Image Credits: Maternal Mental Health Alliance
By Wasim Kakroo
PERPETUALLY spoken common statement ‘zou aur te jahan aur’ which is in vogue in our society signifies the importance of health in our life/world. The World Health Organisation defines health as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. Usually we see that the physical ailments are quite often recognised easily and then diagnosed. But mental health issues are very subtle and not easily recognised. They need a more detailed examination and investigation for their diagnosis. Even sometimes these subtle mental health issues remain hidden from the diagnostic eye and have detrimental consequences on the smooth living of the people. Such issues are not necessarily manifested as depression or anxiety but may present as distress, loss of happiness, heaviness of heart, vague pain, headache etc.
Why is studying mental health issues of women important?
Women and men differ not only in their noticeable physical appearances, but also in their psychological makeup. There are actual differences in the way they process information and react to events and stimuli. Women and men differ in the way they communicate, deal in relationships, express their feelings, and react to stress. Thus, the gender differences are based in physical, physiological, and psychological attributes.
For centuries, society has defined and distorted the differences between men and women through a lens of sexism in which men assumed superiority over women and maintained it through domination. This has led to underestimating the role a woman plays in the evolution of human society. In addition to all these social influences, the women are genetically wired in such a way that they are prone to some mental health issues more than men. All these discriminations and natural differences between men and women may quite understandably lead to some mental health issues.
It is therefore necessary to understand and discuss the challenges women face, especially with respect to their mental health so that they are helped to deal with them so that our society has a better evolutionary trajectory.
Depression, Anxiety and Somatization in Women
Studies have shown that gender differences affect the occurrence of common mental disorders (CMDs)-depression, anxiety, and somatic complaints wherein women predominate. E.g., Unipolar depression is twice as common in women. Women are more likely to present with atypical symptoms of depression such as increased appetite and weight gain (usually depression leads to weight loss and appetite loss). Furthermore, the lifetime risk of anxiety disorders (e.g., generalized anxiety disorder, GAD) is 2–3 times higher in females as compared to males.
Studies across the world have indicated that women are, on average, 2–3 times, at greater risk to be affected by Common Mental Disorders.
Now the question is what makes females apparently more vulnerable?
It has been hypothesized that hormonal factors related to the monthly cycle may play a role in women’s increased vulnerability to depression. Other factors responsible for their vulnerability to various CMDs may be because of the disadvantages related to their gender. These include excessive partner substance use, sexual, and physical violence by the husband, being widowed or separated, having low autonomy in decision making, and having low levels of support from one’s family. Furthermore, stressful life events have been seen to be closely associated with the occurrence of depression in vulnerable individuals. During their lifetimes, females are faced with various life stressors including childbirth and maternal roles, caring and nurturing the old and sick of the family. In addition, women are less empowered due to lesser opportunities of education and respectable employment.
Bipolar Affective Disorder
The clinical features of bipolar disorder differ between men and women; women have more frequent episodes of depression, and a seasonal pattern of mood disturbances.
Suicide and Deliberate Self Harm
Studies of suicide and deliberate self-harm have revealed a universally common trend of more female attempters and more male completers of suicide.
Common Mental Disorders, exposure to violence, etc. have been found to be strongest predictors of the attempted suicide cases. It has been found that a large degree of attempts is as a response to failures in life, difficulties in interpersonal relationships, and dowry-related harassment. Some of the precipitants for suicide among women compared to men include Dowry disputes; love affairs; and quarrels with spouse or parents-in-law.
Deliberate self-harm (DSH) can be defined as the intentional injuring of one’s body without apparent suicidal intent. These acts are usually nonfatal and not intended to end life. DSH includes but is not restricted to acts such as self-cutting, burning, ingestion of a substance or medication in excess of its therapeutic/prescribed dosage, ingesting a recreational or illicit compound in a bid to harm self, and consuming a non-ingestible compound, etc. Overall gender ratio studies about DSH have shown higher rates of DSH in females than in males possibly because of various emotional (biological) and social factors. Borderline Personality Disorder has been found to be one of the causal factors for DSH in women.
Violence and Abuse
According to one study, around two-third of married women in India were victims of domestic violence. The common forms of violence against Indian women include female feticide, domestic violence, dowry death or harassment, mental and physical torture, sexual trafficking etc. The reproductive roles of women, such as their expected role of bearing children, the consequences of infertility, and the failure to produce a male child have been linked to mental health issues and female suicide.
Common mental health problems reported by abused women include depression, anxiety, post traumatic stress, insomnia, and alcohol use disorders, as well as a range of somatic and psychological complaints. Abused women are much more likely to require psychiatric treatment and are much more likely to attempt suicide.
Reproductive Health
Mood and behavioral changes have been observed to be associated with the monthly cycle. The symptoms such as irritability, restlessness, anxiety, tension, migraine, sleep disturbances, sadness, dysphoria, and the lack of concentration occur more frequently during the premenstrual and menstrual phase. A premenstrual dysphoric disorder consisting of extremely distressing emotional and behavioral symptoms is closely linked to menstrual cycle.
Mental disturbances frequently occur during late pregnancy and in the postpartum period. Postpartum blues is the most common illness affecting a good proportion of new mothers, whereas postpartum depression constitutes a major depressive episode with an onset within 6 weeks postpartum in a majority of cases. The risk is highest among the most socially and economically disadvantaged women. The other important risk factors include gender-based factors such as the bias against female babies; role restrictions regarding housework and infant care; especially in multi-generational households in which a daughter-in-law has little independence to take decisions regarding household and other affairs, and gender-based violence. Also, menopause has long been known to be accompanied by depression and other mental disturbances in women who have had genetic and socio-economic vulnerability.
Reproductive health factors, particularly gynecological complaints such as vaginal discharge and dyspareunia and Poly Cystic Ovarian Syndrome (PCOD) are independently associated with the risk for various Common Mental Disorders.
Substance Use
Women who abuse alcohol or drugs are more likely to have been sexually or physically abused than other women, when they were young. Alcoholism and Substance abuse may lead to major depression and anxiety disorders in females. In our valley, substance abuse among the female population is increasing day by day possibly because of untreated mental illnesses (such as Borderline Personality Disorder) among them.
Social Challenges of Women with respect to Mental Health
Women with mental health issues may have to face social consequences such as abandonment by marital families, homelessness, vulnerability to sexual abuse, and exposure to HIV; and other infections which can contribute to the difficulties in the recovery of such women. Stigma has been reported to be more toward ill women than men.
What is the way forward?
It is clear from the whole discussion that women’s mental health cannot be considered in isolation from social, political, and economic issues. In order to deliver effective help, women’s health must incorporate mental and physical health across the life cycle in addiction to reproductive health.
In order to understand the determinants of poor mental health of women, the focus needs to be shifted from individual and “lifestyle” risk factors to the recognition of the broader, social, economic, and legal factors that affect women’s lives. It is essential to recognize how the socio-cultural, economic, legal, infrastructural, and environmental factors that affect women’s mental health are taken care of in the given community setting.
Education, training, and interventions targeting the social and physical environment are crucial for addressing women’s mental health. Identification of significant persons in government departments and other relevant groups in the community, to obtain and record data indicating the extent of women’s problems and the burden associated with women’s mental problems and the development of policies to protect and promote women’s mental health are extremely crucial.
The primary care providers including Asha workers, social workers, general physicians working at various primary care centers etc. must be educated about the identification and assessment of major mental health problems affecting women, so that they routinely enquire women about their common mental health problems, provide the most appropriate intervention and support and provide education to the community on issues related to the mental health of women and refer more complex cases to various professionals including psychiatrists and clinical psychologists working in various facilities across state.
Criminal justice response to violence against women must be improved in order to get a timely help before any such legal issues leads to the development of any mental health issue.
In summary, combined efforts at social, political, economic, and legal levels can bring change in the lives of women and contribute to the improvement of the mental health of these women.
Views expressed in the articles are the author’s own responsibility. The content is not intended to be a substitute for professional medical advice, diagnosis, or treatment and is strictly for educational/informative purposes only
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