Depression in women: an interview with Lucie Joly

You are a psychiatrist specializing in perinatal psychiatry at Saint-Antoine Hospital. Can you tell us more about this specialty?

Lucie Joly: Perinatal psychiatry is a rapidly evolving specialty, at the interface between pediatrics, gynecology and psychology. Long focused on the newborn, in recent years it has shifted its focus to the mother, concentrating on the cerebral changes that occur during pregnancy and the post-partum period. This is a crucial area, as one in five women suffers from post-partum depression, and suicide is the leading cause of maternal mortality in the year following childbirth. It is therefore essential to understand what goes on in mothers' brains in order to better manage, identify and prevent these depressions.

What are your areas of research at Sorbonne University?

L. J.: I'm particularly interested in perinatal neuroplasticity, the cerebral changes that appear early in pregnancy, under the influence of hormones such as estrogen and progesterone. These changes prepare the mother to respond to the needs of the newborn, and determine part of the phenomenology of pregnancy for the mother and the attachment processes that gradually take shape. Much of this maternal phenomenology is based on the mother's perceptions of fetal movements, a theme at the heart of our research at Sorbonne University, and which we highlighted in our book Dans le cerveau des mamans (In the Brains of Moms).

Working with Dr Hugo Bottemanne, we have developed the concept of maternal interoception, which refers to the perception of bodily signals during pregnancy. Contrary to what we might think, these bodily perceptions are biased and often inaccurate: many mothers feel fetal movements in the absence of actual movements, or feel nothing despite fetal movements. Interoceptive systems are crucial to understanding maternal sensory impressions, and shed new light on mysterious phenomena such as pregnancy denial or phantom baby syndrome.

In parallel with this research, I broadened my field of study to take a wider interest in women's mental health, including other periods of vulnerability that a woman may encounter during her life.

You're also working on concrete projects, like an application, aren't you?

L. J.: Today, we know that less than a third of women receive specialized treatment for post-partum depression. More often than not, mothers receive neither treatment nor support, despite the severity of their symptoms. Against this backdrop, we worked with the Agence Régionale de Santé (the Regional Agency for Health) to set up a team at Sorbonne University, based at Hôpital Saint-Antoine, specializing in the treatment of perinatal depression. This team relies on a specialized digital application for simplified online screening of symptoms. Combining a team of mental health specialists with a digital screening tool, this system offers a way of staying at the bedside of mothers trapped in their suffering during the postpartum period.

In your book La Dépression au féminin, you point out that women are twice as likely to suffer from depression as men. Can you explain the main reasons for this prevalence?

L. J.: The fact that women are twice as likely to suffer from depression as men is striking. We set out to understand how the different stages of a woman's life might influence this prevalence. For example, during pregnancy or the post-partum period, around 20% of women are affected by depression. When women are in precarious situations, this figure rises to 30%. During pre-menopause, the proportion varies between 10% and 30%.

This high prevalence of depression among women can be explained by a multitude of factors. Of course, there are biological causes, but there are also psychological, social and cultural factors, such as working conditions, marital organization, and the violence and harassment to which women are often subjected.

You mention that the symptoms of depression in women can be different from those observed in men. What are these specific symptoms?

L. J.: Depression, which affects around 5% of the world's population, or 350 million people, is a complex illness that can take many different forms. In particular, it can take on a different face depending on the gender. Men’s symptoms are often "classic", whereas women are more prone to so-called "atypical" signs, such as increased appetite, a tendency to sleep more, anxious ruminations, psychomotor acceleration, body pains... Men, on the other hand, are more prone to "angry depression", marked by irritability, addictive behaviors such as alcohol or cannabis consumption, and over-investment in areas such as sport, work or sexuality.

There is also a rhythm to the symptoms in women. For example, with premenstrual dysphoric disorder, and a sensitivity to variations in temperature or brightness, which can lead to seasonal depression. Studies also show that depression in women is more likely to be prolonged and chronic, with a higher risk of relapse.

You see biological cycles, contraception, pregnancy and menopause as factors influencing women's psychological health.

Can you explain how these elements affect the female brain?

L. J.: One of the main explanations for female depression lies in hormonal variations, which affect brain plasticity. The most striking example is premenstrual dysphoric disorder, characterized by severe depressive symptoms that occur before menstruation, during the luteal phase. Unlike premenstrual syndrome, which affects 20-50% of women, premenstrual dysphoric disorder can include severe symptoms, such as suicidal ideation, and have a severe impact on daily life.

What's more, between 10% and 30% of women suffer from depression during pre-menopause, a period that is often more difficult than menopause itself. Throughout life, neurons are constantly making new connections in response to the body's needs and to prepare itself to react to changes in the environment. Hormones influence this plasticity, and combined with stress, inflammation and environmental factors, can contribute to the emergence of depressive disorders at these times of life.

You also discuss the influence of cultural and social factors, such as violence, cultural stereotypes and inequalities at work, on female depression.

L. J.: Yes, the pitfall of biology is that it offers a powerful explanatory power that can divert attention from other important factors. For example, women who experience precariousness, violence or harassment are more likely to suffer from depression. Yet women are the main victims of physical and sexual violence. In Europe, around 20% of women have suffered violence at the hands of their partner. In France, there were over 120 feminicides in 2022. In the hospital environment, 8 out of 10 women have been subjected to sexist remarks, and moral harassment is still rife, sometimes with total impunity. These statistics are alarming.

Economic inequalities must also be taken into account: women's average salary is around 24% lower than men’s are, while women still carry out 71% of household chores. These inequalities, combined with violence and discrimination, contribute to the higher prevalence of depression among women.

How can taking these specific features into account by researchers and healthcare professionals improve the way depression is treated in women?

L. J.: For years, clinical trials were carried out mainly on men, on the assumption that hormonal fluctuations in women would skew the results. However, the opposite is true: by including women in these trials and taking account of these hormonal variations, we can better adapt treatments to their physiology, enabling us to adjust treatments and dosages, and target the right receptors.

It is also essential to strengthen the training of healthcare professionals in this field. We need to introduce more courses in perinatal or general psychiatry, taking into account gender-specific clinical and therapeutic aspects to better spot signs and prevent disorders. Whether in cardiology, neurology or psychiatry, symptoms are different in men and women, and training must reflect these differences for a more personalized approach.

At Saint-Antoine Hospital, we're working on the creation of a department dedicated to women's mental health, in order to collaborate with other specialties, such as internal medicine or gynecology, on typically female problems such as endometriosis.

What message would you like to send to women suffering from depression?

L. J.: It's important to consult early. Very often, women consult us late. This is largely due to the fact that in France, psychiatry still has a frightening or archaic image, even though it's a specialty that's undergoing major transformation, with young practitioners, new methods of care and numerous medical innovations.

In perinatal psychiatry, in addition to the stigma attached to mental health, many women are reluctant to seek help because of the social pressure associated with motherhood. Society too often associates motherhood with a state of euphoria, whereas this is not always the case.

The sooner depression is addressed, the easier it is to treat. On the other hand, the longer it persists, the greater the impact, not only on the woman herself, but also on her newborn baby. A depressed woman interacts differently with her baby, which can lead to psycho-affective development disorders in the child. Consult a doctor if you feel psychological pain, or if you feel you're losing your footing.