Past trauma and present functioning of patients attending a women's psychiatric clinic.

A women's psychiatric clinic, incorporated within a university teaching general hospital and staffed entirely by women, was opened in March of 1980. The authors studied a sample of 100 women who came to the clinic and characterized them by demographic variables, psychiatric diagnoses, health problems, chronic illness, death in the family, and traumatic incidents. Death in the family before she was 18 was found to predict a woman's subsequent request for or completion of sterilization. Physical or sexual abuse was significantly related to abortion, and abortion and trauma were significantly correlated.

PIP: Data were collected from the intake forms completed by 100 patients of a women's psychiatric clinic in order to characterize them by demographic variables, psychiatric diagnoses, health problems, chronic illness, death in the family, and traumatic incidents. Having postulated that the sample could be divided into specific groups according to the history of trauma, history of deaths in the family, and chronic illness in the patient and her family, an attempt was made to discover any relationship between such histories and the patient's current health problems. The existence of specific and different health issues and implications for the trauma group, the death group, and the chronic illness group was postulated. The only demographic characteristic that was significantly correlated with other variables was education. Women having no more than high school education were more likely to have experienced physical or sexual abuse than were those having postsecondary education. Members of the former group also were significantly more likely to have had an abortion. There was no statistically significant relationship between education level and other health or trauma variables. 49% of the sample had experienced the death of a family member. Of these, 25% had experienced at least 1 of these deaths before age 18. There was a small but significant correlation between death in the family and a personal history of chronic illness and 3 or more gynecological problems. There was a small statistical correlation between death in the family and a diagnosis of neurotic or adjustment disorder and finding of a high stress level. There was no statistical correlation between death in the family and abortion, there was a highly significant correlation between death in the family and request for or completion of sterilization. When the factor of physical and/or sexual abuse was examined separately, there was a significant correlation with abortion and a somewhat weaker correlation with sterilization. Abortion correlated very significant with 3 or more trauma factors; sterilization correlated also but at a less significant level than abortion.

Sexual assault and psychiatric disorders among a community sample of women.

The authors examined the relationships between sexual assault and psychiatric disorders in a sample of 1,157 women 18-64 years old in the North Carolina site of the NIMH Epidemiologic Catchment Area Program. The results suggest that sexual assault is a risk factor for a number of psychiatric disorders. In addition, several characteristics of the assault among sexual assault victims were significantly related to one or more psychiatric disorders. However, there was no clear pattern relating characteristics of the assault to the risk of specific psychiatric disorders.

PIP: This paper examines the relationships between sexual assault and psychiatric disorders, as well as the extent to which characteristics of the sexual assault affected these relationships. Data were collected from a sample of 1157 women 18-64 years old in the North Carolina site of the National Institute of Mental Health Epidemiologic Catchment Area Program. Findings revealed that sexual assault was a risk factor for a number of psychiatric disorders but more so for some than for others. Major depression, alcohol abuse or dependence, drug abuse or dependence, panic disorder, post-traumatic stress disorder, and obsessive-compulsive disorder were psychiatric disorders associated with sexual disorders. In addition, strong associations were seen in alcohol abuse or dependence, drug abuse or dependence, panic disorder, post-traumatic stress disorder, and obsessive-compulsive disorder. However, no clear pattern relating characteristics of the assault to the risk of specific psychiatric disorders was noted. Further study employing a very large sample is recommended.

Building therapeutic staff: client relationships with women who self-harm.

PIP: This article examines the aims and objectives of a training package devised for nurses working directly with women who self-harm and detained in institutions. The training package aims to change and inform staff attitudes toward self-harming behavior and to encourage therapeutic responses and interventions. The first key step in helping these women is to understand why they resort to self-harm. Some of the underlying reasons why these women try to hurt themselves include dominance of older women, histories of abuse, and feelings of powerlessness. The training program uses a seminar format followed by reflective practice sessions which enables the nursing staff to explore how both theoretical constructs and women's experiences could inform and influence the delivery of care. It utilized community-produced and focused support networks, and consisted of six sessions, each lasting around 2 hours and 30 minutes. Seminar topics include reasons for self-harm, types of women who self-harm, caring for and myths about these women, and communication issues.^ieng

Overdose and termination of pregnancy: an important association?

Are taking an overdose and undergoing termination of pregnancy linked? In one practice this study has identified a significant association between the two events. If this finding is supported more widely, could one event act as a risk marker for the second?

PIP: A retrospective review of the records of 1359 female patients 15-39 years of age registered with a general practice in the UK revealed an association between deliberate self-harm and induced abortion. 163 (12%) of these women had undergone pregnancy termination, primarily at age 19 years or younger, and 47 (3.5%) had a history of deliberate overdose; 15 women had a history of both of these events, generally within 2 years of each other. The association between induced abortion and overdose was significant (p 0.01). Although abortions were more likely to follow than precede overdoses, this trend was not significant. It was speculated that both events are related to similar psychosocial factors, including socioeconomic deprivation and self-destructiveness. If this association is confirmed in larger studies, methods to identify women at risk should be explored.

Family planning knowledge, attitudes and practices in women with schizophrenic spectrum disorders.

This study set out to test three hypotheses about family planning in women with schizophrenic spectrum disorders, as compared to demographically comparable non-mentally ill control women: that they (1) report at least as much unprotected intercourse while not desiring pregnancy; (2) have less knowledge about contraception; and (3) perceive more, and different, obstacles to obtaining or using birth control. A semistructured Family Planning Interview was administered to subjects (n = 44) with Research Diagnostic Criteria diagnoses of schizophrenia and schizoaffective disorder, and to non-mentally ill control subjects (n = 50). The participants had high rates of unprotected intercourse, as did non-mentally ill controls. They had significantly less reproductive and contraceptive knowledge than the control subjects, and were more likely to perceive birth control as difficult to obtain. The most common reason women with schizophrenic spectrum disorders gave for failing to use birth control was that they did not expect to have sex, while that given by non-mentally ill subjects related to side-effects of birth control. Important obstacles to family planning in women with schizophrenic spectrum disorders include relative lack of knowledge and difficulty planning ahead. Although many women with schizophrenia could benefit from long-acting, reversible contraception, many may be unaware of those options and/or may find them difficult to obtain. Integrating family planning with mental health care might better address the unique needs of this population.

PIP: A semi-structured interview was used to gather data in testing the three hypotheses about family planning in women with schizophrenic spectrum disorders, as compared to demographically comparable non-mentally-ill control women: 1) that they report at least as much unprotected intercourse while not desiring pregnancy; 2) that they have less knowledge about contraception; and 3) that they perceive more, and different, obstacles in obtaining or using birth control. A total of 44 women with Research Diagnostic Criteria diagnosed of schizophrenia and schizoaffective disorder, and 50 non-mentally-ill control subjects were administered with the Family Planning Interview. The interview elicited detailed information about sexuality, pregnancy history, education and communication about family planning, and birth control knowledge, practices and attitudes. Results revealed that the participants had high rates of unprotected intercourse, as did non-mentally-ill controls. They had significantly less reproductive and contraceptive knowledge than the control subjects, and were more likely to perceive birth control as difficult to obtain. The reason most commonly endorsed by women with psychotic disorders had to do with not expecting to have sex, and not thinking about birth control while having sex. It also provides support for the hypothesis that difficulty planning ahead was a major obstacle to the use of birth control methods. These findings underscore the importance of gearing family planning programs to the particular needs of mentally ill women.

Use of hormonal contraceptives in an institutional setting: reasons for use, consent and safety in women with psychiatric and intellectual disabilities.

AIM: To describe the use of hormonal contraceptives in institutionalised women with psychiatric and/or intellectual disabilities. METHODS: Women who had been disability or mental health service inpatients for six months or more and were prescribed hormonal contraceptives were included. Data were collected from their clinical files and from structured interviews of the women and of their primary care givers. RESULTS: Forty two women were prescribed contraceptives, of whom 23 were intellectually disabled and 28 had mental illnesses. Most women had no children; four had had one child and two, two children. Thirteen were not sexually active. Depot medroxyprogesterone acetate (Depo Provera) was prescribed for 69%, combined oral contraceptive agents for 14% and progestin-only oral contraceptives for 17%. Contraceptives were initially prescribed by hospital staff for all but 1 woman, and were administered without consent for over half the group, including 11 women for whom this administration was not legally authorized. Less than half the group had blood pressure measured within the previous 12 months and only a third had a cervical smear within the previous 3 years. Of the women who were sexually active, less than half knew how to protect themselves from sexually transmitted diseases and less than 10% regularly used condoms. CONCLUSIONS: Improvements in reproductive health care for these women are needed, in particular attention to education and client participation in decisions about contraceptive treatment. It is suggested that gynaecological and family planning services be provided separately from psychiatric services.

PIP: A study was made of all women who had been inpatients of the mental health or disability units of Porirua Hospital in New Zealand for at least 6 months who were prescribed oral or injectable hormonal contraceptives during January 1992. The aim was to describe the use of hormonal contraceptives in this population and assess the appropriateness and safety of this method as well as the patient consent process and patient satisfaction. Data were collected from medical records and from interviews with the patients (when possible) and their nurses. 42 women were prescribed contraceptives (60% of those under 50). 3 were married, 3 separated or divorced, and 36 never married. 32 were nulliparous, none had more than 2 children. 11 were Maoir, 1 Pacific Islander, and 29 New Zealand pakeha. 23 women were intellectually disabled, 28 had mental disorders, 9 had both. 29 of the women received Depo Provera, 7 progesterone-only oral contraceptives (OCs), and 6 combined OCs. 25 had been using their current contraceptive for more than 3 years. Treatment was prescribed by psychiatric staff in 16 cases, other staff in 25, and outside practitioners in 1. The reason for treatment was contraception in 32 women and menstruation prevention in 9. 27 women were smokers (21 heavy). 7, including 6 of the heavy smokers, had other contraindications to the use of estrogens. Of the 26 women interviewed, 12 complained of side effects, 8 of weight gain, 2 of depression, and 5 of other effects (the nurses identified only 2 of 42 women as suffering side effects). Of the 22 interviewees who were treated for contraception, 15 stated they were sexually active. The nurses thought that 29 of the 42 were or might be sexually active. Therefore, 13 women considered definitely not sexually active were prescribed contraceptives. Very few of the women used condoms, although 38% knew how to practice safe sex. 14 of the women interviewed stated they chose contraception. The nurses said 8 had given consent, the families of 2 gave consent, consent information was unknown for 10, and a unilateral staff decision was made for 22. 17 of the 28 women definitely treated without consent were mentally retarded. The women were given very little information about their contraceptive method and knew of very few other methods. These results indicate that contraceptives have been used to manage menstrual hygiene and address staff concerns. In some cases, their administration without consent was illegal. The patients received inadequate medical care and some of the prescriptions were inappropriate. Ethically correct ways in which to address the problem of contraception in this population exist through educationally-focused family planning services for both in- and out-patients.

Impact of sexual and physical abuse on women's mental health.

The level of psychiatric symptomatology was assessed with the General Health Questionnaire and the Present State Examination in a random community sample of women. Subsequently it was ascertained which of the women had been the victims of sexual or physical abuse, in either childhood or adult life. Women with a history of being abused were significantly more likely to have raised scores on both measures of psychopathology and to be identified as psychiatric cases. 20% of women who had been exposed to sexual abuse as a child were identified as having psychiatric disorders, predominantly depressive in type, compared with 6.3% of the non-abused population. Similar increases in psychopathology were found in women who had been physically or sexually assaulted in adult life. These findings indicate that the deleterious effects of abuse can continue to contribute to psychiatric morbidity for many years.

PIP: A study conducted in New Zealand examined the relation between women's mental health and past experiences of sexual and physical abuse in a randomly selected community sample. The level of psychiatric symptomatology was assessed using the General Health Questionnaire (GHQ) and the Present State Examination (PSE). About 13.1% of the women interviewed and 9.9% of the original random sample reported having some form of sexual abuse as a child. About 4.6% of the subjects interviewed and some 3.5% of the original sample reported experiencing sexual abuse as an adult. About 20.1% of the interviewed sample and 16.2% of the original sample identified themselves as having been physically abused as an adult. These women with histories of abuse have higher GHQ and PSE scores than the nonabused and were more likely to be identified as psychiatric cases. Psychiatric disorders were identified in 20% of women who experienced childhood sexual abuse; similar increases in psychopathology were found in women who had been abused as an adult. The results of this study indicate that the harmful effects of abuse can continue to contribute to the psychiatric morbidity of women for many years.

Ethically justified guidelines for family planning interventions to prevent pregnancy in female patients with chronic mental illness.

OBJECTIVE: This article proposes ethically justified clinical guidelines for family planning interventions to prevent pregnancy in female patients. STUDY DESIGN: We reviewed literature on family planning and consequences of pregnancy in patients with chronic mental illness and related that literature to ethical principles. RESULTS: Patients with chronic mental illness are ethically unique because they have chronically and variably impaired autonomy. Existing guidelines and proposals for family planning interventions for mentally retarded patients are shown not to apply to such patients. CONCLUSION: Three sets of guidelines for three groups of patients, representing the continuum of chronically and variably impaired autonomy, are proposed: (1) a set of guidelines for patients who can achieve thresholds of autonomy, (2) a set of guidelines for patients irreversibly near thresholds of autonomy, and (3) a set of guidelines for patients irreversibly below thresholds of autonomy. These guidelines should contribute significantly to the quality of obstetric and gynecologic care for female patients with chronic mental illness.

PIP: On the basis of a review of the literature, ethical clinical guidelines for the prevention of pregnancy in women with chronic mental illness have been developed. Such women are characterized as having chronically and variably impaired autonomy in terms of their ability to make decisions about health care, including family planning. The overall strategy should be to restore impaired autonomy in health care decision making. The decision-making process involves 6 steps: 1) attending to information provided by the physician; 2) absorbing, retaining, and recalling this information; 3) cognitive understanding of the significance of the information for the woman and any potential offspring; 4) evaluation of these consequences; 5) expression of both cognitive and evaluative understanding; and 6) communication of a decision based on such understanding. Patients who can negotiate this process are capable of informed consent; those who cannot should be provided with interventions aimed at improving impaired aspects of decision making. Patients who are irreversibly near the thresholds for autonomous decision making can at least assent to medical care and should be presented with alternatives that are consistent with their values. More complex is the management of patients who are irreversibly below thresholds of autonomy in their decision-making abilities. In such cases, consideration must be given to the patient's interests (e.g.., whether pregnancy is likely to pose significant mental health and physical benefits or risks), risks to possible future children (genetic and social), and the social costs. In no case is it ethically justifiable to force the most impaired mentally ill woman to accept surgical sterilization.

Chronic schizophrenic women's attitudes toward sex, pregnancy, birth control, and childrearing.

Interviews with 23 chronically institutionalized, schizophrenic women living on a chronic care unit indicated that the majority had a continuing interest in sex and engaged in sexual activity. Fourteen of the women wanted to become pregnant. Few seemed to recognize their limited potential to be adequate parents. Respondents often gave bizarre or inaccurate responses to the interview questions, indicating that their ideas about contraception, pregnancy, and childrearing were affected by psychopathology. The authors concede that the task of designing and implementing birth control programs for severely ill schizophrenic patients is formidable but encourage mental health professionals to openly discuss sex, birth control, and having children with their patients.

PIP: Interviews with 23 chronically institutionalized, schizophrenic women living on a chronic care unit and ranging in age from 20-58 years were interviewed to provide initial systematic data about the attitudes of chronic schizophrenic women toward sex, pregnancy, birth control, and childrearing. All of the subjects, patients at the Middle Tennessee Mental Health Institute, had been receiving neuroleptic medications for at least 3 months before they were interviewed. All had some outside grounds privileges allowing them to have unsupervised contact with male patients. Subjects had been continuously hospitalized for a minimum of 3 months. 2 of the women were married. 12 of the 23 women had borne children. The number of children ranged up to 9. At the time of the interview, 2 women were not using contraceptives, 9 were taking oral contraceptives (OCs), 1 had an IUD, and 2 had had tubal ligations. 1 women had had a hysterectomy, and 8 had already gone through menopause. Each patient was interviewed by the ward charge nurse (AH) who had become well acquainted with the patients during many months and even years of care. 13 of the 23 women reported they would like to have an active sex life. After describing the kind of man they would find attractive, 16 of the women reported they would not hesitate to have sex with such a man if the opportunity were available. 15 reported having had intercourse during the previous 3 months. The frequency of intercourse ranged from once during the entire 3 months to once a day during that period. The nursing staff who constantly worked with these women judged that 14 probably had been sexually active during the 3 months before the interview. 6 of the women reported they would currently like to become pregnant. 8 said they would like to become pregnant in the future. 9 reported no desire to become pregnant. 8 said they would currently like to have children or more children; 6 said they would not like to have more children now but would like to do so in the future. The 3 women who had been surgically sterilized all said they wanted to become pregnant and have more children. Despite the majority's accurate description of birth control, when the women were questioned about its advantages, only 10 understood that women could use birth control to avoid pregnancy. Psychopathology, manifested in unusual responses and inaccurate answers, often disrupted the reasoning of these patients and could potentially lead to illogical conclusions and imprudent activities.

Family planning and parenthood needs of women with severe mental illness: clinicians' perspective.

Family planning and parenthood are important issues for women with severe and persistent mental illness (SPMI). The role of adult mental health clinicians with regard to these issues has been under investigated. Clinicians treating patients with SPMI at a large community health center completed survey forms on 419 women. Clinicians reported that a large fraction of sexually active women were not thought to be using birth control. Despite this, many clinicians had not discussed birth control with these patients. Clinicians had concerns about childcare in 72% of cases where the patient with SPMI was the primary custodian of a younger child; however, the majority of these families were not receiving child or family services. Further consideration of the role of the adult mental health clinician in addressing issues of family planning and parenting is required.

Respecting the autonomy of chronic mentally ill women in decisions about contraception.

Treatment of women patients with chronic mental illness who are at risk of unwanted pregnancies presents ethical challenges to the clinician who wishes to respect the patient's autonomy while also helping her avert the potential adverse consequences of unwanted pregnancy. The clinician who simply allows the patient to continue at risk or coerces her into using contraception may not have adequately considered the variable nature of the patient's autonomy. The authors suggest that the clinician should assess and treat conditions underlying the patient's variable impairment of autonomy to maximize her ability to participate in family planning decisions. Case examples are used to illustrate assessment of patients' decision-making capacity, development of family planning approaches that respect patients' autonomy, and use of a newly available contraceptive implant.

PIP: Chronically mentally ill women of reproductive age pose major ethical dilemmas for mental health professionals if the patient does not accept contraception. Ethically questionable responses have ranged from letting the patient continue at risk of pregnancy out of a respect for her autonomy to manipulating or coercing the patient into using contraception. A third course of action assumes that mentally ill women exhibit both chronically and variably impaired autonomy with limitations in decision-making ability manifested in varying degrees over time. 3 case histories illustrate these issues. A 38-year-old schizophrenic woman wanted to become pregnant and was having unprotected intercourse. It was questionable whether the patient could give informed consent or understand contraceptive options. This impaired autonomy might lead a psychiatrist to act paternalistically to forestall a pregnancy. An alternative to this response would be to improve the patient's capacity to participate in the informed-consent process by treating underlying factors which pose barriers to the exercise of autonomy. If impairment is too severe for this treatment, beneficence-based obligations to potential children may override concerns for the patient's autonomy. In the second case, a 30-year-old schizophrenic woman was admitted in active labor in a psychotic state. Her baby was put in foster care. When her psychosis cleared, she refused to discuss birth control. The reproductive risks encountered by chronically mentally ill pregnant women can not be predicted with certainty and are not serious enough to constitute reasons to control the mother's decision-making process. In this case, an alternative approach may be to offer only reversible methods of birth control and provide information about HIV and other sexually transmitted diseases. In a hypothetical case, a 24-year-old schizophrenic woman consented to receive a contraceptive implant at the end of a hospitalization. When she regressed into a psychotic state, she requested that the implant be removed. Her doctors chose to honor the decision she made while she was not acutely psychotic and did not remove the implant. Because the risks the patient runs without the contraceptive are preventable, reversible, or uncertain, the clinician may not be justified in every case in refusing to honor a request by a patient even when she is severely psychotic. Removal of the device may relieve the patient of anxiety, even if the anxiety is delusional. The frustration involved with these problems may lead clinicians to accept any decision made by a patient, even if the principle of autonomy is thus inappropriately applied. An awareness of the variable nature of chronic mental illness, on the other hand, may help clinicians avoid a paternalistic approach. This requires the support of hospitals and clinics which, unfortunately, sometimes override ethical considerations because they must operate with a shortage of staff and resources. With contraceptive implants now available, mental health facilities should develop guidelines which address the unique ethical issues involved in their use.

Contraception in women with intercurrent disease.

Prescribing a contraceptive method for women with intercurrent disease poses a difficult clinical management problem for physicians. The contraceptive chosen may adversely affect the underlying disease of the patient. Conversely, failure of contraception could result in pregnancy, which could also adversely affect the patient's underlying disease. These factors must be taken into consideration in selecting appropriate and effective contraceptive agents to avoid complications and undesired pharmacologic interactions.

PIP: The selection of a contraceptive method for women with intercurrent disease necessitates complex balancing of the medical risks inherent in pregnancy and effects of the method on the underlying disease process. Presented in this review are contraceptive options for women with psychiatric, coagulation, cardiovascular, endocrine, and neurologic disorders as well as sickle cell disease and acquired immunodeficiency syndrome (AIDS). In women who are taking antidepressants or anti-anxiety medications, drug interactions can lower the efficacy of estrogen. Those with cardiovascular disorders face the potential adverse effects of exogenous steroids contained in oral contraceptives (OCs); at the same time, the need for effective methods is great given the increased cardiovascular demands of pregnancy. Current OC preparations can be safely prescribed to women with chronic nonvascular headaches, while the relationship between OC use and migraine remains inconclusive. In all cases, thorough counseling is essential to ensure informed consent and compliance.

Mental disabilities affect method options.

PIP: The provision of reproductive health services to people with psychiatric disturbances or mental retardation requires consideration of factors such as the nature of the disability, whether pregnancy would exacerbate the disturbance, the setting in which the person lives, their level of functioning, and their ability to understand the consequences of contraceptive decisions. Schizophrenic women have high rates of unintended pregnancy and are especially vulnerable to exacerbations of their disease in the postpartum period. Women who are depressed, anxious, or suffering from thought disorganization may be unable to use contraceptive methods such as the pill or condoms correctly. This article reviews issues associated with the provision of various contraceptive methods to, first, women with psychiatric conditions and, second, those with intellectual disabilities. It is important that reproductive health services for those with psychiatric disabilities or retardation are not coercive. Providers should be aware of the legal requirements for obtaining informed consent, including an explanation of benefits and risks, options, and a determination of whether the person is competent to understand the information.^ieng

AIDS and family planning counseling of psychiatrically ill women in community mental health clinics.

Eighty-two of 83 mental health professionals, including psychiatrists, were surveyed to determine their attitudes and behaviors toward AIDS prevention and family planning counseling with psychiatrically ill female outpatients. Nearly all reported that information should be provided on AIDS and family planning. However, they reported that they had raised topics of AIDS with only 19% of patients and family planning with only 25% of patients. This lack of communication was confirmed by patients' own reports. Factors which might relate to this lack of communication are explored.

PIP: 82 mental health professionals including psychiatrists and 80 female chronic psychiatric patients (50% schizophrenia and 37% schizoaffective and affective disorders), both groups from 5 public funded university affiliated county mental health clinics in the US, completed questionnaires concerning AIDS and family planning. 87% of the mental health professionals believed they should take responsibility to educate patients about family planning and 95% said they should educate them on AIDS. 73% of patients felt mental health professionals should provide family planning information and 87% felt that the professionals should inform them about AIDS. Yet only 19% of mental health professionals had talked to their patients about AIDS and 8% of patients brought AIDS up as an issue. The corresponding numbers for family planning were 25% and 12%. Female professionals were more likely to discuss family planning than male professionals (p.05), but both male and female professionals were equally as likely to discuss AIDS. Mental health professionals tended to underestimate the percentage of patients who sought medical treatment outside the mental health clinics and the percentage of patients who had accurate knowledge about AIDS (p.05). For example, only 43% of the mental health professionals claimed that patients had seen a physician in the past year while 76% of the patients said that they did indeed visit a physician in the past year. 82% of mental health professionals said that patients were anxious during sexual history taking, but only 27% of patients actually reported being anxious (p.05). These results indicated that their is a definite lack of communication between mental health professionals and patients. The overestimation of patient anxiety during sexual history taking may represent anxiety on the part of the mental health professionals.