Gender differences in Psychiatric Disorders
Women use more health care services than any other group in the U.S. and they spend 2 of every 3 health care dollars.
Recognizing the underrepresentation of women in major clinical research trials, the NIH (National Institutes of Health) established the Office of Research on Women’s Health in 1990. Following that was the National Institutes of Health Revitalization Act of 1993, which stipulated that the NIH-funded clinical research should address therapeutic efficacy for women and minorities. Since 1993, active trials in gender-specific aspects of mental health have led to a better understanding of the psychiatric disorders to which women are vulnerable.
| Lifetime Prevalence of Psychiatric Disorders in Women | ||
| Prevalence | ||
| Disorder | Women | Men |
|---|---|---|
| Depression | 21.3 | 12.7 |
| Dysthymia | 8.0 | 4.8 |
| Bipolar I | 0.9 | 0.7 |
| Bipolar II | .05 | .04 |
| Seasonal Affective Disorder | 6.3 | 1.0 |
| Panic Disorder | 5.0 | 2.0 |
| Social Phobia | 15.5 | 11.1 |
| GAD (Generalized Anxiety Disorder) | 6.6 | 3.6 |
| Schizophrenia | 1.7 | 1.2 |
| Alcohol Dependence | 8.2 | 20.1 |
| Alcohol Abuse without Dependence | 6.4 | 12.5 |
| Drug Dependence | 5.9 | 9.2 |
| Drug Abuse without Dependence | 3.5 | 5.4 |
| Anorexia Nervosa | 0.5 | 0.05 |
| Bulimia | 1.1 | 0.1 |
| Antisocial Personality Disorder | 1.2 | 5.8 |
Gender differences in Psychiatric Conditions may be due in part to psychosocial factors. Many women face daily challenges to fill multiple roles and meet conflicting demands. In addition, women’s traditionally disadvantaged social status, lower wages, and increased vulnerability to sexual and domestic violence may contribute to their higher rates of depressive and anxiety disorders.
Biologic differences related to gender may also explain some of the differences in psychiatric illnesses between men and women. Research is increasingly revealing that gender differences exist in brain anatomy and that male and female reproductive hormones produce psychoactive effects (Durston, et al. 2001; Steiner et al. 2003). The psychoactive effects of estrogen and progesterone have received particular attention. Estrogen’s anti-dopaminergic and serotonergic effects, and the modulation of gamma-amino butyric acid (GABA) receptors by metabolites of Progesterone may play a role in Psychiatric disorders in women.
The Comprehensive Psychiatric Assessment of Women
Gender-Specific aspects explored in the Psychiatric assessment of women include:
Assessment of the relationship of the patient’s symptoms to her menstrual cycle, inquiry about the possibility that she may be pregnant, inquiry about contraception, and discussion about concomitant use of Psychiatric medications that may reduce the efficacy of oral contraceptives.
Assessment of the patient’s plans regarding pregnancy, as this may influence the choice of treatment with psychotropic drugs.
Inquiry about seasonality of mood symptoms, as Seasonal Affective Disorder is more common in women than men.
Exploration of any history of Eating Disorder symptoms, as Eating Disorders are 10 times more common in women than in men.
Inquiry about any history of psychiatric symptoms occurring in relation to a particular reproductive life event (e.g., during use of oral contraceptives, during the premenstrual or postpartum period, or during periods of increased perimenopausal symptoms), as these women may be at risk for developing psychiatric symptoms at future times of hormonal changes.
Issues you may want to address during your Psychiatric Evaluation:
What effects, if any, are there of hormonal contraception on mood?
Are there any drug interactions between my oral contraceptive and Psychiatric medications?
I’m taking several Psychiatric medications, but would eventually like to get pregnant. What is the most prudent way to treat my illness during gestation? What are the potential risks and potential benefits of taking or not taking each medication during gestation and breastfeeding?
What is Post-Partum Depression, and is it different than the “baby blues?” What are the symptoms, what are the risk factors, what are the risks associated with treating and with not treating PPD, what are the most appropriate treatments for PPD?
What are the potentially harmful effects to my fetus associated with my use of legal or illegal drugs or alcohol, and at what point in gestation are they most significant?
Perimenopause and Menopause:
Definition and History
The average age for Menopause, the point at which a woman has permanently ceased menstruating, is age 52. Perimenopause, which typically occurs 5 to 7 years before menopause, is the interval between regular ovulatory menstrual cycles and complete cessation of ovarian function. Natural menopause occurs between the ages of 44 and 55. Because women in the United States now live to an average age of 81 years, the post-menopausal years often constitute more than one-third of a woman’s life. In addition to experiencing physiological changes during the perimenopausal and menopausal years, some women experience mood alterations.
Hormonal Changes
Menopause has been presumed to be solely a response to ovarian failure. Thus, in response to decreased estrogen production by the ovary, the levels of 2 pituitary hormones—LH (Leutinizing Hormone) and FSH (Follicle-stimulating hormone) rise. The ovarian hormone Inhibin, which negatively feeds back to inhibit FSH release, also decreases and is thus thought to contribute to the rise in FSH.
More recent data from The Study of Women’s Health Across the Nation (SWAN) suggest that menopause may rather result from a relative hypothalamic-pituitary insensitivity to Estrogen (Weiss et al. 2004). At and after menopause, levels of Estradiol, the biologically active form of Estrogen remain below 25pg/ml and levels of FSH remain above 40 MIU/mL
Mood Changes Associated with Natural Menopause
In general, longitudinal studies have NOT found that natural menopause increases the risk for depression in most women, although some women experience depression during perimenopause. At higher risk are those who experience a lengthy perimenopause, those with a history of depression (including post-partum depression), a history of severe PMS, poor sleep, unemployment, financial problems, death of a partner, death of a child, and the presence of hot flashes. After menopause, mood symptoms often return to baseline.
Mood Changes Associated with Surgical Menopause
For women who undergo surgical menopause to relieve severe physical symptoms, psychological functioning tends to improve after surgery. Women with psychiatric histories, however, are more likely to experience adverse psychological reactions after a hysterectomy. Other risk factors for a poor psychiatric outcome after a hysterectomy include having the hysterectomy at a young age, undergoing the procedure emergently rather than electively, having a poor social support system, experiencing marital dysfunction, having a low socioeconomic status, and having a history of multiple surgeries.
For perimenopausal women who undergo a procedure involving removal of both uterus and ovaries, one possible outcome is a precipitous drop in Estrogen level. These women almost invariably experience hot flashes, which can be particularly troublesome and may cause significant sleep disruption and depression. These women can be treated with estrogen to relieve vasomotor symptoms, thereby eliminating one possible cause of postoperative depression.