Oxford Textbooks in Psychiatry

The issue of gender and depression within the general population has been given substantial research attention and an association between female gender and increased risk for depression is established. Adverse childhood experiences, sociocultural roles, and vulnerability to life events are thought to increase the prevalence, incidence, and morbidity risk of depressive disorders in females. Biological factors seem to play a less important role in the emergence of gender differences (Piccinelli et al. 2000). ...Affective disorder, and in particular depression, is more common in people with intellectual disabilities (ID). Higher rates of physical illness including epilepsy, socioeconomic adversity, past experience of abuse, and reduced life supports are thought to be relevant risk factors (Richards et al. 2001; Lunsky 2003; De Collishaw and Maughan 2004). When people with ID become depressed, all psychological and somatic symptoms of depression can be observed, but changes are often subtle and develop over time. Depression in this population often remains undiagnosed, atypical symptoms are common, and self-injurious or aggressive behaviour may dominate the clinical picture of people with more severe ID (Gravestock et al. 2005).In this chapter, we will discuss the presentation of two major disorders, depression and bipolar affective disorder in women with ID. We will highlight epidemiological studies that have taken gender issues into account and explore gender-related risk factors. The assessment of females with ID and affective disorder will be discussed, as well as diagnostic, treatment, and service delivery issues for this highly vulnerable group.Less

The American Association of Suicidology (AAS) (http://www.suicidology.org) was founded by clinical psychologist Edwin S. Shneidman, PhD, in 1968. After co-directing the Los Angeles Suicide Prevention Center (LASPC) since 1958 with Norman Farberow, PhD, Dr Shneidman was appointed Chief of The Center for Suicide Prevention at the National Institute of Mental Health (NIMH). There he had the opportunity to closely observe the limited available knowledge-base regarding suicide. Consequently, with the support of the NIMH, he organized a meeting of several world-renowned scholars, determined the need for and fathered a national organization devoted to research, education, and practice in suicidology, and advancing suicide prevention. ...Given his leadership at the LASPC Shneidman was quick to recognize the contemporaneous and rapid expansion of the crisis centre/ hotline movement across the United States. The newly established AAS embraced these centres as sources of research information on suicidal clients. Soon, the relationship between the AAS and these centres was symbiotic. AAS became the central clearing house for support and the hub of a many-spoked wheel, networking these centres to common needs, training materials, and goals.As a result of this marriage of research and crisis counselling, the AAS developed a set of standards and criteria for certification of crisis centers throughout the United States and Canada. Since certifying its first center in 1976, the AAS has accredited more than 160 centres meeting what has been described as ‘the gold standard’ of service and training accreditation programmes. In 1989, the AAS began a certification programme for individual crisis workers as well. More than 400 individuals to date have passed a rigorous examination of their knowledge and application of crisis theory to their workLess

In 1987, leading experts on suicide joined with families who had lost a loved one to suicide to form the American Foundation for Suicide Prevention (AFSP). ...Following the approach that had proven to be effective in advancing the treatment and prevention of heart disease, cancer and diabetes, AFSP began with the goals of furthering the research necessary to understand and prevent suicide, and educating mental health professionals and the public about effective treatment and suicide-prevention strategies. From its inception, the work of the Foundation aimed to lower suicide rates, increase the public and private resources available for suicide prevention, and develop and support programmes to assist survivors of suicide loss. Over time, AFSP’s focus broadened to include representatives from the civic and business communities, as well as people suffering from depression and other mood disorders that convey suicide risk.More than 20 years later, AFSP remains the leading national non-profit organization in the US, exclusively dedicated to understanding and preventing suicide through research and education, and to reaching out to people with mood disorders and those impacted by suicide. From a single national office in New York City, the Foundation has expanded to include twenty-eight Chapters throughout the United States that bring AFSP programmes to states and communities and play an important role in focusing public attention on suicide.Less

Anxiety disorders are common in women and although often disabling they are eminently treatable (Kessler et al. 2005, 2007; NCS-R 2007). Nevertheless for many reasons they are frequently under diagnosed and/or inadequately managed (Wang et al. 2005; Wittchen and Jacobi 2005). Sufferers may not seek professional help, may receive incorrect diagnoses, or have symptoms of anxiety confused with medical complaints, especially cardiac complaints (Leon et al. 1995; Wang et al. 2005). While both men and women with anxiety disorders often receive suboptimal treatment, this is especially true for women. Women are more likely to receive benzodiazepines and are less likely to avail themselves of other effective pharmacological or psychological treatments (van der Waals et al. 1993). Moreover, women are more likely than men to suffer with anxiety disorders (NCS-R 2007). In this chapter we will present epidemiological data on specific anxiety disorders in women. We will review management, as well as consider hormonal and perinatal issues in relation to anxiety disorders in women. ...Less

In this chapter we shall present the main tools used by epidemiologists to measure the occurence and aetiology of disease in populations, and we shall summarize the results of epidemiological studies when applied to mental disorders. ...Less

In this chapter we will present a brief account of attachment theory and its evolution, then describe the contribution of attachment theory to the understanding of some key disorders that are more frequently seen in women. ...Less

Predicting suicide is difficult due to the low base rate, even in high-risk groups, and the multi-causal nature of suicidal behaviour. Retrospective and cross-sectional studies have identified a number of biologic abnormalities associated with suicide and suicide attempt. Prospective studies provide estimates of the predictive utility of biologic measures. Here, we review prospective studies of suicidal behaviour and serotonergic, noradrenergic, dopaminergic systems and the hypothalamic–pituitary– adrenocortical (HPA) axis function in mood disorders. The most promising biologic predictors are low CSF (cerebrospinal fluid) 5-hydroxyindoleacetic acid (5-HIAA) and HPA axis dysfunction as demonstrated by dexamethasone non-suppression that are each associated with about 4.5-fold greater risk of suicide. ...Less

Scientific interest in the effects of the female sex steroids on modulating mood and behaviour stems largely in the modern era from the well-recognized sex differences found in certain psychiatric disorders. ...The finding across many cultures and ethnic backgrounds from large epidemiological studies that women have twice the prevalence rate for depression as men, that this only becomes apparent after the onset of puberty, and that after the menopause rates return to near parity between the sexes, is a strong finding implicating a role for female gonadal hormones in playing an active part in such discrepancy. Further epidemiological evidence for sex steroids' capability to impact on mood and behaviour comes from the high rate of mood disturbance and psychosis seen in the postpartum period, a time of dramatic and rapid change in gonadal steroid secretion, in addition to the occurrence of a discrete menstrual cycle-related mood disorder (the premenstrual or late luteal phase dysphoric disorder), for which removal of the ovaries has been noted to be curative. Some conditions which may not be associated with a sex difference in lifetime prevalence rates are nevertheless associated with marked differences in course or outcome between the sexes, such as the later age of onset of schizophrenia in females, who generally manifest a less severe disorder which is more responsive to treatment, and who display a second peak onset around the time of the menopause, all suggestive of a somewhat protective role for gonadal steroids in this disorder.How do gonadal steroids have such widespread effects on the brain so as to explain these sex differences? While current knowledge is far from complete on this issue, this chapter will outline some key structural and functional differences between a female and male brain which arise due to the differential actions of the gonadal steroids. In particular, those central structures and systems which are believed to play an integral role in the psychiatric disorders for which a marked sex difference exists will be focused upon, including the limbic system, the various neurotransmitter systems such as serotonin, noradrenaline, and dopamine, and finally the neuroendocrine system involved in the stress response, the hypothalamic–pituitary–adrenal axis.Less

Most clinicians working with borderline personality disorder (BPD) take a pragmatic multimodal approach to treatment. Historically, patients were managed within general adult psychiatric services, and often considered problematic, untreatable, and only reluctantly accepted as suffering from a mental illness. There were, nonetheless, important treatment developments in therapeutic community settings. Over the past decade there has been increasing recognition and understanding of personality disorder as a disorder (Department of Health 2003) with inspiring new developments in psychological treatments and an expansion of specialist services The National Institute for Clinical Health and Excellence (NICE) guidelines for the treatment and management of BPD in the United Kingdom will further influence the range of National Health Service services and treatment approaches available. It emphasizes the role of psychological treatments, complex interventions, and crisis management, and recommends developing a care pathway for people with BPD (2009). It also reviews cost-effectiveness of psychological treatments (Brazier et al. 2006). ...Less

The basic morality of Buddhism is based on the content of the five precepts: killing is an evil; stealing is an evil; sexual misconduct is an evil; lying is an evil; and taking intoxicants is an evil. ...Buddhism does not consider killing merely in its form but in its origin, and judges whether or not it is immoral case by case, according to its complicated and contextual factors. Suicide is a type of killing, and the moral rules applying to all types of killing, apply also to suicide. All of the precepts in Buddhism are written in general form, meaning that there is considerable room for interpretation. This chapter discusses interpretations of cases when suicide may be considered as morally wrong and when it can be morally acceptable. Generally speaking, suicide is not necessarily an evil in the Buddhist perspective: some are morally acceptable. All sects of Buddhism agree that death is just a transformation of life, and that we live to die and we die to live again. Therefore, suicide is viewed differently from other religions, which do not believe in life after death or reincarnation.The chapter concludes with epidemiological data concerning suicide in different Buddhist countries in Asia, which show a range of 6/100,000 in Thailand to 35/100,000 in Sri Lanka. In accordance with the statistics, the Buddhist religion may impact the suicide rate differently depending on the national context.Less