et cetera, birth control pills. But in my area, antidepressants, especially what we call selective serotonin reuptake inhibitors, SSRIs are extremely effective. And this is very specific to PMDD that generally speaking, if you have seen a psychiatrist or a psychiatrist professional, everybody tells you that it will take up to four to six weeks before the symptoms improve, depression symptoms improve with SSRI or medication. But one thing in PMDD is that these medications are immediately effective. So you mean otherwise it will be counterintuitive to use these medication if it takes four to six weeks. But in this condition, SSRIs start working almost immediately. Now various doctors prescribe these medications in various ways, meaning some doctors would prefer to prescribe throughout the month, continuous prescription. Some doctors would suggest to prescribe only in the later half of the menstrual cycle. And some would even suggest that you start taking the medication on the day you start having symptoms and continue up until the symptoms go away with onset of menstruation. So there is really no benefit of taking it month long as far as the studies are concerned. And therefore, later half, a week, meaning after 14th or 15th day of menstrual cycle or symptom onset dosing is appropriate. So this is, we talk about PMDD. Now in next few slides, we will be talking about depression around pregnancy. So, first, let's talk about the depression in pregnancy, who gets depression in pregnancy. Again, risk factors are that if you have history of depression, you are more likely to develop depression during pregnancy. Same goes with if you have had postpartum depression or PMDD. If you have relationship problems ongoing, you don't have social support or if the pregnancy was unintended or unwanted, or if you had a miscarriage. These are some risk factors because of which you are more likely to develop depression. Same goes for infertility treatments are associated with depression. And it goes without saying that if you were being treated with antidepressant and it was effective and you discontinued it, then it is likely that you will develop depression in pregnancy. Now, sometimes apart from pregnancy, you may be going through many other stressors in your life. If that is the case, that is also a risk factor. So, these are the risk factors who develop depression in pregnancy, and science and symptoms of depression in pregnancy are similar to as we discussed for major depressor episodes like depressed mode, appetite, sleep changes, concentration, suicidal ideation, everything. All gamut can occur. So, these are the risk factors and symptoms. Now, let's see what does depression do to pregnancy. This is very important to understand because depression during pregnancy has its consequences. And that is why it is so important that we treat depression. So, what happens if you have depression during pregnancy that symptoms themselves like poor appetite can result in nutritional problems for you and the baby. That is one very self-evident thing. Same thing is that there is a symptom of depression that you lose interest in doing things or motivation goals that can result in poor self-care or poor follow-up with prenatal care. Again, a harmful thing for the baby and yourself. Now, depression is also associated with harmful substance use, such as smoking, drinking. So, that obviously has not only harmful effect on you, but also on the baby. So, that can be a consequence of different untreated depression. Now, when you are not interacting with other people in your life because of depression, you may lose support from friends and family, and this may complicate pregnancy. Then, one effect of depression is well established that people who have depression during pregnancy tend to have preterm labor and birth, and their babies are low birth weight babies. So, these are some of the effects of depression. So, you can see that depression can affect pregnancy in multiple ways, and all of those are harmful to you as well as the baby. And therefore, depression needs to be treated aggressively. Then, the second syndrome as we discussed earlier on that develops around pregnancy is baby blues. Baby blues is basically a temporary condition which occurs as we discussed in up to 80% of the childbirths. It occurs around two to three days after the delivery of the baby and results within 10 days. Generally speaking, without much consequences in most people, but it is not as, you know, benign a condition as we initially thought because people who have history of baby blues. This can be a risk factor for developing postpartum depression and subsequent pregnancies. So, what are the symptoms of baby blues? Again, last only for about a week or so, developing two to three days after the delivery, over by 10 days after delivery. But during those six, seven days, the person may have crying spells, irritability, poor sleep, emotional reactivity, these are the symptoms of baby blues. Now, there's really no specific treatment required except that the mother should be assured rest and sleep. Mother should continue to keep her interest in activity levels should not hesitate to ask for help from others and all these symptoms all these interventions will lead to improvement in symptoms and majority of people will recover from these blues without any adverse outcome. But then, if you remember, we had discussed that second postpartum condition was postpartum depression, which is not baby blues it's not going to go away in seven to 10 days time it is a condition which will cause significant impairment in function and will require treatment. So, that is the second condition which we call, which again comes under the umbrella term of peri natal or peripartum depression, but generally people know by the term postpartum depression. So, again, who are the people who are likely to develop postpartum depression. And again, as we discussed early on if you remember one in every five to eight women will have postpartum depression so it is fairly common condition and should not be confused with baby blues, which is self limiting syndrome so to say. So, again, the women who have history of depression during pregnancy or prior to becoming pregnant. So if you have a steer depression before during pregnancy you're likely to develop postpartum depression. Same goes for PMDD. If there's a family history of more disorder that increases your risk of developing, you know, postpartum depression. Some other respectors are that if there was some ambivalence meaning you were not sure whether you should become pregnant or not. But you did that can be a respectors. And so is if you carry multiple pregnancies such as having twins or triplets, young mothers who are living alone and have a number of children, more than one child. Those are other respectors to develop postpartum depression. And so is also true. If you have a child who has significant health problems or a child with special needs, you're likely to have depression in postpartum period. So limited social support marital conflict and if you have stress, some other type of stress in your life. So all these are the risk factors for postpartum depression. So one should be aware that if somebody has history or depression in the past or develop depression during pregnancy, one should be a lookout. For postpartum period, you know, because it may occur and may need to be treated. So, what are the symptoms of postpartum depression. Basically symptoms are same as the major depressive episode we discussed, but there may be some other symptoms like person may be crying, having feelings of anger. The person may withdraw from loved ones, feeling disconnected from the baby. A very specific thing and occurs commonly that they worry that you might hurt your baby in some ways, and feeling guilty as if you are not a good mom, or you will be able to care for your baby. So these are some additional symptoms of depression in postpartum period, along with depressive symptoms we discussed before. Now, let's discuss how do we treat depression in the perinatal or peripartum period, meaning all three trimesters of pregnancy, and after the pregnancy, after the childbirth. Now, again, we are not going to go into every single medication, use and pros and cons of that, but we'll just discuss some general principle of treatment of depression during pregnancy. So, first and foremost, everybody should know that untreated depression has adverse consequences for mother and baby as we just discussed, right. And there is sufficient support in literature, which supports treatment of depression adequately during pregnancy, rather than leaving and untreated. Risk of treatment always should be weighed against leaving depression untreated before embarking on treatment. So, before you start treatment, definitely you should weigh the risk pros and cons of treatment versus not treating, but evidence is heavily in favor of treating depression. Now, when you're discussing with a doctor, you should discuss not all available treatment options, but also option of no treatment should be discussed. Now, one thing which I cannot emphasize enough is that if you are already on treatment, you should not automatically discontinue the treatment without discussing with your doctor, because risk of relapse is very high in perinatal period. So that definitely goes without saying. Now, what other principles we should follow during pregnancy in postpartum period. This is one which I generally recommend that if psychotherapy or top therapy is a viable option, we should consider it. There is really no better option if it is a viable option though. And we should avoid medication. In general, you might have heard this thing in first trimester pregnancy, all external substances should be avoided, you know, if possible, and that goes for antidepressant as well. But it doesn't mean that you cannot treat depression with antidepressant even in first trimester. Now, if medication is the treatment of choice, it is generally recommended that you treat a patient in pregnancy with one single medication rather than exposing the patient and the child with multiple medication. But again, that should not leave depression under treated. So if needed in a particular case more than one medication, yes, we should go there. But generally speaking, if you can avoid it, better it is. Now, during the later half of pregnancy or third trimester pregnancy you may have to increase the dose of antidepressant. The reason being that the volume of distribution, the medication becomes very high and the medication gets diluted because of the increased volume. And therefore those may need to be increased. So that is another principle we follow. And you should always continue to those, meaning antidepressant should be continued throughout delivery as well as beyond. Last thing I will say about antidepressant treatment, antidepressants are equally effective, you know, no one is better in pregnancy as well as outside pregnancy, all antidepressants are equally effective. It's just simply a matter of finding the right medication for a person. Now, why we are so worried about treatment of depression during pregnancy and postpartum period. So basically the concerns are what are what may be the concern a person or a doctor may have that can these medication result in blood defect. Can these medication result in effect on baby, meaning on baby's growth. Can these medication cause medications cause behavioral problems in the baby, or can these medications result in withdrawal symptoms when the baby is out of mother's womb, because still now the baby was getting this medication now he's out of circulation. So whether it will cause withdrawal symptoms. So let's discuss one by one very quickly. Number one. The first line antidepressant medications SSRI SNRI. Now we have sufficient data to suggest that there's really no increased risk of birth defects with first line antidepressant medication so we can rest on this. Meaning on this issue that antidepressant use will result in increased risk of depression. Increase the scope of defects. But again, the first principle we had to follow that if we can avoid a medication during first trimester we should do it but if we had to treat, then there's really no evidence suggesting a clear risk of birth defects with with antidepressant use. The second question is whether the antidepressant medication result in some growth issues or preterm birth. Yes, there is some evidence for that that kids born while being exposed to antidepressant and lower birth rate and preterm birth. But if you remember your own untreated depression has the same effect as well. So we cannot really tease out whether leaving depression will be better choice or treating it. So I think here we are equal on the same level treating on treating so I would go in favor of treating depression. Now whether antidepressant result in longer lasting behavioral problems in the kids who were exposed in uterus. Actually there's no real evidence that behavioral disturbance or cognitive problems are more common in babies who were exposed. And I would not have that concern being on my mind very heavily. Last thing is withdrawal symptoms. Yes, those can happen in the neonate. Those who are exposed to the antidepressant. But again, these are self limiting mild symptoms, which neonate can tolerate very well and this should not. This alone should not be the reason not to offer treatment. So these are the four concerns which anybody would have when deciding whether to treat or not. And in general treatment is considered safer. Same goes for breastfeeding. Actually, again, we would like to avoid any exposure to the breastfeeding neonate or infant, but not breastfeeding has even more risk than antidepressant exposure to the infant. In general, with current first line medications, breastfeeding can be done without much risk. But again, it should be discussed with your provider. One last thing I will add in postpartum depression that autoimmune thyroid diet is very common postpartum periods. So if somebody develops postpartum depression, they should be checked for the thyroid function. And around pregnancy, this is the last syndrome, which is postpartum psychosis. If you remember it happens in one in 1000, but it is really a very serious and dangerous condition in which the person develops symptoms of psychosis and mania so to say. Now, who is at risk of developing those people who have a bipolar disorder, who have had postpartum psychosis and previous pregnancy they are at increased risk. Those women who have family is the psychosis of bipolar disorder. Those can develop people have a state of the seniors to affect a disorder. And lastly, if somebody who was on medications, psychiatric medication and discontinued during pregnancy can have postpartum psychosis. One thing I want to say about postpartum psychosis generally people are women who develop postpartum psychosis in the internal to have bipolar disorder majority of times. So it is basically undiagnosed bipolar disorder, declaring itself in postpartum period that is what the clinical picture is. Now symptoms they are multiple symptoms but I just because we are running out of time so I'll just go through basically person presents with severe manic symptoms so to say, and also psychotic symptoms such as delusions or hallucinations. Delusions are the beliefs or the thoughts or beliefs such as that you may suddenly start believing in postpartum period that you have won the lottery. You may think that your baby's possessed by devil or becoming paranoid that people are out to get you these are some delusions which you can develop and hallucinations like you can, you will may see or hear things which are not there. So, and same way manic symptoms are that you feel very high on top of the world all the time, you have rapid changes in mode, feel restless and agitated, and you behave out of character. So these are some symptoms of postpartum psychosis. Again, very, very dangerous situation. And how do we treat it? Basically patient really, these patients need hospitalization they cannot be treated under any circumstance as an outpatient. Now generally we know that baby and mother should not be separated it is not ideal, but in this condition it is needed. So you have to. I also mother should not be left alone with the baby and unless you have treated postpartum psychosis adequately, and you want to treat psychosis agitation insomnia early on to prevent worsening of these symptoms. And the medications I just put some names there but these are not the only medications, but you use antipsychotic medications to treat psychotic symptoms, sedative medications to prevent agitation and improve sleep and mood stabilizers you use to treat, you know, basically manic symptoms of mood instability. Now, generally you can breastfeed your child in these with these medications on board but it is important that this discussion should happen and if your provider says no we should not be exposing then we can do without breastfeeding also. In the last condition in a woman's life which is perimenopausal depression as we discussed earlier on. Again, symptoms are similar to major depression. Again, perimenopausal women are more at risk of developing depression as we discussed symptoms are similar to major depression, but then there can be some additional symptoms such as heart flashes, which are the hallmark of menopause anyway. Treatment is also the same with medications and psychotherapy. There's really no FDA approved hormone replacement therapy for perimenopausal depression, although multiple hormonal treatments have been tried but if you ask me that how would you treat a perimenopausal woman who comes with depression, I would still be treating with regular antidepressant as any other episode of depression. So, in summary, this I believe the last slide. Depression is common, especially in women, but most women this I want all of us to understand this thing that depression may be more common women but most women do not become depressed at various stages of reproductive cycle. I mean, they go through these whole hormonal cycle throughout their lifespan without becoming depressed, but compared to men they have more likely. There's another fact which we need to pay attention to that majority of people, men and women for life do not seek treatment for depression and treatment depression is effective treatment so I mean there should be more awareness and probably as we talk about treatment of depression like in these forums, it will increase awareness and probably see more people will seek treatment. Now, as we discuss untreated depression can have very serious consequences for you as well as the baby, and therefore treatment should be sought. As we discussed and talked about depression is very treatable across lifespan in men and women, and even during various stages of hormonal life of a woman. So, at least get this from this talk that depression in pregnancy around pregnancy and other stages of reproductive life is very treatable. Generally, these treatment treatments are very safe for mother and baby and scientific evidence actually tells you that it is better to treat depression across women's lifespan rather than leaving it untreated.