Women`s Mental Health –Still Not A Priority, Still Not Good Enough

Women’s Mental Health –Still
Not A Priority, Still Not Good
Enough
Prof Jayashri Kulkarni
Monash Alfred Psychiatry Research Centre
www.maprc.org.au
Melbourne, Australia
Kulkarni,J ANZJPsychiatry 2014 48(8) :702-704
Women in 2014 –
Where are we now?
Let Us Consider the domains of :
Personal Safety
Wages
Life Expectancy
Attitudes to Female Leaders
Mental Health
Violence Against Women
• In Victoria, male intimate partner violence
is found to be the leading contributor to
death, disability and illness for women
aged 15 to 44 years (VicHealth 2004).
• Ref “Preventing violence against women”
http://www.vichealth.vic.gov.au
Violence Against Women
•
The Personal Safety Survey is a survey of 16,400 Australians aged 18 years and
over conducted by the ABS (2006).
•
Some Findings :
Well over one-third of women (40 percent) had experienced physical and/or sexual
violence.
•
Just under one in three women (29 per cent) had experienced physical assault.
•
Nearly one in five (17 per cent) had experienced sexual assault.
•
Nearly one in seven (15 per cent) had experienced physical and/or sexual violence by
a previous partner.
•
Two per cent had experienced physical and/or sexual violence by their current partner
(ABS 2006).
Violence Against Women
• Meanwhile, since the age of 15 years;
•
One-third of women (33 per cent) had experienced
inappropriate comments about their body or sex life.
•
One-quarter (25 per cent) had experienced unwanted
sexual touching.
•
Nearly one in five (19 per cent) had been stalked.
The Gender Pay Gap
In Australia: In the quarter ended February 2012, the gender pay gap stood at 17.4 %*. The average weekly ordinary
time earnings of females working full time were $1,186.90 per week, or $250.50 per week less than men, who earned an
average weekly wage of $1,437.40 per week. The figures show that the gap has reduced 0.2 percentage points (pp) from
the previous quarter and has not changed from a year ago (17.4 % in February 2011). Over the period of 18 years, the
pay gap has increased by 1.5 pp ( fig 1.)
The Gender Pay Gap
Private and public sector
The pay gap in the private sector is considerably larger than the public sector (Figure 2). In February
2012, the private sector gender pay gap was 20.8 % (-0.2 pp) over the quarter and no change over the
year, compared with 12.9 % in the public sector (+0.1 pp) over the quarter and +0.4 pp over the year.
International Comparisons
Life expectancy at birth in selected countries 2005-2010
Source: Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat; World Population
Prospects: The 2008 Revision Population Database; www.un.org
•
According to United Nations’
estimates for 2005-10,
Australian life expectancy is
ranked among the highest in
the world.
•
Life expectancy at birth for
Australian boys is exceeded
only by boys in Iceland,
Hong Kong (SAR of China)
and Switzerland.
•
Life expectancy at birth for
Australian girls is exceeded
by girls in Japan, Hong Kong
(SAR of China), France,
Italy, Switzerland and Spain.
Sexism in Politics
Women and Mental
Health
•
•
•
•
•
Women constitute the greatest percentage of the
population receiving treatments for mental illness in most
societies.
Women aged 16-24 years had nearly twice the prevalence
of 12-month Affective disorders compared with men in the
same age group (8.4% and 4.3% respectively).
Women aged 25-34 years experienced almost twice the
prevalence of 12-month Anxiety disorders, compared with
men (21% and 12% respectively).
Women still play the major role in caring for both children
and older parents and hence experience negative and
positive impacts on their own mental health as a result.
(National Survey of Mental Health and Wellbeing: Summary of
Results, 2007)
Women and Mental
Disorders
• Women have increasing rates of alcohol abuse
Women and Mental
Disorders
• Psychiatric illnesses may present very differently in
men and women because of gender differences in
social responsibilities and expectations.
• Certain psychiatric illnesses are only seen in women
such as post partum disorders.
• Diagnostic methods and labels are heavily influenced
by gender eg: Borderline Personality Disorder
Overall Assessment of the state
of Independence & Quality of
Life for Australian Women
Women’s Mental Health
Some Key Factors Impacting on Mental Health:
• Environment – Violence, Alcohol & Drugs
• Psychological – Self esteem
• Biological – Hormone factors
• COMBINATIONS OF ALL OF THE ABOVE
ENVIRONMENTAL
FACTORS
Stress and its impact on
Mental Health
•
Major environmental stresses for women include gender based
violence, abusive relationships, financial, migration.
•
Lead to both physical and mental ill health.
•
Women with a background of childhood maltreatment have higher
waist circumference, increased BMI, obesity, greater anger, lower
SHBG.
•
Depression associated with coronary artery calcification
( Midei, Jannsen 2011)
Cortisol and Memory
• Glucocorticoids
(cortisol and corticosterone)
released from the adrenal
cortex during stress have
adverse effects on cognitive
functions such as learning
and memory. Newcomer et al
(1999)
Antenatal Domestic
Violence
• Antenatal violence associated with maternal depression in
pregnancy and postpartum.
• Behavioural problems seen in the child up to 4 years.
• Due to impact of cortisol and CRF on fetal neurons.
• Profound impact of maternal depression on baby/child
development.
( Flasch et al 2011 – AVON longitudinal study of parents and
pregnancies studies and followed)
children.14,451
Stress and Hormones
in Women
• In children, stress impacts on cortisol, leading to
changes in learning capacity, attention, anxiety.
• Girls with sexual abuse history often present later with
“Borderline Personality Disorder” – marked by self harm,
high anxiety, unstable self identity, mood swings, and
can have transient psychotic symptoms.
• Sequelae of heightened sensitivity to later stresses.
Increasing rate of sexual
abuse of Australian girls
• As seen, there is a greater number of early – mid teenaged
girls with incidences of maltreatment – sexual abuse, physical
violence and/or neglect.
• The biological impact of this is long – lasting, with obesity,
poor education attainment, health services engagement due
to self harm and rage with resultant poor quality of life.
• Furthermore, the cortisol changes – may be linked to
serotonin transporter gene – so that environmental factors
such as abuse affects gene expression and may be passed
down to offspring.
Borderline Personality
Disorder
• Key symptoms – self harm, dissociation, rage, “emptiness”,
fears of abandonment, high mortality.
• Women/ girls have higher and longer duration cortisol
responses to conflict. Highest cortisol levels with sexual
abuse, and emotional abuse.
• Noted raised cortisol response in social rejection in women,
raised cortisol response in achievement stressors in men.
• Cortisol impacts fertility in women, weight gain more
prominent.
• Thought to be related to SHBG gender differences.
(Stroud 2002, Kudielka 2005)
Stress Response Neural
Circuitry
• fMRI study showed significant sex difference in
brain activity in stress response circuitry, with
changes across menstrual cycle. This suggests
that hormone regulation is important in stress
management
(Goldstein, J. 2010)
EARLY SEXUALISATION OF GIRLS
& Mental Illness
•
•
•
•
•
Premature sexualisation is linked with serious mental health problems like
eating disorders, low self-esteem and depression.
Sexualisation puts girls in danger. It contributes to exploitation and
violence against girls and women. It increases sexism, sex bias, and sexist
attitudes.
Strong evidence indicates the exposure to ideals of sexual attractiveness in
the media is associated with greater body dissatisfaction among girls and
young women.
If girls and women are seen exclusively as sexual beings rather than as
complicated people with many interests, talents, and identities, boys and
men may have difficulty relating to them on any level other than the
sexual.
( Ref Womensforum Australia 2013)
Monash Alfred Psychriatry Reseacrh Centre
Violence on our Psychiatry
Inpatient Units
• Since the 1960’s, psychiatry inpatient units in
many parts of the world have housed male and
female patients together.
• Mixed gender wards are common practice in
both the private and public sectors.
• There are a number of incidents of aggression
and assault, in our psychiatry wards
predominantly against women inpatients.
Safety for Women Inpatients
In 2006, a survey of women inpatients found that:
• 58.5% identified feeling unsafe in mixed wards,
• 61% identified experiencing harassment, intimidation or
abuse.
• 13% of women specifically identified frightening
experiences of males entering their bedrooms.
• 19% of women specifically identified witnessing significant
aggression.
• 11% of women specifically identified experiencing sexual
harassment.
• 5% of women specifically identified sexual assault.
Ref: (Clarke and colleagues, Victorian Women and Mental Health Network (VWMHN)
Gender Segregated Ward:
An Alfred Hospital Study
• To determine whether capital works making a
women only area on one ward (ground floor
ward) impacted on the number of incidents of
sexual vulnerability experienced by female
patients.
• Comparison made of the number of incidents
for six months following the opening of the
women only area on the Ground Floor with a
standard mixed ward.
Results
• Significant improvement in the number of
incidents in women’s ward.
• Significant subjective improvement in overall
women’s ward atmosphere.
• Improvement in staff – patient interaction.
• Improvement in staff awareness of women’s
needs.
• Overall significant improvement in the women
patients’ experience of hospitalisation.
• ( In press Australasian Psychiatry 2014)
Ongoing Campaign
• Need to continue lobbying for women’s
only areas in psychiatry wards.
• About to start a 10 nation study of safety
for women inpatients in psychiatry wards.
• A “Bricks & Mortar” solution is possible like
in the UK.
PSYCHOLOGICAL
FACTORS
Self Esteem in Women
• A point of concern with poor self esteem linked to
depression, anxiety disorders that are more
common in women.
• The “Fraud” syndrome – female dominant.
• Stress of appearance, performance.
• Rumination wrecks sleep, time waster.
BIOLOGICAL
FACTORS
Hormones & Mental
Ilness in Women
• PMS
• PMDD
• Perimenopausal Depression/ Late Onset
Borderline
• Psychosis relapse
• Depression and the Pill
ESTROGEN & MENTAL ILLNESS
•
•
Growing appreciation for the positive
impact estrogen, a potent
neurosteroid can have on symptoms
of severe mental illnesses
Illnesses include, depressive
disorders – postnatal, premenstrual
& perimenopausal depression plus
schizophrenia
ESTROGEN
‘Estrogen Action’
• Estrone E1 – most abundant; 50% ovary 50%
peripheral conversion of androstenedione & others
(from ovary & adrenals)
• Estradiol E2 – most potent; from ovary
• Estriol E3 – from placenta
ESTROGEN RECEPTORS
Clinical Pharmacology & Therapeutics (2011) 89 1, 44–55. doi:10.1038/clpt.2010.226
Estrogen Receptors: Therapies Targeted to Receptor Subtypes S Nilsson1,2 and J-Å Gustafsson2,3
From: An Update on Estrogen: Higher Cognitive Function, Receptor Mapping, Neurotrophic Effects
J Neuropsychiatry Clin Neurosci. 2001;13(3):313-317 doi:10.1176/appi.neuropsych.13.3.313
Figure Legend:
New areas in which estrogen receptors have been confirmed in primates are illustrated on a sagittal drawing of the human brain
(Cover) and on axial human brain slices (Figure 1)Structures are color-coded by function: memory (blue: basal forebrain,
hippocampal formation, mammillary body); emotion (pink: amygdala); movement (green: subthalamic nucleus, substantia nigra).
Copyright © American Psychiatric Association.
All rights reserved.
Date of download:
4/30/2012
ESTROGENS AND THE CNS
•
Within CNS, estrogen acts as a neuroprotective agent
 Genomic (delayed)
 mediated by the activation of estrogen receptors and gene
transcription
 Non-genomic (rapid)
ESTRADIOL
Prevention of
cell death
Axonal
sprouting
Regeneration
Synaptic
transmission
NEUROPROTECTI
ON
Figure reproduced from Garcia-Segura et al. (2001) Progress in Neurobiology, 63, 29 - 60
ESTROGENS AND
NEUROTRANSMITTERS
•
•
•
•
Dopamine – a major neurotransmitter implicated in the
symptoms of delusions.
Serotonin – a major neurotransmitter implicated in the
symptoms of hallucinations and depression.
Cholinergic system - plays an important and large role in
memory
Estrogen modulates both Dopamine and Serotonin and
enhances the cholinergic system in the CNS. It can act like
an antipsychotic medication and also has antidepressant
effects.
ESTROGEN AS A TREATMENT FOR
MENTAL ILLNESS – LITERATURE
• Women with a diagnosis of postnatal depression, including
those resistant to antidepressants, have also shown significant
improvements in mood after receiving transdermal estradiol
(200 mcg for three months)
A. J. Gregoire, R. Kumar, B. Everitt, A. F. Henderson, J. W. Studd, Lancet 347, 930 (Apr 6, 1996).
• Similarly, promising results have been demonstrated using
transdermal estradiol to treat depression in perimenopausal
women (100 mcg for three months(
C. N. Soares, O. P. Almeida, H. Joffe, L. S. Cohen, Arch Gen Psychiatry 58, 529 (Jun, 2001).
“Estrogen is the hormone of the
new Millennium”
- George Fink 2000
3 DEPRESSIVE DISORDERS &
ESTROGEN TREATMENT
• Depression and The Oral Contraceptive
• PMDD
• Perimenopausal Depression
Premenstrual Dysphoric Disorder
(PMDD)
•
•
•
•
•
•
•
•
A real entity – included in the DSM5
80% of women have some challenge relating to menses, 40% have
PMS,10-15% have PMDD
CRITERIA FOR PREMENSTRUAL DYSPHORIC DISORDER A. In most
menstrual cycles during the past year, five (or more) of the following
symptoms were present for most of the time during the last week of the
luteal phase, began to remit within a few days after the onset of the
follicular phase, and were absent in the week postmenses, with at least
one of the symptoms being either (1), (2), (3), or (4):
Markedly depressed mood, feelings of hopelessness, or self-deprecating
thoughts
Marked anxiety, tension, feelings of being “keyed up” or “on edge”
Marked affective lability (e.g., feeling suddenly sad or tearful or increased
sensitivity to rejection)
Persistent and marked anger or irritability or increased interpersonal
conflicts
Decreased interest in usual activities (e.g., work, school, friends, hobbies)
PMDD TREATMENTS
•
•
For severe PMDD ( NOT PMS, not another psychiatric
condition), vitamins, herbal treatments, lifestyle changes
are ineffective
Hormone treatments very important – suggest trying first
line:
- A) OCP – continuous. We favour “Zoely” – natural estradiol
+nomegestrol acetate
- B) OCP plus estradiol
PMDD
2nd Line treatments:
•SSRIs – use short half life drugs, less agitating ones –
eg:citalopram, sertraline. Test with pharmacogenomic testing
www.genesfx.com.au
3rd Line treatments
•SSRI + estradiol
•SSRI + aldosterone
4th Line treatments
•GnRh agonist drugs (eg: Synarel) + add back estradiol (chemical
menopause)
Perimenopausal Depression
PERIMENOPAUSE
DEPRESSIVE SYMPTOMS
•
•
•
•
•
•
•
•
•
Plummeting self – esteem
Paranoid ideation
Aggressive
Disconnection
No libido
Irritable / agitated
Weight gain
Poor sleep (compounded by hot flushes)
Memory/ concentration changes
PERIMENOPAUSAL
DEPRESSION
• Very high incidence of first onset depression in
perimenopause. Even higher relapse risk of depression in
women with past history
• Declining/ chaotic HPG axis function occurring from age 4555. CNS changes first – up to 5 years before hot flushes,
amenorrhoea
• Depression continues to decline in the postmenopause group
• Reinforces the theory that it is the change in E2 that may
cause depression rather than stable low levels
PERIMENOPAUSE DEPRESSION
MANAGEMENT
•
•
•
•
•
Depression in middle aged – multifactorial
Antidepressants or HRT?
Sleep regulation
Natural medicines
Psychotherapy
CASE STUDY
•
•
•
•
Jenny is a 53 year old public
servant, who has three children
aged 31, 21 and 12.
She divorced 2 years ago after
being married for 29 years. Her
ex- husband is the father of her 3
children.
Presented with depression plus
self harm + “out of character”
sexual behaviour, drugs
Symptoms were tiredness,
tearfulness, poor sleep pattern,
weight gain
CASE STUDY
Past History/ Family
• Lonely and “unreal”.
• Has two siblings – younger sister
and older brother
• Absent father who drank alcohol
to excess on occasion and then
was verbally abusive. Father was
a politician and was a
parliamentarian for 12 years.
• Mother housewife,depressed “A
pathetic person”
CASE STUDY
•
•
•
•
•
Age 15 – sexual experience with
several boys. The “class tramp”
label.
During an election campaign, a
photo was taken of her in a
drunken, semi clad state and her
father managed to stop its
publication
Jane sent to Catholic boarding
school
Nearly expelled on several
occasions for drinking, having
parties in her room and for
running away to meet boys
Finished year 12. Went on to do
Arts at Uni
CASE STUDY
•
•
•
•
Jenny met David when in Uni. He
was doing Teaching degree/Arts
“He stabilized me”.
Relationship was serious, then
Jane became pregnant at age 22.
Her family insisted they marry
and “I wanted to anyway”
“We were blissfully happy for a
long while, especially when the
kids were young”
CASE STUDY
•
•
•
•
Many descriptions of feeling
fragmented, occasional episodes
of emptiness. Dealt with by
“keeping busy, and being needed
by my kids”. Finished Arts degree
Worked in Public Service and
promoted over the years
“I juggled it all and did it well”
Relationship stresses over the
years
CASE STUDY
•
•
•
•
•
Jenny had unplanned pregnancy
with youngest son – “perhaps I
wanted to go back to a happy
time – being pregnant”
Happier til son aged 8.
Jenny, aged 47, had an affair with
workmate - for few months.
“I never told David and I don’t
think he ever knew – but I just got
angrier and angrier with him”
David left after 2 years of
ferocious fighting. “I kept
provoking him – I was horrible
CASE STUDY
Treatment:
• HRT - Tibolone
• Low dose quetiapine (25mg
nocte)
• Psychotherapy
CASE STUDY
•
•
Jenny’s latest comment : “I feel
real, and nearly whole again”
David and Jenny have now
established a routine of Sunday
brunch together and are
discussing reconciliation
WHAT HAPPENED TO JENNY?
•
•
-
•
-
Biological
Hormone shifts related to
perimenopause
Depression related to change in brain
neuroendocrinology
Psychological
Unmet needs as a child, inconstant
attachment, grandmother’s death,
acting out
Social
Life roles, relationship changes, work
PERIMENOPAUSE – UNCOVERING
THE BURIED PROBLEMS
• Early trauma/ loss/ poor attachment
• Protection by E2 / Drive to “work and love”
• Reproduction = biological neuroprotection plus role “to
protect/ nurture”
• End of reproduction - loss of biological “protection” plus
change in role plus new traumas
• Late onset borderline personality disorder plus depression
PERIMENOPAUSE - UNCOVERING
THE BURIED PROBLEMS
•
•
•
•
Dormant Bipolar Affective Disorder Type 2/ Borderline PD
Stabilised schizoaffective disorder becomes destabilised
Previous depression related to HPG axis shifts
A biopsychosocial approach is imperative
Mood & Oral Contraceptives - Is There a
Relationship?
An Observational Trial With Australian
Women
AIMS
• To determine whether
– The use of hormonal contraception is associated with
negative mood change
– Progestogen-only contraceptives are more or less likely to
be associated with negative mood change than combined
oral contraceptives
– Newer progestogenic compounds are less likely to be
associated with negative mood change than older types of
progestin
• To establish any predisposing factors for hormonal
contraceptive-related negative mood change
STUDY DESIGN
• Observational cross-sectional design
• Collection of both quantitative and qualitative data
– Quantitative data from standardised, self-administered
mood rating scales
– Qualitative data from an interview process
• Variables
– Independent variable = type of contraceptive medication
being (or not being) used
– Dependent variables = scores on a battery of mood rating
scales and the GAF
PARTICIPANT GROUPING &
NUMBERS
EE2 DOSE VS. NON-USERS
• Significant differences in BDI, CESD-R, POMS and GAF scores
between different EE2 dose groups and non-users (p < 0.05)
• Users of 20g COCPs had significantly higher mean scores on
all mood rating scales than all other groups (p < 0.05, partial
eta2 > 0.15)
• Users of 20g COCPs had significantly lower mean GAF score
than all other groups ( p < 0.05, partial eta2 = 0.12)
• SUMMARY: Low dose estradiol pill (20g) assoc with more
depression. Older progestins also assoc with more depression
WHERE TO FROM HERE?
Integration of Society
• We need to tackle the alcohol and drug culture – to
decrease violence, increase productivity, for good mental
and physical health.
• Pursue Women’s Health and Mental Health agendas
vigorously.
• Continue with “White ribbon” programmes and more.
• Pursue gender equality in pay, social responsibility and
equity domains.
The Future
• Increasing worldwide change to improve
women’s mental health.
• Key priorities to decrease violence, poverty.
• Raising awareness that women’s mental health
is a priority. It is everyone’s business and
needs separate, better attention
• Improving women’s outcomes is intimately tied
to improving the next generations’ outcomes.
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