Causality, menopause, and depression: a critical review of the literature: Fig 1

Abstract Objective : To assess whether causal criteria can be used to find out whether there is support in published research for maintaining that menopause causes depression. Design : Ninety four articles from 30 years of research examining the relation of natural menopause to depression were traced by using Medline and systematic follow up of reference lists. Specified exclusion and inclusion criteria were applied, and the resulting 43 epidemiological primary research articles were classified and tabulated according to sample and measures used and the researchers' own conclusion as to whether or not an association had been established. This material was qualitatively evaluated with Hill's nine criteria for causality. Result : There is insufficient evidence at present to maintain that menopause causes depression. In addition to methodological and statistical problems, a temporal problem in the menopause concept hinders research in this area. Conclusion : Causal criteria can usefully be used to structure a literature review. Further theoretical work is required to integrate standard clinical epidemiological concepts. Key messages Causal and methodological criteria can be used to structure the findings and draw conclusions in a literature review Menopause has so far not been shown to cause depression In addition to methodological and statistical constraints, a temporal problem related to the menopause concept hinders research in this area Theoretical work is required to integrate causal criteria and standard clinical epidemiological con- cepts