Mood Disorders in Women

Mood Disorders in Women. Steiner M, Yonkers KA, Eriksson E, editors. London: Martin Dunitz; 2000. 573 pp with index. ISBN 1-85317-545-5 (cloth). US$90.

It was a pleasure to read and review this comprehensive book edited by Meir Steiner and colleagues. As a clinician with an interest in women’s mental health, this book was a godsend. The 31 chapters in Mood Disorders in Women provide comprehensive coverage of a broad range of topics related to women and psychiatry. International contributors, including 6 from Canada, hail from Italy, Ireland, Austria, Sweden, Australia, Belgium, Scotland and the United States. This is truly an international collaboration and may have come out of the Marcee Society, to which many of these clinicians belong.

It seems to me that the purpose of this book is to educate us, but also to raise our awareness of the incredible paucity of information regarding women’s mental health. By reviewing the literature and noting that what we don’t know about this area far outweighs what we do know, the authors hope, as do I, that some corrective action will be taken.

In reading this book, I found myself constantly looking at the references and running to the library to read them for myself. This volume is excellently referenced — it is an evidence-based book that balances review of the literature with pragmatic guidelines.

The first 2 chapters of the book discuss hormonal, neurobiological, sociopolitical, economic and evolutionary theories as to why twice as many women as men suffer from mood disorders. These theoretical chapters are followed by 2 very scientific chapters on neuroanatomy and neurochemistry. I found parts of these biological chapters difficult to read — especially the discussion of rat and primate brains. However, this highlights the paucity of information on humans and the possible sex differences in this area.

The chapter entitled “Gender Differences in Dysthymia” deals with double depression, dysthymia and chronic depression and what is known about women with these conditions. The review of the literature here is sparse, again pointing out the lack of information in these areas. There is an in-depth look at one study by Yonkers in this chapter, which I didn’t find particularly helpful, but given that she wrote the chapter, this is forgivable.

The chapter on unipolar depression is well written, especially the review of sex differences in pharmacokinetics.

Leibunluft, who wrote the chapter on bipolar illness in women, has edited a whole book on this topic, which certainly makes her an expert. However, she emphasizes that it is difficult to know whether to treat pregnant women with bipolar illness because the clinical course of the disease has not yet been elucidated in pregnant women. This is a huge problem for those of us who treat these women.

Three chapters are devoted to reviewing the effects of steroids and hormones on the brain. There is detailed and rich information here, including a review of oral contraceptives and studies of the effects of androgens on women.

The chapter on grief and bereavement in women was disappointing. Much has been written about the loss of a spouse, and this chapter merely parrots what we already know. More helpful would have been information and guidance on treating mothers who have lost children. This is an area that is emotionally difficult, clinically, and needs more research.

Another chapter poorly done is entitled “Seasonal Affective Disorder.” It provides a superficial look at the topic, without much mention to sex differences. Having just attended a lecture by a Canadian psychiatrist, Dr. Raymond Lam, on this topic, I wonder why he was not asked to write on this topic. His knowledge and ongoing research would be worth sharing with the reading audience.

The review of late life mood disorders has very little mention of sex differences and lacks discussion of the psychosocial stressors faced by the elderly.

The following 5 chapters are reviews of the literature on topics related to reproductive psychiatry and follow the life cycle. These include chapters on menarche, the premenstrual period, pregnancy, the postpartum period and lactation. Most wonderful is the list of references here. With some overlap, there are over 650 articles and books listed in these 5 chapters alone. This is heaven for those of us who wish to read the original literature. As well, there are practical, clinical reviews for psychiatrists who need guidance on the treatment of psychiatric conditions related to reproductive issues.

The chapter on personality disorders reviews sex differences in diagnostic criteria, precipitating life events and prevalence and reminds us of the futility of categorizing neuroses. It also gives helpful insights about the sex-related biases in the DSM and ICD methods of diagnosis.

The chapter on eating disorders reviews the literature and summarizes salient studies. I especially liked the chapter on the more general topics of obesity, weight gain and dieting. It provides a wonderful refreshing look, using a scientific stance, at a common concern for women. The authors report on the connection between overeating, mood states, tryptophan ingestion and serotonin synthesis. They also point out that, contrary to all other areas, women are vastly over-represented in the eating disorder literature.

The chapter “Alcohol and Drug Abuse in Women” debunks the myth that substance dependence in women is more often a secondary consequence of another psychiatric disorder than it is in men. As well, the notion that substance dependence is less severe in women is challenged.

Pain disorders, a relatively understudied area in psychiatry, are also more prevalent in women, and this chapter reviews the understanding of the relation between pain disorders and mood and anxiety disorders in women.

There is also a chapter on psychoneuroimmunology, which is a huge and rapidly growing area of research. The main take-home message of this chapter is that we are just beginning to understand the complex mind–body interactions and, in particular, the way mood states affect our immune system.

“Sex Differences in Medication Treatment of Depression” highlights sex differences in pharmacokinetics and pharmacodynamics. Although this information is not new, it is useful to have it reviewed. There is also a review of the effects hormonal fluctuations in women (other than in pregnancy and lactation) have on metabolism and the clearance of agents used in the treatment of depressive disorders.

The chapter on psychosocial treatment for mood disorders in women is written by 2 therapists intimately knowledgeable in interpersonal psychotherapy. This is a very important area, and the authors stress that, although some research has been done in this area, there is a vast deficit in our knowledge of what works for whom in pregnant and lactating women with mental illness.

The last chapter was troubling, to my mind. I took offense to Ms. Phillips’ accusation that we all work in the “male medical model.” As a female psychiatrist who used to be a female general practitioner, I think Ms. Phillips is out of touch. Philosophically, a model is neither “male” nor “female” — just as money is neither “good” nor “bad.” These things are gender neutral. It is the beholder who is sex biased. Ms. Phillips’ assertion that a woman must be “expert about her life” puts a heavy burden on women already prone to guilt and suffering. It is this attitude that often prevents women from coming for help, I find. There is no shame in not knowing everything and asking for expert opinion. It may be that Ms. Phillips is talking more about those of us who have neurosis or psychosocial stressors, rather than mental illness.

Research on women’s mental health and mental illness will increase as women climb corporate ladders to hold more influential positions as university administrators and research directors. To do this, there needs to be more women in medical schools and in specialties. This is currently the case, at least in Canada, so we are on our way to furthering research on women’s mental health issues.