A comprehensive vision for women's mental health

Howard et al's scholarly, comprehensive and evidence-based review of women's reproductive mental health1, across eight related topics, is a welcomed addition to earlier work on perinatal psychiatry, which has long dominated the women's mental health discourse2. On reading the paper, I was struck by how interrelated the covered topics are, and how deeply they are impacted by the social determinants of health (consider, for example, contraception, reproductive coercion, sexual violence, and abortion). This brings to mind the syndemic theory proposed by anthropologists3, which refers to clustering of two or more health conditions, their adverse interactions, and contextual factors that create the conditions for interactions worsening health outcomes. This highlights that health issues are entangled in complex biological and social processes, which often require expertise from diverse fields to engender a more socially conscious medicine for prevention and integrated care3. Psychiatrists will recognize these concepts as the biopsychosocial model, in which individual biological and psychological factors are influenced by social, economic, cultural and environmental conditions. These intertwining and multiplicative interactions are richly highlighted in women's reproductive mental health. To further illustrate this complex intertwining, consider the impact of serious mental illness and its treatment across women's reproductive mental health. Antidepressant medications may dampen women's sexual desire, affecting both fertility and relationships. Depression itself may affect sexual libido, as well as lessen motivation and self-efficacy to use contraceptives or seek abortion for an unwanted pregnancy. Mania may lead to hypersexuality and lack of concern about contraception or possible pregnancy, or damage relationships. Psychosis may render women more vulnerable to sexual violence and reproductive coercion, as well as reduce their ability to use contraceptives or seek abortion. Serious mental illness may also lead to marginalization and economic deprivation, and lessen access to health, reproductive and mental health services. Conversely, intimate partner violence and sexual violence may lead to serious mental illness. Multiple roles at home, as caregivers, and at work may burden many women, leading to anxiety and depression. So, a complex circle evolves. The impact of social factors, culture, religion and policy across women's reproductive mental health is enormous. For example, social stigma, patriarchy, religion and ultraconservative policies may curtail or prohibit sex education, access to contraceptives, emergency contraception, and surgical and medical abortion. The prioritization of “motherhood” and “family life” may mitigate women's autonomous choices, and promote reproductive coercion. Recent political influences on legal decisions and health policy have severely hampered access to abortion in some US jurisdictions. Increasing evidence shows that abortion restrictions lead to increasing anxiety, depression and suicidality among reproductive-aged women. On the other hand, fatally flawed research by anti-abortionists alleging negative mental health outcomes of abortion has been cited as “evidence” in related legal proceedings, despite well-conducted research refuting this4. In considering women's reproductive mental health, both psychiatry and obstetrics/gynecology have been slow to incorporate the social determinants of health into their education, research and clinical services. A lifespan perspective is lacking across women's mental health. Life does not begin at initiation of menses or end at menopause. Sex/gender issues related to childhood and old age mental health need more attention, as well as sex/gender issues in efficacy and side effects of psychiatric medications. Mind-body relationships are belatedly receiving their due attention in psychiatry and medicine in general. Gender/sex based perspectives, instead, are slower to emerge. For example, autoimmune and rheumatologic diseases disproportionately affect females, yet little is known about whether their etiology, symptoms, course, treatments, outcomes and psychological aspects are different in females and males. A sex/gender perspective on etiology and treatments may improve outcomes. Coronary artery and cerebrovascular disease are major killers, and research has shown that there are sex differences in prevention, etiology, symptoms and treatments. The roles of anxiety and depression in heart disease etiology and outcomes are increasingly understood, but a gender/sex perspective is lacking. The field of women's health and mental health is relatively recent, with appointment of the world's first chair in women's health occurring only in 19955. The development of chairs and programs in women's health and mental health has now spread to most Western countries. Many psychiatric associations, including the WPA, now have a Section on Women's Mental Health, which promotes education, research and career development in this field. As women gradually become medical leaders, it is not surprising that interest in women's health and mental health is increasing. However, these developments are still absent or only gradually emerging in low- and middle-income countries. A seminal paper in 2001 stated that “women's mental health can only be understood by considering the context of their lives” and listed a broad range of human rights and public health concerns6. The international women's mental health consensus statement approved by the WPA in Cairo in 2004 reinforced this wide scope7. Human rights issues start with females being considered equal to males. United Nations data show that worldwide females have a disproportionate share of poverty, child abuse and neglect, lower education levels, and poorer access to quality health services8. Education is the key to power, health (particularly reproductive health, as expressed by fertility and maternal mortality rates), better nutrition, higher economic status, education of offspring, participation in democracy, and social status among women, as well as lower intimate partner violence. Violence against women remains a global human rights and public health problem that drastically endangers their mental health, resulting in depression, anxiety, stress disorders, eating disorders and emotional suffering. The WPA curriculum on intimate partner violence and sexual violence against women, translated into several languages on the Association's website, can help mental health care providers safely identify and manage abused women. Prevention of gender-based violence, however, requires broader human rights and public health perspectives that enforce quality of care, provide policy and legal safeguards, and advocate and model respectful relationships in education and work9. In conclusion, Howard et al have made a vital contribution to women's reproductive mental health. There is still much to be done for a comprehensive approach to this area in policy, research and clinical practice.