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InPsych 2017 | Vol 39

Cover feature : Women's mental health

Women and mental health

InPsychFrom conception the life experiences of girls and women differ from those of boys and men. Some of these pertain to the intrinsic biological differences in female and male reproductive potential, but the more prominent differences are gender-based and reflect disparities in opportunities, responsibilities and roles throughout the life course. These have consequences for all aspects of health, including mental health.

Gender-based risks to mental health have been overlooked in much prior research, clinical training, health promotion, and undergraduate and postgraduate education in psychology. Psychologists are active and influential in all these fields and, in bringing gender-informed approaches to evidence generation, psychology's contribution to knowledge translation, clinical practice, and education, are more likely to be effective.

Prevalence of severe and common mental health problems

Mental health surveys to estimate population prevalence of ‘mental disorders’ vary by location and method of ascertainment. Some are extrapolated from inpatient populations or subgroups defined by socio-demographic characteristics like age or migration status. Point, period, lifetime and life-stage prevalence data are reported, but not always specified, and the data are not always disaggregated by sex and mostly generated in high-income nations.

There is substantial variation in prevalence of common mental disorders within and between nations. Enticott, Meadows, Shawyer, Inders, and Patten (2016) found a major and significant disparity in Australia between the prevalence of high- and very-high prior-month K10 scores among people living in the most socioeconomically disadvantaged compared to the most advantaged areas. Systematic reviews conclude that in high-income settings, about 10 per cent of women who are pregnant and 13 per cent who have recently given birth (Hendrick, 1998) experience depression (O’Hara & Swain, 1996). Equivalent research about women living in low- and lower-middle income countries has only been conducted more recently, with most of the research published since 2000 (Fisher et al., 2012). A systematic review of the evidence from these settings revealed that the weighted mean average prevalence of antenatal mental disorders (15.6%, 95% CI 15.4–15.9) and postnatal disorders (19.8%, 95% CI 19.5–20.0) was substantially higher than in high-income nations (Fisher et al., 2012).

Severe mental disorders

  • Between 0.2 per cent and 2.0 per cent of adults develop schizophrenia and 0.4 per cent to 1.6 per cent develop a bipolar mood disorder across the life span. Women with bipolar disorder have more depressive episodes, more mixed affective and dysphoric manic states and higher chances of rapid cycling than men (Castle, McGrath, & Kulkarni, 2000).
  • In a systematic review of 188 studies (Saha, Chant, Welham, & McGrath, 2005) found no difference in the lifetime prevalence of schizophrenia between females and males but women tend to have a later age of onset of schizophrenia and, in addition to disturbed cognition, to present with mood or affective symptoms.
  • Women experience an increased risk of psychosis after the birth of a child but men do not.
  • Eating disorders occur most commonly among adolescent and young adult women and at rates ten times higher than among men (Abbas & Palmer, 2009). Prevalence estimates of anorexia nervosa (0.5–1.0%), bulimia nervosa (0.9–4.1%) and sub-syndromal abnormal eating behaviours (5–13%) have been derived in high-income settings.

Common mental disorders

  • Depressive, anxiety, adjustment and somatoform conditions are much more prevalent among women than men (Goldberg & Huxley, 1992).
  • Lifetime prevalence of major depression is 1.6 to 2.6 times higher among women and prevalence ratios of chronic mild depression or dysthymia in women and men is two to one (Fisher & Herrman, 2009; Kessler, 2003; Kessler et al., 1994).
  • Unipolar depression is the leading cause of years lived with disability among adults, and women carry a 50 per cent higher burden than men (Mathers, Lopez & Murray, 2006).
  • Lifetime prevalence rates of generalised anxiety disorder, panic disorder and simple phobias are two to three times higher among women than men (Kadri & Alami, 2009; Mathers, Lopez, & Murray, 2006).
  • Comorbidity or the co-occurrence of more than one diagnosable condition is associated with higher disability and observed more frequently among women than men (Astbury & Cabral de Mello, 2000; Kadri & Alami, 2009).

Substance use disorders

  • In general, women begin to use alcohol at a later age, consume less alcohol per occasion and have lower rates of alcohol dependence and heavy episodic or binge drinking than men (Mann et al., 2005). However, compared to men, women have a more rapid progression to alcohol dependence and to alcohol-related brain volume reduction.

Determinants of mental disorders among women

It is generally agreed that mental health problems are multifactorially determined by interactions among biological, psychological and social risk and protective factors. A number of hypotheses related to these determinants are proposed to explain the differences in the prevalence of mental disorders between women and men.

Biological

Causal models of psychotic disorders, which are described as ‘hypercomplex’, include that risk is associated with place and season of birth, genetic, epigenetic, intrauterine and environmental factors, but that as yet the interactions among them are unclear. Heritability is estimated to be 64 per cent for schizophrenia and 59 per cent for bipolar disorder. It is not suggested that there are different causal pathways among women and men (Sullivan, 2005) but gender is a relevant determinant of the course of disorders, via interactions with family members, health services and healthcare professionals. While acknowledging potential intercultural differences, Nasser, Walders and Jenkins (2002) propose that as expectations of educational achievements and occupational roles are often lower for females, women with schizophrenia are less likely to experience family disapproval for being unable to meet aspirations in these domains than men are. Women experience greater symptom reduction if families are involved in treatment than if they are not, and this is attributed to a reduction in rejecting behaviours by family members.

Many investigators have presumed that sex differences in rates of common mental disorders are biologically determined. Hormonal differences, especially those associated with puberty, the menstrual cycle, pregnancy and childbirth, and menopause are assumed to be responsible and to render women intrinsically vulnerable to poor mental health. Eminent public health psychiatrist Vikram Patel (2005) argues that sex differences in the prevalence of depression and anxiety cannot be attributed to “over-simplistic biological or hormonal explanations for the female excess because few biological parameters show this degree of variability” (pp. 14–15). While biological differences may contribute, in particular through different individual sensitivities to hormonal fluctuations, systematic reviews conclude consistently that depression and anxiety in women are not related to sex hormones (Astbury & Cabral de Mello, 2000; Piccinelli & Wilkinson, 2000).

Psychological

A second group of theories ascribes women’s greater vulnerability to mental disorders as attributable to individual psychological functioning. In particular, that women tend disproportionately to have maladaptive ways of thinking, to catastrophise, personalise and worry excessively, and to be ‘neurotic’ with more ’emotion-focused’ and less ‘solution-focused’ coping styles in the face of adverse life events (Astbury & Cabral de Mello, 2000; Kadri & Alami, 2009). However, critics of these theories argue that women’s propensity to worry reflects entrenched patterns of socialisation in which girls and women are confined to passive roles and are given fewer developmental opportunities to develop mastery and experience agency than their male counterparts (Astbury & Cabral de Mello, 2000).

Clinicians and researchers, who are socialised and shaped within cultures, form stereotypes about what constitutes ‘normality’ in females and males and therefore what divergence from these should be classified as abnormal. Broverman, Broverman, Clarkson, Rosenkrantz and Vogel (1970) and Heesacker et al. (1999) found that women are more likely to be perceived by health professionals as psychologically healthy if they are not competitive or aggressive, and are easily emotionally aroused.

Social

The last general explanation covers social causation hypotheses, which argue that aspects of women’s and men’s lives make them more or less vulnerable to different patterns of ill-health, including mental health. The World Health Organization’s Commission on the Social Determinants of Health (the Commission) was established to review the evidence about disparities in prevalence of non-communicable diseases, including mental disorders. It concluded that gender norms restrict the rights, opportunities and full development of all capacities among girls and women. Further, it found that discrimination, subordination and exploitation of girls and women cause excesses in the burden of disease and experiences of social suffering (World Health Organization, 2008).

Structural factors

The Commission conceptualised the structural determinants of health as those reflecting the unequal distribution of power, income, goods, and services within and between countries. Chen, Subramanian, Acevedo-Garcia and Kawachi (2005) investigated the links between structural determinants and self-reported depressive symptoms using data from surveys of more than 7700 women, and from publicly available information from the 50 American states in which they lived, including:

  • political participation (number of female elected officers, availability of a legislative body for the status of women and number of females registered to vote)
  • reproductive rights (state-supported access to legal abortion, modern contraception and fertility treatment)
  • economic autonomy (legislated right to equal employment, number of female-owned businesses and proportion of women with incomes below the poverty line)
  • employment and earning (median female income and rates of female labour-force participation).

Women who lived in states in which female political participation was high, reproductive rights recognised, and employment and economic autonomy assured, on average had significantly lower- levels of depressive symptoms. It was concluded that as it is safe to assume that women in general are biologically and psychologically the same across the states, that structural social determinants outweigh both intrinsic biological and individual psychological factors in explaining gender differences in rates of depression.

Immediate social circumstances

The Commission conceptualised that the social determinants of health pertain to people’s living circumstances, including their access to financial resources, education, health care and leisure, and the conditions of their work, housing, family relationships and community resources.

Poverty

Although definitions of poverty vary, including whether it is absolute (below the poverty line) or relative (individual or household income in relation to median population income), people occupying lower socioeconomic positions have fewer resources to secure any commodities. Women invariably occupy lower socioeconomic positions than men and are therefore more likely to experience both absolute and relative poverty (Astbury & Cabral de Mello, 2000). In the context of poverty, women are more vulnerable than men to common mental disorders (Lund et al., 2010).

Exposure to violence

Gender-based violence

Interpersonal violence is a global public health problem. Violent transgressions of the human rights of females begin prior to birth. Since the early 1980s when ultrasound technologies that could be used to determine fetal sex were first available, selective abortion of female fetuses has increased. It occurs predominantly in countries with a strong cultural preference for sons rather than daughters. However, analyses of 766,688 singleton live births between 2002 and 2007 in Ontario, Canada found that the male-to-female ratio was significantly higher among infants of women born in South Korea and India than among infants of Canadian-born women. This was interpreted as being indicative that elective abortions had been sought for female fetuses.

One of the most common violations of girls is sexual abuse. The impact of childhood sexual abuse on adult mental health has been investigated comprehensively, but is difficult to elucidate as it often co-occurs with other risks to adult mental health including neglect, exposure to conflict and emotional and physical abuse. Estimates of experiences of sexual abuse perpetrated by an adult against a child vary by definition, age cut-off and method of assessment. Disclosures are governed by shame, health literacy and availability of an adult in whom to confide (Watts & Zimmerman, 2002). It is experienced by boys, but much more commonly by girls. Anderson, Martin, Mullen, Romans, and Herbison, 1993 found that almost one-third of a randomly selected cohort of 3000 women in New Zealand reported having had at least one unwanted sexual experience by the age of 16. Finkelhor and Dziuba-Leatherman (1994) in a review of epidemiological studies, including nationally representative surveys, found that seven to 36 per cent of girls had experienced sexual abuse, most commonly perpetrated by a male who was known to them. The seriousness, severity and chronicity of exposure to childhood sexual abuse is associated with a higher risk of mental health problems (Astbury & Cabral de Mello, 2000).

Intimate partner violence

Multiple descriptors are used for violence in the intimate partner relationship: spousal abuse, wife abuse, intimate partner violence, sexualised violence, domestic violence and family violence. Violence perpetrated by an intimate partner occurs in all societies, but is most prevalent where there are rigid gender stereotypes and role restrictions, and where women’s rights are not respected and they have low status. Psychological and sexual violence in intimate partnerships are experienced much more commonly by women than by men. Intimate partner violence is a clear and consistent predictor of depression, anxiety, trauma symptoms, suicidal ideas and substance abuse among women wherever they live (Astbury & Cabral de Mello, 2000). Mental health problems are even more common than physical injuries following intimate partner violence (Kamo, 2009). In the World Health Organization Multi-Country Study of Domestic Violence and Women’s Health, women who had experienced intimate partner violence were at two to three times higher risk of suicidal thoughts and suicide attempts than those who had not (Garcia-Moreno, Jansen, Ellsberg, Heise, & Watts, 2005). Depression diminishes among women who have left violent relationships and are living in refuges, and this improvement is attributed to the benefits associated with cessation of violence, provision of professional and peer support, and an environment in which personal agency is promoted (Kamo, 2009).

Unpaid work and caregiving

Women carry primary responsibility for the unpaid work of household tasks and caregiving throughout the world. This work is not dignified with the descriptors or language of work and is therefore essentially unrecognised. Gendered roles underpin the division of routine household labour. The essential daily tasks of cleaning, food preparation, laundering clothes and the care of dependent children are stereotypically regarded as female responsibilities. The invisibility and low social value of this work means that women who are primary caregivers are described invariably in public, clinical and domestic discourses as ‘not working’ or as having ‘given up work’.

The burden of caregiving for people who are ill, frail or disabled falls disproportionately on women. Eighty per cent of caregivers are women who are diverse in age and relationship to care recipients. Most are middle aged or elderly, two-thirds are caring for someone in a different generation, many giving 24-hour care, seven days a week (Grant, Elliott, Weaver, Bartolucci, & Giger, 2002; Prince, Livingston, & Katona, 2007; Schofield et al., 1998).

There is consistent evidence that caregivers have worse mental health than non-caregivers. In the Nurses’ Health Study with 37,000 participants across 11 American states, women who provided at least 36 hours of care per week for disabled or ill spouses were six times more likely than non-caregivers to experience symptoms of depression or anxiety (Cannuscio et at., 2002). Elsewhere caregivers report consistently greater medication use and worse self-rated health, life satisfaction, affect, energy and access to social support than non-carers (Schofield et al., 1999). ‘High care’ recipient needs, problematic family functioning, lack of support and financial hardship are all associated with diminished confidence, lowered vitality and increased risk of social isolation and mental health problems among caregivers (Biadgilign, Deribew, Amberbir, & Deribe, 2008; Edwards & Higgins, 2009). These are, in turn, associated with caregiver self-reports of potentially harmful behaviour towards the care-recipient, a precursor to mistreatment (MacNeil et al., 2010).

Ioving women’s mental health

In the past two decades Australia has led the world in public policies to promote mental health and to increase access to mental health care, including pharmacological and psychological therapies. Despite these efforts there has been no reduction in the population prevalence of psychological disorders during this period (Jorm & Reavely, 2012). There is only modest consideration of violent victimisation as a risk to mental health in these national strategies. Most mental health problems among adults first emerge during adolescence. Jorm and Reavely (2012) conclude that strategies of case recognition and referral for psychiatric care are proving ineffective in reducing prevalence and that direct attention to understanding the social determinants of mental health problems (among which violent victimisation is prominent) is required in order to inform more effective population-based prevention and early intervention, and treatment strategies.

Gender-informed psychology practice

Clinical, counselling and community practice

  • Use respectful language to challenge and disrupt gender stereotypes e.g., ‘When are you starting work as a mother?’, rather than ‘When are you giving up work?’ and ‘How is work shared in your household?’, rather than ‘Does he help you?’.
  • Challenge devaluing self-descriptions such as, ‘I’m just a…’ or ‘I’m only a…’.
  • Enquire with sensitivity and skill into past and recent experiences of maltreatment and interpersonal violence, ascertaining experiences of specific behaviours and forms of abuse and not using global questions like ‘Have you experienced abuse?’.
  • Believe disclosures of any form of maltreatment.
  • Explain that most mental health problems follow experiences of humiliation and entrapment.
  • Teach cognitive- and solution- rather than emotion-focused responses to challenging circumstances.
  • Name unpaid work and recognise the impact of occupational fatigue where the home is the workplace.
  • Explore solutions that promote agency and autonomy.
  • Promote and encourage women to seek positions of responsibility and authority in community organisations, advocacy groups, workplaces and political processes.

Research

  • Assess risk and protective factors for mental health problems and the outcomes of interventions comprehensively.
  • Analyse and report data disaggregated by sex.

Education

  • Expect and demonstrate critical analysis of gender stereotypes in the literature.
  • Include consideration of the social determinants of mental health including gender-based risks in all psychology courses.

Mental health cannot be realised without justice, equality of human rights, inclusion of all, fairness of opportunity, and access to adequate resources on which to live (Mathers et al., 2006). These are intrinsically gendered. The roles and rights of women have undergone major change in some parts of the world, but women’s rights to equality of participation, personal safety, reproductive choice and freedom from discrimination are not universally recognised.

Gender-informed psychology practice requires practitioners to be aware of their own gender stereotypes and how these influence the questions they ask in clinics, classrooms and research; and their responses to what they hear and learn. It is characterised by a rights-based approach which seeks to understand circumstances and predicaments, avoid victim-blaming, and enquire about experiences of interpersonal violence, including in intimate relationships, families of origin, workplaces and communities.

The author can be contacted at jane.fisher@monash.edu

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Disclaimer: Published in InPsych on February 2017. The APS aims to ensure that information published in InPsych is current and accurate at the time of publication. Changes after publication may affect the accuracy of this information. Readers are responsible for ascertaining the currency and completeness of information they rely on, which is particularly important for government initiatives, legislation or best-practice principles which are open to amendment. The information provided in InPsych does not replace obtaining appropriate professional and/or legal advice.