Legal abortion for mental health indications.

Where legal systems allow therapeutic abortion to preserve women's mental health, practitioners often lack access to mental health professionals for making critical diagnoses or prognoses that pregnancy or childcare endangers patients' mental health. Practitioners themselves must then make clinical assessments of the impact on their patients of continued pregnancy or childcare. The law requires only that practitioners make assessments in good faith, and by credible criteria. Mental disorder includes psychological distress or mental suffering due to unwanted pregnancy and responsibility for childcare, or, for instance, anticipated serious fetal impairment. Account should be taken of factors that make patients vulnerable to distress, such as personal or family mental health history, factors that may precipitate mental distress, such as loss of personal relationships, and factors that may maintain distress, such as poor education and marginal social status. Some characteristics of patients may operate as both precipitating and maintaining factors, such as poverty and lack of social support.

Psychological and physical sequelae of intimate partner violence among women with limitations in their activities of daily living.

OBJECTIVE: To compare the psychological and physical sequelae of physical/sexual intimate partner violence in women with and without activity limitations. METHODS: We analyzed data from the Canadian 1999 General Social Survey. We included women reporting intimate partner violence in the previous 5 years (n = 897). RESULTS: As a result of the violence, women with activity limitations were significantly more likely to feel ashamed/guilty (21.7 vs. 14.5%), depression/anxiety (31.5 vs. 19.8%), fearful (43.0 vs. 33.0%), lowered self-esteem (35.2 vs. 21.1%), increased caution/awareness (20.3 vs. 10.9%), and problems relating to men (16.4 vs. 5.4%). Significantly more women with activity limitations reported physical injury from violence (57.0 vs. 36.6%) and having to take time off from everyday activities (42.1 vs. 30.3%). Women with activity limitations had higher medication use for sleeping problems (OR = 3.17, 95% CI = 1.36, 5.73), anxiety (OR = 3.29, 95% CI = 1.75, 6.19) and depression (OR = 2.63, 95% CI = 1.41, 4.90). CONCLUSION: Results suggest an additive effect between intimate partner violence and activity limitations that adds disproportionately to the burden of health for women with activity limitations.

Age of menarche: the role of some psychosocial factors.

BACKGROUND: The goal of this study was to determine associations between the age of first menstrual period (menarche) and adverse childhood experiences in a random community sample of New Zealand women. Previous reports have linked early menarche to absence of a live-in father figure and to family conflict, as well as genetic determination of early puberty and adiposity. METHOD: Two groups of women randomly selected from the community on their responses to a mailed screening questionnaire on childhood sexual abuse (CSA) were interviewed in detail. Data about their childhood experiences, including age of menarche, were collected on two occasions, 6 years apart. Early menarche was defined as first menstruation occurring before the age of 12 years. RESULTS: Univariate analyses identified a number of adverse childhood experiences preceded early menarche, which was reported by 20.3% of this sample. These included low family socio-economic status, absence of father, a number of variables showing family conflict, poor relationships between the girl and either/both parents, a self-rated childhood personality style as a loner, childhood physical and sexual abuse. Sequential modelling showed parental rows, being a loner and the duration of CSA to be most important, although lack of a father and any CSA were each also independently associated with early menarche. No variables survived the modelling exercise as predictors of early menarche for those women who did not report childhood sexual abuse. CONCLUSIONS: The identified variables statistically interacted with each other in a highly complex manner. The attempt to rank their importance was only partially successful, for methodological reasons (half the sample reporting CSA). Chronic or protracted CSA needs to be added to the list of factors associated with early menarche in future studies.

The views of Otago urban and rural general practitioners on mental health services.

AIM: To examine the views of Otago general practitioners (GPs) about local mental health services and their role in providing such health care. METHODS: A questionnaire was distributed to all GPs working in Otago. RESULTS: 100 replies (59%) were received. There were large differences between GPs in the estimated numbers of patients with psychiatric conditions they were seeing. 85% were keen on sharing management of patients with mental health services. Average confidence levels for diagnosis and management of depression and anxiety were good. GPs felt less confident about psychosis, somatisation, eating and personality disorders. Obstacles to GPs doing more mental health work included time, cost, access to specialist services and training. On balance, GPs viewed the present mental health services as adequate. CONCLUSIONS: GPs appeared prepared to do more mental health work if the barriers of cost and time could be overcome and they were provided with adequate education and backup from specialised services.

Determinants of overweight and obesity in patients with bipolar disorder.

OBJECTIVE: To examine lifestyle-related determinants of the excess adiposity observed in patients with bipolar disorder. METHOD: Eighty-nine male and female patients with DSM-IV bipolar disorder who were attending a specialist bipolar clinic or another psychiatric outpatient clinic (19% with body mass index [BMI] > or = 30) and 445 age- and sex-matched reference subjects (12% with BMI > or = 30) participated in a cross-sectional study of nutrient intake and physical activity. Main outcome measures included macronutrient intakes (assessed with 24-hour recall), percentage of energy derived from various food sources, and physical activity levels (assessed with the Life in New Zealand Questionnaire). RESULTS: Mean total energy intake was higher in female patients than in reference subjects: 8468 kJ compared with 6980 kJ (95% confidence interval [CI] = 583 to 2392 kJ). Total daily sucrose and percentage of energy from carbohydrate were higher in patients than in reference subjects; for women, 73 g and 49% (95% CI = 20 to 56 g, 3% to 10) and for men, 89 g and 47% (95% CI = 15 to 59 g, 3% to 9%). Total fluid intake and intake of sweetened drinks were higher in patients than in reference subjects (ratio of geometric means: women, 1.2 and 2.3, respectively [95% CI = 1.1 to 1.4, 1.9 to 2.8]; men, 1.1 and 2.1, respectively [95% CI = 1.0 to 1.23, 1.8 to 2.41). Patients reported fewer episodes of low- to moderate-intensity and high-intensity physical activity as compared with reference subjects (p < or = .05). CONCLUSION: This study confirms that drug-induced changes in food preference can lead to an excessive energy intake largely as a result of a high intake of sucrose. Dietary advice regarding the use of energy-rich beverages along with encouragement to increase levels of physical activity may help prevent weight gain in bipolar patients. The findings also have some bearing on dietary advice aimed at avoiding overweight and obesity in the general population.

Uses of Community Treatment Orders in New Zealand: early findings.

OBJECTIVE: To assess the uses of Community Treatment Orders (CommTOs) in New Zealand. METHOD: A retrospective study of patients' records held by the regional administrator of mental health legislation and a survey of psychiatrists attending a conference in Dunedin. RESULTS: Males under Community Treatment Orders (CommTOs) outnumbered females 6:4; a high proportion were considered to have a major psychotic disorder; and one fifth remained under a CommTO for more than a year without inpatient care. Among the psychiatrists, there was a high level of agreement that, when used appropriately, the benefits of CommTOs outweigh their coercive impact on the patients; the most strongly supported indicator for use was the promotion of compliance with medication. The rate of use of CommTOs in Otago is remarkably similar to the rate in Victoria, Australia. CONCLUSIONS: Records suggest that a significant proportion of patients under CommTOs are not soon readmitted; and many clinicians in New Zealand consider CommTOs to be a useful strategy for managing the community care of long-term patients with schizophrenia and major affective disorders.

Child sexual abuse and later disordered eating: a New Zealand epidemiological study.

OBJECTIVE: This community-based study examined how some women who have experienced childhood sexual abuse (CSA) develop an eating disorder (ED), whereas others develop depression and anxiety, and others show no adverse psychological sequelae. METHODS: A two-stage random community sampling strategy was used to select two groups of women: (1) women with CSA prior to age 16 years and (2) a comparison group of women reporting no abuse. Both groups completed the Parental Bonding Instrument (PBI), the Present State Examination, and additional ICD-10 eating disorders questions. Information on the nature and frequency of the CSA was obtained at interview. CSA women with ED (CSA+ED) were compared with CSA women without ED (CSA-noED) and with CSA women with anxiety and/or depression (psychiatric comparison group). RESULTS: Higher rates of EDs in women who have experienced CSA were confirmed in this study. Belonging to a younger age cohort, experiencing menarche at an early age, and high paternal overcontrol on the PBI independently increased the risk of developing an ED in women who had experienced CSA. Low maternal care was specifically associated with the development of anorexia nervosa, whereas early age of menarche differentiated women with bulimia nervosa. Younger age and early age of menarche also differentiated the CSA+ED women from the psychiatric comparison group. DISCUSSION: Early maturation and paternal overcontrol emerged as risk factors for ED development in women with CSA. Although these variables are also risk factors in the general population, women with CSA may be vulnerable to ED development because these risk factors are particular domains of concern that emanate from experiences of CSA.

The mental and physical health of female sex workers: a comparative study.

OBJECTIVES: The objective of this study was to compare the mental and physical health, adult abuse experiences and social networks of female sex workers with data previously collected from two large community samples of age-matched women. METHOD: A convenience sample of sex workers were interviewed and completed two well-established questionnaires, the General Health Questionnaire (GHQ-28) and the Intimate Bond Measure (IBM). Sex workers were invited to reflect on their experiences of their work. RESULTS: There were no differences in mental health on the GHQ-28 or in self-esteem (measured by an item on the Present State Examination) between the two groups. Neither were there any differences in their assessment of their physical health or the quality of their social networks. Sex workers were less likely to be married and had been exposed to more adult physical and sexual abuse than the comparison group. They were more likely to smoke and to drink heavily when they drank. One-third said that their general practitioner was not aware of their work. A subgroup not working with regular clients or in a massage parlour had higher GHQ-28 scores and may be an at-risk group. Narrative information about the work, particularly its intermittent nature, is presented. CONCLUSIONS: No evidence was found that sex work and increased adult psychiatric morbidity are inevitably associated, although there may be subgroups of workers with particular problems. The illegal and stigmatized nature of sex work are likely to make usual public health strategies more difficult to apply, considerations which should give concern from a preventive health standpoint.

Impact of bipolar affective disorder on family and partners.

BACKGROUND: Successful management of major mental illness in the community relies significantly on an informal or non-professional network of caregivers. The needs and experiences of such caregivers have been little studied with respect to major chronic mood disorders. METHOD: A sample of caregivers (n=41) of RDC bipolar disorder was systematically interviewed to determine how this role affected them. RESULTS: Caregivers reported significant difficulties in their relationships with the patient when s/he was unwell, with considerable impact on their own employment, finances, legal matters, co-parenting and other social relationships. Violence was a particular worry for partner/parent caregivers of both male and female patients when the patient was manic. The caregiver's own mental health appeared unaffected. Despite this, the caregivers appeared emotionally committed to the patients and showed considerable tolerance of problem behaviours, which they rank-ordered for difficulty. Among nonfamily partners, knowledge of the illness before cohabitation was poor. LIMITATION: The sampling does not capture caregivers who have abandoned their role, such as spouses who have divorced the bipolar sufferer. CONCLUSIONS: Management of this illness requires a partnership between mental health professionals and the informal caregivers and the authors suggest that each group needs to understand the difficulties encountered by the other. Although erosion of relationships is a well-known complication of bipolar disorder, findings indicate that treating clinicians can rely on caregivers committed to the welfare of the patient.

Prevalence of overweight and obesity in bipolar patients.

BACKGROUND: Patients who receive pharmacologic treatment for bipolar illness frequently gain weight. This study evaluated the prevalence of overweight and obesity in an unselected group of bipolar patients and matched reference subjects. METHOD: The prevalence of overweight, obesity, and central adiposity was evaluated in 89 euthymic bipolar (DSM-IV) patients and 445 reference subjects, matched for age and sex, using a cross-sectional study design. RESULTS: Female patients were more often overweight and obese than female reference subjects (chi2 = 9.18, df = 2, p = .01). The frequency of overweight was similar in male patients and male reference subjects, but male patients were more likely to be obese. Patients were more centrally obese than the general population in women (chi2 = 32.21, df = 1, p = <.001) and in men (chi2= 8.81, df = 1, p = .003). Patients treated with antipsychotic drugs were more obese than patients not receiving these drugs (chi2= 4.7, df = 1, p = .03). CONCLUSION: Body fat is more centrally distributed in pharmacologically treated bipolar patients than in matched population controls. Obesity is more prevalent in patients than in the general population. Obesity prevalence is clearly related to the administration of antipsychotic drugs.

The perpetrators of domestic violence.

There has been little useful research in recent years into those who perpetrate domestic violence. Domestic violence is always anchored in a social context in which the aspirations of men and women are dealt with unequally. The majority of perpetrators of domestic violence are men. Perpetrators are often young, troubled, unemployed, and of low self-esteem; they have often experienced abuse (of various types) themselves. However, these factors do not justify their abusive behaviour. General practitioners and other health workers have a responsibility to broach the subject of domestic violence with both perpetrators and victims. They are in a key position to break the silence that allows it to continue. Programs for stopping domestic violence can be effective for those who are motivated to change their behaviour and see the programs through to completion.

Psychological defense styles in women who report childhood sexual abuse: a controlled community study.

OBJECTIVE: The psychological defense styles of women who reported childhood sexual abuse were assessed and compared to those of women without childhood sexual abuse. METHOD: Subjects in a random community sample (N = 354) of New Zealand women were interviewed and completed two relevant questionnaires, the Defense Style Questionnaire and the Dissociative Experiences Scale. RESULTS: Women reporting childhood sexual abuse showed more immature defense styles, and those who experienced the most severe childhood sexual abuse showed the most immature styles. Dissociation, however, as measured on the Dissociative Experiences Scale, was not linked to childhood sexual abuse. CONCLUSIONS: Reporting childhood sexual abuse was associated with more immature coping styles, although not dissociation, in this community sample of women. Coping styles are likely to be a major mechanism through which childhood sexual abuse increases rates of later psychological problems.

Prevalence of migraine in bipolar disorder.

BACKGROUND: This study was undertaken to estimate the prevalence of migraine in people suffering from bipolar affective disorder. METHODS: a headache questionnaire incorporating the newly introduced International Headache Society (IHS) criteria was given to 117 patients on the Dunedin Bipolar Research Register. RESULTS: a total of 81 (69%) completed the questionnaire, out of which 21 (25.9%) reported migraine headaches. 25% of bipolar men and 27% of bipolar women suffered from migraine. CONCLUSIONS: these rates are higher than those reported in the general population with the rate for bipolar men being almost five-times higher than expected. An increased risk of suffering form migraine was particularly noted in bipolar patients with an early onset of the disorder. This may represent a more severe form of bipolar affective disorder.

Early developmental experiences of female sex workers: a comparative study.

OBJECTIVE: The aim of this paper is to explore the early family environment of a sample of female sex workers and compare the findings with a large community data set of similarly aged women. METHOD: Sex workers recruited by a snowball method were given a semi-structured interview, which included the Parental Bonding Instrument. These results were compared to those from the Otago Women's Child Sexual Abuse (OWCSA) study. RESULTS: The sex workers' families were of lower socioeconomic status and had experienced more parental separation than had the OWCSA families. The mothers of sex workers were more frequently the family's main wage earner. Sex workers described both parents as less caring than did the OWCSA women. They were significantly more likely than the OWCSA women to report childhood sexual abuse. The sex workers were more likely to have left home early, to have become pregnant before the age of 19 years and to not have completed tertiary study. CONCLUSIONS: The sex workers studied came from families with more interpersonal difficulties during childhood and adolescence than did a control community sample of similarly aged women. The relevance and generalisability of this conclusion to the wider sex worker population is difficult to determine, given the non-random selection of this sex worker sample.

Cognitive coping styles of women sexually abused in childhood: a qualitative study.

OBJECTIVE: The aim was to investigate cognitive coping strategies used by a nonclinical sample of women with a history of childhood sexual abuse, to examine whether cognitive appraisals affected their current coping strategies and psychological well-being. METHOD: Qualitative research methods were used to enable the sample to convey their own ideas about factors and meanings they attributed to their experience of child sexual abuse. The sample of 40 was drawn from one of two stratified sub samples randomly selected from electoral rolls for interview in 1989 and re-interviewed in 1995. One sub sample had reported childhood sexual abuse and the other had reported none. Inductive content analysis and coding of themes were carried out using appropriate software and supplemented by quantitative interview data. RESULTS: Six main coping strategies were identified and then assessed to determine their mediating influence on psychiatric disorder, self-esteem and self reported difficulties experienced as adults. Overall, abuse characteristics did not predict outcome but women who "deliberately suppressed" the abuse incidents were more likely to have low self-esteem and women who "reframed" were significantly less likely to have a psychiatric diagnosis. CONCLUSIONS: Some cognitive coping strategies employed after experiencing child sexual abuse impinge on later psychological well-being or subsequent relationships with other people. One of the more challenging findings to come out of the study was that women who "reframed" the sexual abuse event were more likely to have favorable mental health outcomes but were also more likely to report that their own child had been sexually abused.

Transition to young adulthood in Ullrich-Turner syndrome: neurodevelopmental changes.

Studies describing the neurocognitive profile of Ullrich-Turner syndrome (UTS) have focused primarily on neurodevelopmental changes in childhood and adolescence or in adults with UTS. The objective of the present study was to describe neurodevelopmental changes that occur in UTS females during the transition from adolescence to young-adulthood. The subjects included 99 females with UTS and 89 normal female controls matched for age and socioeconomic status. Subjects were between the ages of 13 and 21 years. All subjects received a battery of neurocognitive tests designed to assess general cognitive ability, academic achievement, memory, language, executive function, visual-spatial/perceptual and motor skills, affect recognition, attention, and motor skills. Results from our study indicated that females with UTS performed significantly less well than controls on measures of spatial/perceptual skills, visual-motor integration, affect recognition, visual memory, attentional abilities, and executive function, consistent with previous reports of cognitive abilities in adolescent UTS females. Moreover, our results indicate that decreased performance in some of these areas persists through late adolescence and into early adulthood while improvement occurs in other areas. It is possible that catch-up in certain cognitive deficiencies in UTS females represents a maturational/developmental lag. Alternatively, the neurodevelopmental changes that were observed in UTS females may result from the cumulative effects of estrogen replacement therapy during adolescence. Therapeutic interventions specific to the demands of young-adulthood are also discussed.

Professional help sought for emotional problems: coping with child sexual abuse in a Dunedin community sample of women.

AIM: To investigate how often women reporting child sexual abuse obtain professional help for emotional reasons compared with non-abused women and how useful they find it. METHOD: In a follow-up survey of a random community sample of women, information on formal help for emotional problems was analysed by demographic, health status and abuse information. RESULTS: In the year prior to survey, 11.8% of women in this community sample sought professional help for emotional problems. Women in the child sexual abuse sub-sample were significantly more likely than the comparison sub-sample to have sought help (16.6% vs 7.3%) but marital status (separation) was a more significant predictor. Problematic relationships or depression were the reasons given most often for help-seeking. Therapists/counsellors and general practitioners were the health professionals most often approached. Most help-seekers thought the help useful but some child sexual abuse help-seekers did not. The child sexual abuse sub-sample were more likely to report cost as a barrier. CONCLUSIONS: Relationship difficulties and depression are the most common reasons for seeking professional help for emotional problems. Women giving a history of child sexual abuse have higher rates of formal help-seeking and are more likely than other women to report that help they receive is not useful.

How effective is lithium in the prevention of relapse in bipolar disorder? A prospective naturalistic follow-up study.

OBJECTIVE: The effectiveness of lithium in preventing recurrences of bipolar disorder was examined prospectively for 2 years in two representative samples of bipolar I patients being treated in a comprehensive program following recommended guidelines. METHOD: One hundred and twenty patients were recruited from consecutive admissions to two catchment area psychiatric services (one in the United Kingdom, the other in New Zealand). They were seen at 3-monthly intervals by a member of the research team. Treatment was adjusted according to clinical needs. RESULTS: Overall, two-thirds of the patients had a recurrence. Of the 57 on lithium as sole treatment, 39 (68%) had a further episode; 17 after stopping lithium. The 42 on other mood stabilisers and/or an antipsychotic, with or without lithium, did no better. By contrast, only eight (38%) of the 21 who were taking no prophylactic medication had a recurrence. CONCLUSIONS: Lithium is much less effective in clinical practice than would be expected from clinical trial results. A major reason for this is poor compliance. Alternative treatment strategies are needed to improve the outcome for bipolar disorder patients.