Psychiatric Disorders
Laura J. Miller
Orit Avni-Barron
Joji Suzuki
Ellen B. Astrachan-Fletcher
Florina Haimovici
Jennifer Boisture
Leena Mittal
Mental health problems are common presenting and comorbid complaints in gynecologic practices.1 In this chapter, we review the psychiatric disorders encountered most frequently in gynecologic settings, noting clinically relevant gender differences. We summarize effects of reproductive cycle events on mental health, including puberty and menarche, the perinatal period, and perimenopause. Finally, we review assessment of suicide risk, the most common psychiatric emergency encountered in gynecologic settings.
MOOD DISORDERS
Major Depressive Disorder
Major depression is the leading cause of disability in women.2 Women experience major depression almost twice as often as men, with a lifetime prevalence of up to 25%.3 Its predominance in women is posited to be related to genetics, the effects of hormonal flux, and gender-linked psychosocial challenges. As compared to men, women tend to have longer lasting depressive episodes, higher recurrence rates, and more comorbid anxiety and eating disorders.4, 5, 6, 7
A major depressive episode is characterized by depressed mood most of the day, and/or markedly diminished interest or pleasure, for 2 weeks or more. Those mood changes are accompanied by most or all of the following symptoms: changes in sleep, changes in appetite or weight, fatigue and/or loss of energy, psychomotor agitation or slowing, feelings of worthlessness, excessive or inappropriate guilt, diminished ability to think or concentrate, indecisiveness, and recurrent thoughts of death or suicide. The differential diagnosis includes addictive substance use, medication side effects, bipolar disorder, bereavement, and medical conditions such as thyroid disease.
The diagnosis of major depression is based on the patient’s reported symptoms, collateral information, and a mental status examination. When patients do not directly disclose depression, “clues” may include appearance (e.g., disheveled or disinterested), behavior (e.g., lack of direct eye contact, monotonous tone of voice), vague statements (e.g., “I haven’t been myself”), or vague complaints (e.g., generally not feeling well, fatigue). Asking direct questions in an accepting manner may elicit more information.
Given the prevalence of depression, universal screening is warranted during gynecologic visits. It has been found that a single question (“Are you depressed?” or “Do you think you suffer from depression?”) has adequate sensitivity and specificity as an initial screen.8,9 Formal self-report screening tools can also be used to detect depression and to assess symptom severity and track response to treatment. The 9-item Patient Health Questionnaire (PHQ-9) is well validated in primary care settings10 and has been used in gynecologic settings11 (see Appendix 17.A).
Untreated episodes of major depression can last 6 to 13 months, whereas most treated episodes end within 3 months. Relapse rates are estimated at more than 50% after a single depressive episode and 80 to 90% after the second one.12 With time, episodes tend to develop more frequently, with more intense symptoms, and without identifiable triggers. For these reasons, in cases of severe or recurrent depressive episodes, maintenance treatment may be indicated.
Antidepressant medications are recommended for moderate to severe major depressive episodes. Patients who suffer from milder depression (also referred to as subsyndromal depression) may also benefit from medication if they are not responding to other measures. Prior to initiating antidepressant medication, it is helpful to address other potential influences on depressive symptoms, such as medical conditions and medication side effects. This includes identifying and correcting nutritional deficiencies that may worsen depressive symptoms, such as iron, folate, omega-3 essential fatty acids, and vitamins B12 and D.
If the patient has a personal or family history of manic or hypomanic symptoms, it is advisable to consult with a psychiatrist prior to initiating treatment because antidepressants may precipitate a switch from depression to mania. Psychiatric referral is also indicated in cases where the patient is experiencing hallucinations, delusions, catatonia, or suicidal thoughts.
Antidepressant medications have comparable efficacy to one another, so the choice of a specific antidepressant
is often based on side effect profiles (Table 17.1). In women, special considerations in choosing antidepressant agents include the following:
is often based on side effect profiles (Table 17.1). In women, special considerations in choosing antidepressant agents include the following:
TABLE 17.1 Common Side Effects of Antidepressants and Their Management | |||||||||||||||||||||
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Pregnancy, breastfeeding, or plans to conceive
Premenstrual exacerbation of symptoms
Comorbid disorders such as anxiety disorders, eating disorders, sleep disorders, obesity, and medical conditions that could be exacerbated by some medications
Other symptoms that can concomitantly be alleviated by certain antidepressants. Examples include the following:
Serotonin-noradrenergic reuptake inhibitors can alleviate pain, especially neuropathic pain.15
Bupropion can facilitate smoking cessation.16
Side effects of particular concern to women, such as bone density reduction, weight issues, and sexual side effects
Because antidepressant pharmacokinetics can differ by sex, standard starting doses and dose ranges may be too high for some women. Women who are sensitive to initiation side effects may benefit from starting at a low dose (e.g., half the initial dose) for 4 to 5 days and then increasing at 1- to 3-week intervals as tolerated and needed. Most side effects develop within the first few days of initiation or dose increases. Many side effects are self-limiting and resolve within 2 to 3 weeks. It may take 6 to 8 weeks for an antidepressant medication to produce its maximum therapeutic effect. During this time, frequent follow-up (e.g., every 1 to 3 weeks) is indicated. If the maximum recommended dose produces no response or a partial response, psychiatric consultation should be considered for further diagnostic evaluation (e.g., assessing for contributory factors that may impede recovery) and treatment recommendations (e.g., different approaches or augmentation strategies).
It is important to educate patients about the risk of discontinuation syndrome should their antidepressant be stopped abruptly. This non-life-threatening yet uncomfortable syndrome may develop in up to 20% of patients and may include flulike symptoms, nausea, fatigue, dizziness, anxiety, and irritability.17
Women with mild to moderate depression may benefit from psychotherapy instead of, or in addition to, antidepressant medication. Cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT) have well-demonstrated efficacy for treating major depressive disorder.18 CBT focuses on dysfunctional thoughts and behaviors, whereas IPT focuses on improving interpersonal skills. Stress reduction, effective sleep hygiene, improved self-care, and regular physical activity can also help alleviate depressive symptoms and maintain remission.19,20
Seasonal Affective Disorder
Seasonal affective disorder (SAD) is a condition in which major depressive episodes occur during the fall and winter seasons and resolve in the spring. SAD is more prevalent in women than in men and often co-occurs with premenstrual dysphoric disorder.21 Symptoms often include hypersomnia, hyperphagia with carbohydrate craving, weight gain, fatigue, and lack of energy. Before diagnosing SAD, it is important to rule out reactions to seasonally recurring stressors, such as holidays, anniversaries, or business cycles.
Phototherapy (light therapy) can be effective for SAD. Phototherapy consists of sitting 1 to 2 ft away from a therapeutic light box and glancing up at it every few seconds for 20 to 30 minutes each morning during the fall and winter months. Properly designed light boxes emit 10,000 lux of light and shield the user from ultraviolet rays. Side effects may include fatigue, irritability, insomnia, and headaches. These are usually mild and self-limiting and can be alleviated by reducing the duration of exposure. Phototherapy can induce manic symptoms in patients with bipolar diatheses.
Adjustment Disorder With Depressed Mood
Adjustment disorder with depressed mood is a short-lived, maladaptive reaction to an identifiable stressor or stressors (excluding physical illnesses, natural disasters, and bereavement). By definition, symptoms develop within 3 months of the stressor’s onset and remit within 6 months of its resolution. Symptoms may include depressed mood, tearfulness, and hopelessness that cause marked distress and/or impairment in functioning. The trigger may be a common event, such as job stress, marital tension, school problems, or financial strain. The stressor’s objective severity is irrelevant; symptoms
stem from the patient’s personal interpretation of and adaptation to the stressors. Women are afflicted twice as often as men.22 The treatment of choice is either individual or group psychotherapy focused on stress management.
stem from the patient’s personal interpretation of and adaptation to the stressors. Women are afflicted twice as often as men.22 The treatment of choice is either individual or group psychotherapy focused on stress management.
Dysthymic Disorder
Dysthymic disorder is a chronic, low-grade form of depression with an insidious onset that lasts almost continuously for 2 years or more and impairs interpersonal and/or occupational functioning. Early onset (before age 21 years) is common. Afflicted patients may say that they have been depressed for their entire lives or that this is simply the way they are. Symptoms may include low energy, fatigue, low self-esteem, poor appetite or overeating, poor sleep or hypersomnia, hopelessness, irritability, and poor concentration. Patients tend to be pessimistic, socially withdrawn, and rarely enthusiastic about anything. The prevalence of dysthymic disorder is 6%,23 and it is about twice as common in women as in men. Common comorbidities include major depression, anxiety, substance abuse, and personality disorders. The most effective treatment for dysthymic disorder is a combination of psychotherapy and antidepressant medication.
Depression Secondary to a General Medical Condition or Substance Abuse
Many medical conditions and substances can directly cause signs and symptoms of depression regardless of the patient’s emotional response to the illness. A high index of suspicion is especially important when a depressed patient:
Has a medical illness known to cause symptoms of depression (Table 17.2)
Uses addictive substances or a prescribed medication known to cause depression as a side effect
Has no personal or family history of depression
Has depressive symptoms characterized by sudden onset or fluctuating severity
Has symptoms and/or signs that are not part of a typical depressive disorder
Table 17.3 summarizes and compares common types of depressive disorders.
TABLE 17.2 Medical Conditions and Depressive Symptoms | ||
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BIPOLAR DISORDER
Bipolar disorder is a chronic mood disorder characterized by recurring episodes of mania or hypomania as well as episodes of major depression. A manic episode is a period of a week or more of persistent euphoric and/or irritable mood accompanied by decreased need for sleep, grandiosity, pressured speech, racing thoughts, distractibility, increased risk taking, impulsivity, and/or increased activity. Symptoms can include delusions and/or hallucinations. Hypomanic episodes include fewer and less severe manic symptoms, with no psychotic symptoms. Patients who experience only hypomanic episodes, along with depressive episodes, have bipolar disorder type II.
A later onset of illness
More seasonal patterns of mood episodes, with depressive episodes in the fall and winter months and manic episodes in the spring
More bipolar type II
More rapid cycling (four or more mood episodes per year)
More frequent and lengthier depressive episodes
More episodes of mixed depressive and manic symptoms
The mainstay of treatment for bipolar disorder is mood-stabilizing medication. Antidepressants are sometimes also used to treat and prevent depressive episodes but may trigger manic symptoms and/or rapid cycling unless a mood stabilizer is used also.26 Treatment may also include psychotherapy and/or electroconvulsive therapy (ECT). Special considerations for women taking mood-stabilizing agents include the following:
Studies suggest that the mood stabilizer valproate may increase the risk of polycystic ovary syndrome, although data are inconclusive.27
Several mood-stabilizing agents pose risks during pregnancy. However, over 70% of women with bipolar disorder who discontinue mood-stabilizing agents while pregnant have a perinatal symptom recurrence.28 Expert consensus guidelines29 and specialty consultation can guide treatment plans that reduce the risks of both untreated symptoms and of medications.
ANXIETY DISORDERS
Panic Attacks and Panic Disorder
A panic attack is the sudden onset of discrete period of intense fear or discomfort, usually peaking within 10 minutes and lasting 20 to 30 minutes. During these attacks, patients experience physical symptoms, such as tachycardia, sweating, shaking, shortness of breath, chest discomfort, and feelings of light-headedness, as
well as cognitive changes such as a fear of losing control or dying.30
well as cognitive changes such as a fear of losing control or dying.30
TABLE 17.3 Characteristics of Depressive Disorders | |||||||||||||||||||||||||||||||||||
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Panic disorder exists when patients have recurrent, unexpected panic attacks. Many patients with panic disorder also have agoraphobia, or anxiety about being in public places or situations, such as crowds or public transportation, from which escape may be difficult or humiliating in the case of a panic attack.30 Patients with panic disorder may present repeatedly to emergency rooms.
The physical symptoms characteristic of panic disorder require a workup to rule out cardiac, thyroid, parathyroid, and adrenal conditions as well as rare diagnoses such as carcinoid syndrome and pheochromocytoma. Substance-induced syndromes, such as cocaine or stimulant intoxication and alcohol withdrawal, may also mimic panic attacks.
The lifetime prevalence of panic attacks is approximately 22.7%,31 whereas the lifetime prevalence of panic disorder is approximately 4.7%,32 indicating that many patients with panic attacks do not develop panic disorder. Panic disorder is two to three times more common in women than in men.33 Among patients with panic disorder, women complain more often than men of feeling faint, short of breath, or smothered.34
Antidepressants are effective for treating panic disorder. However, some patients with anxiety disorders, including panic disorder, experience an initial increase in anxiety upon starting antidepressants. Educating patients about this possibility, using low starting doses, and gradually increasing doses as tolerated may help patients achieve and maintain therapeutic doses. Benzodiazepines are also effective in treating panic disorder. However, given the risk for tolerance and dependence, these agents are generally best used as short-term treatment, then tapered as the antidepressant takes effect.
Psychotherapy, particularly CBT focused on relaxation techniques and cognitive restructuring, is also an effective treatment for panic disorder. Psychotherapy may be used alone or in combination with medication.35
Obsessive Compulsive Disorder
Obsessive compulsive disorder (OCD) is a type of anxiety disorder characterized by obsessions (persistent, intrusive thoughts) and/or compulsions (behaviors that a person feels compelled to do repetitively even though they are senseless or excessive). OCD is diagnosed when obsessions and compulsions cause marked distress and/or interfere with a person’s functioning. The lifetime prevalence of OCD is somewhat higher in women than in men. The mean age of onset is later in females than in males, with the peak age of onset in females occurring during the reproductive years.36 A subset of women appears to be vulnerable to onset or exacerbation of OCD during the luteal phase of the menstrual cycle, the perinatal period, and perimenopause.37
Symptom presentation can be influenced by gender and by reproductive events. Washing and cleaning rituals, fear of contamination, and aggressive obsessions are experienced more commonly by women, whereas obsessions about sex, symmetry, and exactness are experienced more often by men.38 Aggressive obsessions about harming babies are especially frequent in postpartum OCD.39 Mothers with nonpsychotic obsessions about harming their babies are generally horrified by these thoughts and have no desire or intent to act on them. The main risk in such cases is that the woman will avoid the baby due to her anxiety about the thoughts.
CBT is a highly effective treatment for OCD, particularly a form of CBT called exposure and response prevention. In this type of psychotherapy, patients are taught relaxation techniques and then gradually and systematically expose themselves to situations that usually trigger their compulsive behaviors. They prevent themselves from performing the compulsive behaviors while practicing techniques to manage the resultant anxiety. Serotonergic medication can also alleviate OCD symptoms.
Posttraumatic Stress Disorder
Posttraumatic stress disorder (PTSD) is an anxiety disorder in which sufferers experience persistent symptoms after experiencing a highly distressing, traumatic event. The symptoms include re-experiencing the traumatic event (e.g., via nightmares or flashbacks), avoiding reminders of the event (e.g., not returning for postnatal care after a traumatic labor and delivery), and experiencing heightened arousal (e.g., difficulty sleeping, excessive startle responses). About twice as many women as men develop PTSD.40 The median time from onset of PTSD to remission is about 1 year for men and 4 years for women.41
The “conditional risk” of a trauma is the likelihood that someone exposed to that trauma will develop PTSD. The traumas with the highest conditional risk— rape, sexual abuse, and intimate partner violence—are predominantly experienced by women.42 Other traumas that predominantly affect women are difficult labor and delivery, pregnancy loss, neonatal complications, and sexual abuse of a child.
Psychotherapy is the mainstay of treatment for PTSD, particularly specific variants of CBT developed for this purpose. Antidepressant medications, including selective serotonin reuptake inhibitors (SSRIs), tricyclics, and monoamine oxidase inhibitors, can alleviate PTSD symptoms and may be useful adjuncts to psychotherapy.
Generalized Anxiety Disorder
Patients with generalized anxiety disorder (GAD) suffer from excessive, uncontrollable worry that causes marked distress and functional impairment. GAD is a chronic disorder with insidious onset and waxing and waning severity.43 Symptoms can include pessimistic expectations, restlessness, irritability, difficulty concentrating, muscle tension, fatigue, and sleep disturbance. The focus of the patient’s anxiety is not confined to just one area of concern. The lifetime prevalence is about 5 to 6%, with women being affected about twice as often as men.44
The GAD-7 is a validated 7-item self-administered tool that can be used to screen for GAD and to assess its severity45 (see Appendix 17.B). The diagnostic workup also includes ruling out other potential causes of the patient’s symptoms, including other mental health disorders, medical conditions, and prescribed or illicit substances.
CBT is more effective than pharmacotherapy for treating GAD.46 When pharmacotherapy is needed, effective agents include SSRIs or serotonin-norepinephrine reuptake inhibitors (SNRIs) as first-line treatment,47 with paroxetine, escitalopram, and venlafaxine found to be the most effective specific agents. Imipramine, buspirone, benzodiazepines, and pregabalin are second-line treatment options.48 Other treatments that have shown some success include biofeedback49 and the herb kava (Piper methysticum).50 Results of treatment with these non-FDA-approved remedies are inconclusive, and treatment with kava has been associated with drug-drug interactions, dermopathy (with prolonged use of large amounts), and liver toxicity.51
EATING DISORDERS
Eating disorders have a strong predominance in women. The self-evaluation of most patients with eating disorders is strongly influenced by their weight and body shape. Specific symptoms can include binging, purging or other compensatory behavior, and/or food restriction. Binging is eating a large amount of food in a discrete period of time, with associated feelings of being out of control while eating, and feelings of shame during and after. Forms of purging include self-induced vomiting, enemas, and use of medications such as laxatives, diuretics, insulin, and ipecac. Other compensatory behaviors include compulsive overexercising and spitting out food after chewing it.
Eating disorders may arise from biological (genetics, hormones, and neurochemistry), psychological (thoughts, feelings, and beliefs), and social (cultural and interpersonal) factors. Core attitudes and symptoms of eating disorders have high heritability.52 Social pressure to be thin is also a strong influence.
Patients often minimize or deny eating disorders, rarely reporting symptoms directly. In gynecologic practice, patients with eating disorders may present with menstrual irregularity, infertility, sexual dysfunction, low bone density, and/or fatigue.53 Directly asking about symptoms in a nonjudgmental manner may help patients acknowledge their eating disorders. Specific areas to assess include the following54:
Body image concerns
Dieting habits
Exercise habits
Binging and purging
Use of laxatives, diuretics, thyroid hormone, insulin, ipecac, stimulants, and/or enemas to lose weight
Weight-related surgery, including gastric bypass, gastric banding, or liposuction
Body mass index (BMI)
Gynecologist can help patients to engage in treatment for eating disorders by the following:
Helping them focus on the misery and isolation they are suffering
Reviewing facts about physical complications and repeating the facts if patients deny or minimize
Letting patients know there is help
There is a significant crossover phenomenon among eating disorders. Although anorexia nervosa and bulimia nervosa are classified as distinct diagnoses, 30 to 63% of people with anorexia nervosa become bulimic at some point, and 8 to 25% of people with bulimia nervosa develop anorexia at some point.55,56
Anorexia Nervosa
Anorexia nervosa is a disorder that includes a refusal to maintain a minimum normal weight for age and height, related to intense fear of weight gain and becoming “fat.” Patients with anorexia nervosa have a disturbance in how they experience their weight and body shape, and often deny the seriousness of their low body weight. In nonpregnant postmenarchal females who are not taking steroid hormones, the diagnosis of anorexia nervosa includes an absence of at least three consecutive menstrual cycles. There are two subtypes of anorexia. The restrictive type does not regularly engage in binging or purging behavior, whereas the binge eating/purging type regularly engages in binging and purging behaviors. Those with the restrictive type are likely to present with obsessive symptoms, a desire for perfectionism, rigid cognitive styles, and a lack of sexual interest. Those with binge eating/purging type are likely to present as impulsive and somewhat self-destructive, with higher risks for suicidal ideation.57
Anorexia nervosa has a lifetime prevalence of 0.5 to 3.7% in females. There is a 10% mortality rate due to starvation, suicide, and electrolyte imbalance. The most frequent age of onset is in early adolescence, but onset can occur at any age. Patients with anorexia nervosa may complain of fatigue, poor concentration, amenorrhea, loss of libido, dizziness, palpitations, coldness of the extremities, muscle weakness, or musculoskeletal pain. Appearance may be notable for overlayered clothes, relatively restricted facial expressions, lanugo bodily hair, and dull and brittle scalp hair. Electrocardiogram (ECG) may show bradycardia and/or QT prolongation.
Common psychiatric comorbidities include depression, dysthymia, OCD, other anxiety disorders, and personality disorders.58, 59, 60 Common medical complications include malnutrition, hypothermia, muscle wasting, decreased gastrointestinal motility, and osteoporosis. Cardiac complications are frequent causes of death, often stemming from hypokalemia.
A central aspect of treatment is nutritional rehabilitation. Hospitalization should be considered in cases of the following:
Weight loss to more than 20 to 30% below expected, and/or a BMI less than 17.5
Symptomatic hypotension or syncope
Heart rate 35 to 45 bpm; cardiac arrhythmias, and/or prolonged QT interval on ECG
Psychotherapy is the mainstay of treatment. Effective forms of psychotherapy include psychoeducation, motivational interviewing, and family-based treatment (FBT) (for adolescents).61 Dialectical behavioral therapy (DBT) is a promising treatment requiring further study.61 DBT is a combination of standard CBT and also calls on concepts of distress tolerance, acceptance, and mindful awareness. It involves individual as well as group therapy. SSRIs can be helpful for patients with comorbid depressive, obsessive, and compulsive symptoms, although patients may refuse SSRIs due to fear of weight gain. In the absence of comorbid psychiatric disorders, psychotropic medications have not been shown to be effective in decreasing relapse nor in restoring BMI.62 Bupropion is relatively contraindicated due to increased risk for seizures.
Bulimia Nervosa
Bulimia nervosa is a disorder consisting of recurring episodes of binge eating and compensatory or purging behaviors to prevent weight gain. The binge eating and/or compensatory behaviors occur at least twice weekly for 3 months on average. Self-evaluation is excessively influenced by body weight and shape. There are two subtypes of bulimia nervosa. The purging type involves the use of self-induced vomiting or other efforts to “get rid of” calories consumed. The nonpurging type involves compensatory methods such as fasting and overexercising.
Bulimia nervosa occurs in 1 to 5% in women. Ninety percent of patients with bulimia are women. There is a high prevalence of comorbid depression, anxiety, substance abuse, and personality disorders, especially of the borderline and avoidant types.63
Patients with bulimia may complain of cramping, diarrhea, rectal bleeding, fatigue, difficulty concentrating, and/or irregular menses. Some patients will only report binging, purging, or other symptoms if directly asked about them. Physical signs can include dental erosion, salivary gland enlargement, and scarring of the hand (Russell sign—due to the knuckles brushing against the teeth when self-inducing vomiting). Electrolyte abnormalities may include hypokalemia, hyponatremia, elevated serum bicarbonate (due to metabolic alkalosis from vomiting), and hyperchloremia (due to metabolic acidosis from laxative abuse).
Nutritional rehabilitation is the first component of treatment. The primary goal is to reducing binge eating and purging by establishing a regular eating schedule in which the patient is eating every 3 to 4 hours instead of having long periods of restriction, which lead to urges to binge. Effective forms of psychotherapy include motivational interviewing, CBT, IPT, and DBT. Antidepressants can reduce binge eating and purging episodes while also alleviating depression, anxiety, and impulsivity. Fluoxetine is approved by the U.S. Food and Drug Administration (FDA) for this indication. Bupropion is relatively contraindicated in patients with purging due to the increased risk for seizures.
Binge Eating Disorder
Binge eating disorder consists of recurrent episodes of binge eating for at least 2 days a week over 6 months, in which at least three of the following are present:
Eating much more rapidly than normal
Eating until feeling uncomfortably full
Eating large amounts of food without being hungry
Eating alone due to being embarrassed about one’s eating habits
Feeling disgusted with oneself, depressed or guilty over eating
Binge eating disorder affects 3.5% of women and 2% of men among North American adults. Not all patients with binge eating disorder are obese, and not all patients who are obese have binge eating disorder. However, most patients with binge eating disorder are obese, with resultant complications of diabetes, high blood pressure, high cholesterol, heart disease, sleep apnea, arthritis, and stroke. Frequent comorbidities with binge eating disorder include depression, anxiety, compulsive behaviors, and substance abuse.64
Many patients with binge eating disorder state that they have tried every diet and still cannot lose weight or keep it off. Addressing emotional eating patterns may improve outcome. Behavioral weight loss is less effective than motivational interviewing, IPT, and CBT.65 DBT is a promising treatment that is being studied.66
Antidepressants can be effective adjuncts to treatment, with the caveat that several antidepressants can cause weight gain as a side effect. Another option is the FDA-approved antiobesity agent sibutramine. Although naltrexone and topiramate have been used to decrease binge eating, neither is FDA-approved for this indication.
ADDICTIVE DISORDERS
Substance use disorders are highly prevalent chronic illnesses, in which relapses are common and long-term care strategies are critical in producing good outcomes.67 Historically, substance use disorders in women have been under-recognized.68 Although the prevalence is higher in men, over the last few decades, increasing numbers of women have been identified as having substance use disorders.49,69, 70, 71 Large national surveys have found that the lifetime prevalence of alcohol use disorders is 19.5% of women and 42.0% in men,70 whereas the 12-month prevalence for drug use disorder is 6.2% in women and 9.9% in men.71 The gender differential is reduced in participants aged 12 to 17 years.71 There is a higher prevalence of depression, anxiety, eating disorder, and PTSD in substance-using women as compared to men.72,73
A striking gender difference in the clinical course of substance use disorders, particularly alcohol, is the “telescoping” effect, where the progress from first use to treatment seeking tends to be shorter for women than men.74 A possible explanation is that women may be more susceptible to the medical and psychiatric consequences of substance use.75 For example, women become more intoxicated and experience higher serum alcohol concentrations than men. Women also develop liver disease as well as die from liver cirrhosis after consuming less alcohol and for a shorter duration than men.76 Women cigarette smokers may be more at risk for lung cancer than men and are more likely to contract HIV from intravenous drug use.77
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