How do mental health issues affect women?

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Women experience a higher rate of depression than men do, and they are more likely to experience depression related to life changes, including trauma and stress, hormonal changes, and role changes. Other serious mental illnesses such as bipolar disorder and schizophrenia are as likely to occur in men as in women, but they may manifest differently in women.
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Introduction

During their lifetimes, women undergo multiple biological and psychological changes involving hormonal fluctuations, childhood trauma, physical and emotional stress, and role changes. Combined with genetic dispositions and environmental factors, these events can result in mental diseases such as depression, schizophrenia, and bipolar disorder.

During their lifetimes, women undergo multiple biological and psychological changes involving hormonal fluctuations, childhood trauma, physical and emotional stress, and role changes. Combined with genetic dispositions and environmental factors, these events can result in mental diseases such as depression, schizophrenia, and bipolar disorder.

Depression, in particular, is highly prevalent in women, with women having twice the incidence of depression as men do. The menstrual cycle, pregnancy, infertility, childbirth, and menopause are associated with depression in women. Although there are many studies examining possible links between abnormalities in sex hormone levels and depression, no conclusive relationships have been established. In the absence of identifiable markers and biochemical diagnostic tests, practitioners have to rely on careful evaluation of symptoms and the taking of medical and mood histories. A variety of diagnostic tools are available to aid in the collection of this information. For women suspected of having depression related to the menstrual cycle, childbirth, or menopause, records of how their moods and symptoms fluctuate over time are important for diagnosis.

Unlike depression, schizophrenia and bipolar disorder are equally prevalent in men and women. However, these diseases may manifest differently in women and men. There are a variety of pharmacological and cognitive and behavioral treatment options for women with mental disorders. In some cases, treatment with a single therapy works well, and in other cases, a combination of different therapies results in optimal outcomes.

Prevalence and Causes of Depression

Majordepressive disorder, which affects twice as many women as men, is characterized by decreased energy, reduced concentration, loss of interest or pleasure in activities that an individual used to enjoy, feelings of hopelessness, and disordered sleep (sleeping too much or too little). Some depressed patients may also have suicidal thoughts. Depression in women may be triggered by hormonal changes, stressful events, and seasonal fluctuations. Apart from the psychological effects, depression also causes problems in work and social functioning and is associated with comorbid diseases and a 10 to 15 percent suicide rate. Although depression has many causes, with both biological and environmental influences, there are specific conditions in women that are associated with especially high rates of depression. These conditions include the experience of childhood trauma, the presence of certain personality traits, hormonal changes associated with the menstrual cycle, infertility, the aftermath of giving birth (postpartum), and the experiences of entering into and undergoing menopause.

Women are more likely than men to experience childhood trauma such as childhood sexual abuse, which predisposes for adult depression. Certain personality traits such as strong interpersonal sensitivity and a more passive, ruminative type of coping are more prevalent in women and are also associated with depression. Some women experience depressive symptoms, mood fluctuations, and social and work impairment in the ten days before the onset of menses. This condition, termed premenstrual dysphoric disorder, is gaining recognition as a bona fide mood disorder separate from major depression. Infertility is an increasingly prevalent condition in women, with a 1995 study reporting 6.1 million infertile women aged fifteen to forty-four and 9.3 million women using infertility services in the United States. This condition is frequently associated with symptoms of depression and anxiety. Women experiencing infertility report twice the depression rates of fertile women. For women undergoing in vitro fertilization (IVF), depression appears to fluctuate with the phases of the IVF cycle. Depression rates are particularly high after a failed IVF attempt, with a high percentage (13 percent) of women having thoughts of suicide. Postpartum depression occurs in 8 to 22 percent of women, depending on the diagnostic method used. Women with a history of depression and other psychiatric illnesses, teenage mothers, and mothers living in poverty are more prone to developing postpartum depression, with the latter two groups having incidence rates of approximately 26 percent and 27 percent, respectively. The causes of postpartum depression are unclear; although there are many hypotheses and some circumstantial evidence about the role of abnormal sex hormone levels (cortisol is elevated and serum thyroid hormone suppressed in women with postpartum depression), there is a lack of reproducible and conclusive studies.

Menopause is a process that stretches out over a number of years. Perimenopause starts one year before a woman’s last period and ends one year after her last period. When the woman has gone one year without a period, she can be referred to as postmenopausal. Perimenopausal and postmenopausal women experience hormonal changes, resulting in a wide range of physical and emotional symptoms. One of these symptoms is depression, which is especially common in women with a history of depression. This may be due to the reduced levels of estrogen and other sex hormones in menopausal women.

Diagnosis of Depression

To treat women with depression, accurate diagnosis is essential. An important consideration in diagnosis is that depression manifests differently in men and women, with depressed women having more abnormal eating problems (either loss of appetite or overeating), anxiety, and atypical symptoms, while depressed men have higher rates of substance and alcohol abuse as well as higher rates of completed suicide. Women also tend to have longer depressive episodes and are more likely to have chronic or recurrent depression. Physicians make use of information such as a patient’s symptoms and history of depression and other psychiatric disorders, as well as the patient’s past responses to medications to make a diagnosis of depression. Diagnostic tools may help in the process of obtaining important information and making an accurate diagnosis.

One tool that is especially conducive to the primary care setting, where there is limited time for patient evaluations, is the two-question depression screen. This consists of the following two questions:

•In the last month, have you lost pleasure in the activities you normally enjoy?

•In the last month, have you felt sad, down, depressed, or hopeless?

If the answer is yes to both questions, the patient is considered positive by this depression screen and is likely to be depressed. Additional information should be obtained to make a definitive diagnosis of major depression.

Other, more complex diagnostics tools include the BATHE technique, the SIG-E-CAPS system, and the PHQ-9 questionnaire. The BATHE technique includes questions about life events, emotions, what is troubling the patient most, and the patient’s methods for dealing with these emotions. The last component of the BATHE technique is empathizing with the patient. The SIG-E-CAPS system determines the degree to which a patient is experiencing each of the diagnostic symptoms of depression, according to the American Psychiatric Association’s Diagnostic and Statistic Manual of Mental Disorders: DSM-5 (5th ed., 2013). The PHQ-9 contains nine questions and allows the severity of depression to be determined.

For depression occurring in specific conditions, additional symptoms and characteristics may be helpful in establishing an accurate diagnosis. Postpartum depression usually occurs in the first month postpartum and remains through the first six months postpartum, after which symptoms tend to lessen and resolve. Symptoms of postpartum depression include fatigue, sleep problems, decrease in libido, and disruptions in appetite, features that are commonly mistaken as part of the normal course of childbirth and the postpartum period. Rating scales such as the Edinburgh Postnatal Depression Rating Scale and the Postpartum Depression checklist may be helpful in diagnosing postpartum depression.

Treatment Options for Depression

Once a diagnosis of depression is made, appropriate treatment can be initiated. Depression may be treated with various medications, including those that block the reuptake of specific neurotransmitters. This class of agents includes selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs). Older antidepressants such as monoamine oxidase inhibitors (MAOIs) and tricyclic antidepressants (TCAs) may also be used, although these therapies are accompanied by more adverse effects than are SSRIs and SNRIs. There is some evidence that women respond more slowly to antidepressants than men do, and that women respond better to treatment with SSRIs, SNRIs, and MAOIs than to treatment with TCAs. Whenever antidepressants are used to treat depression, three factors are important in ensuring successful treatment outcomes: sufficient length of treatment, adequate antidepressant dose, and frequent monitoring for symptomatic or functional improvement. In addition, antidepressant treatment may be combined with psychotherapy, cognitive behavior therapy, or both if patients do not respond completely to antidepressants alone. Cognitive behavior therapy has also been shown to maintain remission and prolong the time to relapse in patients who have responded well to antidepressants.

There are additional considerations that need to be considered when treating depression in specific groups of women. Treatment with estrogen appears to improve depressive and physical symptoms in perimenopausal and postmenopausal women, but more research is required to confirm this benefit. The addition of estrogen therapy also appears to boost the response of perimenopausal women to SSRIs but not to SNRIs. In postmenopausal women, on the other hand, evidence suggests that SNRIs may promote remission more effectively than SSRIs. However, because of the potential risks of estrogen treatment, risk-benefit assessments need to be determined for each patient before initiating estrogen therapy. Prophylactic antidepressant treatment has been used in women who have given birth and who have a history of postpartum depression or recurrent depression.

Prevalence and Causes of Schizophrenia

Schizophrenia is a disease in which internal realities are separated from external realities, and thought is separated from perception. The behavior of schizophrenics appears to be motivated by inner demons that confuse senses, disrupt logical thinking, and interfere with social functioning. There is an equal incidence of schizophrenia in women and men, but the peak age of onset differs between the genders. Schizophrenia is most likely to develop in men between the ages of seventeen and twenty-seven. In women, the peak onset of schizophrenia occurs three to four years later than in men, followed by another peak around menopause. Schizophrenia afflicts all ethnic groups and social classes, although it appears to be more prevalent among people of lower socioeconomic status. Although there appears to be a genetic component, with children of schizophrenic parents having a 35 percent probability of developing the disease, cases have been reported in people who lack a family history of schizophrenia. External factors that have been suggested to play a role in schizophrenia onset include complications in birth and pregnancy, in utero exposure to a viral agent, and influenza infection. Another factor that has been recently linked to schizophrenia in women is reduced estrogen levels. Reduced estrogen and androgen levels in men have also been associated with more severe schizophrenia symptoms.

Diagnosis of Schizophrenia

Symptoms of schizophrenia can generally be classified as either positive symptoms, which are the result of an excess or abnormality of normal functions, or negative symptoms, which are the result of attenuation or loss of normal functions. Positive symptoms include hallucinations (visual, auditory, or olfactory), delusions, disjointed speech, and loss of logical association. Negative symptoms include apathy, poverty of speech (reduced speech and decreased vocabulary), social withdrawal, blunted or inappropriate emotional responses, and dysphoric mood (depressed, anxious, or irritable). The DSM-IV diagnostic criteria for schizophrenia include having two or more positive symptoms for at least one month, unless hallucinations or delusions are particularly bizarre, in which case only one positive symptom is required. Negative symptoms are harder to diagnose, because they are an absence or reduction in normal functioning. This is especially true in treated schizophrenic patients, in whom an adverse effect of antipsychotics may be a blunted affect.

Treatment Options for Schizophrenia

The most frequently prescribed treatments for schizophrenia are antipsychotics, both the first-generation antipsychotics, such as haloperidol (Haldol), and the newer atypical antipsychotics, including aripiprazole (Abilify), clozapine (Clorazil), olanzapine (Zyprexa), quetiapine (Seroquel), risperidone (Risperdal), ziprasidone (Geodon, Zeldox), and paliperidone (Invega). The newer atypical antipsychotics generally cause fewer extrapyramidal side effects (EPS), which include repetitive, involuntary movements, and prolactin elevation, which are major adverse effects that plague the first generation antipsychotics. Atypical antipsychotics, however, are associated with weight gain, hyperglycemia, and insulin resistance, with varying effects depending on the particular drug. When treated with the appropriate psychopharmacological regimens, schizophrenia can be effectively controlled, with only 10 to 15 percent of patients suffering a relapse. Without treatment, 65 to 70 percent of schizophrenic patients suffer relapses. Cognitive behavioral therapy has not been used to much success in treating schizophrenia. Women with schizophrenia may also benefit from estrogen therapy administered together with their regular medications for schizophrenia. In a study conducted in Melbourne, Australia, schizophrenic women were treated with either a combination of estradiol (a type of estrogen) administered through the skin and oral antipsychotics, or with antipsychotics alone. The women who received estradiol and antipsychotics showed improvement in positive symptoms of schizophrenia compared with women treated with antipsychotics alone.

Prevalence and Causes of Bipolar Disorder

Bipolar disorder affects women and men equally. The first manifestation of bipolar disorder usually occurs as a manic episode in men and as a depressive episode in women. Bipolar I disorder is present in 0.4 percent to 1.6 percent of the population and appears to have a genetic component, with offspring of people with bipolar disorder or depression being more likely to have bipolar disorder. A small proportion of bipolar patients experience symptoms of psychosis, such as hallucinations, delusions, and paranoia; this is often accompanied by violent behavior. In rare cases, women may experience psychosis in the first four to six weeks postpartum. This is a psychiatric emergency in which mothers exhibit obsessive thoughts about the baby, hallucinations, paranoia, and disturbed sleep.

Diagnosis of Bipolar Disorder

Bipolar disorder is underdiagnosed in both primary care and psychiatry. There are several reasons for this, including the fact that patients frequently seek medical help while in a depressive rather than a manic episode. Another reason is that approximately 50 percent of bipolar patients do not realize that they have manic symptoms, and either fail to seek treatment or do not report their manic symptoms to their practitioner. Bipolar disorder is thus often misdiagnosed as depression. The DSM-IV details diagnostic criteria for bipolar disorder, including bipolar I disorder, bipolar II disorder, and bipolar disorder with rapid cycling.

Bipolar I disorder is characterized by one or more manic episodes or mixed episodes (featuring rapidly alternating symptoms of mania and depression) for at least one week. Bipolar II disorder is characterized by one or more hypomanic episodes (a less severe form of mania) and major depression for at least one week. A manic episode or mania is defined by the DSM-5 as the presence of abnormally and persistently elevated, expansive, or irritable mood, lasting at least one week, plus three or more of the following symptoms (or four if the mood is only irritable): inflated self-esteem or grandiosity, decreased need for sleep, unusually talkative or expansive mood, flight of ideas (many ideas appearing at once or in rapid succession), distractibility, increase in goal-directed activity, and excessive involvement in pleasurable activities that have a high potential for painful consequences (for example, risky investments and sexual indiscretions). In addition, the episode must be severe enough to cause marked impairment in work or social functioning or to necessitate hospitalization to prevent harm to the self or others, or if psychotic features are present. The diagnostic criteria for a hypomanic episode is similar to that for a manic episode, with the exception that work and social functioning are not severely affected, hospitalization is not warranted, and there are no psychotic features.

Some individuals suffer from bipolar disorder with rapid cycling; in these patients, four or more manic or depressive episodes occur in one year. Some experts, however, believe that the DSM-5 criteria are overly strict and may exclude individuals who have some symptoms of bipolar disorder but do not precisely fulfill the criteria. An alternative view of bipolar disorder has been proposed that presents a spectrum of mood conditions, with depression at one end and mania at the other. All individuals fall somewhere along this spectrum. Those with some symptoms of both depression and mania are considered to be in the bipolar spectrum and may benefit from therapy.

Bipolar disorder with psychosis is typically characterized by hallucinations, delusions, or paranoia. Some people with this condition also exhibit violent behavior and are in danger of hurting themselves and others. The rare cases of women with postpartum psychosis appear to be linked to bipolar disorder. Women with a personal and family history of bipolar disorder have a higher risk of developing postpartum psychosis.

Treatment Options for Bipolar Disorder

Bipolar disorder can be most effectively treated with a combination of medications and psychotherapy, including cognitive behavioral therapy. Expert guidelines recommend that bipolar patients should typically be treated first with a mood stabilizer such as lithium, lamotrigine (Lamictal), or valproic acid (Valproate, Depakene), or with a mood stabilizer and an antipsychotic. Patients with depressive symptoms that do not respond to mood stabilizers may be treated with a combination of mood stabilizers and antidepressants. A bipolar patient should never be treated with antidepressants alone, because this can trigger rapid cycling or the emergence of a manic episode. Many bipolar patients mistakenly diagnosed as having major depression are discovered to have bipolar disorder when mania occurs in response to antidepressant treatment. A major problem for patients with mental diseases is poor adherence to medications. Bipolar patients often stop taking their medications because of a lack of insight into their condition or because of their inability to tolerate adverse effects, such as the weight gain that is often experienced with lithium, antidepressants, and some antipsychotics.

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