5 questions: Why women need gender-specific mental-health care

Villanova University nursing faculty member Amy McKeever focuses on obstetrics and gynecology.

Her colleague, Sue Ellen Alderman, a psychiatric nurse practitioner, focuses on women's mental health.

Now the two have teamed up to develop a course addressing mental health from a women's perspective that addresses the body and the mind, the physical and the psychological — and how they are all interrelated.

The course was designed to teach nursing students about collaborating in a health system that has become increasingly fragmented. But their experience designing and teaching this curriculum also holds many lessons about gender-specific care. We spoke recently to Alderman about women's mental health issues.

Why is it important that women's mental-health issues be addressed separately?
One of the reasons is because infants and children tend to be directly affected by their mother's  mental health. Studies show that children of depressed moms are more likely to be depressed. With postpartum depression, the infants don't get that reciprocity — that eye gaze or mannerisms that are so important for early attachment. Studies show that can lead to later depression, even depression in childhood. Depression can be genetic, or from a number of other factors, but it's two times more common in women than in men. It is forecasted to become the greatest cause of disability by the year 2020.

Also, more women are diagnosed with mental-health disorders, possibly due to identification bias because women are also more likely to seek help. The World Health Organization found that 29 percent of women, compared to 17 percent of men, are treated for a mental-health disorder. Women are also more likely to be prescribed psychotropic medications.

Even so, women tend to underreport mental illness — especially during pregnancy and during the postpartum period, and that's a big concern. It's due to fear of stigma, and the fear of having their children taken from them.

Anxiety is two times more common in women than in men. Also, we see a higher incidence of abuse — sexual, physical, emotional — in women. We know that childhood trauma and adverse experiences are predictors of later mental illness across genders, but again, it is greater in females.

And this is just the tip of the iceberg. Eating disorders are three times more common in females than in males. Borderline personality disorder is two times more common in women.

Physiologically, women experience hormonal differences, making them more susceptible to mental illness during times of hormonal fluctuations, including puberty and pregnancy.

Also, women traditionally face societal stressors that differ from men's. It's the old competing roles of raising children and having jobs, and then caring for aging parents. The sandwich generation. Even though men are contributing more, women still feel the societal pressure to be perfect in the job and in the home. Women also report experiencing empty-nest syndrome more strongly than men. They feel lost and lonely.

Is addiction different in women?
Women go more quickly to a problem. They have more of what we call a telescoping between their first use, their dependence, and their treatment.

First, there are biological differences. Blood-alcohol concentrations are higher in women because they have a lower amount of enzymes that break up alcohol. Also, women have more fat. Men have more water. Alcohol is soluble in water, not in fat. So women can't metabolize the alcohol like men do. Therefore, their blood levels of alcohol are much higher, given a corresponding amount of alcohol.

Also, because women tend to have more depression and anxiety and eating disorders, their substance-abuse disorders are more complex. They are more likely to have childhood and adult trauma, and because of it their brain chemistry can actually change. When someone lives with untreated trauma, the brain is always in fight-flight-freeze mode, as opposed to responding to a stressor and subsequently resetting to a baseline level of calm. Survivors of trauma are hypervigilant, constantly operating in survival mode. They have higher levels of stress hormones. Women are more susceptible to comorbidity of addiction and mental illness because of all this.

So we need gender-specific treatment in both the medical and psychological realms. Also, what I always like to get across to the public is the need for routine screening for substance abuse and depression – in the primary-care physician setting, not just in mental-health settings. Now, we have different screening techniques – with more detailed and more specific questions – that will enable us to detect problems sooner.

When it comes to the opioid crisis, we need specific interventions for pregnant women who are addicted. This is a subgroup that really needs attention. Many methadone clinics have specialized programs for pregnant women. If they go to a methadone clinic, we know they will more likely get prenatal care. This is a form of harm reduction: With medication-assisted treatment, the substitution of another opioid, methadone, is monitored under controlled conditions instead of heroin. There's also a newer, somewhat safer drug, Suboxone, that, like methadone, decreases their cravings and their need for opioids. There also is evidence that perinatal outcomes can be improved by just frank conversations.

Can you talk about another important women's mental health issue, sexual assault on college campuses?
We know that 20 percent to 25 percent of female college students will experience some sexual assault. Yet more than 20 percent of campuses do not provide any sexual assault report training for faculty and staff. That is changing, but not fast enough.

One thing that's very important about violence is that it leads to more chronic physical illness overall, not just mental-health issues such as depression and post-traumatic stress and suicidal thoughts.

The buzzword nowadays — and what we need to see more of — is bystander involvement or intervention. Basically, the bystander effect is when an individual witnesses a high-risk or emerging situation with respect to interpersonal violence, but they fail to help the victim because they think that the presence of other bystanders reduces responsibility. Now, the push is for the bystander prevention approach. To make this a community responsibility, we also need to address and change social norms. We need to train students on campuses so we dispel victim blaming and stop perpetuating the myth that the victim has somehow provoked the perpetrator.

What are some of the biggest needs at the moment?
We need much more research on mental-health issues for pregnant women.

Some of the researchers are learning that gender-specific groups have better outcomes for women, especially with traumatized women. We need more randomized trials that compare all-women treatment to mixed-gender treatment, especially for substance abuse disorders.

We need more institutions or health-care providers that train people how to deal specifically with women who have experienced trauma. For example, you wouldn't put that patient in restraints. You wouldn't talk to her in an authoritative way. You would collaborate with that patient.

Can you cite an example of something that's being done right?
Main Line Health has a center that has been booming, the Women's Emotional Wellness Center. I was on a task force that helped to form this. They treat women with all the problems we have been talking about, with the exception of addictions. These women can come to a center where it's just women. Often, they are treated using mindfulness and similar cognitive approaches. You feel safe going to an all-women's center. The other piece is that they take insurance.

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