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A study of premenopausal psychiatric disorders.

SUMMARY One hundred consecutive women attending psychiatric services at NIMHANS during the period of January 1987 - March 1987 were studied to see differences in demographic profile, presenting complaints and psychiatric diagnosis in the two different age groups (25-35 years and 40-50 years). The majority of patients in age group 40-50 years (Perimenopausal) were illiterate, multiparous and coming from a rural Hindu background. Somatic, depressive/somatic features were commonest presenting complaints (66%). Most of the perimenopausal women were suffering from affective/neurotic syndromes (87%). 21 % of the women (age group 40-50 years) had associated physical problems.

Mensturation is at best a physiological inconvenience; at worst it contributes to chronic ill-health (Editorial BMJ 1979). There seems to be a general agreement that, even if there is not a specific menopausal syndrome, a tendency does exist for some women in middle life, especially around the time of menopause and involution (climactrium) to experience a variety of physical and psychological symptoms in addition to vasomotor symptoms brought about by estrogen deficiency (Ballinger 1976, 1977, Greene and Cooke 1980. The role of Menopause itself in the etiology of these symptoms is however open to question and many regard envitonmental factors as more important (Munro 1969, Slater & Roth 1969. Most general population surveys, gynaecological and general practice studies have reported an elevation in some somatic and psychological symptoms around the time of involution and menopause (Neugarten and Kraines 1965, Greene and Cooke 1980, Ballinger et al. 1977, 1985. So far most of the studies were conducted to identify psychiatric problems in those middle aged who were either atending gynaecological clinics general practice or were residing in community.
In this study we planned to determine the prevalence and nature of psychiatric disorders in women in their perimenopausal age and to see the differences in demographic characteristics and clinical diagnosis as compared to a second group of women in the age range 25-35 years attending the same psychiatric outpatient department.

Material and Methods
One hundred consecutive woment attending psychiatric out-patient clinic were selected for the study during a three month period.
Index group: Women in the age range of 40-50 years were taken as perimenopausal women.
Control Group: Women in the age range of 25-35 years were taken as control group.
'Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, India Index group patients were selected consecutively while control group selection was done randomly.
All demographic details, obstetric and gynaecological history, physical examination, relevant investigations and clinical diagnosis (both psychiatric and physical) were recorded on a proformaspecifically designed for the study. The data collected was then subjected to statistical analysis. Psychiatric diagnosis were given according to I.C.D.9 (WHO 1978).

Results
Out of 100 female patients attending psychiatric out-patient 24 women were in the age group of 40-50 years. The control group of another 24 women in the age range of 25-35 years was taken at random from the same population (Table 1).  Table 2 shows that in the Index group majority of patients came from rural background (62%); were uneducated (75%), Hindu (75%), married (75%), and multiparous (67%). Most of the patients were either menopausal (46%) or having irregular menstural cycles (29%). In 16% of the perimenopausal women details about mensturation were not available. Most of the Index group patients were suffering from neurotic syndromes or affective syndromes (37%) ( Table 3). 33% of the patients (Perimenopausal group) had predominantly

Domicile
Urban Rural

Religion
Hindu Muslim

Discussion
As the results show majority of the Index group patients were married, uneducated, Hindu females either in menopausal phase or with irregular menstruation from rural background. Most of them presented with somatic, somatic/depressive features and some of them had associated medical problems (21%). While in control group majority of the patients were literate, urban biparous and with less somatic complaints.
In previous studies (Ballinger 1975, 1976, 1977, 1985, Munro 1969 the same trend had been noted. Menstrual irregularity was a common finding in perimenopausal patients who presented to our clinic, this is in keeping with the findings of an excess psychiatric morbidity in women who were immediately perimenopausal (Ballinger 1975). A high proportion of women in the perimenopausal age group had three or more children, coming from a joint family is also similar to the findings of a previous study by Ballinger in 1975. Somatic symptoms and excessive concern towards bodily functions along with generalised weakness, depressed mood and thoughts were the common presenting symptoms in the study group. The same trend was noted in previous studies by Ballinger et al. 1977.
The presence of physical diagnosis associated with psychiatric morbidity like hypertension, diabetes, malignancy and hypothyroid features along with various gynaecological operations like hysterectomy were reported in 21 % of study group. As the age advances, the chronic physical problems are perhaps expected in this age group.
Hysterectomy was a common operation done in this age group for various gynaecological complaints specifically dysfunctional uterine bleeding is known to be associated with high psychiatric morbidity (Barket 1968, Subramaniam andVarghese 1982).
Illiteracy was one of the statistically significant factor found in the study. More perimenopausal women were illiterate as compared to control group. This may be a factor associated with their age and can be explained on the basis of increasing literacy rate in our country.
This study emphasises the importance of various demographic factors, detailed gynaecological/obstetric history and a thorough physical examination in perimenopausal women attending psychiatric hospitals for their problems. Further studies with larger samples and better designs are expected in future to see the definite trends in this age group.