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Clinical Manual of Women’s Mental health

Mary Morreale, MD

Wayne State University, Detroit, MI, USA

Vivien K. Burt and Victoria C. Hendrick; American Psychiatric Publishing, Inc.; Arlington, Virginia; 2005; ISBN: 1-58562-186-2; pp 192; $58.00 (paperback).

Gender differences significantly contribute to presentation and treatment of many psychiatric disorders and therefore clinicians need to recognize them. This comprehensive yet concise manual examines how hormonal fluctuations—such as menstruation, contraceptive usage, pregnancy, and menopause—infertility, abortion, and pregnancy loss affect women’s mental health. The book also discusses potential differences in response to psychotropic medications and psychiatric comorbidity associated with breast and gynecologic cancers.

This manual is an update of the second edition of the authors’ Concise Guide to Women’s Mental Health. The authors note that the entire book has been revised, with “particularly extensive” revisions regarding contraception, psychotropic use in pregnancy and breast-feeding, abortion, and hormone replacement. The book consists of 10 chapters and an appendix, which lists women’s health resources and contact information for support groups.

The Introduction examines broad gender differences in psychiatric disorders, and includes a comprehensive table comparing lifetime prevalence rates of major psychiatric diagnoses in women and men. Specific considerations related to pharmacokinetics, pharmacodynamics, and laboratory assessment for women are discussed. The chapter ends by addressing psychiatric assessment of female patients and includes an excellent table summarizing this information.

The second chapter discusses diagnosis of premenstrual dysphoric disorder and reviews hormonal fluctuations during the menstrual cycle. Diagnosis—including a prospective daily rating chart of symptoms—etiology, risk factors, evaluation, and treatment also are presented. The authors thoroughly review psychiatric and nonpsychiatric treatment options, such as vitamins and minerals, herbal preparations, and hormonal agents.

Chapter 3, “Hormonal contraception and effects on mood,” begins by describing hormonal contraceptive methods, including failure rates, benefits and risks, and absolute contraindications. A detailed chart lists the estrogenic, progestogenic, and androgenic activities of 26 oral contraceptives. Despite the chapter’s title, the bulk of this section is focused on the aforementioned topics. The authors briefly conclude the chapter with a discussion of hormonal contraception’s effects on mood.

The fourth chapter, “Psychiatric disorders in pregnancy,” is one of the lengthiest. It begins with issues related to pre-pregnancy and pregnancy counseling for women with psychiatric histories. A schematic drawing illustrates critical periods in human development. Although nonpharmacologic interventions are touched upon, most of the chapter focuses on psychopharmacology. The authors discuss the teratogenic and potential perinatal effects of commonly used antidepressants, mood stabilizers, antipsychotics, and anxiolytic medications. The chapter also includes procedural considerations for electroconvulsive therapy during pregnancy. The authors continue with information on the course and management of psychiatric disorders during pregnancy, including depression, bipolar disorder, schizophrenia, anxiety, and eating disorders. Chapter 4 ends with a discussion of substance abuse and pregnancy. A chart reviews the teratogenic potential of multiple substances and the principle features of fetal alcohol syndrome. A brief review of substance abuse treatment options concludes the chapter.

Chapter 5 covers postpartum psychiatric illness and begins with a thorough comparison of “blues,” depression, and psychosis. The authors review incidence, course, clinical features, risk factors, and treatment of all 3 conditions and discuss biological and psychological theories related to etiology. Postpartum anxiety disorders are mentioned briefly. The last section of this chapter reviews psychotropic medications and breast-feeding. A chart presents broad comments on antidepressant, anxiolytic, antipsychotic, and mood stabilizer use during lactation, with references to pertinent journal articles.

Chapter 6 addresses induced abortion and pregnancy loss, and summarizes prenatal diagnostic tools and abortion techniques. The authors also discuss the psychological effects of elective abortion and counseling techniques. The chapter concludes with a discussion of pregnancy loss, including miscarriage (before 20 weeks’ gestation), preterm birth (between 20 and 37 weeks), and stillbirth (after 37 weeks). In addition, the authors present perceptions and dynamic aspects of pregnancy loss and treatment recommendations.

Chapter 7 covers the psychological implications of infertility. Several pages address current infertility treatment protocols and discusses psychological reactions to these treatments. The chapter finally concludes with how to treat psychiatric problems arising from infertility procedures.

Chapter 8 begins with a review of the hormonal and physical changes that occur during the menopausal transition. The authors compare development of depression in a “natural” menopause with depression after surgically induced menopause, and they address potential changes in sexual function in both groups. The results of the Women’s Health Initiative (WHI) and Women’s Health Initiative Memory Study (WHIMS) are thoroughly covered. The authors explain the rationale for using androgen and testosterone to increase libido in menopausal women. The chapter includes a discussion of depression evaluation and treatment in menopausal women and concludes with a limited examination of cognitive changes associated with menopause. It also addresses the quandary of treating this condition, because the WHIMS has indicated hormone therapy as a potential risk factor for developing dementia.

Chapter 9, “Gender issues in the treatment of mental illness,” discusses epidemiology and special considerations for treating women who have schizophrenia, depression, bipolar disorder, seasonal affective disorder, or anxiety disorders. The authors present the epidemiology of substance abuse in women and the factors predisposing women to developing these disorders. In addition, the authors suggest screening tools, including the CAGE questionnaire and laboratory assessments, and make basic treatment recommendations. The chapter continues with a discussion of eating and sleep disorders. Finally, the epidemiology of sexual assault and domestic violence is examined, and related specific considerations for treatment are mentioned.

The last chapter of the book is quite short and reviews “female-specific” cancers. The chapter includes a table summarizing risk factors for developing breast cancer and a very brief summary of basic treatment. Gynecologic cancers are then discussed. The chapter concludes with an examination of potential psychiatric and psychological comorbidities related to a cancer diagnosis, including depression and anxiety, interpersonal issues, and common fears and concerns.

Drs. Burt and Hendrick have written an extensive, comprehensive, and well-referenced text. Despite the scope of this manual, it is written in a concise, easy-to-read manner. The many well-designed tables summarize information effectively and contribute significantly to the text. The breadth of detail about medical procedures and medications not typically part of the psychiatric armamentarium is helpful for those who don’t usually provide or prescribe them. This book would be beneficial to psychiatrists, obstetrician/gynecologists, internists, and family practice physicians who are responsible for the overall health of their female patients. Although the book covers a broad spectrum of topics, some areas are covered superficially. In addition, the relatively recent demotion of paroxetine to category D status in pregnancy is absent, which is understandable given the manual’s publication date. Despite these limitations, I plan to use this book as I prepare to teach women’s mental health to psychiatric residents.