Key points

Introduction

Mental health conditions are more prevalent among women, with 27.2% of females experiencing any mental illness (AMI) compared to 18.1% of males, and a similar pattern observed with serious mental illness. Additionally, women with AMI were more likely to receive mental health services (51.7%) than men (40.0%). 40% of office visits for mental health concerns occur in primary care settings, with primary care physicians responsible for 47% of prescriptions for mental illness. Over 36% of active psychiatrists are over age 65 and only 12.3% are under 40. As such, the reliance on primary care physicians to deliver mental health care is going to increase. This chapter explores common mental health diagnoses and treatment in women.

Anxiety disorders

The lifetime prevalence for anxiety disorders is 30.5% for women and 19.2% for men. Women with anxiety are more likely to engage the medical system than men through emergency room (ER), urgent care, and doctor office visits (1.04 visits/month vs 0.71 visits/month) and more than half of the medical costs for individuals with anxiety are related to nonpsychiatric expenditures. Women with anxiety are more likely to experience fatigue, lassitude, autonomic disturbances, sleep reduction and pain than men.

Nonpharmaceutical approaches are as effective as monotherapy or as augmentation to pharmacologic treatments. Cognitive Behavioral Therapy (CBT) is particularly beneficial for treating anxiety, surpassing other forms of psychotherapy. For women who want to minimize pharmacologic exposure during pregnancy or while trying to conceive, CBT is especially advantageous. Regular exercise, stress management techniques (eg, yoga, mindfulness meditation, tai chi), and certain diets like the Mediterranean diet have also demonstrated benefits in reducing anxiety and improving mood disorders.

First-line pharmaceutical treatments for anxiety disorders include Selective Serotonin Reuptake Inhibitors (SSRIs) and Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs). Females respond better to serotonergic antidepressant medications than men, but this increase in effect wanes in postmenopausal women. Benzodiazepines may be used short-term but have dose-dependent side effects and addiction risks; intermediate-acting (eg, chlordiazepoxide) or long-acting (eg, clonazepam) benzodiazepines carry a lower dependency risk.

Sertraline, Fluoxetine, Escitalopram, and Citalopram are specifically recommended as first-line medications in pregnancy by ACOG, though previously effective anxiety medications should also be considered. Benzodiazepines should be avoided or used sparingly during pregnancy due to their side effect profile, dependency risk, and potential for neonatal withdrawal.

Managing anxiety in pregnant and postpartum patients is crucial, underscored by the United States Preventitive Services Task Force (USPSTF) and American College of Obstetricians and Gynecologists (ACOG) recommending anxiety screening during pregnancy and postpartum. Severe anxiety during pregnancy is an independent risk factor for mood and behavioral issues in offspring and is associated with pre-term delivery and low birth weight. ^, During perimenopause and menopause, anxiety symptoms are linked to vasomotor symptoms, though the effectiveness of hormone replacement therapy (HRT) in treating anxiety in these patients shows mixed results and is not recommended to solely treat anxiety symptoms.

Sleep disorders

The percentage of adults taking sleep medications increases with age, and women are more likely to be prescribed medications than men (10.2% vs 6.6%). The American Academy of Sleep Medicine recommends CBT-I before prescribing sleep medications, and Brief Behavioral Therapy for Insomnia can be used in the primary care setting while awaiting CBT-I. CBT-I combines traditional CBT methods with stimulus control and sleep restriction therapy. While non-pharmacologic management is preferred for women, especially when pregnant or breastfeeding, medication use may be acceptable in certain cases ( Table 1 ). During pregnancy, sleep disturbances are common with 80% of women reporting sleep concerns at some point. A Danish study of over 1,300 pregnant women taking benzodiazepine receptor agonists, such as zolpidem, did not find an increased risk of teratogenicity. However, transplacental transfer occurs, and neonatal withdrawal symptoms have been documented. Benzodiazepines and benzodiazepine receptor agonists may be associated with increased risks of preterm labor, cesarean section, and low birth weight. In breastfeeding women, discussing sleep medication use can be supported by internet-based resources, such as InfantRisk and LactMed. Poor sleep quality and sleep disorders are highly prevalent during menopause, independent of vasomotor symptoms. As with other life stages, CBT-I should be the first-line intervention for menopausal patients. For menopausal patients with or without vasomotor symptoms, hormone therapy has shown a small benefit on perceived sleep quality and can be considered in select women.

Somatic symptom disorders

Somatic symptom disorders are characterized by significant preoccupation with physical symptoms, leading to functional impairment. Somatic symptom disorder is prevalent in 5% to 7% of the general population, with a notable female-to-male ratio of 10:1. Unlike previous editions, the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) does not require these symptoms to be “unexplained”, and may have chronic medical conditions with an abnormal, heightened response to the physical symptoms, potentially warranting an additional diagnosis of somatic symptom disorder. Effective treatment combines psychotherapy, particularly cognitive-behavioral therapy (CBT) and mindfulness, with medication. Avoiding over-testing and maintaining frequent, short-interval follow-ups have been shown to be beneficial. Cognitive-behavioral therapy is highly effective in addressing maladaptive thoughts and behaviors related to physical symptoms. Mindfulness-Based Stress Reduction (MBSR) techniques can help manage stress and reduce symptom severity. SSRIs and SNRIs can be effective, especially when treating comorbid anxiety and depression, with a number needed to treat (NNT) of 3. Tricyclic antidepressants (TCAs), like amitriptyline, can also be used at lower doses but must be prescribed cautiously due to anticholinergic side effects and potential teratogenic risks in patients who are pregnant or planning pregnancy. Treatment effectiveness can be monitored using the Somatic Symptom Scale-8 (SSS-8), a validated retrospective patient questionnaire (see Table 1 ).

Eating disorders

Between 2.6% and 8.4% of females experience an eating disorder during their life, including subthreshold or atypical eating disorders. Anorexia nervosa and bulimia nervosa are estimated to be three times more likely in women than men. ^, Lesbian and bisexual women are more likely to engage in binge-eating behaviors than any other gender and sexuality. This population also reports a higher prevalence of purging and laxative use than heterosexual groups. ^,

Girls are at the greatest risk of developing eating disorders between late childhood into late adolescence. Women’s reproductive events, especially pregnancy and menopause, reflect a complex blend of biopsychosocial phenomena leaving women psychologically vulnerable. Comparable levels of dieting and disordered eating are now found across young and elderly women. In middle-aged women, aged 40 to 60, 4.6% met the full criteria for a clinical eating disorder, while another 4.8% met the subthreshold standards. In US women over age 50, 79% report that weight/shape affects their self-image; 41% weigh themselves daily; 36% spent at least half of the last 5 years dieting; 13.3% report eating disorder symptoms; and 8% report purging.

Eating disorders affect every system in the body, including electrolyte imbalances, endocrine dysfunction, increased risk for osteopenia and osteoporosis, and a compromised immune system. In adult women, eating disorders can deplete fat stores exacerbates the decline in estrogen level, accelerate natural neuromuscular decline, and raise mortality risk associated with low weight.

Multiple validated screening tools exist for use in primary care settings to help identify possible disordered eating and indications for additional evaluation and treatment. ^,

Trauma related disorders

About half of all women in the U.S. will be exposed to at least one traumatic event in their lifetime. While women are somewhat less likely to experience traumatic events overall, they are more vulnerable to high impact traumas, like sexual assault and childhood sexual abuse, than men. It’s estimated that women experience PTSD at two to three times the rate that men do. U.S. prevalence estimates of lifetime PTSD from the National Comorbidity Survey Replication are 9.7% for women and 3.6% for men.

Women may be more susceptible to mental health consequences of trauma because they are more like to experience trauma within established relationships, or their traumatic exposures are more chronic than those experienced by men (eg, ongoing interpersonal violence). Women are more likely to report co-occurring internalizing disorders like anxiety and depression versus externalizing disorders like substance abuse. ^, They seek more social support after trauma, the lack of it being the most consistent predictor of negative outcome of trauma, and a more powerful resilience factor for women compared to men.

Several psychosocial factors have been identified that increase the risk for PTSD following trauma exposure, ^, including:

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  Pre-existing mental health problems

  
  
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  Family history of mental health problems

  
  
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  Experiencing additional life stressors

  
  
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  Availability of post-trauma social support

The treatments of choice for PTSD are psychological interventions, such as trauma-focused cognitive behavioral therapy and eye movement desensitization and reprocessing (EMDR). ^, Several pharmacological approaches (fluoxetine, paroxetine, sertraline, and venlafaxine) reduce PTSD symptoms, but with a lower effect size than psychological treatments. Evidence suggests women have greater reduction in clinician and patient-rated PTSD symptoms with trauma-focused psychological interventions.

Depression

Depression is up to two times more common in women as compared to men in both the United States and elsewhere in the world. Research shows that women have bimodal peaks of incidence across their lifetime, one at the beginning of adolescence and then again in the late 40s to early 50s. One theory correlates to sex hormone changes, as these ages are associated with onset of menarche and menopause respectively. Potential mechanisms include the effect of estrogen on the hypothalamic-pituitary axis, specifically in regulation of neurotransmitters including serotonin, gaba-aminobutyric acid (GBA) and cortisol. Other psychosocial risk factors include abuse and increased risk of development of depression after a serious life event. Family history of depression significantly increases risk. Notably, women present more with physical symptoms including appetite changes, sleep issues, sexual disturbance and loss of interest and pleasure and are less likely to report substance use/abuse as compared to men. Rates of depression among women of different ethnic groups does vary; however, a study of women of differing ethnic backgrounds with intimate partner violence, supports that decreased education and lower income are associated with increased risk of depression, contributing to the health disparities seen in individuals with lower socioeconomic status. Similar to anxiety, women have better response to serotonergic antidepressants (SSRI/SNRI) than men, and post-menopausal women tend to have decreased response to antidepressants as compared to younger women. In post-menopausal women specifically, SSRIs and SNRIs remain first line therapy for treatment of depression, but hormone replacement therapy has been shown to improve mood and can be considered as an adjunct treatment option. Exercise and behavioral therapy are supported as first line treatments along with medications; however, no difference has been seen in response to these interventions in women compared to men.

Perinatal depression and postpartum depression (PPD) confer increased risk for both infant and maternal health. One study showed rates of minor depression in the perinatal period increased to 17% as compared to 11% in non-pregnant women; however, there was no difference in major depression between the two groups. All pregnant women should be screened for depression at initial prenatal visit, later in pregnancy and during post-partum visits. Although no specific guidelines exist regarding which screening tool should be utilized, the Edinburgh post-partum depression scale (EPDS) is commonly utilized. ^, Specifically in the post-partum period, rates of depression peak at two and 6 months. The American Academy of Pediatrics recommends screening post-partum mothers at one, two and 4 months postpartum. Multiple studies have shown an association with increased behavioral issues, poorer language and IQ development, and increased rates of gastrointestinal and lower respiratory tract infections in children of mothers with PPD. Growing literature suggests that the EPDS may under diagnose post-partum depression in African American women who have higher rates of discrimination stress, systemic and structural racism stress and abuse by their partner, and that women with these exposures are at two-fold higher odds of developing depression during pregnancy. ^, One study of 261 African American women showed that an initial obstetric visit EPDS score ≥ 10 was associated with increased risk for preeclampsia, preterm birth and low birth weight. ACOG guidelines recommend psychotherapy as first line treatment for mild to moderate perinatal depression. Initial pharmacologic treatment for both perinatal and PPD is SSRIs; however, SNRIs are considered reasonable second line.

Premenstrual syndrome/premenstrual dysphoric disorder

Premenstrual disorders encompasses both premenstrual syndrome (PMS) as well as the more severe form of premenstrual dysphoric disorder (PMDD), diagnostic criteria. The integrative medicine chapter reviews many of the nonpharmaceutical and diet approaches to treatment of premenstrual disorders and this section will focus on pharmaceutical treatment consideration. First line pharmacologic treatment includes SSRIs and can be dosed either continuously or intermittently (at onset of symptoms through menses) with similar efficacy. ^, Combined oral contraceptives have been shown to have moderate decrease in overall symptoms compared to placebo; however, evidence is low to moderate and has not shown improvement in mood specific symptoms. For severe cases that fail these treatments, Gonadotropin-Releasing Hormone Agonists can be used to induce anovulation, and failing this surgical management with oophorectomy may be considered. Other treatments recommended by ACOG with low quality evidence include acupuncture and nonsteroidal anti-inflammatory drugs during the luteal phase.

Bipolar disorder

Bipolar disorder (BD) affects 0.5% to 1.0% of the world’s population and is characterized by alterations in mood, levels of energy, and functioning. Sex may affect epidemiology and clinical features at presentation ( Table 2 ). For instance, hormonal oscillations related to the menstrual and reproductive cycle may influence clinical course and treatment and symptoms may worsen when gonadal hormone levels are low. A recent meta-analysis found an overall postpartum relapse risk of 35%. Discontinuation of psychopharmaceutical interventions during pregnancy may trigger a mood recurrence leading to disruption of daily functioning and ability to parent. Clinicians must balance the risk-benefit analysis of pharmacotherapy for BD during pregnancy for each patient, considering illness severity, past pregnancy treatment outcomes, psychosocial supports, and key windows during fetal development.

Table 2

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