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Ask the Mental Health Expert Archives 2001-2004

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History of Mental Treatment

Q. I am interested in the treatment of women with mental illness in the past... the early 1900s, 1960s, 1970s to present. What have been the major changes that have given women more effective therapies and how have these altered how women are treated with their mental health?

A. Since women are the biggest consumers of health care in the US, and are disproportionately affected by a variety of depressive and anxiety disorders, your question is very important. For good general reviews on the issue of "women and mental health", I would recommend the book Women's Mental Health by Vivien K. Burt MD, and Victoria C. Hendrick MD (American Psychiatric Press, 1997) and volume 14 of the American Psychiatric Press Review of Psychiatry (1995), edited by JM Oldham and MB Riba.

In terms of historical trends, I think it must be said that, to some degree, the mental health care of women has benefited from many of the same factors that have improved psychiatric care for men. Both men and women have benefited from more effective antidepressant, antianxiety, and antipsychotic medications, and the development of highly effective forms of psychotherapy.

There is, however, a growing recognition that sex-specific factors are relevant to the psychiatric treatment of women. For example, there is some evidence that women respond preferentially to serotonergic antidepressants (such as Prozac and Zoloft), when compared with men (Kornstein S, J Clin Psychiatry suppl 15, 1997). Women may also metabolize antidepressants differently than men. We have also learned that the course of illness in women may differ from that in men, with respect to both depression and schizophrenia. For example, a study by Philibert et al (J Clin Psychiatry August 1997) showed that patients with onset of depression after age 40 are at higher risk of poor outcome than those with onset prior to age 40, and that this is particularly true in women.

With respect to schizophrenia, we have learned in the past twenty years or so that women often run a different course than men, with a greater tendency toward late onset of schizophrenia. Although the practical significance of this at the moment is not clear, it may point the way to specific treatments in women with schizophrenia. For example, some data suggest that high levels of estrogen protect against symptom exacerbation in women with schizophrenia (Seeman, 1996), and preliminary data in psychotic women suggest at least a transient augmenting effect when estradiol is added to ongoing neuroleptics (Kulkarni et al, 1996).

In other areas, I think the mental health profession has become increasingly aware of women's unique psychological issues and needs; e.g., with respect to post-partum depression, perimenopausal depression, eating disorders, and post-traumatic stress disorder. In each of these disorders, more effective treatments in the past two decades have contributed to improved care of women, in my opinion. For example, recent evidence indicates that women are about twice as likely as men to develop post-traumatic stress disorder (PTSD) (N. Breslau, in Psychological Trauma, edited by R. Yehuda, American Psychiatric Press, 1998). This realization, in my view, has led to heightened sensitivity to the role of trauma in women with dissociative symptoms.

As far as treatment of women with mental illness in the early 20th century, I don't know of specific resources; however, you may want to see the book American Psychiatry After World War II, edited by RW Menninger and John C. Nemiah (American Psychiatric Press, 2000). Two other books that may interest you are Gender Differences in Mood and Anxiety Disorders, by Ellen Leibenluft; and Psychological Aspects of Women's Health Care, edited by Nada Stotland and Donna Stewart.

July 2001

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