Menopause: social expectations, women's realities.

The experience of menopause, and the ramifications of that experience for psychiatric treatment, is significantly shaped by social and historical context and by the implicit and explicit expectations they arouse in women. American society is heavily youth-oriented. Although in fact many women experience this time as one of liberation and self-actualization, society views them as bereft of their families and devoid of sexual interest. Their expectations for their social roles at this time of life may not comport with those of their children. The emphasis on hormone treatment, incorrectly termed "replacement," has exacerbated women's fears of aging.

Depression in women.

UNLABELLED: Depression is a common and serious psychiatric disorder, more common in women than in men. It can be triggered by abrupt hormonal changes, life events, or nothing at all. It causes enormous debility and significant mortality, and it costs the American economy hundreds of millions of dollars a year. Depression can be readily diagnosed and treated, but, more often than not, it is neither diagnosed nor effectively treated in the primary care setting. The stigma of mental illness and misconceptions about depression in particular, hinder recognition. The signs and symptoms of clinical depression as outlined in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, are valid and reliable. Both psychotherapeutic and psychopharmacologic treatments are effective. The obstetrician/gynecologist plays a crucial role in identifying depression, helping the patient, and sometimes her family, to understand the nature of the problem, suggesting treatment, and facilitating either referral or treatment within the Ob-Gyn setting. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians LEARNING OBJECTIVES: After completion of this article, the reader will be able to understand the stigmata and misconceptions associated with a depression, to be aware of the various etiologies of depression and typical and atypical presentations, as well as the various management strategies for depression, and have a better understanding of which patients should be referred.

Psychiatry, the law, and public affairs.

The law is a public affair. The involvement of psychiatrists and psychiatry in legal and judicial proceedings themselves, not to mention the ever-increasing media commentary, is an opportunity to educate the public, but it also entails the very real risk of compounding public misinformation and misgivings about our field. The American Psychiatric Association has both a professional staff Division of Public Affairs and a membership component, the Joint Commission on Public Affairs. Staff and members field queries from the public and the media, plan educational campaigns in collaboration with advocacy organizations, prepare and distribute fact sheets, media kits, and issue kits for members, brochures for the lay reader, booklets for important audiences including clergy, educators, and legislators, and many other resources. Given their critical influence on the lay-person's image and understanding of psychiatry, the participation of forensic psychiatrists in the public affairs activities of our major professional organization is not only welcome, but vital.

Abortion: social context, psychodynamic implications.

PIP: A case report presented by a US psychoanalyst suggests that the trauma of reproductive loss, such as miscarriage of a wanted pregnancy, can trigger suppressed feelings associated with an earlier induced abortion. The patient entered psychoanalysis when she was a 24-year-old graduate student to address relationship problems. As a 19-year-old college student, she became pregnant and chose to have an induced abortion because she was not ready to make a permanent commitment to her boyfriend or to provide properly for a child. She reported feeling grateful at the time that motherhood was not imposed on women as punishment for being sexually active and that childbearing was a free choice. The patient married during psychoanalytic treatment and decided she wanted to have a child. She experienced a hydatiform molar pregnancy, following which memories of the abortion 10 years earlier began to surface in the analysis for the first time. Her grief about the recent pregnancy loss melded with emotions about the earlier abortion. Through the analytic relationship, the patient was able to experience and express this sadness. This case underscores the need for psychotherapists to ensure that the political importance of protecting women's right to reproductive choice does not obstruct the exploration of complex emotions that may be associated with a voluntary induced abortion.^ieng

Psychosocial aspects of induced abortion.

PIP: US anti-abortion groups have used misinformation on the long-term psychological impact of induced abortion to advance their position. This article reviews the available research evidence on the definition, history, cultural context, and emotional and psychiatric sequelae of induced abortion. Notable has been a confusion of normative, transient reactions to unintended pregnancy and abortion (e.g., guilt, depression, anxiety) with serious mental disorders. Studies of the psychiatric aspects of abortion have been limited by methodological problems such as the impossibility of randomly assigning women to study and control groups, resistance to follow-up, and confounding variables. Among the factors that may impact on an unintended pregnancy and the decision to abort are ongoing or past psychiatric illness, poverty, social chaos, youth and immaturity, abandonment issues, ongoing domestic responsibilities, rape and incest, domestic violence, religion, and contraceptive failure. Among the risk factors for postabortion psychosocial difficulties are previous or concurrent psychiatric illness, coercion to abort, genetic or medical indications, lack of social supports, ambivalence, and increasing length of gestation. Overall, the literature indicates that serious psychiatric illness is at least 8 times more common among postpartum than among postabortion women. Abortion center staff should acknowledge that the termination of a pregnancy may be experienced as a loss even when it is a voluntary choice. Referrals should be offered to women who show great emotional distress, have had several previous abortions, or request psychiatric consultation.^ieng

Conceptions and misconceptions. Decisions about pregnancy.

Induced abortion has been practiced in every known society and in every era of history. Psychological concomitants of abortion are as much a product of the social and interpersonal context as of the process itself. Though abortion results in the loss of a potential human life, it is not associated with significant psychiatric morbidity, and, in fact, represents for many women--and men--a significant milestone in which they assume responsibility for the direction of their lives for the first time. However, assertions that abortion is psychologically damaging have characterized much of the recent bitter debate over the legality and availability of abortion. It is important that mental health professionals are knowledgeable about the subject of abortion so that they can discuss policy with their patients.