Women’s mental health: Still not a priority,still not good enough

Introduction

In 2014, women in Australia and around the world are struggling with many serious issues that impact adversely on their quality of life and happiness.

There are many factors that impact differentially and specifically on women’s mental health, in the domains of the environment, sociocultural contexts, psychology and biology. It is widely acknowledged that women form the greatest percentage of patients receiving psychotropic medications and services, yet the consideration of women as a specific group with particular needs is rare. When women’s mental health issues are mentioned, a common response is “what about men’s mental health?” Or in the case of reported violence against women as a contributor to mental disorders – “isn’t it just that there is more reporting of it now?” These responses obfuscate the very real need to consider women’s mental ill health as an area of health that needs specialized, focused attention. Of course men suffer greatly from mental illnesses too, but a gendered approach may permit a better-tailored, focused plan of action for all.

In the near future, The Royal Australian and New Zealand College of Psychiatry will release new guidelines for the management of key disorders such as schizophrenia and affective disorders. A great deal of hard work has been put in by committees of experts, dedicated to drawing up the best guidelines with solid evidence to guide psychiatrists’ management of these severe and prevalent mental disorders. I was part of the schizophrenia panel and can attest to the huge amount of work involved in developing these guidelines. However, apart from a small section in the schizophrenia guidelines devoted to women with psychosis, the issue of how mental illness impacts on women, the need for special assessment and treatments are largely overlooked. Similarly, the mood disorders guidelines includes a section on postnatal disorders but makes no recommendations about specific female treatment strategies for women with depression and bipolar disorder.

Why has this happened? Perhaps because women’s mental health is not a priority in Australia and New Zealand. It’s time it was.

Examples of women’s mental illness

Gender differences in the rates of major depressive disorder (MDD) are a highly consistent finding in epidemiological research. In Australia, the rate of depression experienced by women is almost twice that in men (Australian Bureau of Statistics, 2008). Similarly, women experience more anxiety disorders compared with men (Australian Bureau of Statistics, 2008), whereas men present with greater substance use and abuse as “depressive equivalents”. Unfortunately, recent data trends show that women are increasingly abusing alcohol and other substances (Australian Bureau of Statistics, 2008). Middle-aged women’s drinking patterns are understudied but increasingly damaging and clinically noted to be more difficult to treat.

Women and men have equal prevalence in the rates of onset of schizophrenia but the well documented differences in age of onset and patterns of related causal factors mean that women and men need different, tailored treatment approaches (Hafner, 2003). There is a perimenopausal related rise in the onset of new psychosis in women (Cohen et al., 2006) and clearly, postnatal psychosis is a female disorder with significant repercussions for the new mother and her child.

The spectrum of bipolar disorders also reveals female preponderance in both phases over a lifetime (Arnold, 2003). There is also considerable over-representation of women in the diagnosis of Bipolar Type 2. This may be due to the significant number of women with borderline personality disorders who are given the diagnosis of Bipolar 2 and then treated with mood stabilizers, antidepressants and antipsychotic medications (Bassett, 2012; Mitchell, 2012). This is an important example of the lack of gender sensitivity leading to a line of clinical treatment that may not necessarily lead to the best outcomes for the female patient.

Borderline personality disorder is a female dominant severe mental illness. This bizarrely named disorder is a profoundly difficult condition to treat with high mortality and morbidity, and often evolves from a background of trauma or loss in a woman’s early life. It is an important example of a serious mental illness that receives little attention, both in terms of research funding and clinical resources. This illness will be discussed in more detail later.

A similar situation exists with eating disorders, which also affect women more than men (Hudson et al., 2007). Clinicians working with women who have eating disorders or borderline personality disorder are greatly hampered by the lack of recognition at a national level of the substantial mortality and morbidity associated with these conditions. Despite the great efforts made by under resourced clinicians, we have not improved the quality of life for women with these disorders.

Special factors that impact on women’s mental health

Violence against women

In Australia, male intimate partner violence has been found to be the leading contributor to death and illness for women aged 15–44. A personal safety survey of 16400 Australians aged 18 and over was conducted in 2006 by the Australian Bureau of statistics (Australian Bureau of Statistics, 2006). Forty percent of the women surveyed had experienced physical and/or sexual violence, nearly one in five had experienced sexual assault and nearly one in seven had experienced physical and/or sexual violence by a previous partner. In 2012, in a bigger sample (Australian Bureau of Statistics, 2013), an estimated 17% (1,494,000) of all women aged 18 years and over had experienced sexual assault since the age of 15.

Pregnant women are at greater risk of violence from intimate partners and this is associated with maternal depression in pregnancy and post-partum (Liu, 2011). Subsequent to this, women who have experienced violence during their pregnancy have been studied and their children have behavioural problems that can be measured up to the age of 4 years and beyond (Flach et al., 2011). Although mental health clinicians may be aware of the importance of violence against women as a contributing factor to the development of mental illnesses, the specific impact of early violence and comprehensive assessments of this plus holistic management approaches are yet to be widely implemented for women.

Childhood violence and mental ill health in women

Childhood maltreatment of girls is a major issue with long lasting effects. Women with a background of childhood maltreatment experience severe stress, which has a profound effect on mental and physical health for their entire life. Women with childhood maltreatment have a higher waist circumference, increased BMI and obesity, lower sex hormone binding globulin levels, higher rates of depression and greater anger issues (Rohde et al., 2008). These are tangible markers that we can measure in adult life and reveal the physical results of childhood maltreatment. Depression is associated with coronary artery calcification and in combination with obesity, increased BMI leads to a greater rate of ischaemic heart disease in women with a history of childhood maltreatment.

Borderline personality disorder – a severe mental illness in women

Chronic stress, experienced by girls who are victims of abuse, causes elevation in cortisol, which has been shown to compromise higher cognitive functioning and induce anxiety (Newcomer et al., 1999).

This is not new finding, but it has been well replicated and adds considerably to our understanding about the impact of chronic stress on learning and well-being. Female victims of trauma who are diagnosed with borderline personality disorder involving deliberate self-harm and other expressions of anger are often discriminated against within our health systems. Borderline personality disorder is a diagnosis with considerable stigma. It is a very changeable and complex amalgamation of symptoms. There appear to be an increasing number of new presentations of this condition in young women, many with a background of childhood maltreatment, early sexualization, family violence and substance use. The vague name of this severe condition “Borderline Personality Disorder” adds to the underwhelming response by the general community. A better term for this condition could be “chronic post-traumatic stress disorder” to encapsulate the dissociative, emotional dysregulation and severe anxiety aspects of borderline personality disorder. Furthermore, removing the “personality disorder” tag may help to underline that the woman is actually the victim in this situation and needs empowering assistance.

Violence against women in psychiatric inpatient units

Since the 1960s, psychiatric inpatient units in many parts of the world have housed male and female patients together (Henderson and Reveley, 1996). In most psychiatry inpatient units in Australia, women and men are managed together, with little or no gender separation in the sleeping, bathroom and activity areas. The level of illicit drug and alcohol use in the inpatient population, both prior to and during hospitalization, heightens the level of behavioural disinhibition in the inpatient population (Alterman et al., 1982). Overall, in Australian, with well-developed community psychiatric services, the illness acuity threshold for admission to psychiatric inpatient units has been raised, the length of stay has shortened and rates of readmission have increased (Quirk and Lelliott, 2001). These combined factors lead to a greater risk of aggression and assault, predominantly against women inpatients, who often already have a history of sexual abuse and other traumas (Frueh et al., 2005).

The UK adopted a policy of gender segregation on psychiatric wards (Scobie et al., 2006) in response to escalating assaults on inpatient units. Providing an Australian context, a survey conducted by the Victorian Women and Mental Health Network in 2006 found that of 75 women patients, 59% identified feeling unsafe in mixed wards and 61% identified experiencing harassment, intimidation or abuse (Clarke, 2007).

Overall, there is little research regarding the frequency and perceptions of sexual assault and harassment of women on psychiatric wards (Hatch-Maillette and Scalora, 2002); however, those studies which do exist confirm high rates of such incidents (Frueh et al., 2005). Some action on this issue has been taken across Australia. In Victoria, recent renovations in some psychiatry units in the public hospital sector have improved safety by providing separate areas for women. This is one area of violence against women that we can tackle more easily than other areas. Building women-only areas in our psychiatry inpatient units that ensure women’s safety, privacy and dignity must be a priority for all our hospitals and community psychiatry treatment facilities.

Reproductive hormones and mental health in women

There are many women who suffer with menstrual cycle related mood and anxiety disorders caused by their biological sensitivity to the impact of reproductive hormones on key neurotransmitter systems within the central nervous system.

Recently recognized by the DSM 5, premenstrual dysphoric disorder or depression (PMDD) is a severe depressive disorder that occurs on a monthly basis. It may not occur exactly in the week leading up to menstruation, but it is related to hormone changes. The oral contraceptive pill, while empowering women with reproductive control, can have adverse effects on mood. Yet very little is understood about this aspect of “the pill” which is used by millions of women worldwide. It is important to correctly identify and manage these issues in usual psychiatric practice to enable better outcomes for women with hormone related mood disturbances.

The rate of depression is increased 14 fold in 45–54-year-old women (Cohen et al., 2006), and is often related to the hormone changes of the perimenopause. Reproductive hormone levels in the brain fluctuate considerably during the perimenopause and can take up to 10 years to restabilize. Estrogen, progesterone and other sex steroids interact with serotonin, dopamine and other major neurotransmitters that determine mood. Mood and anxiety disorders related to the menopause begin much earlier than the physical body changes of menopause such as hot flushes. This is something that is under recognized by many clinicians.

Obviously, reproductive hormone shifts are only part of the changes experienced in midlife by women, but nonetheless menopause can be a time of great turbulence for many women. Mental health clinicians generally ignore the impact of menopause on the mental health of their female clients, due to a lack of knowledge about this universal life event. Menopausal women as a result receive inadequate treatment for mental disorders that can severely impact their quality of life.

Perinatal psychiatry

We need to greatly improve the understanding of the many complex factors that can lead to mood, anxiety and psychotic disorders in the antenatal and postnatal periods. The number of specialist services for pregnant women with mental disorders is totally inadequate across Australia. Even worse, the impact of such a major life event in terms of biological, psychological and social factors on many women is still not adequately researched in an integrated manner and translated into integrated clinical practice. As an example, there are times when psychotropic medications are needed in pregnancy to optimize the health of mother and baby, and yet we remain relatively uninformed about the best choice of medication for pregnant women. This is due to a chronic lack of funding for adequate research in this important area.

The future

So where to from here? A significant number of women with mental illnesses feel disempowered, invalidated and experience profound self-doubt. Neglect of their specific needs in their personal relationships, by mental health and other health systems, impairs their mental health. This appears to be at the heart of the worsening quality of life for many women experiencing mental ill health. Violence against women is a major issue that impacts deeply on women’s mental and physical health, both in the short term and very long term with broad effects on children as well. Violence against women is a big issue that must be tackled urgently and through many avenues, including drug and alcohol containment, education of men, ensuring that legal aspects to deal with the perpetrators of violence and abuse are appropriately provided and easily accessible, early identification of women’s needs for the adequate provision of care, and support for trauma victims. Assisting women to develop a stable self-identity is vital to diminish the need for excessive external validation, and thereby protects women against substance use, poor choice of life partner and enable good career options. Mental health clinicians need to adopt a holistic approach in their management of women, including a much better understanding of the effect of reproductive hormones on mental health.

Above all, we need a culture change – especially among mental health and health professionals. Let us destigmatize borderline personality disorder for a start. We need to vigorously pursue women’s mental health as a priority. Women’s mental health is an extremely poorly funded area of the mental health spectrum and unrecognized as an area of need. The specific issues that impact on women’s mental health, including violence, biological hormone issues and psychological aspects, need to be understood more in the context of recognizing that women experience mental health problems differently to men. We need different approaches and solutions for women with mental ill health.

Improving women’s mental health is critical for the quality of life of women, their families and community, and to improve outcomes for future generations. Women’s mental health is not “just women’s business”, but everyone’s business.