Book Review
Women’s Mental Health
Psychological Aspects of Women’s Health Care: The Interface Between Psychiatry and Obstetrics and Gynecology. 2nd Edition. Nada L Stotland, Donna E Stewart. Washington (DC): American Psychiatric Press Inc; 2001. 654 p. US$65.00.
Reviewer
rating*: Good
Review by: Vera Lantos, MD, FRCPC
Ottawa, Ontario
The critical importance of the dynamic interplay between women’s reproductive and mental functioning has been appreciated from ancient times; at the beginning of the 21st century it is an ambitious project to span the vast range of issues and give all the information that is relevant and currently available.
This book’s chapters are organized under 3 headings: “Pregnancy,” “Gynecology,” and “General Issues.” The “Pregnancy” section deals with themes of normal and medically complicated pregnancies, as well as adolescent pregnancies; psychiatric disorders during pregnancy and lactation; current treatment strategies; and fetal anomalies, perinatal loss, and postpartum disorders.
For clinicians considering electroconvulsive therapy (ECT) and psychotropic drug treatment, the information on physiologic changes in drug metabolism and potential teratogenicity during pregnancy and lactation is both vital and humbling. Adolescent pregnancy is discussed in a developmental framework, with particular attention to the group at the highest risk for abuse, promiscuity, addictions, and sexually transmitted disease (STD). The simple and clear postpartum disorder classification is very useful as well.
The chapters on fetal anomaly and perinatal loss elaborate on grieving—a complex process with several individual components (for example, the actual loss and possible prior losses, deprivation of normal narcissistic motives for pregnancy, and blows to self-image)—as well as on interpersonal, circumstantial, and cultural variables that all ask for particular sensitivity from health care professionals.
The “Gynecology” section discusses issues of induced abortion, infertility, and new reproductive technologies, along with psychological aspects of the menstrual cycle and its end in menopause. Also discussed are gynecological pathologies from pain, disorders requiring surgery, and cancer and HIV. The pragmatic description of the neuroendocrine basis of menses and cyclicity is easily readable. The list of disorders (both somatic and psychiatric) affected by the menstrual cycle is satisfactory. Research on premenstrual syndrome (PMS) is fraught with methodological and political dilemmas, and considerable space is allotted to it. Clinicians will do well to pay more attention to the interaction between psychotropic and other medications and fluctuating estrogen levels—whether the fluctuation is caused by menses, oral contraceptives, or hormone replacement therapy (HRT). The chapter on menopause elaborates on the peripheral and central effects of estrogen and the mechanism of its impact on mood.
The host of highly charged ethical dilemmas surrounding the new reproductive technologies and induced abortion continue to challenge us all and influence the political arena. Section 2 discusses these dilemmas in terms of their psychosocial implications, while section 3 discusses them from a developmental and psychoanalytic perspectve.
The management of several chronic gynecological conditions benefits from collaboration between the gynecologist and the psychiatrist—particularly in the area of oncology. Useful tables summarize medications that induce depression, offer a guide to assessing major depression in cancer patients and to discriminating it from the medical illness, and provide help in the difficult choice of antidepressants in this context (for example, extra care is needed in regard to side effects).
The guiding principle in this book’s organization is not clear: issues overlap and interrelate in a complex way. In the “General Issues” section, one reads about female sexual dysfunctions, eating disorders, addictions, psychopharmacology, breast cancer, women and violence, lesbian health care, ethics—even issues of minority rights. It seems that the interface of psychiatry and obstetrics and gynecology, having so many sociocultural implications, reaches into the political field. I particularly appreciated information concerning sex differences in pharmacokinetics. It is educational to read a discussion of related processes offered from different perspectives, even if some of it thereby becomes a bit repetitive.
Unfortunately, the scientific and empathic tone of this volume seems to shift into the oversolicitous in the discussion of addictions and abuse. Presenting women as victims has grave consequences, because it places the bulk of responsibility for change elsewhere, thus further depriving women of power. Women who are aware of their influence exercise it constantly—in choosing a partner, in maintaining or ending a relationship, and in rearing their female (thus, role modelling) and male (thus, planting the seeds of future heterosexual connecting) children. The acknowledgement that partner abuse appears comparable between lesbian and heterosexual couples (p 481) underlines our questioning of the premise that abuse is primarily a male–female issue. The time is ripe for a more comprehensive trauma framework—one that will improve our understanding of abuse’s impact on the development of identity and personality structure (that is, cognitive and emotional consequences or limitations), as well as its transgenerational impact. I credit the authors for including the male perspective: the review of the transferential and countertransferential spectrum offers a satisfying balance.
The editorial in the June 2002 issue of the Journal (1) addresses women’s mental health. We are about to open the Women’s Health Clinic in Ottawa. As we learn more about sex differences in metabolism, neurohormonal regulation, and brain wiring, a book that offers a responsible, readable, and up-to-date review of the issues at the interface of obstetrics and gynecology and mental health is a welcome reference.
Reference
1. Dickson R. Women’s mental health: focus on sexual and reproductive issues. Can J Psychiatry 2002;47:417–8.
*Reviewer
Rating Scale/ Échelle d’évaluation du réviseur
Excellent / Excellent
Very Good / Très bon
Good / Bon
Fair / Passable
Not recommended / Pas recommandé
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