Gender disparities in mental health

Abstract

This paper examines current evidence regarding rates, risk factors, correlates and consequences of gender disparities in mental health. Gender is conceptualized as a structural determinant of mental health and mental illness that runs like a fault line, interconnecting with and deepening the disparities associated with other important socioeconomic determinants such as income, employment and social position. Gender differentially affects the power and control men and women have over these socioeconomic determinants, their access to resources, and their status, roles, options and treatment in society. Gender has significant explanatory power regarding differential susceptibility and exposure to mental health risks and differences in mental health outcomes. Gender differences in rates of overall mental disorder, including rare disorders such as schizophrenia and bipolar disorders, are negligible. However, highly significant gender differences exist for depression, anxiety and somatic complaints that affect more than 20% of the population in established economies. Depression accounts for the largest proportion of the burden associated with all the mental and neurological disorders and is a particular focus of this paper. It is predicted to be the second leading cause of global burden of disease by 2020. To address this mounting problem, a much improved understanding of the gender dimensions of mental health is mandatory. Evidence is available on some aspects of the problem but serious gaps remain. It is known that: • Rates of depression vary markedly between countries suggesting the importance of macrosocial factors. Nevertheless, depression is almost always reported to be twice as common in women compared with men across diverse societies and social contexts. • Despite its high prevalence, less than half the patients with depression disorder are likely to be identified by their doctors in primary care settings. Gender differences in patterns of help seeking and gender stereotyping in diagnosis compound difficulties with identification and treatment. Female gender predicts being prescribed psychotropic drugs. Even when presenting with identical symptoms, women are more likely to be diagnosed as depressed than men and less likely to be diagnosed as having problems with alcohol. • Men predominate in diagnoses of alcohol dependence with lifetime prevalence rates of 20% compared with 8% for women, reported in population based studies in established economies. However, depression and anxiety are also common comorbid diagnoses, highlighting the need for gender awareness training to overcome gender stereotypes and promote accurate diagnosis of both depression and alcohol dependence in men and women if they are present. • Comorbidity is associated with mental illness of increased severity, higher levels of disability and higher utilization of services. Women have higher prevalence rates than men of both lifetime and 12 month comorbidity involving three or more disorders. Depression and anxiety are the most common comorbid disorders but concurrent disorders include many of those in which women predominate such as agoraphobia, panic disorder, somatoform disorders and post traumatic stress disorder. • Reducing the overrepresentation of women who are depressed must be tackled as a matter of urgency in order to lessen the global burden caused by mental and behavioural disorders by 2020. This requires a multi-level, intersectoral approach, gendered mental health policy with a public health focus and gender-specific risk factor reduction strategies, as well as gender sensitive services and equitable access to them. • Gender acquired risks are multiple and interconnected. Many arise from women's greater exposure to poverty, discrimination and socioeconomic disadvantage. The social gradient in health is heavily gendered, as women constitute around 70% of the world's poor and earn significantly less than men when in paid work. • Low rank is a powerful predictor of depression. Women's subordinate social status is reinforced in the workplace as they are more likely to occupy insecure, low status jobs with no decision making authority. Those in such jobs experience higher levels of negative life events, insecure housing tenure, more chronic stressors and reduced social support. Traditional gender roles further increase susceptibility by stressing passivity, submission and dependence and impose a duty to take on the unremitting care of others and unpaid domestic and agricultural labour. Conversely, gains in gender development that improve women's status are likely to bring with them improvements in women's mental health. • Globalization has overseen a dramatic widening of inequality within and between countries including gender-based income disparities. For poor women in developing countries undergoing restructuring, rates of depression and anxiety have increased significantly. Increased sexual trafficking of girls and women is another mental, physical, sexual health and human rights issue. The mental health costs of economic reforms need to be carefully monitored. • Finally, the epidemic of gender based violence must be arrested. The severity and the duration of exposure to violence are highly predictive of the severity of mental health outcomes. Rates of depression in adult life are 3 to 4 fold higher in women exposed to childhood sexual abuse or physical partner violence in adult life. Following rape, nearly 1 in 3 women will develop PTSD compared with 1 in 20 non victims. Current levels of detection of violent victimization are poor and primary health care providers require better training to intervene successfully to arrest the compounding of mental health problems. • Rates of psychiatric comorbidity and multi somatization are high, but neither well identified nor treated. The gendered nature of comorbidity poses complex therapeutic challenges regarding detection and appropriate models of care. • Research needs to be conducted into the relationship of violence to comorbidity. Women are at significantly increased risk of violence from an intimate and are over represented amongst the population of highly comorbid people who carry the major burden of psychiatric disorder. Equally, research is needed to understand better the sources of resilience and capacity for good mental health that the majority of women maintain, despite the experience of violence in their lives. • Access to safe affordable housing is essential if women and children are to escape violent victimization and the cessation of violence is highly therapeutic in reducing depression. Improved balance in gender roles and obligations, pay equity, poverty reduction and renewed attention to the maintenance of social capital would further redress the gender disparities in mental health.

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