Women Hold Up Half the Sky: Women and Mental Health Research
Mental illnesses affect women and men differently-- some disorders are more common in women, and some express themselves with different symptoms. Scientists are only now beginning to tease apart the contribution of various biological and psychosocial factors to mental health and mental illness in both women and men. In addition, researchers are currently studying the special problems of treatment for serious mental illness during pregnancy and the postpartum period. Research on women's health has grown substantially in the last 20 years. Today's studies are helping to clarify the risk and protective factors for mental disorders in women and to improve women's mental health treatment outcome.
In the U.S., nearly twice as many women (12.0 percent) as men (6.6 percent) are affected by a depressive disorder each year. 1 These figures translate to 12.4 million women and 6.4 million men. 2 Depressive disorders include major depression, dysthymic disorder (a less severe but more chronic form of depression), and bipolar disorder (manic-depressive illness). Major depression is the leading cause of disease burden among females ages 5 and older worldwide. 3
Depressive disorders raise the risk for suicide . Although men are 4 times more likely than women to die by suicide, 4 women report attempting suicide about 2 to 3 times as often as men. 5 Self-inflicted injury, including suicide, ranks 9th out of the 10 leading causes of disease burden for females ages 5 and older worldwide. 3
Research shows that before adolescence and late in life, females and males experience depression at about the same frequency. 6,7 Because the gender difference in depression is not seen until after puberty and decreases after menopause, scientists hypothesize that hormonal factors are involved in women's greater vulnerability. Stress due to psychosocial factors, such as multiple roles in the home and at work and the increased likelihood of women to be poor, at risk for violence and abuse, and raising children alone, also plays a role in the development of depression. 8
While many women report some history of premenstrual mood changes and physical symptoms, an estimated 3 to 4 percent suffer severe symptoms that significantly interfere with work and social functioning.9,10 This impairing form of premenstrual syndrome, also called Premenstrual Dysphoric Disorder (PMDD), appears to be an abnormal response to normal hormone changes.11 Researchers are studying what makes some women susceptible to PMDD, including differences in hormone sensitivity, history of other mood disorders, and individual differences in the function of brain chemical messenger systems. Antidepressant medications known to work via serotonin circuits are effective in relieving the premenstrual symptoms.12,13 Women with susceptibility to depression may be more vulnerable to the mood-shifting effects of hormones.
Postpartum depression is a serious disorder where the hormonal changes following childbirth combined with psychosocial stresses such as sleep deprivation may disable some women with an apparent underlying vulnerability. NIMH research is evaluating the use of antidepressant medication and psychosocial interventions following delivery to prevent postpartum depression in women with a history of this disorder.
NIMH researchers recently found that women who suffer depression as they enter the early stages of menopause (perimenopause) may find estrogen to be an alternative to traditional antidepressants. The efficacy of the female hormone was comparable to that usually reported with antidepressants in the first controlled study of its direct effects on mood in perimenopausal women meeting standardized criteria for depression. 14
Anxiety disorders, which include panic disorder, obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), phobias, and generalized anxiety disorder, affect an estimated 13.3 percent of Americans ages 18 to 54 in a given year, or about 19.1 million adults in this age group. 15 Women outnumber men in each illness category except for OCD and social phobia, in which both sexes have an equal likelihood of being affected. 16,17
Results from an NIMH-supported survey showed that female risk of developing PTSD following trauma is twice that of males. 18 PTSD is characterized by persistent symptoms of fear that occur after experiencing events such as rape or other criminal assault, war, child abuse, natural disasters, or serious accidents. Nightmares, flashbacks, numbing of emotions, depression and feeling angry, irritable, or distracted and being easily startled are common. Females also are more likely to develop long-term PTSD than males and have higher rates of co-occurring medical and psychiatric problems than males with the disorder. 19
Females comprise the vast majority of people with an eating disorderanorexia nervosa, bulimia nervosa, or binge-eating disorder.20 In their lifetime, an estimated 0.5 to 3.7 percent of females suffer from anorexia and an estimated 1.1 to 4.2 percent suffer from bulimia.20 An estimated 2 to 5 percent experience binge-eating disorder in a 6-month period.21,22 Eating disorders are not due to a failure of will or behavior; rather, they are real, treatable illnesses. In addition, eating disorders often co-occur with depression, substance abuse, and anxiety disorders, and also cause serious physical health problems. 20 Eating disorders call for a comprehensive treatment plan involving medical care and monitoring, psychotherapy, nutritional counseling, and medication management.20 Studies are investigating the causes of eating disorders and effectiveness of treatments.
Schizophrenia is the most chronic and disabling of the mental disorders, affecting about 1 percent of women and men worldwide. 23 In the U.S., an estimated 2.2 million adults ages 18 and older, about half of them women, have schizophrenia. 2 The illness typically appears earlier in men, usually in their late teens or early 20s, than in women, who are generally affected in their 20s or early 30s. 13 In addition, women may have more depressive symptoms, paranoia, and auditory hallucinations than men and tend to respond better to typical antipsychotic medications. 24 A significant proportion of women with schizophrenia experience increased symptoms during pregnancy and postpartum. 25
The main risk factor for developing Alzheimer's disease (AD), a
dementing brain disorder that leads to the loss of mental and physical functioning and eventually to death, is increased age. 26 Studies have shown that while the number of new cases of AD is similar in older adult women and men, the total number of existing cases is somewhat higher among women. 26,27 Possible explanations include that AD may progress more slowly in women than in men; that women with AD may survive longer than men with AD; and that men, in general, do not live as long as women and die of other causes before AD has a chance to develop. Research is being conducted to find ways to prevent the onset of AD and to slow its progression.
Caregivers of a person with AD are usually family members- often wives and daughters. 27 The chronic stress often associated with the caregiving role can contribute to mental health problems; indeed, caregivers are much more likely to suffer from depression than the average person. 28 Since women in general are at greater risk for depression than men, female caregivers of people with AD may be particularly vulnerable to depression.
1 Regier DA, Narrow WE, Rae DS, et al. The de facto mental and addictive disorders service system. Epidemiologic Catchment Area prospective 1-year prevalence rates of disorders and services. Archives of General Psychiatry, 1993; 50(2): 85-94.
2 Narrow WE. One-year prevalence of mental disorders, excluding substance use disorders, in the U.S.: NIMH ECA prospective data. Population estimates based on U.S. Census estimated residential population age 18 and over on July 1, 1998. Unpublished.
3 Murray CJL, Lopez AD, eds. The global burden of disease and injury series, volume 1: a comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. Cambridge, MA: Published by the Harvard School of Public Health on behalf of the World Health Organization and the World Bank, Harvard University Press, 1996.
4 Hoyert DL, Kochanek KD, Murphy SL. Deaths: final data for 1997. National Vital Statistics Report, 47(19). DHHS Publication No. 99-1120. Hyattsville, MD: National Center for Health Statistics, 1999.
5 Weissman MM, Bland RC, Canino GJ, et al. Prevalence of suicide ideation and suicide attempts in nine countries. Psychological Medicine, 1999; 29(1): 9-17.
6 Birmaher B, Ryan ND, Williamson DE, et al. Childhood and adolescent depression: a review of the past 10 years. Part I. Journal of the American Academy of Child and Adolescent Psychiatry, 1996; 35(11): 1427-39.
7 Bebbington PE, Dunn G, Jenkins R, et al. The influence of age and sex on the prevalence of depressive conditions: report from the National Survey of Psychiatric Morbidity. Psychological Medicine, 1998; 28(1): 9-19.
8 Sherrill JT, Anderson B, Frank E, et al. Is life stress more likely to provoke depressive episodes in women than in men? Depression and Anxiety, 1997; 6(3): 95-105.
9 Johnson SR, McChesney C, Bean JA. Epidemiology of premenstrual symptoms in a nonclinical sample. I. Prevalence, natural history and help-seeking behavior. Journal of Reproductive Medicine, 1988; 33(4): 340-6.
10 Rivera-Tovar AD, Frank E. Late luteal phase dysphoric disorder in young women. American Journal of Psychiatry, 1990; 147(12): 1634-6.
11 Schmidt PJ, Nieman LK, Danaceau MA, et al. Differential behavioral effects of gonadal steroids in women with and in those without premenstrual syndrome. New England Journal of Medicine, 1998; 338(4): 209-16.
12 Yonkers KA, Halbreich U, Freeman E, et al. Symptomatic improvement of premenstrual dysphoric disorder with sertraline treatment. A randomized controlled trial. Sertraline Premenstrual Dysphoric Collaborative Study Group. Journal of the American Medical Association, 1997; 278(12): 983-8.
13 Pearlstein TB, Stone AB, Lund SA, et al. Comparison of fluoxetine, bupropion, and placebo in the treatment of premenstrual dysphoric disorder. Journal of Clinical Psychopharmacology, 1997; 17(4): 261-6.
14 Schmidt PJ, Nieman L, Danaceau MA, et al. Estrogen replacement in perimenopause-related depression: a preliminary report. American Journal of Obstetrics and Gynecology, 2000; 183(2): 414-20.
15 Narrow WE, Rae DS, Regier DA. NIMH epidemiology note: prevalence of anxiety disorders. One-year prevalence best estimates calculated from ECA and NCS data. Population estimates based on U.S. Census estimated residential population age 18 to 54 on July 1, 1998. Unpublished.
16 Robins LN, Regier DA, eds. Psychiatric disorders in America: the Epidemiologic Catchment Area Study. New York: The Free Press, 1991.
17 Bourdon KH, Boyd JH, Rae DS, et al. Gender differences in phobias: results of the ECA community survey. Journal of Anxiety Disorders, 1988; 2: 227-41.
18 Breslau N, Davis GC, Andreski P, et al. Traumatic events and posttraumatic stress disorder in an urban population of young adults. Archives of General Psychiatry, 1991; 48(3): 216-22.
19 Breslau N, Davis GC, Andreski P, et al. Posttraumatic stress disorder in an urban population of young adults: risk factors for chronicity. American Journal of Psychiatry, 1992; 149(5): 671-5.
20 American Psychiatric Association Work Group on Eating Disorders. Practice guideline for the treatment of patients with eating disorders (revision). American Journal of Psychiatry, 2000; 157(1 Suppl): 1-39.
21 Spitzer RL, Yanovski S, Wadden T, et al. Binge eating disorder: its further validation in a multisite study. International Journal of Eating Disorders, 1993; 13(2): 137-53.
22 Bruce B, Agras WS. Binge eating in females: a population-based investigation. International Journal of Eating Disorders, 1992; 12: 365-73.
23 Report of the international pilot study of schizophrenia. Volume 1. Geneva, Switzerland: World Health Organization, 1973.
24 Hafner H, Maurer K, Loffler W, et al. The influence of age and sex on the onset and early course of schizophrenia. British Journal of Psychiatry, 1993; 162: 80-6.
25 Miller LJ. Sexuality, reproduction, and family planning in women with schizophrenia. Schizophrenia Bulletin, 1997; 23(4): 623-35.
26 National Institute on Aging. Progress report on Alzheimer's disease, 1999. NIH Publication No. 99-4664. Bethesda, MD: National Institute on Aging, 1999.
27 McCann JJ, Hebert LE, Bennett DA, et al. Why Alzheimer's disease is a women's health issue. Journal of the American Medical Women's Association, 1997; 52(3): 132-7.
28 Schulz R, O'Brien AT, Bookwala J, et al. Psychiatric and physical morbidity effects of dementia caregiving: prevalence, correlates, and causes. Gerontologist, 1995; 35(6): 771-91.
Source: NIH Publication No. 01-4607