Serious Mental Illness in Women

Marcela Almeida; Sun J. Fletcher

Disclosures

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

In This Article

Perimenopause

The menopausal transition is marked by the loss of the neuroprotection conferred by estrogens during the reproductive period, leading to psychiatric exacerbations.[51] Antipsychotic doses often need to be adjusted and women show inferior responses to antipsychotics than during premenopause,[52] which may worsen medical comorbidities. Estrogen receptor modulators, such as raloxifene, have been effectively added to treatment with antipsychotics allowing to decrease their doses, which results in lower risk for metabolic and cardiovascular side effects.[39] Given the protective effects of estrogens on the course of SSD, estrogen replacement therapy should be considered for postmenopausal patients, who are more vulnerable to side-effects and yet require higher dosages of most antipsychotics to reach similar efficacy.[9]

Studies have shown an increased risk of depres sive symptoms among women during the menopausal transition. Although a prior history of depression is a risk factor for menopause-related exacerbation, women without a history of MDD are also at risk.[53,54] Similarly, women with bipo lar disorder may experience worsening symptoms during the menopausal transition.[15,55]

Among elderly patients, the leading mental health problems include depression, organic brain syndromes, and dementias, all of which affect pre dominantly women (https://www.who.int/teams/mental-health-and-substance-use/promotion-pre-vention/gender-and-women-s-mental-health).

It is important to highlight that menopausal women, because of the decline of sex hormones, are at higher risk for developing QTc prolongation and torsades de pointes when prescribed antipsy-chotics and clinicians should be cautious about this risk, particularly in those with a history of cardio vascular disease.[9]

Psychological, Social, and Cultural Aspects of Women's Mental Health

Finally, an article about women's mental health would not be complete without considerations of important psychosocial aspects that heavily influence their lives. Those include socioeconomic disparities, unequal employment rates and conditions, societal roles, access to education, trauma, and gender-based violence. Women continue to carry the bulk of childcare, eldercare, and household responsibilities in most parts of the world.[56,57]

According to the United Nations, women between 15 and 44 years are more at risk from rape and domestic violence than from cancer, car acci dents, war, and malaria and that one in three women worldwide has experienced physical or sex ual violence.[58] Women are often reluctant to disclose a history of abuse because of social stigma unless the clinician asks about it directly. Approxi mately 80% of people affected by violent conflicts, civil wars, disasters, and displacement are women and children (https://www.who.int/teams/mental-health-and-substance-use/promotion-prevention/gender-and-women-s-mental-health). Female geni tal mutilation continues to happen in many parts of the world, a human rights violation that affects more than 125 million girls and women alive. Almost 80% of victims of human trafficking are female individuals and one-third are children.[59]

Income inequality and wage gaps continue to exist, with women being paid approximately 77% of their male counterparts' for equivalent work, with even more pronounced disparities for women of color.[60,61]

The United States is the only industrialized country not to offer mandated paid maternity leave, which is associated with a healthy bonding and attachment between a mother and her newborn and prevention of psychopathology. An additional week of maternity leave may decrease infant mortality rates by 0.5 deaths per 1000 live births.[62]

Finally, despite data showing that depriving women of their reproductive rights has negative consequences on maternal and offspring mental health and that those limitations disproportionately impact minorities, women remain hostage to restrictive laws and scarcity of resources in several parts of the globe.[63]

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