Marrtritas, 1 (1979) 153-158 @ l:lsevier/North-Holland Biomedical Press
PHYSIOLOGICAL, PSYCHOLOGICAL AND SITUATIONAL DEPRESSION DURING THE CLIMACTERIC
153
STRESSES IN
MELINDA SCHNEIDER ’ and PATRICIA BROTHERTON 2
’ Department of Psychology, Melbowne State College, Carlton: 2 Department of Psychology, University of Melbourne, Melbourne, Australia (Received 26 April 1978, accepted 22 August 1978)
The present study examined the characteristics and circumstances which distinguished between groups of depressed and non-depressed menopausal women; 20 women were studied overall. The Beck Depression Inventory (BDI) was used to assess depression levels, while the administration and content analysis of a semistructured interview provided information regarding the presence or absence of stress across a number of variables. While the depressed group were not found to differ significantly from the non-depressed group in terms of stress due to physical symptomatology, they did differ on a number of the psychological and social stress variables, and showed a significantly greater combination of stresses compared with the non-depressed group. Some recommendations concerning management are made. (Key words: Climacteric, Depression, Psychological stress, Social stress)
INTRODUCTION
In recent years, increased interest in the physiological changes occurring during the middle years of the female life-cycle has led to a greater understanding of the so-called “menopausal syndrome” [ I]. The aetiology and treatment of two conditions frequently reported during the climacteric, however, remain poorly understood. The first condition is the lowering or extinction of libido, which does not appear to be related to physiological changes in the genital system, as is the case in dyspareunia. The second condition refers to a set of psychological symptoms such as anxiety, tension, depressed mood and irritability, which are reported to increase in frequency during the climacteric [ I]. As both sexual and psychic well-being are of considerable importance in maintaining the quality of life, the continued lack of information in these areas is not without heavy cost to the women involved. A number of hypotheses have been proposed as to the aetiology of the psychological changes reported to occur during the climacteric. Some writers have adopted an essentially biological/hormonal explanation, relating such changes to diminishing oestrogen levels [2]. Other writers have emphasized the changed role requirements of this phase in the female life-cycle, with the termination of many traditional, instrumental (work), and expressive (interpersonal) roles, and the subsequent stress of recovering productive and
154
fulfilling interests [3]. Yet another group of writers has stressed the individual woman’s premorbid functioning or personality structure. They propose that only women with an inadequate or maladaptive personality development and little ego strength, will manifest psychological disturbance in the face of the losses and stress associated with the menopause [4]. With the increasing number of women seeking help for menopausal symptoms, there is a need for increased information about the factors that contribute to the emergence of psychological difficulties during the climacteric, hence facilitating identification of any high-risk group. The present study was directed at examining the characteristics and circumstances which differentiated a group of depressed menopausal women from a group of non-depressed women. The purpose was to gain an increased understanding of the ways in which certain physiological, social and psychological stresses may combine to contribute to the marked psychological morbidity in this particular phase of the female life-cycle. The study is part of a larger programme which also investigated the effects of conjugated oestrogens upon the depression scores of menopausal women, the results of which have been reported earlier [5]. PATIENTS AND METHODS
Women were drawn from the first admissions to the Menopause Clinic at Prince Henry’s Hospital, Melbourne, over a 3-mth period. In some cases the women had been referred from outside practices while others had come to the clinic of their own accord. All women presenting exhibited a wide range of symptomatology including tiredness, reduced physical and mental activity, dyspareunia, irritability, increased difficulty in decision-making, decrease in the ability to plan simple tasks, insomnia, depression and memory lapses. Subjects ranged in age from 39 yr to 58 yr with a mean age of 50 yr. To obtain a homogeneous group, only married women in good general health and without any past history of depressive illness were included. Women receiving any other form of treatment, either medical or psychological, were excluded. The diagnosis of menopause was based upon a combination of clinical symptoms, gynaecological examination and blood analyses of the follicle-stimulating hormone (FSH), luteinizing hormone (LH) and oestrogen (E-3 levels. No effort was made to select women who complained specifically of depression or related nervous disorders. Subjects were drawn in a purely accidental way on the basis of their presence at the clinic. Subjects were initially interviewed and examined and blood samples were taken. The Beck Depression Inventory (BDI) was used to provide a quantitative assessment of the intensity of depression. The BDI is a self-report scale composed of 21 categories of symptoms and attitudes, where each category describes and consists of graded series of 4 ‘or 5 self-evaluative statements. It has been shown to be valid and appropriate for use with Australian samples [6]. The BDI was administered to subjects on their first contact at the clinic and they were then interviewed in their homes within a week of this first testing at the clinic. Interview questions were formulated to reveal information concerning a number of likely stresses discussed in the literature pertaining to psychological changes during the
155 menopause. Stress was taken to refer to a state of strain, whether physical, social or psychological. The areas of stress examined included the following: (1) Loss of the reproductive function. (2) Early developmental disturbances; for example, the loss of either one or both parents during the subject’s childhood, or reported frustration of basic emotional needs such as love, acceptance, and affection. (3) The general effects of ageing and the losses associated with ageing; for example, decreased stamina or perceived changes in physical attractiveness. (4) The care requirements or dependence of aged parent(s). (5) Marital dissatisfaction. (6) Losses related to the parental role or the so-called “empty nest” syndrome. (7) Impairment in either instrumental (work) or expressive (interpersonal) roles, evidenced by either a lack of interest or an inability to function adequately in the area. (8) Economic difficulty. (9) Possible precipitating factors, such as the death of a loved one, illness or operation. (10) Severity of hot flushes and other physical symptoms. In all cases interviews were tape recorded and, in order to code the relevant information, the method of content analysis was applied to the interview transcripts [7]. RESULTS
All women were classified as depressed or non-depressed on the basis of their BDI score [ 51. Analysis of the interview data revealed that the depressed and non-depressed women differed significantly on a number of the psychological and social stress variables selected for study, but did not differ significantly in terms of stress due to physical symptomatology (Table I).
TABLE 1 Summary of differences Exact Test).
between
depressed
and non-depressed
women on stress variables
(Fisher’s
Source of stress
Direction of stress D/ND *
N = 20; P = 0.05
1. Loss of the reproductive function 2. Role impairment in either expressive or instrumental roles 3. Marital dissatisfaction 4. Aged parents 5. Economic difficulty 6. Early developmental 7. Precipitating factors 8. Parental role, the “empty nest” syndrome 9. Physical symptomatology
D = ND D>ND
NS ** P < 0.05, one-tailed
D>ND D=ND D>ND D>ND D = ND D = ND D = ND
P < 0.025, one-tailed NS P < 0.05, one-tailed P < 0.005, one-tailed NS NS NS
* D indicates depressed women; ND indicates nondepressed ** NS indicates no significant difference between groups.
women.
156
The depressed women showed a significantly greater frequency .of stress due to marital dissatisfaction, economic difficulty, role impairment and early developmental disturbances. Stress associated with the loss of the reproductive function, the care of aged parents, precipitating factors and changes in parental role, was not significantly different for the depressed and non-depressed groups. Combined stress across the 4 psychological stresses (Table I, Nos. 1, 2, 6, 8) the 4 social environmental stresses (Table I, Nos. 3-5, 7) and physical stress (Table 1, No. 9) was computed for the depressed and non-depressed groups. The results indicated that the depressed women experienced a significantly greater combination of stresses when compared with the non-depressed women (P < 0.01, one-tailed, Fisher’s Exact Test). DISCUSSION
Before discussing the results of the present study a number of methodological issues should be considered. First, since the size of the subject sample was relatively small, the data can be suggestive only, forming a basis for future, more extensive research. Secondly, some discussion of the measurement instruments is required to indicate the advantages and disadvantages of the scales employed. The BDI has been subjected to a variety of tests to determine its reliability and validity and the results indicate that the inventory is highly reliable, with reasonable validity [6]. The change in BDI scores over time also have been found to have a high positive correlation with changes in psychiatric evaluation of patients, a finding which has been supported by a number of studies employing clinical ratings and/or other psychometric measures such as the Hamilton Rating Scale [8,9]. A major criticism of self report techniques has focussed upon the accuracy of the subject’s own appraisal of depression level. The possibility of distortion in subjective ratings due to the depressive state itself is an important consideration. It takes on a greater importance, however, when the subjects are drawn from a psychiatric population where forms of denial which are a part of the illness may invalidate self report measures reliant on the subject’s perceptions if employed without corroborative data. Self reports of stress based on interview data are similarly vulnerable to distortion when sampling severely depressed patients. However, the fact that none of the subjects in the study were drawn from a psychiatric population but were maintaining adequate functioning without observable distortions in reality testing, suggests that the results were less susceptible to this form of distortion. The difficulty of controlling for subjective distortions in the self-report data would have been increased by an increase in the number of coding categories used in the scaling of the stress variables from the interview data. For that reason, in the present study only two coding categories were employed to rate the severity of stress, “stress present” and “stress absent”. Taking into account the preceding points, the results of the present study raise a number of questions. First, in view of the importance which is frequently placed upon the loss of the woman’s reproductive function as an explanation for the psychic changes during the menopause, it is notable that stress from this source was negligible among the women studied, and certainly did not distinguish between the depressed and non-depressed
groups. This result therefore calls into question the frequently employed and facile explanation that the menopausal woman becomes depressed simply because she can no longer bear children or because her children are leaving home. In contrast, of the 20 women studied, 7 out of the group of 10 depressed women reported childhoods which, in their perception, were disturbed. The disturbance was related either to early losses of significant people and/or to chronic frustration of basic emotional needs. In particular, deprivation of love and acceptance or feelings of helplessness due to the frustration of self-protective needs were implicated. In no instance was this type of perceived disturbance reported by the non-depressed women. This result does suggest support for those writers who believe that premorbid functioning and personality are important predictors of a woman’s ability to cope with the stresses of the menopausal period [4]. The results also indicate that the depressed women reported a significantly greater frequency of stress due to alterations in their ability and motivation to function within both instrumental and interpersonal roles. Such a result supports the view that in assessing the morbidity associated with the menopause and in planning intervention procedures for the menopausal woman, it is unlikely to be sufficient to assess her simply within the context of her changed physiological state. An assessment of the woman’s functioning within a broader social context may reveal that it is the inability to fulfil usual roles as competently as previously which is contributing to her diminished psychological wellbeing. The middle years are characterized by increased introspection and stock-taking, and, hence, the inability to carry out usual roles competently may greatly aggravate feelings of inadequacy and self doubt. The medical practitioner is in a fine position to provide support and reassurance through a discussion of the woman’s unrealistic expectations, and by emphasising the need for a more balanced set of expectations and goals. In the past, the acceptance of an essentially hormonal explanation for the psychological changes occurring during the climacteric has had a number of ill effects; in particular it has promoted a single-minded approach in both the assessment and treatment of menopausal complaints, and a failure to consider the relationship and interaction between physiological, psychological and social stresses [5]. The menopausal woman is confronted with the difficulty of coping with a broad spectrum of change. Her altered hormonal status frequently produces acute physical discomfort, major changes in traditional roles may leave her with fewer social and psychological resources, and losses associated with the general ageing process may mean that alternative resources are hard to obtain. It has recently been pointed out that the result of a lack of communication between doctor and patient over problems which, while not life threatening, are essential to the patient’s quality of living, produces a gap between the expectations of the patient and the doctor, and increased hostility from both parties [lo]. For the busy practitioner the menopausal woman may arouse feelings of frustration and irritability, due partly to the apparent absence of severe physical discomfort and partly to the prevalence of menopausal complaints. Closer examination and questioning, however, may reveal a patient in need of specialized care or referral to an appropriate community service. It is possible that the cost of ignoring the psychosocial needs of this particular patient group is
158
reflected in the high frequency of psychological and social disturbance reported by women during their middle years. The menopause is characterized for women as a time of diminished control, not only over their own bodies, but also over their immediate personal environment and their external social environment. Unfortunately treatment styles and stereotypes have frequently aggravated this sense of powerlessness rather than promoting a much needed feeling of collaboration and reassurance. While those who bear the responsibility for treatment of the menopausal woman may be unable to remove all sources of stress, they can help the woman to gather the resources she has available and to regain a sense of personal control. This style of intervention cannot be achieved without some costs in terms of time; however, the long-term benefits for both the helping professions and the women involved, may more than justify the time spent. REFERENCES
[l] Greenblatt, R.B., Mahesh, V.B. and McDonough, P.G., Editors, (1974) The menopausal syndrome, pp. 85-87. Medcom Press, New York. [2] Klaiber, E.L., Broverman, D.M., Vogel, W. et al. (1972) Effects of oestrogen therapy of plasma MAO activity and EEG driving responses of depressed women. Am. J. Pyschiatry 128, 1492. [ 31 Bart, P. (1967) Depression in middle-aged women: Some sociocultural factors, Doctoral dissertation, University of California. Diss. Abstr. Int. B 28/H. [4] McCranie, E.J. (1974) Psychodynamics of the menopause. In: The menopausal syndrome. Editors: R.G. Greenblatt, V.B. Mahesh and P.G. McDonough, Medcom Press, New York. (51 Schneider, M.A., Brotherton, P.L. and Hailes, J. (1977) The effect of exogeneous oestrogens on depression in menopausal women. Med. J. Aust. 2, 162. [6] Beck, A.T., Ward, C.H., Mendelson, M., Mock, J. and Erbaugh, J. (1961) An inventory for measuring depression. Arch. Gen. Psychiatry 4,53-62. [ 71 Carney, T.G. (1972) Content analysis: A technique for systematic inference from communications. Batsford, New York. [S] Schwab, J.J., Bialow, M.R. and Holzer, C.E. (1967) A comparison of two rating scales for depression. J. Clin. Psychol. 23, 94. [9] Williams, J.G., Barlow, D.H. and Agras, W.S. (1972) Behavioural measurement of severe depression. Arch. Gen. Psychiatry 27, 330. [ 101 Wren, B.C. (1977) The gap between the expectations of patients and doctors over what constitutes adequate health care cover. Med. J. Aust. 2,160.
PHYSIOLOGICAL, PSYCHOLOGICAL AND SITUATIONAL DEPRESSION DURING THE CLIMACTERIC
153
STRESSES IN
MELINDA SCHNEIDER ’ and PATRICIA BROTHERTON 2
’ Department of Psychology, Melbowne State College, Carlton: 2 Department of Psychology, University of Melbourne, Melbourne, Australia (Received 26 April 1978, accepted 22 August 1978)
The present study examined the characteristics and circumstances which distinguished between groups of depressed and non-depressed menopausal women; 20 women were studied overall. The Beck Depression Inventory (BDI) was used to assess depression levels, while the administration and content analysis of a semistructured interview provided information regarding the presence or absence of stress across a number of variables. While the depressed group were not found to differ significantly from the non-depressed group in terms of stress due to physical symptomatology, they did differ on a number of the psychological and social stress variables, and showed a significantly greater combination of stresses compared with the non-depressed group. Some recommendations concerning management are made. (Key words: Climacteric, Depression, Psychological stress, Social stress)
INTRODUCTION
In recent years, increased interest in the physiological changes occurring during the middle years of the female life-cycle has led to a greater understanding of the so-called “menopausal syndrome” [ I]. The aetiology and treatment of two conditions frequently reported during the climacteric, however, remain poorly understood. The first condition is the lowering or extinction of libido, which does not appear to be related to physiological changes in the genital system, as is the case in dyspareunia. The second condition refers to a set of psychological symptoms such as anxiety, tension, depressed mood and irritability, which are reported to increase in frequency during the climacteric [ I]. As both sexual and psychic well-being are of considerable importance in maintaining the quality of life, the continued lack of information in these areas is not without heavy cost to the women involved. A number of hypotheses have been proposed as to the aetiology of the psychological changes reported to occur during the climacteric. Some writers have adopted an essentially biological/hormonal explanation, relating such changes to diminishing oestrogen levels [2]. Other writers have emphasized the changed role requirements of this phase in the female life-cycle, with the termination of many traditional, instrumental (work), and expressive (interpersonal) roles, and the subsequent stress of recovering productive and
154
fulfilling interests [3]. Yet another group of writers has stressed the individual woman’s premorbid functioning or personality structure. They propose that only women with an inadequate or maladaptive personality development and little ego strength, will manifest psychological disturbance in the face of the losses and stress associated with the menopause [4]. With the increasing number of women seeking help for menopausal symptoms, there is a need for increased information about the factors that contribute to the emergence of psychological difficulties during the climacteric, hence facilitating identification of any high-risk group. The present study was directed at examining the characteristics and circumstances which differentiated a group of depressed menopausal women from a group of non-depressed women. The purpose was to gain an increased understanding of the ways in which certain physiological, social and psychological stresses may combine to contribute to the marked psychological morbidity in this particular phase of the female life-cycle. The study is part of a larger programme which also investigated the effects of conjugated oestrogens upon the depression scores of menopausal women, the results of which have been reported earlier [5]. PATIENTS AND METHODS
Women were drawn from the first admissions to the Menopause Clinic at Prince Henry’s Hospital, Melbourne, over a 3-mth period. In some cases the women had been referred from outside practices while others had come to the clinic of their own accord. All women presenting exhibited a wide range of symptomatology including tiredness, reduced physical and mental activity, dyspareunia, irritability, increased difficulty in decision-making, decrease in the ability to plan simple tasks, insomnia, depression and memory lapses. Subjects ranged in age from 39 yr to 58 yr with a mean age of 50 yr. To obtain a homogeneous group, only married women in good general health and without any past history of depressive illness were included. Women receiving any other form of treatment, either medical or psychological, were excluded. The diagnosis of menopause was based upon a combination of clinical symptoms, gynaecological examination and blood analyses of the follicle-stimulating hormone (FSH), luteinizing hormone (LH) and oestrogen (E-3 levels. No effort was made to select women who complained specifically of depression or related nervous disorders. Subjects were drawn in a purely accidental way on the basis of their presence at the clinic. Subjects were initially interviewed and examined and blood samples were taken. The Beck Depression Inventory (BDI) was used to provide a quantitative assessment of the intensity of depression. The BDI is a self-report scale composed of 21 categories of symptoms and attitudes, where each category describes and consists of graded series of 4 ‘or 5 self-evaluative statements. It has been shown to be valid and appropriate for use with Australian samples [6]. The BDI was administered to subjects on their first contact at the clinic and they were then interviewed in their homes within a week of this first testing at the clinic. Interview questions were formulated to reveal information concerning a number of likely stresses discussed in the literature pertaining to psychological changes during the
155 menopause. Stress was taken to refer to a state of strain, whether physical, social or psychological. The areas of stress examined included the following: (1) Loss of the reproductive function. (2) Early developmental disturbances; for example, the loss of either one or both parents during the subject’s childhood, or reported frustration of basic emotional needs such as love, acceptance, and affection. (3) The general effects of ageing and the losses associated with ageing; for example, decreased stamina or perceived changes in physical attractiveness. (4) The care requirements or dependence of aged parent(s). (5) Marital dissatisfaction. (6) Losses related to the parental role or the so-called “empty nest” syndrome. (7) Impairment in either instrumental (work) or expressive (interpersonal) roles, evidenced by either a lack of interest or an inability to function adequately in the area. (8) Economic difficulty. (9) Possible precipitating factors, such as the death of a loved one, illness or operation. (10) Severity of hot flushes and other physical symptoms. In all cases interviews were tape recorded and, in order to code the relevant information, the method of content analysis was applied to the interview transcripts [7]. RESULTS
All women were classified as depressed or non-depressed on the basis of their BDI score [ 51. Analysis of the interview data revealed that the depressed and non-depressed women differed significantly on a number of the psychological and social stress variables selected for study, but did not differ significantly in terms of stress due to physical symptomatology (Table I).
TABLE 1 Summary of differences Exact Test).
between
depressed
and non-depressed
women on stress variables
(Fisher’s
Source of stress
Direction of stress D/ND *
N = 20; P = 0.05
1. Loss of the reproductive function 2. Role impairment in either expressive or instrumental roles 3. Marital dissatisfaction 4. Aged parents 5. Economic difficulty 6. Early developmental 7. Precipitating factors 8. Parental role, the “empty nest” syndrome 9. Physical symptomatology
D = ND D>ND
NS ** P < 0.05, one-tailed
D>ND D=ND D>ND D>ND D = ND D = ND D = ND
P < 0.025, one-tailed NS P < 0.05, one-tailed P < 0.005, one-tailed NS NS NS
* D indicates depressed women; ND indicates nondepressed ** NS indicates no significant difference between groups.
women.
156
The depressed women showed a significantly greater frequency .of stress due to marital dissatisfaction, economic difficulty, role impairment and early developmental disturbances. Stress associated with the loss of the reproductive function, the care of aged parents, precipitating factors and changes in parental role, was not significantly different for the depressed and non-depressed groups. Combined stress across the 4 psychological stresses (Table I, Nos. 1, 2, 6, 8) the 4 social environmental stresses (Table I, Nos. 3-5, 7) and physical stress (Table 1, No. 9) was computed for the depressed and non-depressed groups. The results indicated that the depressed women experienced a significantly greater combination of stresses when compared with the non-depressed women (P < 0.01, one-tailed, Fisher’s Exact Test). DISCUSSION
Before discussing the results of the present study a number of methodological issues should be considered. First, since the size of the subject sample was relatively small, the data can be suggestive only, forming a basis for future, more extensive research. Secondly, some discussion of the measurement instruments is required to indicate the advantages and disadvantages of the scales employed. The BDI has been subjected to a variety of tests to determine its reliability and validity and the results indicate that the inventory is highly reliable, with reasonable validity [6]. The change in BDI scores over time also have been found to have a high positive correlation with changes in psychiatric evaluation of patients, a finding which has been supported by a number of studies employing clinical ratings and/or other psychometric measures such as the Hamilton Rating Scale [8,9]. A major criticism of self report techniques has focussed upon the accuracy of the subject’s own appraisal of depression level. The possibility of distortion in subjective ratings due to the depressive state itself is an important consideration. It takes on a greater importance, however, when the subjects are drawn from a psychiatric population where forms of denial which are a part of the illness may invalidate self report measures reliant on the subject’s perceptions if employed without corroborative data. Self reports of stress based on interview data are similarly vulnerable to distortion when sampling severely depressed patients. However, the fact that none of the subjects in the study were drawn from a psychiatric population but were maintaining adequate functioning without observable distortions in reality testing, suggests that the results were less susceptible to this form of distortion. The difficulty of controlling for subjective distortions in the self-report data would have been increased by an increase in the number of coding categories used in the scaling of the stress variables from the interview data. For that reason, in the present study only two coding categories were employed to rate the severity of stress, “stress present” and “stress absent”. Taking into account the preceding points, the results of the present study raise a number of questions. First, in view of the importance which is frequently placed upon the loss of the woman’s reproductive function as an explanation for the psychic changes during the menopause, it is notable that stress from this source was negligible among the women studied, and certainly did not distinguish between the depressed and non-depressed
groups. This result therefore calls into question the frequently employed and facile explanation that the menopausal woman becomes depressed simply because she can no longer bear children or because her children are leaving home. In contrast, of the 20 women studied, 7 out of the group of 10 depressed women reported childhoods which, in their perception, were disturbed. The disturbance was related either to early losses of significant people and/or to chronic frustration of basic emotional needs. In particular, deprivation of love and acceptance or feelings of helplessness due to the frustration of self-protective needs were implicated. In no instance was this type of perceived disturbance reported by the non-depressed women. This result does suggest support for those writers who believe that premorbid functioning and personality are important predictors of a woman’s ability to cope with the stresses of the menopausal period [4]. The results also indicate that the depressed women reported a significantly greater frequency of stress due to alterations in their ability and motivation to function within both instrumental and interpersonal roles. Such a result supports the view that in assessing the morbidity associated with the menopause and in planning intervention procedures for the menopausal woman, it is unlikely to be sufficient to assess her simply within the context of her changed physiological state. An assessment of the woman’s functioning within a broader social context may reveal that it is the inability to fulfil usual roles as competently as previously which is contributing to her diminished psychological wellbeing. The middle years are characterized by increased introspection and stock-taking, and, hence, the inability to carry out usual roles competently may greatly aggravate feelings of inadequacy and self doubt. The medical practitioner is in a fine position to provide support and reassurance through a discussion of the woman’s unrealistic expectations, and by emphasising the need for a more balanced set of expectations and goals. In the past, the acceptance of an essentially hormonal explanation for the psychological changes occurring during the climacteric has had a number of ill effects; in particular it has promoted a single-minded approach in both the assessment and treatment of menopausal complaints, and a failure to consider the relationship and interaction between physiological, psychological and social stresses [5]. The menopausal woman is confronted with the difficulty of coping with a broad spectrum of change. Her altered hormonal status frequently produces acute physical discomfort, major changes in traditional roles may leave her with fewer social and psychological resources, and losses associated with the general ageing process may mean that alternative resources are hard to obtain. It has recently been pointed out that the result of a lack of communication between doctor and patient over problems which, while not life threatening, are essential to the patient’s quality of living, produces a gap between the expectations of the patient and the doctor, and increased hostility from both parties [lo]. For the busy practitioner the menopausal woman may arouse feelings of frustration and irritability, due partly to the apparent absence of severe physical discomfort and partly to the prevalence of menopausal complaints. Closer examination and questioning, however, may reveal a patient in need of specialized care or referral to an appropriate community service. It is possible that the cost of ignoring the psychosocial needs of this particular patient group is
158
reflected in the high frequency of psychological and social disturbance reported by women during their middle years. The menopause is characterized for women as a time of diminished control, not only over their own bodies, but also over their immediate personal environment and their external social environment. Unfortunately treatment styles and stereotypes have frequently aggravated this sense of powerlessness rather than promoting a much needed feeling of collaboration and reassurance. While those who bear the responsibility for treatment of the menopausal woman may be unable to remove all sources of stress, they can help the woman to gather the resources she has available and to regain a sense of personal control. This style of intervention cannot be achieved without some costs in terms of time; however, the long-term benefits for both the helping professions and the women involved, may more than justify the time spent. REFERENCES
[l] Greenblatt, R.B., Mahesh, V.B. and McDonough, P.G., Editors, (1974) The menopausal syndrome, pp. 85-87. Medcom Press, New York. [2] Klaiber, E.L., Broverman, D.M., Vogel, W. et al. (1972) Effects of oestrogen therapy of plasma MAO activity and EEG driving responses of depressed women. Am. J. Pyschiatry 128, 1492. [ 31 Bart, P. (1967) Depression in middle-aged women: Some sociocultural factors, Doctoral dissertation, University of California. Diss. Abstr. Int. B 28/H. [4] McCranie, E.J. (1974) Psychodynamics of the menopause. In: The menopausal syndrome. Editors: R.G. Greenblatt, V.B. Mahesh and P.G. McDonough, Medcom Press, New York. (51 Schneider, M.A., Brotherton, P.L. and Hailes, J. (1977) The effect of exogeneous oestrogens on depression in menopausal women. Med. J. Aust. 2, 162. [6] Beck, A.T., Ward, C.H., Mendelson, M., Mock, J. and Erbaugh, J. (1961) An inventory for measuring depression. Arch. Gen. Psychiatry 4,53-62. [ 71 Carney, T.G. (1972) Content analysis: A technique for systematic inference from communications. Batsford, New York. [S] Schwab, J.J., Bialow, M.R. and Holzer, C.E. (1967) A comparison of two rating scales for depression. J. Clin. Psychol. 23, 94. [9] Williams, J.G., Barlow, D.H. and Agras, W.S. (1972) Behavioural measurement of severe depression. Arch. Gen. Psychiatry 27, 330. [ 101 Wren, B.C. (1977) The gap between the expectations of patients and doctors over what constitutes adequate health care cover. Med. J. Aust. 2,160.
