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Women’s Mental Health: A Public Health Concern: R.Thara* and V.Patel**
 Introduction
The state of women' s mental health is indeed in a state
of flux. On the one hand, it has begun to figure, as never before, on the
agenda of many national and international commissions and organizations. The World Health Report (1)
says, "Women's health is inextricably linked to their status in society.
It benefits from equality, and suffers from discrimination. Today, the status
and well-being of countless millions of women worldwide remain tragically
low."
UNDP has developed two measures of the disparity between
men and women. The Gender Empowerment Measure (GEM) measures gender
inequality in two key areas of economic and political participation and
decision-making. The other GDI (gender related development index) measures
achievement in life expectancy, educational attainment and income. Based on all available data, UNDP (2)
concludes that "no society treats its women as well as its men".
Databases generated by many sources include appalling
statistics on women's health in general and mental health in particular. Notable among these has been the estimate of the Global Burden of Disease (3),
which has named unipolar depression among women to be the second most important
cause of disease burden by the year 2020. The excessive preoccupation of the
health care system, its planners and administrators about mortality has
shifted to morbidity, well-being and quality of life, all of which are
profoundly influenced by mental health. The 1997 Human Development Report
states: "No society treats its women as well as its men".
On the other hand, reports of violence against women are
on the increase, violence of a nature that scars the psyche almost
permanently and even affects the social position of women adversely.
Childhood sexual abuse, female infanticide in some societies, battering of
female children, the resulting homelessness and psychological trauma
inflicted by dowry demands on newly married women in countries such as India are all sordid tales of the
world's apathy, neglect and indifference to women's woes. The relative lack
of education and authority make them extremely vulnerable to all kinds of
abuse, all of which result in increasing emotional morbidity. This inextricable
intertwining of the state of education, economy, autonomy and health makes it
imperative that a multipronged strategy be deployed to systematically address
women’s mental health problems.
Global Burden of Disease
Burden of disease and DALYS (Disability Adjusted Life
Years) which have now been extensively studied, show the importance of mental
health of women in terms of role performance, productivity and health
economics.
 For women, neuropsychiatric conditions were
the second leading cause of disease burden worldwide, following infections
and parasitic diseases.
For women between the ages of 15-44 years of
age, unipolar depression was the leading cause of disease burden in both
developed and developing countries.
Schizophrenia, bipolar disorder and obsessive-compulsive
disorders also ranked in the top ten leading causes of burden for women aged
15-44 years.
The impact of these disorders is also felt on
DALYS.
Projections to the year 2020 still foresee
that the major impact of these six mental disorders will overwhelmingly
affect women in this age group. The aging effect of this population will not
change the profile of the impact of these disorder
Projections
DALYS associated with neuropsychiatric
conditions will increase for women of all ages between 1990 and 2020.
In 1990, the six major mental disorders
accounted for 8.51% of all DALYS for women. This figure will increase to
14.32% in 2020.
By 2020, unipolar major depression alone will
account for 8.62 of all DALYS for women, particularly between the ages of 15
and 44.The bulk of the disease burden will therefore remain in the prime
child-bearing, child-rearing, parenting and working years.
In many countries of the South-East Asia Region, the
mental and social well-being of women is at a low rung largely because of
socioeconomic factors. Women are second-rate citizens and are denied many
rights. Access to health care is often denied to them. Poverty, illiteracy,
big families, number of children all compound this problem. Domestic
violence, abuse of women, attitudes towards the girl child and female
infanticide are other aspects of the spectrum not auguring well for their
well being.
This paper only attempts to provide the readers an
overview of some of the mental health issues affecting women, especially in
this Region. Considering the vastness of the subject and the wide array of
social and political factors impacting them, it is well nigh impossible to do
total justice to this subject within the framework of this chapter.
Women and Common Mental Disorders
From the perspective of women and mental health, the key
epidemiological finding is the much-replicated association of female gender
and Common Mental Disorders (CMD) such as depression and anxiety. Both
community-based studies and studies of treatment seekers indicate that women are, on average, two to three times, at greater risk to be affected by CMD (4,5).
The obvious question thrown up by these findings are the reasons for this
apparent vulnerability, and its significance. There are a number of potential
factors, which may make women more vulnerable to depression. Davar has
reviewed this issue in detail in a recent book on the mental health of women
in India (6).
Some of the implications of the greater vulnerability of women to suffer CMD
are considered below:
There is considerable evidence demonstrating
that stressful life events are closely associated with depression and such events are more common in the lives of women (7,8
). Thus, women are far more likely to be victims of violence in their
homes. The multiple roles played by women such as child-bearing and
child-rearing, running the family home, caring for sick relatives and, in an
increasing proportion of families, earning income, may lead to considerable
stress.
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 wife-battering and female suicide (6 , 9).
Women are far more likely to be denied
educational and occupational opportunities and access to appropriate health
care.
Differences may also be partly accounted for
by a gender bias in the way mental problems are diagnosed, since these are
often influenced by cultural expectations and stereotypes of what is normal
behaviour for men and women.
The impact of mental health problems also
shows a gender differential. For example, whereas women were required to be
the primary carers if their husbands were mentally ill, it was their own
families that were responsible for their care if they were to become ill.
Women with mental health problems are less
likely to receive appropriate health care when sick and when they do seek
help, a gender bias ensures that symptoms are taken less seriously than they are for men (6, 10).
Furthermore, the negative effects of
globalization and economic reform on public health are likely to hit women
harder than men; for example, since the economic reforms and subsequent
crisis in South-East Asia, there has been a rise in the incidence of reported domestic violence, rape and alcohol abuse (11).
Indeed, "it is not surprising that the
health of so many women is compromised from time to time. Rather, what is
more surprising is that stress-related health problems do not affect more women". (9)
Chronic Mental Illness
Although theprevalence of chronic psychotic
illnesses such as schizophrenia and bipolar disorders in women may be less
than that of depression, anxiety and related conditions, they pose an immense
problem in management and rehabilitation. Their propensity to be chronic,
sometimes unresponsive to treatment, the resultant disability in various
aspects of functioning, and above all, the stigma attached to these illnesses
and the social sequelae make it a public health issue, notwithstanding the
smaller numbers.
While men and women are equally affected by
schizophrenia, there have been some differences in their manifestations and
course and outcome. A consistent finding has been a higher mean age at onset
and first hospitalization for women suffering from schizophrenia. Women have
also been found to have more paranoid and affective symptoms, more atypical
symptoms, and more frequently an insidious onset with passivity and social
withdrawal.
The most robust research finding has probably been the
better course and outcome of schizophrenia in women as reported by Thara & Rajkumar (12)
and many others in the developing world. Various hypotheses including the
protective effects of oestrogen have been put forward to explain this
difference.
Social consequences such as homelessness, vulnerability
to sexual abuse and exposure to HIV and other infections contribute to the
difficulties of rehabilitation of women. The absence of any clear welfare
policies in this part of the world for this group of women, and the social
stigma further compound the problem. Stigma has been reported to be more
towards ill women than men. Women caregivers also reported being the target of stigma (13).
Mentally Ill Women and Their Marriages
The Schizophrenia Research Foundation at Chennai, India carried out an ethnographic, qualitative study of 75 mentally ill women who were separated or divorced.(14)
It was found that all but eight of these separated women lived in their
parental homes with the onus of care being borne by the aging parents. Legal
separation had occurred only in 16 cases, all of them being educated women.
None of them remarried, while 34 of the husbands had done so. The fathers
looked after only six of the 26 children. This study sharply brings into
focus some issues, which confront women in many developing countries. They
are:
A lack of awareness of the illness and its
disabilities resulting in a widespread belief that marriage is a panacea for
all ills. This resulted in the parents of the ill women arranging their
marriages, very often suppressing the fact of mental illness from the husband
and his family.
Absence of legal protection including
maintenance for such women.
The burden of care of these women goes back to
the parents, many of whom are aging and themselves sick.
Lack of any state managed programmes, which
will offer some kind of physical, sexual and financial security for such
women.
Negative attitudes of the husband and his
parents and sometimes even the extended family hastened the process of
separation and sometimes desertion.
Suicide and 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. A spate of studies from India in the 90s has reiterated this finding. Biswas et al (15)
found girls from nuclear families and women married at a very young age to be
at a higher risk for attempted suicide and self harm. Malone et al in Dublin (16)
reported a 2:1 ratio of women and men in 100 cases of deliberate self-
poisoning to such behaviours as a response to failures in life, and
difficulties in interpersonal relationships. It may also be noted that
terrorist groups train many women as human live bombs.
However the women in many of these studies were not
referred to psychiatric services. This could be due to a variety of reasons
such as the need to downplay such behaviours in an attempt not to reinforce
them and because of the stigma attached to seeking psychiatric help.
Violence
Although violence against women has been documented even
in ancient historical documents, it is only in the last half century that it
has evoked the attention it deserves. The extent and nature of this problem
have been brought to light by women activists and acknowledged by
international agencies. A WHO report in 1998 called it a priority health
issue. Violence against women is emerging as a pervasive global issue and
contributes significantly to preventable morbidity and mortality for women across diverse cultures(17).
In some regions, violence has reached staggering levels; in a recent
population-based study from India, nearly half the women reported physical violence(18).
There is now substantive evidence demonstrating that amongst the most
disabling and long-lasting health effects of violence are mental health
effects such as depression and Post Traumatic Stress Disorder.
The Fourth World Conference on women held at Beijing in 1995 defines violence against
women as any act of gender-based violence that results in, or is likely to
result in, physical, sexual or psychological harm or suffering to women,
including threats of such acts, coercion or arbitrary deprivation of liberty,
whether occurring in public or private life. Accordingly, violence against
women encompasses but is not limited to the following:
(a) Physical, sexual and psychological violence
occurring in the family, including battering, sexual abuse of female children
in the household, dowry-related violence, marital rape, female genital
mutilation and other traditional practices harmful to women, non-spousal
violence and violence related to exploitation;
(b) Physical, sexual and psychological violence occurring
within the general community, including rape, sexual abuse, sexual harassment
and intimidation at work, in educational institutions and elsewhere,
trafficking in women and forced prostitution;
(c) Physical, sexual and psychological violence
perpetrated or condoned by the State, wherever it occurs.
Acts of violence against women also include forced
sterilization and forced abortion, coercive/forced use of contraceptives,
female infanticide and prenatal sex selection.
There are several and types of violence against women,
all of which need not take the form of brutal assaults. Demands by society on
widows, however young they be, to lead a rigidly austere life, social
isolation and a total lack of access to men have all been condoned for ages
as necessary measures to keep them from temptation and sin. The practice of
"sati" in certain parts of India, by which the wife throws
herself into the funeral pyre of her husband, has been documented to occur in
the not too distant past. Such behaviours of self-denial, torture and even
death are indeed sanctified and glorified and there are even temples erected
for the goddess of sati.
Historically, culture, customs, traditions and beliefs
have fostered in their own way various forms of violence against women.
A very poignant report of the effect of violence on
women in El Salvador can be seen in the book "World Mental Health" (19).
"Women regularly encountered brutal evidence of war, ...
"nerves" is the chief complaint of many of these women.... nearly
all of these women had suffered one or more major depressive episodes within
the past two years,.… many of them also report symptoms of PTSD including
recurrent nightmares of traumatic violence... many of them suffer from
illnesses related to domestic violence and abuse."
Reproductive Health and Mental Health
Reproductive health is a fundamental aspect of women’s
health and is widely considered one of the main public health priority areas
in developing countries. The areas of intersection of reproductive and mental
health are considerable in scope and include, for example, psychological
issues related to childbirth, violence, rape, adverse maternal outcomes such
as stillbirths and abortions, reproductive tract surgeries, sterilization,
premarital pregnancies in adolescents, HIV/AIDS and the impact of caring,
menopause and infertility. These are vast in range and cannot be covered
within the scope of this article. Instead, the article will provide an
overview of some key areas of intersection, focusing on CMD, the commonest
mental disorders in women in developing countries. Gynaecological Morbidity and Psychological
Disorder: Gynaecological symptoms, for example vaginal discharge, are
among the most commonly cited health problems in women in developing
countries. Although much earlier research assumed this symptom to be
indicative of reproductive tract infections, recent studies (particularly
from South Asia) show considerable discordance between symptoms and actual disease(20). Depression typically presents in the
form of medically unexplained physical symptoms. Rates of depression are high
in women attending gynaecological clinics and qualitative studies demonstrate
a strong relationship between vaginal discharge, weakness, psychosomatic symptoms and psychosocial stress(21). Part of the aetiology of ‘medically
unexplained’ vaginal discharge may be that it is a somatic idiom for
depression and psychosocial distress.
Childbirth
and Mental Health: Women are vulnerable to suffer depression during the period immediately following childbirth (22). There is limited literature on
Post-Natal Depression (PND) from Asian countries; this research demonstrates a wide range of prevalence of PND from 3-36% of mothers after childbirth(23 , 24). The majority of PNDs are self-limiting
though, if untreated, this process of resolution may take upto 6 to 12
months. There is a "compelling body of evidence implicating PND in a
range of adverse child cognitive and emotional outcomes". The detection
of PND is of great public health interest not only because of its profound
impact on maternal and child health but also due to the abundant evidence
that simple inexpensive interventions such as non-directive counselling are
of significant benefit in terms of remission of PND.
Adolescent
Sexuality & Mental Health: The sexual health of adolescents is now a
major issue in reproductive health research and programmes because of the
obvious potential of HIV/AIDS prevention by empowering young people to take
decisions regarding their sexual health. However, there is a risk that the
agendas and priorities of reproductive health workers may miss out on the
other real concerns of adolescents and their families, viz., stress arising
from conflict within families and from pressures in the educational system
and rising unemployment. There is now substantial evidence pointing to the
rising rates of depression and suicide amongst young people; for example,
suicide is the commonest cause of death and hospitalization in adolescents in Sri Lanka (25). Pressures of academic performance in
many developing countries lead to considerable psychological stress and
suicides and symptoms of weakness, lack of concentration, headaches and other
functional symptoms.
HIV/AIDS
and Women’s Mental Health: HIV/AIDS produces mental health problems such
as depression for those who suffer from the disorder for a variety of reasons
including the stigma and discrimination associated with the disorder, the
obvious implications of diagnosis to long-term survival, the impact of
discovering an illness which may have already infected loved ones in the
family, and the direct and indirect effects of HIV and secondary neoplastic
and infectious diseases on the brain. The effect of caring for terminally ill
persons on the mental health of carers is now recognized as an important
cause of CMD. There are reports that women, who are often carers for persons
with HIV/AIDS, suffer considerable mental and physical health problems as a
result of care-giving and that depression, in particular, is common.
*
Director, Schizophrenia Research Foundation (India), R/7A, North Main Road, West Anna Nagar Extension, Chennai-
600 101. India, Email : scarf@vsnl.com.
** Senior Lecturer, London School of Hygiene &
Tropical Medicine, Sangath Centre, 841/1 Alto Porvorim, Goa, INDIA 403521. 
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