Women and mental illness

BRITISH MEDICAL JOURNAL VOLUME 292 18 JANUARY 1986 201 duration of hypo-oestrogenism rather than absolute plasma hormone levels. Similarly, hormone levels are not related to the presence of psychiatric symptoms in younger menstruating women with the premenstrual syndrome. However, the evidence for the cyclical nature of depression and its response to hormone therapy is convincing. The ovarian cycle is associated with well documented changes in more than 200 physiological variables and up to 40 medical disorders, including neurological disorders such as migraine and epilepsy and psychiatric disorders such as depression, anxiety, and psychosis.6 Our own studies have shown that if we ablate the changes in the ovarian cycle by producing anovulation with oestradiol the cyclical influences on depression, the premenstrual syndrome (PMS), and menstrual migraine are removed.7'8 We have further supported this concept in a'double blind placebo controlled trial of oestrogen induced anovulation, which statistically improved every symptom group. in the Moos PMS questionnaire (unpublished). The importance of these psychological changes with sudden changes of ovarian hormones in what we believe should be called the "ovarian cycle syndrome" is supported by our unpublished findings that cyclical progestogen given to women who have undergone hysterectomy reproduces this cyclical depression and anxiety, whereas cyclical placebos do not. Few would deny the social factors which contribute to' the high incidence of depression in middle aged women, but to ignore the frequent and HUGH DUDLEY treatable hormonal contribution to this problem is Past President, Surgical Research Society Chairman, British Journal of Surgery Society to condemn women to the limitations of psychiatry example of the headquarters of the MRC, as exemplified by its permanent staff, failing to move with both the times and with attitudes. Referees for grant applications are not, as far as I am aware, asked-as would happen on any good journal-to couch their comments in terms which could be transmitted to the applicant. If such a policy wereto be adopted then there would be the need only for a photocopier at MRC headquarters for feedback to be possible. In addition, there is no evidence that the MRC adopts a policy of review of outcome of project research such as is routine with the Science and Engineering Research Council. Many of us, faced with the enormous lack of accountability, even handedness, and representation of our disciplines in the affairs of the council, have assumed that we are ineligible for support and have turned elsewhere. Fortunately most of us have not run very short, but it is a national disgrace that an organisation of this kind-however overtly successful it might be-can proceed in the way it does without scientific accountability, without a policy, and encased in its own arrogance. Nothing short of a formal inquiry will convince me that the MRC really serves the public interest in relation to solving the problems of disease now, as distinct from those of science for the future. Academic Surgical Unit, St Mary's Hospital, London W2 INY Women and mental illness SIR,-Rachel Jenkins and Professor Anthony Clare are correct to emphasise the extensive social stresses that women are heir to, but their dismissal of the view that the excess of depression in women is partly explained by "reproductive biology" is incorrect (30 November 1985, p 1521). Unfortunately, even in disorders of common interest psychiatrists seem to be preoccupied with behaviour and expectation, whereas gynaecologists have their own preoccupation with hormones and the metabolic effects of such deficiencies. This dichotomy rarely works in the best interests of understanding these disorders. Our observation that every reference in this leading article is taken from a journal of psychiatry or social medicine, without any gynaecological, endocrinological, or even generalist journal, indicates that we s-hould get together sometime. The evidence that ovarian hormones affect mood is overwhelming. Irritability, anxiety, and depression are common symptoms of the climacteric in women who have previously experienced good mental health. There is a peak incidence of psychiatric disturbances in women at 45 to 49,' and this peak is found usually one to two years before the menopause,2 at a time of hormonal change rather than absolute hypo-oestrogenism. Several placebo controlled prospective trials have shown these symptoms of mental illness in the climacteric to be responsive to oestrogen therapy, either oral3 or by-implant.4 One current study indicates that 62% of women attending our menopause clinic have pathological psychiatric illness when evaluated by the shortened symptom rating test validated by the standard psychiatric interview. The 80 patients studied have shown a significant response for depression, anxiety, headaches, loss of energy, and loss of libido when tAking oestradiol implants with or without added testosterone when compared with placebos. Certainly there is absolutely no association with depression and hormone levels in either postmenopausal women or wvomen who have undergone bilateral oophorectomy.5 This is a mystery and is probably related to the rate ofhormone change and the and social medicine. "no study has yet succeeded in definitely correlating clinical mental states in men or women with concentrations of gonadal hormones," research designed to take such complexity into account has hardly started. Dr Jenkins and Professor Clare tell us that premenstrual tension and oral contraceptives may contribute to the sex difference in psychiatric illness "but this appears to be of small magnitude." As far as I am aware we have no idea of the magnitude in either case. These questions are important. Apart from the enormous quantity of steroids that are given to women for contraceptive or hormonal replacement purposes there are endocrine events during the reproductive years of women, including the menstrual cycle, pregnancy, and lactation, that have no parallel in men. We should not dismiss their relevance to women's psychiatric problems until we have good reason to do so. I personally have no doubt that social factors are enormously important in contributing to this large sex difference in depressive illness, but we should be prepared to find more than one type of explanation. With our present state of knowledge, any claims that reproductive biological factors are unimportant in explaining the excess of depression in women should be treated "with grave caution." JoHN BANCROFr MRC Reproductive Biology Unit, Edinburgh EH3 9EW ***The authors reply below.-ED, BMJ. JOHN STTJDD SIR,-The fact that the evidence that ovarian MARK BRINCAT hormones affect mood overwhelms Mr Studd and ADAM MAGOS his colleagues is quite beside the point, as is the JULIA MONTGOMERY apparent response of a group of highly selected, Dulwich Hospital, Menopause Clinic, London SE22 8PT 1 Ballinger BC. Psychiatric morbidity and the menopause; screening of general population sample. Br MedJ 1975;iii: 344-6. 2 Bungay GT, Vessey MP, McPherson CK. Study of symptoms in middle life with special reference to the menopause. BrMedJ 1980;281: 181-3. 3 Campbell S, Whitehead MI. Oestrogen therapy and the menopausal syndrome. Clinics in Obstetrics and Gynaecology 1977;4: 3147. 4 Brincat M, Magos AL, Studd JWW, et al. Subcutaneous hormone implants for the control of climacteric symptoms. Lancet 1984;i:16-8. 5 Chakravati S, Collins WP, Studd JWW, et al. Endocrine changes in symptomatology following oophorectomy in premenopausal women. BrJ Obstet Gynaecol 1977;84:769-75. 6 Magos AL, Studd JWW. Effects of the menstrual cycle on medical disorders. Brj Hosp Med 1985 Feb:68-77. 7 Magos AL, Collins WP, Studd JWW. Management of the premenstrual syndrome by subcutaneous implants of oestradiol. Joumnal of Pscyhosomatic Obstetrics and Gynaecology 1984; 3:93-9. 8 Magos AL, Zilkha KJ, Studd JWW. Treatment of menstrual migraine by oestradiol implants (1983). J Neurol Neurosurg Psychiatry 1983;46:1044-6. SIR,-Dr Rachel Jenkins and Professor Anthony W Clare advise us that "all claims that the excess of depression in women is explained by their reproductive biology. . . should be treated with grave caution." The implication of their piece is that such claims are widespread, though the evidence they give seems to be derived mainly from the nineteenth century. In recent years sex differences in psychiatric illness: have been established in several epidemiological, studies. But very little attention, certainly little more than lip service, has been paid to the possible relevance of reproductive biological factors. This is particularly noticeable in relation to postnatal depression, which has been extensively investigated in the past 10 years. Yet, apart from three or four limited studies, possible hormonal factors have not been investigated, and, even more surprisingly, lactation, which has profound effects on the woman's hormonal state, has been almost totally ignored. Recent developments in neuroendocrinology have taught us that hormone behaviour relationships are likely to be highly complex, and while it is true that seriously incapacitated women to crude implants of a sex hormone. We nowhere suggested that hormones do not affect mood but rather that there is scant evidence to suggest that the excess of minor psychiatric morbidity can be explained by reference to the effect offemale hormones. It is not a question of us reading each other's psychiatric and gynaecological journals, it is a matter of basic epidemiology. We feel that Dr Bancroft's reservations are more serious, though if he is looking for evidence of the twentieth century tendency to explain the female excess of depression in terms of reproductive biology he need look no further than Mr Studd's letter. Hormone behaviour relations are indeed likely to be highly complex and much more research is required. Likewise, more research is required to clarify the impact of social factors. On the magnitude of the contribution of the postmenopausal syndrome, it is worth noting that whereas a decade ago it was fashionable to claim that upwards of 40% of women suffered from the condition, today's estimate is 10% and falling. Oral contraceptive use is unlikely to be a major factor given that the excess of morbidity holds up across societies independent of their pill take up rates. The menopause can hardly be used to explain a sex difference which is at its most marked during the active reproductive phase of a woman's life. As for the disparaging reference to nineteenth century literature, we would respectfully suggest that even modern psychoendocrinologists could benefit from having a sense of medical history-otherwise they may well be doomed to repeat its mistakes. On Professor Cohen's point (4 January, p 62) recent epidemiological studies, including one just undertaken in this department, make it plain that "minor" psychiatric morbidity is not- just "misery" or "unhappiness" but is most commonly an incapacitating, distressing, and treatable ix-; ture of anxiety and depression and is often not identified and treated appropriately. We agree -with Dr Taylor in distinguishing betwveen illness, where sex differences disappear on controlling' social variables, and illness behaviour, such as