Women Mental Health, its uniqueness and challenges

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Priyaranjan Avinash is psychiatrist at Deva Institute in Varanasi (UP, India). He’s a big expert in legal psychiatry, addiction, women mental health, relationship issues and health policies. He offers specialized articles to India Medical Times. He wrote already about mental health in his motherland – India – for our magazine.



Before we speak of women mental health, we need to understand the issues of women’s health first. The topic of ‘women’s health’ includes health issues and diseases that are unique to women, such as gynaecological conditions; disease that are more prevalent in women and disease that are expressed differently in women and men, meaning that women may present with different symptoms, have more serious form or a different course of illness, or respond differently to interventions.

Women’s health also includes issues of access to care, quality of care and prevention of disease. Many women experience barriers to good health care, including limited access, intensive attitudes in the medical profession, and poorly coordinated referral systems. Whereas earlier views of women’s health focused exclusively on reproductive health, there is now a broader multidisciplinary approach that encompasses all organ system and includes not only biological but also psychological and social-cultural aspects of health and disease across the life span.

Now moving to the women’s mental health in particular, one of the most consistent findings in epidemiological research is that the Unipolar depression is about twice as common in women as in men. Women are also more likely to experience many anxiety disorders and over 90% of cases of eating disorders occur in women. Rates of bipolar disorder are similar in men and women however, women are more likely to develop depressive episodes of bipolar disorder and a rapid-cycling course.

Although alcoholism is much more prevalent in men, mortality rates among individuals with alcoholism are considerably higher in women. Recent researches also have shown gender differences in treatment response for some psychiatric disorders.

Mental disorders in women are most common during the childbearing years and often reproductive events may act as triggers for the onset or exacerbation of symptoms. Advances in medical treatment have led to major improvements in health care. An indication of the extent and burden of these problems comes from the findings of a World Bank project. Mental health problems were found to be one of the largest causes of lost years of quality life, accounting for 10.5% of all disability.

Psychosocial factors also play an important part in the mental health of women.

Gender differences in socializing processes and rates of traumatic abuse, as well as the various social roles of women as wives, mothers, caretakers of elderly parents and workers, all deserve consideration in understanding risk factors of mental illness and the effects of these disorder on women and their families.


Significant mental disorders and problems experienced by women

In investigating common mental, behavioral and social problems in the community we find that women are more likely than men to be adversely affected by:


Gender difference in Psychiatric Disorders

  • Gender difference in the prevalence of psychiatric disorders have long been recognised, the prevalence in women is higher than in men for number of disorders.
  • Gender related differences exist not only in the lifetime prevalence of psychiatric disorders but also in
    • The expression,
    • Co-morbidity, and course of many illnesses. For example, depression and dysthymia, both more common in women than in men, are more likely to be accompanied by anxiety disorders in women.
  • Gender differences in psychiatric conditions may be due to:
    • Psycho-social factors: women’s traditionally disadvantage social status, lower wages and increase vulnerability to sexual and domestic violence may contribute to their higher rates of depressive and anxiety disorders.
    • Biological differences related to gender may also explain some of the difference in psychiatric illnesses between men and women.


Why gender?

  • Gender is a critical determinant of mental health and mental illness. However, it hasn’t received more attention than it deserved. It influences all the determinants of mental health namely: personal, social and the environmental factors.
  • Gender differences occur particularly in the rates of common mental disorders – depression, anxiety and somatic complaints.
  • Unipolar depression, predicted to be the second leading cause of global disability burden by 2020, is twice as common in women.
  • Depression is not only the most common women’s mental health problem but may be more persistent in women than men.
  • Reducing the over-representation of women who are depressed would contribute significantly to lessening the global burden of disability caused by psychological disorders.
  • There are no marked gender differences in the rates of severe mental disorders like schizophrenia and bipolar disorder that affect less than 2% of the population.


Gender specific risk factors

  • Gender specific risk factors are significantly related to interconnected and co-occurrent risk factors such as
    • Biological Factors: hormonal, physiological and reproductive.
    • Psychosocial Factors: gender based violence, socioeconomic disadvantage, gender based roles, stressful  and negative life experiences and events, an unremitting responsibility for the care of others and reproduction, different biological make up.
  • Economic and social policies that cause sudden, disruptive and severe changes to income, employment and social capital that cannot be controlled or avoided, significantly increase gender inequality and the rate of common mental disorders

The mental health impact of long term, cumulative psychosocial adversity has not been adequately investigated.


Gender bias

  • Gender bias occurs in the treatment of psychological disorders;
  • Gender differences exist in help seeking behaviour;
  • Women are more likely to seek help from and disclose mental health problems;
  • Gender stereotypes regarding proneness to emotional problems in women and alcohol problems in men, appear to reinforce social stigma and constrain help seeking along stereotypical lines.

Violence related mental health problems are also poorly identified. Women are reluctant to disclose a history of violent victimization unless physicians ask about it directly.


Women’s Psychobiology and reproductive life cycle:

  • Some reproductive hormones, particularly estrogens and androgens may potentiate Psychiatric symptoms, like increase vulnerability of women to anxiety disorders and depression.
  • Another example may be, women with low serotonin levels may experience increase rather than decrease in anxiety and irritability in the premenstrual phase of the cycle.


Psychiatric aspects of the menstrual cycle

  • Detail assessment of Last menstrual period should be done.
  • The etiology of premenstrual syndrome has yet to be clarified as PMS and PMDD are biological phenomena as opposed to purely psychological and psychosocial events.
  • Many women in their reproductive years, from menarche to menopause have clinically significant menstrual-related emotional as well as physical symptoms.
  • Social beliefs about menstruation, however, vary among different cultures and can influence expectations about the menstrual cycle
  • Age may also influence the reporting of premenstrual symptoms as it was found that older adolescent (16-18 years) had significantly more intense symptoms than younger teens (13-15 years) (Cleckner-Smith et. al., 1998).
  • Onset of distressing symptoms occurs typically when women are in their late 20s to mid-30s (Freeman et. al. 1995a)
  • There is some evidence of worsening premenstrual symptomatology following childbirth (Johnson, 1987).
  • Women with higher levels of education have been shown to report more severe symptoms as well as more psychological complaints of premenstrual symptoms.
  • Thus, it is important to consider that many factors- beliefs, age and levels of education may influence women’s premenstrual experiences.


Psychiatric aspects of pregnancy

  • Although pregnancy is typically considered a time of emotional well-being for many women, pregnancy is not protective for women who suffer from psychiatric illness.
  • Pregnancy can act as an stressor e.g. –relapse of mood disorder and psychosis
  • Pregnancy can cause post partum psychosis and depression. Postpartum Depression describes four syndromes namely,
    • Maternity or Postpartum Blues
    • Postpartum Psychosis
    • Adjustment Disorder of the Postpartum Period
    • Major Depression in the Postpartum (Postpartum Depression)


Psychiatric aspects of menopause

  • Menopause is considered as the end of womanhood in many cultures. It affect about 70% of women approaching menopause.
  • Typical menopause symptoms, such as hot flashes or night sweats, are caused by changing hormonal levels in the female reproductive system.

Almost all women notice early symptoms also called peri-menopause while still having periods. This stage often begins in the early 40s and last for the whole menopause transition (until the mid 50s), but some women may experience them for the rest of their lives. The most common symptoms are: Hot Flashes, Night Sweats, Irregular Periods, Loss of Libido, and Vaginal Dryness.


Gender Issues of individual mental illness

  • In women, rates of new-onset schizophrenia reach a peak between ages 20 and 29 years, around a decade later than in men. (Aleman et al. 2003)
  • They have bimodal curve for onset.
  • Depression.
  • A number of large epidemiological studies have consistently found that women are more likely than men to experience depressive disorders.
  • The increased prevalence of depression in women begins in adolescence and is a cross-cultural phenomenon. Although most exogenous stressors influence the risk for depression similarly in both women and men, women appear to be more likely to become depressed in response to interpersonal difficulties.
  • Anxiety disorders are more prevalent in women than in men, and women with anxiety disorders are more likely than men to experience co-morbid depression.
  • Panic with agoraphobia and generalized anxiety disorder (GAD) are two to three times more common in women than in men.
  • Social phobia is three to four times as common in women as in men (Schwartz et al. 1996).
  • With regard to PTSD, women may be culturally primed to experience traumatic events differently than men, rather than having an increased biological vulnerability.


Bipolar disorder

  • Women with bipolar disorder are approximately two times as likely as men with the disorder to experience rapid cycling, defined as four or more affective episodes per year (Tondo and Baldessarini 1998).

It has generally been accepted that women with the disorder appear to experience more depressive episodes than do men with the disorder.


Sleep Disorders

  • The risk for sleep-related difficulties rises during certain reproductive phases of women’s lives: premenstrual bloating and cramping frequently disrupt sleep;
  • The discomfort women experience in the third trimester of pregnancy, and night sweats produce sleep impairment in approximately one-third of perimenopausal women (Walsleben 1999).


Domestic Violence

  • Women are more likely to be assaulted and injured by a current or former male partner than by all other assailants combined.
  • Often feel that their lives are in danger, and these fears may persist after the assault.
  • Victims of domestic violence are at risk for depression, anxiety, eating disorders, and alcoholism (Eisenstat and Bancroft 1999).
  • Children of battered women are at risk for substance abuse, suicide, school problems, violent and aggressive behavior, sleep disorders, enuresis, and chronic somatic disorders (Eisenstat and Bancroft 1999).
  • Depression, anxiety, psychological distress, sexual violence, domestic violence and escalating rates of substance use affect women to a greater extent than men.
  • Pressures created by their multiple roles, gender discrimination and associated factors of poverty, hunger, malnutrition, overwork, domestic violence and sexual abuse; combine to account for women’s poor mental health.


Sexual Violence

  • Enquiry should be made regarding it
  • Rape, Incest, Marital sexual violence, prostitution and trafficking should be assessed .

Research shows that there are 3 main factors which are highly protective against the development of mental problems especially depression.

  • These are:
    • Having sufficient autonomy to exercise some control in response to severe events.
    • Access to some material resources that allow the possibility of making choices in the face of severe events.
    • Psychological support from family, friends, or health providers is powerfully protective.


Special Aspects and consideration during treatment of mental illnesses among women

  • There is difference in Psycho-pharmacology, which can be either due to pharcodynamical reasons, pharmaco-kinetical reasons or both.
  • Due to women specific life events like pregnancy or lactation , sometimes the treatment needs to be stopped or modified accordingly.
  • Women specific side-effects like hirsuitism, amenorrhoea, or dysmenorrhea, excessive weight gain etc may also affect the treatment response and treatment strategy, including choice of medication and treatment outcome.
  • Socio-cultural aspects like the paternalistic society, prevalent in India, may also affect the treatment adherence, either due to medication side effects ( sedation-Women are supposed to wake up before men and, do household chores), or the mental illness and treatment considered as a taboo, leading to stopping of treatment or hiding the treatment before marriage.


Long term management and rehabilitation of women with mental illness

  • Women have different needs from a rehabilitation centre catering for mentally ill
  • They require different sets of skills
  • There are issues related to reproductive health that needs extra attention
  • The security of Women inmates brings a lot of challenges
  • Due to the patriarchal nature of the society, the risk of abandonment is high.