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Chapter 39. Treatment of Women

Vivien K. Burt, M.D., Ph.D.; Kira Stein, M.D.
DOI: 10.1176/appi.books.9781585623402.317165

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Excerpt

Although overall men and women are at equal risk for developing a psychiatric disorder over their lifetime, there are gender-specific differences in the prevalence and clinical course of a number of specific mental disorders. These differences stem from a variety of factors, including biological and experiential differences between the sexes. Probably due in part to genetically primed alterations in the risk of depression in response to changing hormones during the menstrual cycle, pregnancy, and the postpartum, the heritability of major depression appears to be higher in women than in men (Kendler et al. 2006). These female-specific hormonal and physiological differences not only predispose women to certain psychiatric illnesses but also often inform treatment decisions.

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TABLE 39–1. Reproductive-related times and events of psychiatric consequence in women
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TABLE 39–2. Psychosocial issues of psychiatric consequence in women
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TABLE 39–3. DSM-IV-TR research criteria for premenstrual dysphoric disorder
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TABLE 39–4. Role of the psychiatric clinician in the treatment of the infertile couple
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TABLE 39–5. Treatment of psychiatric illness in pregnancy
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TABLE 39–6. Use of antidepressants in pregnancy: summary points
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TABLE 39–7. Commonly used mood stabilizers in pregnancy: summary points
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TABLE 39–8. Treatment of the bipolar pregnant patient
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TABLE 39–9. Guidelines for management of lithium in the bipolar pregnant patient
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TABLE 39–10. Use of antipsychotics in pregnancy: summary points
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TABLE 39–11. Postpartum mood disorders
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TABLE 39–12. Breast-feeding: issues to consider for postpartum women with psychiatric disorders
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TABLE 39–13. Psychotropic medications in breast-feeding: summary points
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TABLE 39–14. Risk factors for perimenopausal depression
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TABLE 39–15. Special considerations in the evaluation and treatment of women who have been sexually assaulted
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TABLE 39–16. Gender differences in psychiatric disorders
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Although women and men are at equal lifetime risk of developing a psychiatric disorder, there are gender-specific differences in prevalence, clinical course, and treatment of specific psychiatric illnesses.

Women are at particular risk for mood disorders at times of reproductive transition.

When diagnosed properly, premenstrual dysphoric disorder responds robustly to treatment with selective serotonin reuptake inhibitors.

The overall mental health of an expectant mother is an important determinant of the health and well-being of both mother and fetus.

Decisions regarding the use of psychiatric medications in pregnancy are best made after assessing whether it is riskier to both mother and fetus for the mother to have symptomatic psychiatric illness or to be treated with a medication to effectively treat that illness.

Although the antenatal use of many commonly used antidepressants have been associated with an increased risk of adverse effects in pregnancy, when balancing risks and benefits, these agents are sometimes judged to be necessary for the health and well-being of women and their fetuses.

Up to 60% of bipolar women become unstable if their mood stabilizer is discontinued when they become pregnant.

Bipolar women are at substantially increased risk for postpartum mood disorders, including postpartum depression and postpartum psychosis.

Women are at increased risk for major depression as they move into and through perimenopause. That risk is particularly great if there is a past history of major depression.

Treatment of women with psychiatric disorders requires a careful and comprehensive assessment of physiological, genetic, reproductive, medical, and psychosocial risks for current illness as well as relapse and recurrence potential. In light of this assessment, the mental health clinician can choose among varying treatment options to maximize the best possible outcome for the patients, their babies and children, and their families.

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Sample questions:
1.
Premenstrual dysphoric disorder (PMDD) is a common clinical problem that is often quite responsive to psychiatric treatment. Which of the following statements regarding PMDD is false?
2.
Although definitive data on birth defects and selective serotonin reuptake inhibitors (SSRIs) are lacking, a range of transient perinatal symptoms (which may require admission to special care nurseries) have been reported. These perinatal symptoms include all of the following except
3.
Treatment of bipolar disorder during pregnancy is associated with particularly vexing challenges, because of the potential teratogenicity and other effects of mood-stabilizing medication on the newborn. Potential consequences to the neonate from maternal lithium use in pregnancy include all of the following except
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