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Abstract
Medical literature is vast and rapidly expanding. As clinical practice becomes busier and time for reading and reflection becomes even more precious, the ability effectively to peruse the medical literature and, in the future, to become familiar with a knowledge of best practice from modern communication systems will be essential skills for doctors. This explains the importance of understanding of the concept of ”evidence-based medicine”.
Evidence-based medicine” is the enhancement of a clinician’s traditional skills in diagnosis, treatment, prevention and related areas through the systematic framing of relevant and answerable questions and the use of mathematical estimates of probability and risk.
As psychiatric disorders in women constitute a major public health problem, many Egyptian studies were interested in discussing these disorders from many different aspects. These studies must open the door for new researches and their conclusions must direct our clinical practice.
This work was conducted in order to systematically review and appraise the Egyptian studies on these disorders and hence recommendations for further studies are generated.
In order to fulfill that aim several databases were explored in the period from November 2007 to March 2008 to collect Egyptian studies on psychiatric disorders in women. The databases searched were library of faculty of medicine Ain Shams University, library of faculty of medicine Al-Azhar University, library of faculty of medicine Alexandria University, library of faculty of medicine Cairo University, Egyptian journal of psychiatry, and current psychiatry
After collection of the available Egyptian studies on psychiatric disorders in women (31 studies), a literature review was done. In that review, The available data were categorized into data related to epidemiology, etiology, clinical description, management, and outcome as far as possible.
Critical appraisal of the Egyptian studies on those disorders was included and the systematic review was done.
A general idea about the concepts of systematic review and critical appraisal were given with describing the standard appraisal questions that should be answered for proper evaluation of researches. A list of the most commonly used research methods in practice was presented; the specific appraisal questions asked to evaluate each method were discussed in details in this chapter.
We discussed 32 studies concerning epidimiology, etiology, clinical profile, management and outcome of psychiatric disorders in women.
In fact, there were 4 studies targeting prevalence of substance abuse, OCD, PMDD and postpartum psychological disturbances.
Hashim 2002 found out that prevalence of substance use disorders in secondary school females in Cairo was 18.4%. Alcohol was the most common substance used (15.9%) , followed by illicit drugs (3.9%), tobacco smoking (2.5%) and then cannabinoid (0.7%). She mentioned causes of continuation and abstinence in details. While Zarif 1999 found out that PMDD prevalence was 6.59% while premenstrual exacerbation was 3.65%.Symptom profile of PMDD was variable (pain-negative affect-behavioural changes-irritability-mood swings-fatigue-general aches-preference to stay at home-breast tenderness-bouts of excitement-nausea-vomiting-difficulty in concentrating -palpitation-feeling of suffocation) .
While studying post partum psychological disturbances, Youssef 1985 found out that psychiatric symptoms in puerperium were (adjustment disorder with depressed mood 13.2%-maternity blues 7.5%-atypical bipolar disorder 3.8%) while risk factors were (unemployment-positive family history of mental illness-neurotic mood-negative attitude of husband-sex of the baby).
Soltan 2002 studied prevalence of OCD in female secondary schools in Cairo. Prevalence of OCD was 1.2%, while obsessive compulsive symptoms prevalence was 13.01% .The commonest OC symptom was excess conscience (more in rural than urban, more in public than private school).Adolescent OCD was not a rare disorder while subthreshold obsessive compulsive syndrome was widely presented in adolescent population. Culture might Colour the clinical picture but did not affect prevalence. Religion did not affect prevalence of OCD but it was an area where OCD expressed itself.
Many researchers studied the etiological factors related to many psychiatric disorders. Two studies discussed this issue; the first was done by Ibrahim 1999 who studied the etiological relation between level of serum estrogen and cognitive abilities. There was negative correlation between duration since menopause and serum estradiol levels, also between women age and scores of cognitive tests. But there was positive correlation between serum estradiol levels and cognitive function tests. So physiological menopause (estrogen deficiency) had a negative effect selectively on short term verbal memory.
Shawer 2006 studied biological factors of women vulnerability to depression. There was a positive correlation between degree of depression and age of the patient, his marital status, his social class. While
Level of TT3, TT4, FT3, FT4, TSH, and E2 were significantly different between patients and controls. The higher the degree of depression, the lower the level of TT3-TT4-FT3-E2. The higher the E2 level, the higher the TT4 level.
There were two studies discussing spouse role in addiction and psychiatric morbidity among wives of addicts.
Emara 2002 found out that wives of addicts preferred traditional roles while husbands of female addicts did not, Wives had higher level of aggression, depression and anxiety. Couples of drug abusers had ill communication difficult problem solving, sexual dissatisfaction
, conflict over child rearing, disagreement over finances and dissatisfaction with children. While Afifi 2007found out that addicts wives showed significant higher level of (adjustment-major depressive-anxiety-personality-sexual) disorders.
There were problems in areas of family environment, financial management, domestic violence, low parenting capabilities and bad quality of life.
Three studies discussed different types of violence against women. Ezzat 2005 found out that physical abuse was more common than verbal and emotional. Domestic violence had significant relation with history of child abuse. Battered women were more depressed, showed higher scores in middle level of locus of control and higher scores in psychoticism. There was an important relation between divorce, parental troubles and domestic violence. Domestic violence was a general health problem that had psychiatric, medical, social and legal aspects .It was underestimated with insufficient measures to face this problem .While Hussein 2007 found out more detailed problems e.g. Types of violence were (slapping-hitting-beating-kicking-insulting-threatening-abandoning) .There was interpersonal violence between husbands and wives. Causes reported by women were (refusing sex-withholding money-disobedience-joules-house duties).Bipolar patients were more likely to be abused followed by psychotic patients .Severely abused patients usually attempted suicide. Most common psychiatric disorders related to abuse were (depression-generalized anxiety disorder-somatoform disorder).Types of sexual abuse were (street harassment-touching-rubbing-attempt or actual rape-exhibitionism).Risk factor for abuse in women were (illiterate-abused or witnessed abuse in childhood-not working).Risk factors for women who prepare for violence were (illicit drug abuse plus the former factors).
Seif El Dawla 2001 found out that The most commonly reported symptoms were feelings of helplessness, depressive symptoms , lack of self confidence and a chronic feeling of apprehension ,anticipation of violence ,generalized Anxiety disorder , adjustment disorder ,dysthymic disorder ,and major depressive disorder
2-Spouse behavior that women consider violence:
Polygamy -marital rape -preventing wives from going out of the house -withholding children after divorce -enforced obedience
3. Psychological conséquences of violence Psychological réaction
Feelings of helplessness -depressive symptoms, inappropriate sleep and fatigue -lack of confidence in others -chronic feeling of apprehension and anticipation of violence -lack of self confidence -bouts of anger -chronic ambiguous feeling of guilt 68-mood swings 50-flashbacks and nightmares of certain violent incidents
4-Diagnoses were:
(PTSD – Generalized anxiety disorder. - Adjustment disorder - Dysthymic disorder - Major depressive disorder).
Two studies targeted pregnancy related depression. Hewedi ,Fahmy 2006 found out that depression was detected in 30% of subjects in early pregnancy while it was detected in 34% of subjects in late pregnancy. Pre-eclampsia occurred more with combined early and late depression than late depression alone While Abdel Latif 1999 found out that postpartum depression is the same medically but different culturally according to the following risk factors:(family history of psychiatric illness-cesarean section-guardian unemployment-hormonal contraceptives-marital problems-polygamy-not breast feeding-poor social support-postpartum blues-premenstrual tension syndrome-primipara-teenager-undesired infant sex-unwanted pregnancy
A unique study discussing the effect of antidepressants response and side effects on both genders was done by Abdel Raouf 2001 who found out that females were more vulnerable, more symptomatizing of depression, more adherent to treatment, while males responded more to antidepressants. ,it was found that depressed men were more rapidly responding to antidepressants due to differences in pharmacokinetics and pharmacodynamics of antidepressants resulting in different outcome and adverse effects.
Four studies discussed gender differences in many psychiatric diseases e.g. schizophrenia, bipolar disorder, OCD and depression.
As for OCD, Nasr El Den 2001 found out that men expressed more religious, sexual obsessions, hopelessness, controlled oral word association and visual memory span. While women expressed more hoarding, other compulsions, failure to maintain serotonin level. Females were slower, less selectively attentive than males, more impaired as language abilities than males. So sex did not determine OCD severity. Females showed higher serotonin level especially in chronic illness so serotonin was gender specific marker .Attentional deficit was disease specific rather than gender specific. OCD was not a stress related behavior but it was a maladaptive learnt behavior .OCD was not a progressive disorder as regards cognitive dysfunction .While Asaad, Kamel 2001 found out that pregnancy related OCD had a different criteria .The most frequent obsessions encountered were religious thoughts followed by cleanliness thoughts and rituals and then impulses related to harming the foetus .Severity of the disease ranged from moderate to sever .Most of symptoms occurred in the 2 nd trimester.
When discussing depression ,Botros 1997 found out that males showed low self esteem ,indecisiveness , decreased dreams ,neglected self hygiene and prevailing depressed mood ,while females showed fatigue ,crying, dissociative symptoms ,negative self perception ,tendency to go out, decreased sexual desire ,no change in dreams ,adequate self hygiene ,retardation and impaired judgment. Many factors colored clinical picture, symptomatic expression of depression e.g. level of education, work, gender, socioeconomic state, personality and cultural norms of society.
When studying schizophrenia by El Rakhawy 1998, it was found out that gender had little impact on presentation and course of schizophrenia. Assessment should be done in context of sociocultural beliefs
Gender difference was demonstrated as the following:
1-Men: had an earlier age of onset, a poorer premorbid history, more negative symptoms, differential neuro cognitive functions, a poorer response to neuroleptics and a lower family risk for schizophrenia.
2-Women: had more decreased motor activity, self neglect, suicidal attempts, higher scores in paranoia scale of MMPI and a tendency to have more positive family history of schizophrenia
Prevalence rates in women exceeded those of men. Gender difference in mood disorders had an important clinical subtypes or symptoms clusters specific to each sex.
Two studies discussed female sexual dysfunction.Abed 1998 concluded that most common sexual complaints were vaginismus, loss of sexual desire, dyspareunia and anorgasmia. While El Fangry 2003 found out that the most common sexual dysfunctions were desire disorders, orgasmic dysfunction, arousal disorder, dyspareunia and lastly vaginismus. The most common psychiatric disorders in these patients were (mood-anxiety-somatoform-adjustment) disorders. There was high rate of circumcision, manual hymenal perforation in wedding night, discrimination in favor of males, earlier onset of marriage and first information about sex from the family. Psychiatric patients had low (sexual drive, sexual attitude, sexual satisfaction, orgasmic capacity, desire frequency and total sexual functioning) plus more dependent personality disorder than others.
Psychiatric patients showed more sexual dysfunction, personality pathology and marital dissatisfaction than others. There was a high rate of overlap between different sexual disorders in the same patients. Testosterone was positively correlated with sexual desire and orgasm.
A study about sex chromosome disorders e.g. turner syndrome was done by Gaffer 1993 who concluded that early diagnosis, follow up was very important. Recommendations were (overprotection or rejection from parents is forbidden. Early social stimulation and special schooling are necessary. Medical treatment for induction of growth, regular menses must be considered). Cognitive decline in these patients started since childhood and continue to adulthood. Patients had higher femininity score and they could manage appropriately in their homes and they were less symptomatizing than normal girls (due to being defensive in their self reports about symptoms).
When studying outcome of many psychological disturbances, we find important results e.g. Radwan 2007 found out that:
Social phobia was the most encountered, followed by dysthymia, major depressive disorder, obsessive compulsive disorder, agoraphobia and post traumatic stress disorder. There was high prevalence of personality disorder.
Comorbidity between depression and anxiety was high. Women with psychiatric morbidity had difficulty to become pregnant and poorer outcome in general.
Two studies discussed criminality among female psychiatric patients.
Elwan 2005 Compared female psychotic homicidal with female psychotic non-homicidal to detect a correlation in the past history, social circumstances and clinical profile associated with homicide. Results showed that homicidal females scored higher on GAF scale.50% of them were schizophrenics, 35% were bipolar.15% were schizoaffective. Correlates of homicide in psychotic females were :(younger age of onset of mental illness-diagnosis of schizophrenia then bipolar manic then mood episodes of postpartum onset then schizoaffective-being married with children-history of exposure to domestic violence in childhood-past history of sever violent acts especially attempted homicide).While William 1986 found out that mental hospital criminals were not more criminals (bad) than prison criminals .Mental hospital criminals were not more mentally disordered (mad) than patients with no criminal records. Results showed that:
1-Mean age of committing a crime was around 35 year, with more prevalence in rural areas; mostly among married female housewives with low educational level and past history of mental disorder.
2-Family history of criminality and-or mental disorder with absence of father figure as an added factor.
3-Wepons used were either sharp instrument or heavy blunt objects.
4-Victims were usually relatives to patients.(usually husbands).
5-Causes of crimes were (accidental murder-excitement-anger-vendetta-delusion of persecution or infidelity-with out cause).
6-Most of patients have intellectual deterioration and social maladjustment.
7-There was high score for criminality, neuroticism, lie score, depression traits, impulsivity and mal adaptability scale.
8-Psychiatric disorders mostly occurring were (schizophrenia-bipolar disorder-mental subnormality-sociopathy-addiction).
Abdel Hamid 1996 discussed the impact of burn upon females. Results showed that 40% reached level of diagnosable psychiatric illness while 60% did not .Most common diagnoses were (depression-acute stress disorder-delirium-mixed anxiety depression) especially with burns of the face. So burns significantly affected psychological well being of patients.
A study discussing psychosexual aspects of female circumcision was done by Sami 1995, who found out that the chief motive was religious then inherited customs. Women reported physical and hygienic complications after operation .Most women were illiterate, operated upon by midwives or doctors .Most of circumcised females had high neurotic score and reached orgasm with difficulty .The most important side effects of circumcision were sexual dis-satisfaction and anorgasmia.
A study discussed the effect of hysterectomy upon psychological wellbeing of women .Omar 1998 found out that psychiatric diagnosis after hysterectomy were depression ,anxiety then sleep disorders .Quality of sexual life after operation improved .Patients below 40 year ,without children suffered psychologically more than other women .Good husband ,family relationship minimized this stressful situation .The expectations of women ,premenopausal age and premorbid personality determined sequela after operation.
Three studies discussed the effect of breast cancer upon psychological wellbeing of women .El Hennawy 1999 found out that there was high incidence of ( loss of libido-persistent somatic complains not responding to symptomatic treatment-retardation-sleep troubles-fears-worries-eating problems-depressed mood-psychiatric disorders not attributed to any specific disease ).There were (high score in extraversion, low score in neuroticism ,low prevalence of personality disorder in cancer breast patients).While Allam 1999 found out that patients below 50 years old suffered severe symptoms of anxiety ,depression more than those above 50 years old .Quality of life was worse in patients below 50 years .More anxiety was present in patients with lumpectomy(for fear of recurrence).More depression was present in patients with radical mastectomy .Hussein 1986 found out that cancer breast patients suffered from psychiatric manifestations e.g. anxiety , depression, fears and loss of libido. Most common defense mechanisms used were denial, displacement and reaction formation.