Depression and anxiety are known to affect around one in five people, but depression occurs twice as often in women as in men. And when it comes to major depressive disorder – the formal diagnosis of the illness – a comprehensive review of almost all population studies conducted to date in Australia, the United States, Puerto Rico, Canada, France, Iceland, Taiwan, Korea, Germany and Hong Kong has reported more women than men experienced major depression in their lifetime.
Compared to men, women also have significantly higher rates of anxiety and post-traumatic stress disorder (PTSD). While around one in every 12 adults experiences PTSD at some time in their lives, women’s risk of developing PTSD following exposure to trauma is around two times that of men’s. The rate of anxiety disorders has been noted to be four times higher in women compared to men.
Men with mental illness commonly need more help with social skills than unwell women. However, some cultures encourage female independence while others do not. So, the social outcomes are not always clearly male and female differentiated.
Gender differences also occur in the course of bipolar disorder. Women are more likely to develop an unpredictable and unstable form of the illness with more related anxiety. They have a greater likelihood of being hospitalised during the manic phase of the disorder.
Suicide rates and seeking help
Mental health problems are increasingly being recognised in men of all ages, with the highest incidence of mental ill health and suicide reported in elderly men. The highest suicide rate for Australian males in 2015 (39.3 per 100,000 people) was in men aged 85-plus years, with 68 deaths reported overall in this age group.
This rate was considerably higher than the age-specific suicide rate in all other age groups. The suicide rate for men between the ages of 40 and 55 was around 31 per 100,000 people. For women, suicide rates didn’t differ too much across age groups in 2015 – rates were around 8-10 per 100,000 people.
One reason women have lower rates of suicide is that they are more likely than men to seek help. Around 18% of women compared with 11% of men sought help for anxiety in 2007. And 7.1% of women compared with 5.3% of men sought help for mood disorders. Only a small percentage of adolescent boys and men seek help for mental ill health.
Women are also more likely than men to use services for mental health problems. This may reflect greater female psychological knowledge and acceptance of mental illness. Mental illnesses in men are frequently masked by risky behaviours such as alcohol and drug abuse, anger and aggression, speeding on roads and drink driving.
Violence against women and hormones
Women with mental illness often struggle to have their needs recognised by standard psychological and psychiatric treatments. Two areas that clearly impact on women’s mental ill health are often not considered or managed well: violence against women, and the complex interplay between hormone shifts and mental state changes.
Rape, assaults, emotional abuse and deprivation are a spectrum of severely damaging and traumatic events that can have long-lasting adverse effects on women’s mental health. For unclear reasons, the issues of early life traumas in a woman’s life are often ignored or underplayed in the consideration of mental illness development in later life.
Hormone fluctuations also have a significant impact on mental health across the lifespan of many women. The female hormone oestrogen has several key roles in the brain and provides a protective effect against mental illness. At times of lower oestrogen levels, either pre-menstrual or around the menopause, some women experience significant and real depression, as well as anxiety.
Disorders caused by hormones, including menopause-related depression but also premenstrual dysphoric disorder (depression in the week prior to menstruation) and postnatal depression, are poorly understood and managed. This disadvantages female sufferers.
Borderline personality disorder
Another condition where significant gender disparities exist is borderline personality disorder. This is one of the long-term consequences of violence against women and its understanding and management require a significant rethink.
Borderline personality disorder is a female-dominant diagnosis that carries enormous stigma. Men can also be diagnosed with borderline personality disorder, but the presentation of the condition in men is often confounded by the diagnosis of “antisocial personality disorder”. This is a condition where a person experiences a long-term pattern of manipulating, exploiting or violating the rights of others. This behaviour is often criminal.
The hallmark symptoms of borderline personality disorder are deliberate self-harm such as cutting or burning, rage over apparently minor issues, mood swings, poor self-esteem, dissociation (feeling like you’re not in your own body), constant anxiety and difficulties with identity.
Over 80% of people (mainly women) diagnosed with this condition actually have early life traumas. These include incestuous sexual, physical abuse and emotional abuse or deprivation. Yet the condition is termed a “personality disorder”, which carries the connotation it is somehow the person’s fault and ignores the common causal agent of trauma in the majority of cases.
Biological, psychological and social factors all act together to cause mental illnesses and these factors are different among men and women. We must acknowledge this and take a more gendered approach to treating men and women with mental ill health, which integrates a number of biological factors with particular behaviours and external events, to provide better outcomes.
For help or information call Lifeline on 13 11 14, or MensLine Australia on 1300 78 99 78 or visit beyondblue.org.au.
Jayashri Kulkarni, Professor of Psychiatry, Monash University