Women and mental health is a vast topic and we do not presume to cover all aspects of it within the confines of this essay. We will, however, explore a number of relevant themes in some detail by particular reference to peer reviewed literature on the subject. In doing so, we recognise the fact that it is vital to make a critical assessment of the literature as, in any branch of medically related work, it is vital to acquire a firm evidence base. (Berwick D 2005).
Much of the literature that we have assessed for consideration amounts
to little more than simple opinion on a subject, and as such, is only
of use as an opinion rather than a fact that has been subject to proper
scientific scrutiny. (Green & Britten 1998). In this essay we take
note of opinions but aim to present verifiable facts.
Mental illness in general terms
We do know that mental illness
in the UK is associated with a significant burden of both disability
and morbidity in general, and this will vary with both the severity of
the illness at any given time and also the nature of the illness
itself. (Annandale, E1998). A number of studies have shown that, as a
lifetime experience, nearly half of the population will suffer some
kind of quantifiable psychological or psychiatric disorder. (Bayer,
1987)
The actual incidence of morbidity is hard to assess accurately. Firstly
because doctors tend to under-diagnose positive psychiatric morbidity
and secondly because there is a general reluctance to seek medical help
with this type of complaint. It has been suggested that only 40% of
people with a significant mood, anxiety or substance misuse problem
will actually seek help in the first year of the problem becoming
apparent. (Boswell G & Poland F 2004)
In the context of this essay we should note that, in broad terms, the
overall rates of psychiatric disorder are approximately equal in both
men and women, but the significant differences between the sexes are
found in the patterns of how the disorders manifest themselves. (Castle
DJ et al 2001)
It is also fair to comment that an examination of the literature seems
to suggest that the morbidity which appears to be associated with
mental disorders has been the subject of more attention and research
than the actual determinants and mechanisms that appear to be
significant in both the promotion of mental health, and protection
against mental illness, together with those factors which appear to
give a degree of resilience against stress and other adversities which
are gender specific. ( Rogers & Pilgrim 2002).
Gender differences
We do know that a number of psychiatric
illnesses have different rates of presentation. Some, such as
schizophrenia have gender differential modes of presentation and
illness trajectory (Kornstein S & Clayton A 2002).
Just why should this be? A number of authors point to various features
of gender difference that may account for this difference. Castle (et
al 2001) spend a large proportion of their book differentiating the
male and female brain in terms of the effect of testosterone on
neurodevelopment. While this is undeniably a source of difference, it
would appear that their argument rather falls apart when other authors
point to the fact that the differences that we are considering here are
actually better correlated with both gender and culture than actual
biological sex. (Pattison 2001)
Gender has much deeper socio-economic and cultural implications than
simply a sexual consideration. It is gender that is one of the prime
determinants of the differential power and status factors that
influence the degree of control that both men and women have over their
socio-economic situation and social position in their own cultural
hierarchy. This, in turn, determines both their susceptibility, and
indeed their exposure, to significant mental health risks. (Busfield J
1996)
We have already alluded, in passing, to the differential incidence of
various illnesses. We know that depression and anxiety related patterns
of illness, together with those that have a significant element of
somatosisation of their symptomatology, are more likely to occur in
women than men with a ratio of about 3:1. Illnesses such as reactive
(unipolar) depression is found to occur with double the frequency in
women, when compared to men. This particular disease process is
statistically the most common mental health problem that affects women,
but it also tends to be more persistent in women both in terms of
longevity of the episode and in frequency of relapse. (APA 1994)
Gender differences are also apparent when it comes to a consideration
of substance abuse, however it is usual to find the reverse ratio in
most studies on the subject. Alcohol abuse and dependence will occur
2.5 times more frequently in men than women. It is not certain whether
these changes are primarily cultural or biological, as they do vary to
a degree between different cultures, but the sex difference is
generally found. (Kraemer S 2000)
Unlike the unipolar depressive disorder, bipolar disorder, like
schizophrenia, has no differential rate of presentation although there
are defined differences in the disease trajectory in terms of age at
presentation, the frequency and nature of the first rank psychotic
symptoms. This may have a bearing on the longer term sequelae such as
social readjustment and long term disease process outcome. (Kaplan HI
et al 1991)
It is also a demonstrable fact that the degree of morbidity rises
exponentially with multiple degrees of comorbidity. In studies on the
subject, women outnumber men in this area as well.
This consideration then begs the question, “just what are the gender
specific different factors that determine mental health or the
susceptibility to mental illness?”
We have already suggested that many factors are not purely biological,
and a number of different papers point to the fact that many of the
triggers and stressor factors which can be associated with mental
illness, are also gender specific. The gender based role in a
particular society ( certainly in the UK), will produce different
exposure to different stressors and negative life experiences. Equally
it will give different exposure to the protective effect of a positive
life experience. (Moynihan C 1998)
We can cite specific examples in this regard. Women are frequently the
domestic target of male-based violence. This factor is probably
important in the fact that women have the highest incidence of post
traumatic stress disorder (PTSD).(Jewkes R 2002)
There is still a gender gap in the earnings tables, both in total
lifetime earnings and also in average earning levels. This implies that
women tend to be less financially independent and more
socio-economically deprived (on average) that males. In many societies
this is also translated into lower social status that the male and this
is often also associated with fewer social freedoms – all of which may
be associated with an increasing psychological co-morbidity. (Gordon G
et al 2001)
There is also the consideration that in the majority of cultures, it is
the woman who typically bears the major impact of care in the family,
not only of the children, but also of the elderly relatives, and this
frequently produces constant and unremitting levels of stress, which
again, is recognised as a major trigger for psychological morbidity.
(Davies TW 1994)
All of these factors, when considered collectively, appear to exert a
significant influence on the overall patterns of gender specific
distribution of psychiatric morbidity in the community at large. These
factors are generally exacerbated (and the gender differences
accentuated), when there are sudden and unpredicted fluctuations in the
general income level or the stability of the social strata.(Murray M
1995).
We have already alluded to the fact that the rates of diagnosis by the
healthcare professionals tend to underestimate the true incidence of
psychiatric morbidity in the community. It is likely that the
healthcare professional can also skew the results in a different way.
We know, from a number of studies, that gender bias occurs in both the
diagnosis and treatment of mental conditions. Doctors have been shown
to be more likely to make a diagnosis of depression in women than in
men even when the cohorts have been previously matched in terms of
symptom severity and when the present with matched symptoms. Doctors
are also statistically more likely to prescribe psychotropic medication
for women than for men. (Bhui K et al 1995),
Why should this be? Part of the reason is that women have demonstrably
different patterns of presentation of psychological morbidity than men.
Women are more likely to be open and to disclose their problems to a
healthcare professional than a man. Women tend to disclose problems to
a primary healthcare team professional (and therefore be treated in the
community), whereas a man is statistically more likely to present to a
secondary care specialist (which is possibly why men have a
disproportionately high representation of inpatient care) (Boswell G
& Poland F 2004)
This may be due to the general perception of the gender stereotype. It
is more “socially acceptable” for a man to have an alcohol problem.
Some would argue that Dean Martin made a career out of his drinking.
Women are “expected” to be more emotionally labile than men, and the
typical male stereotype is to be stoical and unflinching in the face of
adversity. These patterns of behaviour in both the general public, as
well as in the perceptions of healthcare professionals, go a long way
towards perpetuating many of the gender inequalities that we have
examined thus far. It is certainly possible that they may be
responsible, at least in part, for the apparent varying susceptibility
of the sexes to different illness patterns. (Bandarage A 1997)
Conclusions
In this essay we have considered some of the
evidence that related to the gender differences in the presentation and
trajectory of mental illness. We note that the WHO recognises many of
these factors on a global scale and has put forward three factors that
it considers to be protective in the development of mental morbidity
(especially depression).
In the light of our discussion above, it can be seen that, although the
WHO addresses the points generally to the whole population, they,
arguably, have a greater relevance for women than men, certainly in our
current culture in the UK.
- 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.
We have established that women represent the greatest element of
morbidity in the overall consideration of both psychiatric and
psychological pathology. This may a real finding, but we note that
there is a considerable element of bias in the figures, both from the
differential rates of presentation and also relative gender bias that
appears to exist in the healthcare professionals in general.
There is also additional bias in the fact that women have a longer life
expectancy than men and therefore have more “life chances” to present
with psychiatric morbidity, quite apart from the fact that the
morbidity rates increase with advancing age, primarily associated with
the dementias and various organic brain syndromes (Russell D 1995).
On a world wide basis, women are more susceptible to the destabilising
effect of war, economic instability and natural disasters which add to
the burden of negative life experiences that are a prime risk factor
for the development of mental illness. (Brown GW 1978).
We have also identified the fact that the woman’s position in her
particular culture or society is also a very significant factor in
generating gender differences. There are gender differences in society
and therefore it clearly comes as no surprise that these differences
are reflected in the gender differences in health generally. The woman,
in the majority of cultures is expected to assume a number of different
roles (sometimes simultaneously), each with their own pressures. The
unremitting role of the carer is common and clearly a cause of chronic
stress. This can be both combined with, and exacerbated by, situations
of comparative poverty which again magnifies the effect of all of the
negative stressors which can mitigate towards mental ill-health. Other
factors such as sexual abuse can also play a gender specific role in
the aetiology of mental illness.
In the words of Masson, (J.M. 1986) in his historical overview of the field of psychological disability:
There is a positive relationship between the frequency and severity of
such social factors and the frequency and severity of mental health
problems in women. Severe life events that cause a sense of loss,
inferiority, humiliation or entrapment can predict depression.
Some authors point to the difficulty of communication of the patient
with the healthcare professional. In areas where there are cultural or
perceived socio-economic differences, it is accepted that this may be a
significant factor (Platt, FW & Gordon GH 1999).
If difficulty of communication is a problem, the conscientious
healthcare professional should endeavour to be aware of it and minimise
it’s potential impact with strategies such as a translator or perhaps a
more empathetic or understanding approach. One could hope that this
would go some way to reducing the burden of disclosure from a patient
who may already have a significant burden of psychological illness
themselves.
All in all, we can conclude that the whole area of gender, in relation
to mental health problems, is both difficult, multifactorial and
complex. A significant amount of work has been done in this field, but
there is clearly scope for a great deal more.
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