1. Fareed A. Minhas
Professor & Head
Institute of Psychiatry

2. Depressive disorders account for close to 41.9% of the disability from neuropsychiatric disorders among women compared to 29.3% among men.
Leading mental health problems of the elderly are depression, organic brain
syndromes and dementias. A majority are women.
An estimated 80% of 50 million people affected by violent conflicts, civil
wars, disasters, and displacement are women and children.
Lifetime prevalence rate of violence against women ranges from 16% to 50%.
At least one in five women suffer rape or attempted rape in their lifetime.

3.  Is a critical determinant of mental health and mental illness. The
morbidity associated with mental illness has received substantially more
attention than the gender specific determinants and mechanisms that
promote and protect mental health and foster resilience to stress and
adversity
 Determines the differential power and control men and women have over
the socioeconomic determinants of their mental health and lives, their social
position, status and treatment in society and their susceptibility and
exposure to specific mental health risks
 Differences occur particularly in the rates of common mental disorders depression, anxiety and somatic complaints. These disorders, in which
women predominate, affect approximately 1 in 3 people in the community
and constitute a serious public health problem

4.  Unipolar depression, predicted to be the second leading cause of global
disability burden by 2020, is twice as common in women
Depression may be more persistent in women than men. More research is
needed
 Reducing the overrepresentation of women who are depressed would
contribute significantly to lessening the global burden of disability caused
by psychological disorders
 Gender differences have been reported in age of onset of symptoms,
frequency of psychotic symptoms, course of schizophrenia and bipolar
disorders, social adjustment and long term outcome
 The disability associated with mental illness falls most heavily on those
who experience three or more comorbid disorders. Again, women
predominate

5.  Depression, anxiety, somatic symptoms and high rates of comorbidity are
significantly related to interconnected and co occurrent risk factors such as
gender based roles, stressors and negative life experiences and events
 Gender specific risk factors for common mental disorders that
disproportionately affect women include gender based violence,
socioeconomic disadvantage, low income and income inequality, low or
subordinate social status and rank and unremitting responsibility for the care
of others
 The high prevalence of sexual violence to which women are exposed and
the correspondingly high rate of Post Traumatic Stress Disorder (PTSD)
following such violence, renders women the largest single group of people
affected by this disorder

6.  The mental health impact of long term, cumulative psychosocial adversity
has not been adequately investigated
 Restructuring has a gender specific effect on mental health
 Economic and social policies that cause sudden, disruptive and severe
changes to income, employment and social capital that cannot be controlled
or avoided, significantly increase gender inequality and the rate of common
mental disorders

7.  Gender bias occurs in the treatment of psychological disorders. Doctors are
more likely to diagnose depression in women compared with men, even
when they have similar scores on standardized measures of depression or
present with identical symptoms
 Female gender is a significant predictor of being prescribed mood altering
psychotropic drugs
 Gender differences exist in patterns of help seeking for psychological
disorder. Women are more likely to seek help from and disclose mental
health problems to their primary health care physician while men are more
likely to seek specialist mental health care and are the principal users of
inpatient care
 Men are more likely than women to disclose problems with alcohol use to
their health care provider

8.  Gender stereotypes regarding proneness to emotional problems in
women and alcohol problems in men, appear to reinforce social stigma and
constrain help seeking along stereotypical lines. They are a barrier to the
accurate identification and treatment of psychological disorder
 Despite these differences, most women and men experiencing emotional
distress and /or psychological disorder are neither identified or treated by
their doctor
 Violence related mental health problems are also poorly identified.
Women are reluctant to disclose a history of violent victimization unless
physicians ask about it directly
 The complexity of violence related health outcomes increases when
victimization is undetected and results in high and costly rates of
utilization of the health and mental health care system

9. WHO Report Title on Mental Health in Women-2002
 Scientists are only now beginning to tease apart the contribution of
various biological and psychosocial factors to mental health and mental
illness in both women and men
 Researchers are currently studying the special problems of treatment for
serious mental illness during pregnancy and the postpartum period
 Research on women's health has grown substantially in the last 20 years
 Today's studies are helping to clarify the risk and protective factors for
mental disorders in women and to improve women's mental health
treatment outcome
 According to the WHO Global Burden of Disease 1996 statistics, the
leading cause of disease burden for women in 1990 was Unipolar
depression, amounting to 13% of all causes of disease burden in women of
developing countries

10. WHO Report Title on Mental Health in Women-2002
 The position of women in Pakistan : male-female ratio population wise is
108 males to 100 females of 140 million in Pakistan. Women constituted
48% of the total population and 22% of women are in reproductive age
group and 26% are less than 15 years. Women have low literacy rate i.e.
24% majority of women are housewives and are economically dependent
on men and not conscious of their legal rights
 As per local studies, identified predisposing factors for mental illness in
Pakistan are: low socioeconomic conditions, illiteracy, unemployment or
poor job conditions, denial of justice or lawlessness, social discrimination,
loosening of cohesion in society and violations of human rights
 There is need to explore social and cultural factors contributing in
depression because incidence of mental illness is rising in our country and
the general awareness about existence and causation of mental illness is
lacking

11. • A woman goes through different stages in the reproductive period of her
lifetime : MENARCHE  CYCLIC CHANGES AS MENSTRUAL CYCLES
 CHANGES IN PREGNANCY  MENOPAUSE
• Hormonal changes in menstrual cycle – every 28 days. Psychotropic
hormones are estrogen and progesterone. Estrogen peaks before ovulation
while progesterone afterwards. These are important changes making some
women very vulnerable
• In course of a full-term pregnancy, the corpus luteum and placenta
contribute through : progesterone rising 7-fold, estradiol 130-fold, and
prolactin levels 19-fold
• At menopause, ovaries fail and estrogen/progesterone levels lower,
FSH/ LH levels increase

12. Lipophilic steroids ; ESTRADIOL (E2) most abundant in CNS
Postulated to have a multimodal effect on brain cells; neutralizes the
neurotoxic effects of a variety of stressors
Acts through 2 currently identified receptors : alpha and beta
Estrogen influences can occur through binding to the estrogen response
element on the promoter region of target genes or through direct effects on
membrane receptors. Genomic effects are slow: hours to years. Membrane effects
are immediate (thought to account for estrogen's anti-apoptotic, antioxidant, and
cell proliferative actions)
Next slide gives an illustration with the effects of estrogen on CNS
In fetal life, estrogens organize developing neurons and, after adolescence,
they continue to affect neurite growth and synapse formation, to interact with
nerve growth factor and other neurotrophins and to modulate neurotransmitter
systems (dopamine, serotonin, norepinephrine, acetylcholine, and glutamate)

14. SLEEP : Estrogen arouses and activates while progesterone is required
for sleep maintenance. The estrogen/progesterone ratio may prove to be
interesting in development of postpartum psychosis
COGNITION : Action of estrogen on the adrenergic, serotoninergic and
especially cholinergic receptors helps in learning, retention and recall. Also
causes reduction of stress and improvement of mood
DEPRESSION : Recent study from Sweden details new work showing
that estrogen increases the expression of 5HT2-A gene and serotonin
transporter gene in the dorsal raphe nucleus of rats

15. Include the following – Premenstrual Dysphoric Disorder/Premenstrual
Syndrome, Postnatal depression, Perpeural Psychosis and Bipolar
Disorder and Dysthymic disorder and Major Depressive disorder
PREMENSTRUAL DYSPHORIC DISORDER/ PREMENSTRUAL
SYNDROME –
 Prevalence 3-5 %
Severe mood and related biological/physical changes monthly
Symptoms present atleast a week; premenstrually and disappear
completely after a week of menstruation
Recommended treatment : Regular exercise, SSRI’s and
anxiolytics if necessary
Newer development : use of estradiol skin patches and OCPs
POSTNATAL DEPRESSION -

16.  Regarded as any non-psychotic depressive illness of mild to moderate
severity occurring during the first postnatal year; for a significant
proportion may have onset in antenatal period
 Prevalence (whether point or period) ranges from 4.5% to 28% of women
in the postnatal period. Majority cluster around 10% to 15% with one metaanalysis giving a prevalence of 13%
 Risk factors
past history of psychological
antenatal parental stress
antenatal thyroid dysfunction
disturbance during pregnancy
low social support
coping style
poor marital relationship
longer time to conception
recent life events
depression in fathers
"baby blues"
emotional lability in maternity
parents' perceptions of their own upbringing
blues
low quality social support
unplanned pregnancy
having two or more children
Unemployment
not breastfeeding

17.  Screening EDINBUGH POSTNATAL DEPRESSION SCALE (EPDS) with
a cut-off value of 10 for the general population (above 9 indicating moderate
and 12 severe case) at 6 weeks then 3 months post delivery
 Prevention Current research base for preventive interventions in low-risk
women is limited. In high-risk cases, postnatal visits, inter-personal therapy
and antenatal preparation may be effective
 Management Postnatal depression should be managed in the same way
as depression at any other time, but with the additional considerations
regarding the use of antidepressants/antipsychotics when breast feeding.
Also the infant’s well-being should be monitored
Women educated to breastfeed just before or at least 1-2 hr
after taking their medication
Except doxepin all other TCAs can be used. Among SSRIs
paroxetine preferred due to low milk/plasma ratio. Others can be used too

18.  POSTPARTUM PSYCHOSIS
 A rare condition that occurs in approximately 1-2 per 1000 women
after childbirth
 Onset as early as the first 48-72 hours postpartum. For the majority of
women with postpartum psychosis, symptoms develop within the first
2 weeks after delivery
 Earliest symptoms are typically restlessness, irritability, and sleep
disturbance. In general, postpartum psychosis evolves rapidly and is
characterized by depressed or elated mood, disorganized behavior,
mood lability, and delusions and hallucinations
 Risks of suicide and/or infanticide are high, thus these women often
require hospitalization
 Screening in the antepartum period is important to rule out any risk
factors and educate accordingly if any

19.  Risk factors All Women should be screened during pregnancy for
previous puerperal psychosis, history of other psychopathology (especially
affective psychosis) and family history of affective psychosis
 Prevention Evidence suggests that lithium is an effective treatment in
high risk groups but not of sufficient quality to support recommendation
 Management Pharmacological treatment with anti-depressants, antipsychotics and mood-stabilizers with additional considerations regarding
breast-feeding. Psychosocial approach includes counseling, CBT,
interpersonal therapy and social support (mother-baby units)
 BIPOLAR DISORDER
 Women are more likely to present as major depression but actually have
Bipolar disorder because there are more episodes of depression and
because onset of mania is at a later age for women
 Three times more likely to present with rapid cycling disorder

20.  Importance of keeping women well psychiatrically during their
pregnancies and following delivery in order to optimize outcomes for both
mother and child
 General guidline for mild to moderate BAD is to taper and discontinue
antimanic prophylaxis gradually prior to pregnancy then reintroduce as
needed or during the second trimester. In the event of an unplanned
pregnancy, the clinician and patient may elect to discontinue the antimanic
medication
 For severe or highly recurrent bipolar disorder, recommended is
continuation of the mood stabilizer across pregnancy, if possible along with
use of 1 mg/day of folate, and for valproic acid, he recommended 4
mg/day

21. In the June 2004 CME the issues of substance abuse in women was
discussed in relation to several other disorders prevalent :
 Association between affective and anxiety disorders and substance use
disorders is particularly important for women
 Issues concerning physical and sexual abuse, partner violence, and
PTSD are particularly important for women in substance abuse treatment
 Important that all women with substance use disorders be assessed for
psychiatric comorbidity, history of physical and/or sexual abuse, and,
importantly, ongoing physical or sexual abuse
 New data on the use of opioid replacement therapies in pregnant
women. Specifically, the use of buprenorphine in drug-dependent
pregnant women shows promise
 Promising data indicating that treatment of drug-using partners of
pregnant women can improve outcomes for the women as well as for their
partners

22. o Schizophrenia does not affect men and women in the same way.
Premorbid adjustment is known to be superior in women, the symptoms of
schizophrenia begin later in life, and outcome for the first 10-15 years after
onset is more favorable in women
o The symptomatic expression of illness also differs between the sexes: men
show more apathy, flat affect, cognitive disturbance, paucity of speech, and
social isolation, whereas women are more often depressed
o In addition, women may have more depressive symptoms, paranoia, and
auditory hallucinations than men and tend to respond better to typical
antipsychotic medications
o A significant proportion of women with schizophrenia experience
increased symptoms during pregnancy and postpartum
o Brain Structure Differences :
 In normal as well as schizophrenic women, the IPL is slightly larger on the
right side, and no volume differences can be detected contrary to men

23.  Men with schizophrenia have larger ventricles (the open spaces within the
brain) than do unaffected men, while women show no such difference
 One version of the gene that encodes the protein apoliprotein E (ApoE 4) has
been shown to affect the severity of schizophrenia in women but not in men
 Estrogen appears to have a protective effect on brain cells, to some degree
shielding women with schizophrenia from severe symptoms during high
estrogen phases of the menstrual cycle and possibly delaying early-onset
schizophrenia to late adolescence. Decreases in estrogen levels at menopause
may be related to the second peak of schizophrenia onset seen in women aged
50 and older
 Because women with schizophrenia report more mood symptoms than men,
they often require a more complicated treatment regimen of both
antidepressants and mood stabilizers

24.  Anxiety disorders, which include panic disorder, obsessive-compulsive
disorder (OCD), post-traumatic stress disorder (PTSD), phobias, and
generalized anxiety disorder, affect an estimated 13.3 percent of Americans
ages 18 to 54 in a given year
 Women outnumber men in each illness category except for OCD and
social phobia
 Results from an NIMH-supported survey showed that female risk of
developing PTSD following trauma is twice that of males and have higher
rates of co-occurring medical and psychiatric problems
 PTSD is characterized by persistent symptoms of fear that occur after
experiencing events such as rape or other criminal assault, war, child
abuse, natural disasters, or serious accidents. Nightmares, flashbacks,
numbing of emotions, depression and feeling angry, irritable, or distracted
and being easily startled are common

25.  Females comprise the vast majority of people with an eating disorder—
anorexia nervosa, bulimia nervosa, or binge-eating disorder
 In their lifetime, an estimated 0.5 to 3.7 percent of females suffer from
anorexia and an estimated 1.1 to 4.2 percent suffer from bulimia. An
estimated 2 to 5 percent experience binge-eating disorder in a 6-month
period
 Eating disorders are not due to a failure of will or behavior; rather, they
are real, treatable illnesses and often co-occur with depression, substance
abuse, and anxiety disorders, and also cause serious physical health
problems
 Eating disorders call for a comprehensive treatment plan involving
medical care and monitoring, psychotherapy, nutritional counseling, and
medication management

26.  Studies have shown that while the number of new cases of AD is similar
in older adult women and men, the total number of existing cases is
somewhat higher among women
 Possible explanations include that AD may progress more slowly in
women than in men; that women with AD may survive longer than men
with AD; and that men, in general, do not live as long as women and die
of other causes before AD has a chance to develop
 AD features a distinct type of damage to the white matter of the brain.
Damage to the white matter is more common and more severe in women
than in men suffering from AD
 Female AD patients show more severe early alterations of cells in a
particular part of the brain, the nucleus basalis of Meynert, than do males.
 Myeloperoxidase is an enzyme associated with the plaques that appear
in the brains of people affected by AD. Some versions of the gene that
encode the enzyme increase the incidence of AD in women, while other
versions increase the incidence in men

27. o However, death among women with AD tends to be associated with
measures of disability, such as malnutrition and impairment in performing
the activities of daily living
o Women with AD have lower insulin levels than do men with AD despite
similar body mass, suggesting women with AD are more susceptible to
diabetes
o The accumulation of the protein amyloid beta is thought to contribute to
the development of plaques in the brains of AD patients. Sex hormones,
such as estrogen and testosterone, affect amyloid beta levels
o Estrogen therapy has been proposed for use in the prevention and
treatment of AD in women, but the benefits of this treatment are still
controversial
o Anticholinesterase therapies offer modest benefit to sub groups of AD
sufferers. Men have a 73 percent greater chance of responding to these
therapies than women