Serious Mental Illness in Women

Marcela Almeida; Sun J. Fletcher

Disclosures

Curr Opin Psychiatry. 2022;35(3):157-164. 

In This Article

Abstract and Introduction

Abstract

Purpose of Review: Psychiatric illnesses are very prevalent in the United States and impact women and men differently. In this review, we will explore some gender differences in the expression of psychopathology, discuss the most common serious mental illnesses (SMI) affecting women, and review treatment options according to specific life stages. We hope to raise awareness of these issues and consequently improve outcomes for women with serious mental illness.

Recent Findings: SMI have different rates and are manifested differently in women and men because of biological, psychological, social, and cultural factors. Some SMI are more prevalent in women whereas others uniquely affect them during particular life stages. Even in disorders that have a similar prevalence in men and women or are more prevalent in men, the presentation, course, management, and repercussions can vary significantly between the two genders. Medical and psychiatric comorbidities, which directly influence treatment, prognosis, and disability, are more common in women.

Summary: Several differences in the gender expression of SMI have not yet been fully described. It is important to become familiar with important characteristics of SMI in women, including biological determinants, treatment differences, and psychosocial aspects. Recognizing gender biases, cultural considerations, and adaptive responses can help identify women at risk, promote early recognition of symptoms, and prompt interventions that may lead to improved outcomes.

Introduction

Psychiatric illnesses are very prevalent in the United States, affecting nearly one in five adults (https://www.samhsa.gov/data/release/2019-national-survey-drug-use-and-health-nsduh-releases). Men and women can be impacted differently because of biological, psychological, and social factors.

Several psychiatric disorders are more prevalent among women. Major depressive disorder (MDD) and posttraumatic stress disorder (PTSD) are twice as high among women.[1] An overwhelming majority of eating disorders (85–90%) occur in women.[2]

Biological determinants include hormonal influences, differences in metabolism, brain circuitry, and genetic heritability. For instance, the rates of certain mental illnesses start diverging by sex at puberty[3] and become less divergent after menopause, with increased manifestations around periods of hormonal flux, such as the perimenstrual, postpartum, and perimenopausal periods, which has led to increasing interest in alternative effective treatments that target hormonal systems.[4,5] The role of allopregnanolone, a positive reproductive steroid modulator of GABAA, in the development of psychopathology has been receiving increasing emphasis in recent years.[6,7]

Even in disorders more prevalent in men or with similar prevalence between men and women (e.g. substance use disorders, bipolar disorder, and schizophrenia), symptom presentation, course and morbidity can significantly differ between the two genders because of important psychosocial factors. Psychological factors constitute adaptability responses and defenses. Social factors, including exposure to poverty and unemployment, gender inequities, role expectations and other cultural aspects, trauma and interpersonal violence, all more prevalent in women, significantly add to the burden of mental illness among them.

Serious mental illness (SMI) is defined as a 'mental, behavioral, or emotional disorder resulting in serious functional impairment, which substantially nterferes with or limits one or more major life activities'.[8] In the United States, they affect an estimated 13 million adults, with a higher prevalence in women (6.6%) than men (3.9%)[8] (Figure 1).

Figure 1.

Past year prevalence of serious mental illnesses among United States adults (2019). National Institute of Mental Health.

Women, particularly women of color, are more likely than men to feel stigmatized for suffering from a mental illness, which often leads to delays in treatment (https://womenshealth.obgyn.m-su.edu/). Women tend to have more comorbidities and are prescribed additional medications (e.g. mood stabilizers, contraceptives) more often than men, resulting in important drug–drug interactions and at times affecting compliance.

In this review, we will explore these gender differences in the expression of psychopathology, discuss the most common SMIs affecting women, and review treatment strategies according to specific ife stages. We hope to raise awareness of these issues and consequently improve treatment outcomes for women with SMI.

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