Gender and mental health

In the 19^th and early 20^th centuries, there did not seem much point in considering gender differences in mental health, as women were so clearly inferior. Quoting Le Bon (a 19^th century social psychologist and a disciple of Paul Broca):

“In the most intelligent races, as among our Parisians, there are a large number of women whose brains are closer in size to those of gorilla than to most developed male brains. This inferiority is so obvious that no one can contest it for a moment: only its degree is worth discussion. They excel in fickleness, inconstancy, absence of thought and logic, and incapacity to reason. Without doubt, there are some distinguished women, very superior to the average man, but they are as exceptional as the birth of any monstrosity, as for example a gorilla with two heads, consequently we may neglect them entirely” (Gould, 1981).

Indeed, Vaillant’s 75-year longitudinal study (Vaillant, 1977) of 268 physically and mentally healthy Harvard undergraduates from the classes of 1939–44 only considered men as participants destined for success in life, although some sociological studies such as the Stirling County Study (Murphy et al., 2000) considered both sexes. The explosion of interest in improving diagnostic rigour from the 1960s on led to development of DSM-III and ICD-9 and complementary case-finding instruments which enabled epidemiological study of communities rather than previous clinically based research. This methodology led to some significant community studies looking at rates of mental illness in developed countries, typified by the National Comorbidity Study (Kessler et al., 2005) in the USA, and studies in New Zealand (Wells et al., 1989) and Australia (Australian Bureau of Statistics, 2007).

Gender differences in mental health

A summary of general population studies (Piccinelli and Homen, 2007) found no support for gender differences in lifetime prevalence rates for high-impact, low-prevalence disorders (schizophrenia and bipolar disorders), but men tended to have an earlier onset of symptoms and poorer psychosocial development and functioning. For bipolar disorder, men were more likely to present with a manic episode at first onset and displayed different comorbidity patterns (more substance abuse and ‘acting out’ behaviours) (Kawa et al., 2005), while women had more thyroid disease and anxiety disorders and were more likely to develop the rapid cycling form of the condition.

From the mid-1960s, there were reports of increased rates of depressive and anxiety disorders in women but also an appreciation that differences in social roles and help-seeking made it difficult to know what to make of this. A comprehensive summary of literature on gender differences (Weissman and Klerman, 1977) set the stage by considering possible ‘real’ and ‘artefactual’ causes of gender differences in depression, but many of the issues had broader relevance to psychiatric case-finding for other disorders.

Adolescence was seen as an important time point in this respect. Boys are reported as having higher levels of self-reported depressive symptoms than girls, with a change during adolescence. A study of children aged 10–12 years (Bailey et al., 2007) found that when depressed, girls reported more internalising styles and more negative self-esteem, while boys reported more externalising styles and more school problems, i.e. ‘bad behaviour’. These two studies reflect a consistent gender difference in responses to gender-related styles, where women have higher rates of internalising disorders (depression and anxiety disorders), while men have higher rates of externalising disorders (alcohol/substance abuse, antisocial personality disorders). The peak suicide rate for men in the 20–40 year age range also reflects the higher rates of substance use and impulsive behaviour in younger men (Cochran and Rabinowitz, 2000).

One rarely mentioned finding is that when all psychiatric disorders are combined, lifetime prevalence rates for all disorders are virtually identical for men and women. The summary of the National Survey of Mental Health and Wellbeing (Australian Bureau of Statistics, 2007) is a case in point, where it was reported that, in the previous 12 months, women aged 16–85 years had a higher rate of mental health disorders (22%) than men (18%), largely due to higher rates of anxiety disorders (women almost double the reported rate of post-traumatic stress disorder). However, men were more likely to have had a mental disorder over their lifetime than were females (48% compared with 43%), “which was largely due to the higher proportion who had a Substance Use disorder at some stage in their life”. The community studies noted above reported very similar findings.

A recent Australian study (Sunderland et al., 2014) comparing three cohorts of different ages found that the older cohort (60–85 years) were reported to experience more internalising disorders and poorer physical health but fewer externalising disorders than the young cohort (16–34 years), along with lower life satisfaction and lesser size and quality of social support and network. This is in accord with a UK study which reported that both sexes ‘mellow’ emotionally over the decades (Bebbington et al., 1998). A study of subjective wellbeing in later life (George, 2010) found no gender differences in subjective wellbeing over the life cycle, but when gender was considered women had higher levels of wellbeing than men in adult life, but this trend was reversed as they aged. However, men aged 65+ years have the highest suicide rate of any age group (Osgood, 1992), and the risk factors of illness, substance use and social isolation are important here. Men consistently report higher rates of nicotine, alcohol and other substance use, all of which interact with physical health issues, leading to increased rates of heart disease, hypertension and associated depression. While depression increases the morbidity and mortality from cardiovascular disease, men are at particular risk from increased mortality (Australian Bureau of Statistics, 2013). It is also possible that men’s experience of depression gets ‘lost’ in the context of health and substance use issues.

Women report how they feel, and men what they do

In the high-prevalence disorders, the gender differences attributed to depression seem more related to women reporting higher levels of neuroticism, arousal and anxiety disorders (Breslau et al., 2000) and different methods of interpreting symptoms and dealing with them, rather than depressive symptoms per se. This may also be relevant for cross-cultural differences.

The Sydney Teachers’ Study (Wilhelm et al., 2008) is one of a few that have looked at socially homogeneous groups to cut down the confounding effects of social role and educational status. In that cohort, there were no differences in rates of depression (as episodes or self-report scales) but higher rates of neuroticism and anxiety disorders, and research on other socially homogeneous groups has found the same. The group was notable for extremely low levels of substance abuse and aggressive behaviour. Women also displayed a greater emotional range and anticipated and experienced more pleasure from positive events, and reported use of a wider range of coping styles when stressed.

In the entire study, there was only one item where men rated more highly: they were more likely to report risk-taking behaviour when depressed. A further study seeking to understand more of men’s experience (Brownhill et al., 2005) confirmed that while men and women experience depression similarly, the gender differences lay in the expression of depression and stress. Some of men’s experience (irritability, emotional withdrawal) is outside the standard diagnostic criteria for major depression. The ‘big build’ model provided an understanding of the emotional build-up that occurs, with increasingly risky outcomes if there is no emotional recognition or release. Incidentally, experience in a number of studies with men has shown that they are glad to talk if given the right time and place. This model probably reflects how men respond to stress and anxiety as well.

There are gender differences in how distress and negative affects are expressed: in general terms, men’s experience is reflected more in what they ‘do’ while women’s is more in they ‘feel’. Men’s higher rates of behavioural disturbance as boys and of antisocial personality disorder as adults are partly a reflection of this as well. Men have lower health literacy in emotional areas, are less likely to report how they feel and to seek help, but have higher rates for certain risk-taking behaviours such as drug and alcohol abuse, aggression, withdrawal and completed suicide (Cochran and Rabinowitz, 2000). This can also lead to delay in detection. Even today there are subtle reflections of gender differences in approaching health issues, as ‘men’s health’ is generally concerned with sexually performance and prostate conditions, while ‘women’s health’ is about their reproductive system and emotional problems.

The big picture

Gender affects not only rates of disorders, but also risk, timing of onset and course, diagnosis, treatment and adjustment to mental disorder (World Health Organisation, 2014). It is likely that there are differences in some predisposing and precipitating factors which relate to biology (genetics, sex hormones, pharmacokinetics and pharmacodynamics of medications) and these differences are amplified or diminished by social and cultural factors (such as gender roles, social support, degree of control over their circumstances).

Over the ages, men have been suspicious of women’s ability to take on roles outside the home. In Western societies, women have equal rights to vote, drive and be educated, and have better access to a range of jobs that would have been unthinkable in the 19^th century. These opportunities are still not afforded women in some cultures. Clearly, when considering the picture worldwide, there is a long way to go in terms of women having rights over their lives, their money, and even their bodies, and we all need to respect and support the struggle that those women and their children are going through.

The World Health Organisation Report of Gender and Women’s Mental Health (World Health Organisation, 2014) states that “gender determines the differential power and control men and women have over the socioeconomic determinants of their mental health and lives, their social position, status and treatment in society and their susceptibility and exposure to specific mental health risks.” It quotes three factors that are highly protective against the development of mental problems, especially depression, including having (i) sufficient autonomy to exercise some control in response to severe events; (ii) access to sufficient material resources to enable the possibility of making choices, especially when faced with severe events; and (iii) psychological support from family, friends, or health providers is powerfully protective. Access to safe affordable housing is essential if women and children are to escape violent victimisation, and the cessation of violence is highly effective in reducing depression. But the way women feel is affected by what men do and vice versa, so that men’s issues are also important in a drive for change. After basic rights are addressed, there can be consideration of the biological, health, social and cognitive issues that men and women bring, and they can learn from each other.

To conclude with a paradigm shift from the opening quote, a study which analysed the performance of nearly 2400 companies with/without female board members from 2005 onwards noted that “companies with at least some female board representation outperformed those with no women on the board in terms of share price performance, with less risky investments and improved return on equity” (Credit Suisse Research Institute, 2014). They concluded that companies that had women on boards had more balance with less volatility, due to a greater mix of leadership skills, better reflection of the consumers and improved corporate governance. I wonder what Broca and Le Bon would have made of this! My interest in gender differences has alerted me to the dearth of attention to men, often simply regarded as ‘the norm’.

In closing, gender differences can provide a useful prism to consider a raft of biological and social risk factors, not from the vantage point of consolidating notions of women’s inferiority but to see men and women as ‘equal but different’ and address what factors are shared and what are unique contributions to the biological, psychosocial and cognitive impacts of men and women. The same prismatic approach could be useful when considering ‘us’ and other groups and cultures as well.