Proceedings of a Workshop
Women’s Mental Health across the Life Course through a Sex-Gender Lens
Proceedings of a Workshop—in Brief
The Committee on Population of the National Academies of Sciences, Engineering, and Medicine convened a workshop on March 7, 2018, to help inform research, programs, and policies to better meet the mental health needs of women in the United States. Participants examined trends in mental health as well as risk and protective factors for diverse populations of women, and they considered the research needed for a better understanding of women’s mental health. Important issues of practice and policy also were discussed. Experts explored these topics from a life-course perspective and at biological, behavioral, social/cultural, and societal levels of analysis.
THE BIG PICTURE: FRAMEWORKS AND METHODS
Nicole Greene, Acting Director of the Office on Women’s Health (OWH) at the U.S. Department of Health and Human Services (HHS), described the work of her office in providing national leadership and coordination to improve the health of women and girls through policy, education, and model programs. Greene then introduced Admiral Brett P. Giroir, Assistant Secretary for Health at HHS. Giroir said that mental health problems disproportionately affect women compared to men, and that women’s mental health is affected by many things, including biological and genetic factors, gender roles, and psychosocial elements. Giroir also emphasized that the biological and social conditions of women change across the lifespan, and that the issues faced by women will be different at different stages in the life course.
In her presentation, Kristen Springer (Rutgers University) emphasized the importance of thinking about sex and gender as intimately intertwined and recognizing that it is very difficult to find any sex (biological) effect independent of gender (encompassing social, cultural, and structural factors). She proposed using the composite term “sex/gender” and encouraged researchers to theorize and, when possible, model the interactive effect of sex/gender on all health outcomes.
Springer cautioned that finding a biological difference between men and women does not necessarily mean a biological cause or solely a biological cause. For example, explanations of male/female differences in the incidence of bone fractures often point to molecular and cellular biological changes that occur with age. However, social factors, such as cultural expectations that encourage
women to wear high heels that affect joints and increase the likelihood of falls, also play a role in the magnitude of male/female differences in bone fractures directly and indirectly through molecular and cellular processes. Likewise, Springer noted that that biological explanations of male/female differences in mental health focus on women’s greater activation of the amygdala and hypothalamic pituitary adrenal (HPA) axis (a critical part of stress response) in women with depression, although social factors play a role here as well. For example, said Springer, childhood sexual abuse leads to long-term HPA axis and amygdala activity, and girls are twice as likely as boys to experience sexual abuse. Furthermore, small male/female differences in activation appear to escalate over time, underscoring the importance of a life-course view.
Springer also underscored the importance of using an intersectional perspective to understand variation in women’s mental health outcomes. Most intersectional research follows a group-centered approach, which describes basic patterns between groups such as blacks and whites. However, Springer urged researchers to also use more process-centered and structural approaches to intersectionality. A process-centered approach identifies mechanisms or pathways that link particular groups to certain health outcomes (such as examining racism and sexism instead of “race” and “sex”) and a system-centered approach identifies how stratifying factors, such as race, class, and sex/gender, are embedded in social institutions, governmental practices, and public policies. All three approaches are important, she said, but in order to target interventions toward potentially modifiable factors, such as particular attitudes, beliefs, or structural constraints, the underlying social processes need to be measured directly whenever possible. Taking an “intersectional” approach to research—which examines how sex/gender interact at the group, process, and structural level with race, class, religion, national origin, migration status, and other factors to shape people’s experiences—could help to refine knowledge about sex/gender and mental health.
Nicholas Eaton (Stony Brook University) explained that the limitations of research based on classifications in the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases (ICD) could be addressed by data-driven approaches. The traditional approach to diagnosis assumes that mental disorders fall into discrete categories derived mainly from the a priori opinions of experts, he said. Eaton presented evidence to show that people’s symptoms do not fit neatly into these categories. Comorbidity is the rule rather than the exception, as in the frequent co-occurrence of depression and generalized anxiety; furthermore, heterogeneity of symptoms exists within a diagnosis, and the process used to place people into diagnostic categories is frequently arbitrary. Using borderline personality disorder as an example, he said, “There are 256 different constellations of those nine diagnostic criteria that yield the same diagnosis. And two individuals who have the same diagnoses may have only one criterion in common, like chronic feelings of emptiness.” The hierarchical taxonomy of psychopathology (HiTOP), Eaton said, is a data-driven model that uses hierarchical model-estimation techniques to analyze and detect dimensional patterns in observed symptoms to identify underlying “transdiagnostic factors” that cut across traditional diagnostic categories. As an example, the HiTOP approach was used in one study to identify a cluster of “internalizing” and “externalizing” behaviors evident in the observed symptoms of people diagnosed with a range of mental health disorders.
Eaton argued that the data-driven HiTOP approach has several advantages: it generates scientifically defensible diagnostic categories that replicate globally across sexual orientation and lifespan; its results better align with people’s everyday experiences living with their disorders; it can help to avoid bias in diagnosis; it could lead to interventions that are more efficient because the transdiagnostic factors that underlie multiple disorders can be targeted; and it may reduce stigma for groups and subgroups, such as women and sexual-minority women, who often receive multiple diagnoses.
Vickie Mays (University of California, Los Angeles) emphasized the importance of using “intersectionality models” in research to inform interventions. As an example, said Mays, data from the National Survey of American Life and
the Medical Expenditure Panel Survey1 showed that the likelihood of being at risk for particular mental health disorders and the likelihood of seeking treatment for them differed among foreign-born Caribbean, U.S.-born Caribbean, and U.S.-born African Americans, variations that would have been obscured if all had been coded only as “black.” Family dynamics, attitudes, and concerns about stigma also differed among these three groups. This level of detail is important for adequate screening and interventions for disorders, Mays said, and for making population-based practice decisions about things such as the deployment of patient navigators to help guide patients through the health care system and the use of technology to encourage patients to follow up for care.
Mays also indicated that researchers have for a while known certain information about diversity and mental health from population-based surveys such as the National Comorbidity Survey and the California Quality of Life Survey. The latter showed, for example, that bisexual women had higher depression and anxiety than people of other sexual orientations, and they had a nearly six-fold increase in risk of lifetime suicide attempts compared to heterosexual women.2 The General Social Surveys also found that sexually experienced sexual-minority women were at an elevated risk of suicide mortality.3
According to Mays, increased diversity in research samples will enable the study of intersecting identities. She proposed including sexual orientation and other high-priority intersectionality variables in electronic health records, as discussed in a 2014 Institute of Medicine report,4 and she also suggested considering the possibility of making the collection of such data (with adequate protections of confidentiality) mandatory. Mays further proposed a national population-level survey of lesbian, gay, bisexual, and transgender (LGBT) mental health and added that surveys could be made more costeffective to avoid overlooking certain populations. She said that federal health surveys, such as the National Health and Nutrition Examination Survey (NHANES) and the National Health Interview Survey (NHIS), ought to include mental health information and that better linkages should be made across health and mental health surveys to give practitioners useful information.
PSYCHOLOGICAL AND STRUCTURAL FACTORS
Vicki Helgeson (Carnegie Mellon University) discussed the possible role of relationship orientation in women’s mental health. She said that people with a “communion” orientation focus on the needs of others to a healthy degree and have more balanced relationships in which they both provide and receive support, whereas people with an “unmitigated communion” orientation have more one-sided relationships and become overly involved in the problems and needs of others. This tendency is associated with a range of negative outcomes, Helgeson explained, including psychological distress and depressive symptoms, noncompliance with physician instructions, and poor adjustment to disease. Helgeson indicated that, on average, women score higher in unmitigated communion than men. This difference has been observed from childhood through older adulthood and is fairly stable from early adulthood.
Helgeson offered three possible reasons for the association between orientation and outcomes: First, people high in unmitigated communion define more events in their network as stressful, and they report being more affected by any single stressor. Second, people high in unmitigated communion are more likely to show self-neglect, as in a study of adolescents
1 Jones, A.L., Cochran,S.D., Leibowitz, A., Wells, K.B., Kominski, G., and Mays, V.M. (2018). Racial, ethnic, and nativity differences in mental health visits to primary care and specialty mental health providers: Analysis of the Medical Expenditures Panel Survey, 2010-2015. Healthcare, 6(2).
2 Blosnich, J.R., Nasuti, L.J., Mays, V.M., and Cochran, S.D. (2016). Suicidality and sexual orientation: Characteristics of symptom severity, disclosure, and timing across the life course. American Journal of Orthopsychiatry, 86(1), 69-78.
3 Cochran, S.D., and Mays, V.M. (2015). Mortality risks among persons reporting same-sex sexual partners: Evidence from the 2008 General Social Survey—National Death Index data set. American Journal of Public Health, 105(2), 358-364.
4 Institute of Medicine. (2014). Capturing Social and Behavioral Domains and Measures in Electronic Health Records: Phase 2. Washington, DC: The National Academies Press.
who had Type 1 diabetes.5 Third, unmitigated communion is related to low self-esteem, poor body image, and reliance on the perceptions of others for one’s self-worth, she said.
Social networks can be “a double-edged sword” for women, Helgeson noted, because they can provide support while causing women to have more people to nurture. The effects of social networks on women may depend in part on their relationship orientation, she argued—for example, people high in communion tend to have social skills that they use to harness support. Cultural differences in relationship orientation, and how these interact with gender to affect outcomes for women, may need to be examined.
Deborah Carr (Boston University) discussed the value of the stress and life course model for understanding why, how, and for whom stress affects mental health. The model includes stress exposure (severity, number, quality, and timing), coping resources, and coping styles. Although most research done in this tradition focuses on stressful events and chronic stressors, she noted that it is also important to study daily hassles, which can affect physical and mental health. In addition to considering outcomes such as major depression or anxiety, she also encouraged attention to people who have subclinical symptoms and thus may be more vulnerable to a more serious condition if they encounter additional stressors.
A person’s resources for coping may be structural or psychological. Structural factors have received less research attention, but evidence suggests that these are modifiable and can buffer the effects of stressors, Carr explained. For example, living in states with more financial support for home- and community-based services is associated with lower depression rates among older adults experiencing functional impairment and decline. Members of the LGBT community living in states with protections related to employment, hate crimes, and marriage also have lower risk of some mental health disorders, according to Carr. The ability to link data from research on stress and mental health to policy-related data from states would help researchers to learn more about structural factors that mitigate the effects of stress on mental health. She said that research should also focus on structural factors that affect people’s coping tactics. For example, a problem-focused coping strategy (e.g., altering or exiting a situation by finding a better job or moving to a safer neighborhood) is known to be more effective than an emotion-focused coping strategy (e.g., avoidance, reconsideration, or humor), but structural factors, such as those that affect people’s resources, can constrain choices and make certain problem-focused options less feasible.
Network events—that is, events that happen to other people but still take a toll on one’s mental health (e.g., having a child who is in jail or a sibling who is unemployed)—may be an important albeit largely overlooked factor that helps to explain racial and socioeconomic disparities in mental health. Carr noted that capacity to use data from social networks and dyadic exchanges is needed to learn more about how social interactions in networks affect stress and mental health. She said that “chronic strain” is another type of stress exposure that is commonly studied, although more can be done to capture the variety, duration, and nature of these experiences to be included in health surveys. The National Study of Daily Experiences, which is part of the Midlife in the United States (MIDUS) study, is an example of the kind of add-on to surveys that could be useful to understanding daily experiences, in addition to life-course experiences of stressful events and chronic stressors. More generally, according to Carr, researchers need to think more comprehensively about how to measure both one’s own and network stressors in population surveys. Stressors rarely occur in isolation, and secondary stressors can result from a primary stressor, such as financial strains from widowhood. Research on the interactive effects of multiple stressors and how risk factors, such as poverty, race, and ethnicity, make a person vulnerable would be useful.
Carr also indicated that collecting longitudinal data and thinking creatively about how to retain people in research studies would improve understanding about the accumulation of stressors. Current understandings, such as having more disadvantage leads to a greater toll on mental health, may not apply over the long term. For instance, she explained, low-to-moderate adversity is known to foster the de-
5 Helgeson, V.S., and Fritz, H.L. (1996). Implications of unmitigated communion and communion for adolescent adjustment to Type I diabetes. Women’s Health: Research on Gender, Behavior, and Policy, 2, 163-188.
velopment of effective coping skills such as the ability to marshal one’s resources. Cumulative effects of disadvantage may be additive, multiplicative, or curvilinear. Carr suggested that attention is needed to factors that affect resilience over time.
MENTAL HEALTH OVER THE LIFE COURSE: ADOLESCENCE
Katherine Keyes (Columbia University) described recent behavioral and mental health trends among youths and adolescents. According to a 2006 meta-analysis of 26 studies, the incidence and prevalence of depression changed little for either boys or girls born between 1966 and 1996.6 However, said Keyes, multiple sources indicate worsening mental health in the past 4 to 5 years for children and adolescents, especially girls. Data from multiple national surveys have shown increases, all beginning between 2009 and 2011, in major depressive episodes, depression-like symptoms, serious consideration of suicide, and completed suicides. Given these trends, according to Keyes, it is surprising that during this time period national data also show decreases in substance use and other kinds of externalizing problems, such as binge drinking and daily use of cigarettes, theft, property damage, assault, weapon possession, and arrests; marijuana use for most youth also has held steady during this period.7,8, 9 All of these trends may be part of a broader cultural shift among young people today, Keyes suggested. Although these trends (which include declines in unwanted pregnancies) may be regarded as favorable, behaviors typical of the transition to adulthood, such as getting a driver’s license, dating, and working for pay outside the home, are also declining more rapidly than in previous years.10
Keyes indicated that research is needed to understand how all of these changes in adolescent behavior relate to increases in depression, suicidality, and other mental health problems. In general, according to Keyes, research needs to focus on the etiology of individual variation in psychopathology, population distributions and determinants, and broad societal factors. Keyes said that research on cohort effects shows that as each generation of adolescents comes of age, they experience different historical moments that affect not only mental health but also substance use and well-being. Adolescents today, Keyes said, face an uncertain future: students are experiencing an increase in school shootings, and adolescents with minority social status are particular targets for victimization and trauma. She noted that although the rise of smartphones and social media may be playing a role, the factors in the broader environment that could be affecting this generation of adolescents also need to be examined.
Victoria Ojeda (University of California, San Diego) described the involvement of young adults in the justice system and the consequences for mental health. Ojeda said that 70 percent of youth in state and local juvenile justice systems have a mental illness. Of all lifetime cases of mental illness, 75 percent begin by age 24 with a delay of 8 to 10 years between onset and intervention. According to the Office of Juvenile Justice and Delinquency Prevention, 34 percent of youth offenses among females in 2013 were status offenses and status violations (e.g., running away from home or being truant from school), compared to 20 percent for males. Histories of victimization and relationship dysfunction are especially prominent for females. Women in detention experience unique service needs, Ojeda said. For example, women must cope with the loss of children, which can be traumatic and is associated with adverse behaviors while detained. The juvenile justice system is also not designed to provide mental health services: services are unavailable or delayed, and co-occurring is-
6 Costello, E.J., Erkanli, A., and Angold, A. (2006). Is there an epidemic of child or adolescent depression? Journal of Child Psychology and Psychiatry, 47(12), 1263-1271.
7 Keyes, K.M., Gary, D.S., Beardslee, J., Prins, S.J., O’Malley, P.M., Rutherford, C., and Schulenberg, J. (2017). Age, period, and cohort effects in conduct problems among American adolescents from 1991 through 2015. American Journal of Epidemiology, 187(3), 548-557.
8 Keyes, K.M., Wall, M., Feng, T., Cerdá, M., and Hasin, D.S. (2017). Race/ethnicity and marijuana use in the United States: Diminishing differences in the prevalence of use, 2006-2015. Drug and Alcohol Dependence, 179, 379-386.
9 Miech, R.A., Johnston, L.D., O’Malley, P.M., Bachman, J.G., Schulenberg, J.E., and Patrick, M.E. (2017). Monitoring the Future National Survey Results on Drug Use, 1975-2016: Volume I, Secondary School Students. Ann Arbor: Institute for Social Research, University of Michigan.
sues such as substance abuse and trauma are often not addressed.
Ojeda suggested that interventions include the following: policies to address young women’s incarceration/justice system involvement; procedures that consider young women’s unique needs to avoid re-traumatization while young women are in detention; anti-violence programs that can reduce girls’ involvement in the justice system; safe and stable housing; family-focused services and the establishment of safe supportive communities; services to address co-occurring disorders and trauma at screening, diversion, and incarceration; and community supervision at release. Achieving this, she said, will require a “whole person wraparound model” that can be adaptive for young adults as their life conditions change.
Ojeda also indicated that research needs to focus on how the incarceration of parents affects children, the effects that involvement in the justice system has on youth, and strategies both for meeting the needs of youth involved in the justice system and for preventing re-incarceration.
MENTAL HEALTH OVER THE LIFE COURSE: MIDLIFE
C. Neill Epperson (University of Pennsylvania) identified reproductive life stage, hormonal status, and stress history as important factors in women’s health. Women have dramatic fluctuations in reproductive hormones and gonadal steroid exposure while developing in utero, at puberty, during pregnancy, and during transition to menopause. Some women are at risk for developing mental health disorders during periods of hormonal change. Chronic stress, adversity, and timing of adversity are also important factors, Epperson said. Rapidly developing areas of the brain are vulnerable to the effects of significant adversity and stress during childhood and adolescence. Furthermore, the hormones present when adversity occurs can either accentuate or dampen the effects of stressors.
Epperson described research that illustrated the importance of examining how hormones at different reproductive stages interact with life experiences to affect women’s mental health in both positive and negative ways. She said that women who had early life adversity (i.e., two or more adverse childhood experiences) had greater difficulty with executive functioning and sustained attention at the post-menopause stage, and these difficulties could not be explained completely by reported depression and anxiety symptoms. Epperson also described research showing that postmenopausal women with high versus low levels of adverse childhood experiences displayed different patterns of brain activation when they were completing a cognitive task under experimental conditions of law and normal levels of serotonin. After estradiol treatment, which is known to enhance serotonin function, the brain activation of women with high levels of childhood adversity looked more like those with low levels of childhood adversity even when serotonin levels were experimentally reduced. Epperson further noted that inflammation, which is linked to depression, can increase as women go through menopause and may be a risk factor for the emergence of depression. In her research, those who experienced significant childhood adversity showed a decline in verbal memory performance and cognitive processing speed if markers of inflammation increased across the menopause transition.
According to Epperson, research also suggested that having some degree of early life stress may “inoculate” women from risk of depression later in life, as women who had one adversity in the prepubertal period had a decreased risk of depression either in perimenopause or over their lifetime. Epperson said that women may have critical windows of development during which life experiences make some women more vulnerable or resilient to depression, and more needs to be understood about these relationships from “womb to tomb.”
Natalie Slopen (University of Maryland) presented a model for understanding how sex differences in the linkage between depression and inflammation observed in midlife develop throughout the life course. Inflammation is part of the normal stress response system, but, over the long term, elevated levels of inflammation can be associated with a broad range of illnesses, such as asthma, rheumatoid arthritis, cardiovascular disease, cancer, and chronic pain. Slopen made four key arguments about risk and resilience factors related to the model. First, women experience greater levels of depression and inflammation than men and also
have more social, psychological, and behavioral risk factors that include maltreatment and trauma, sleep problems, obesity and low physical activity, and depressive symptoms. Second, sex disparities in both depression and inflammation emerge during adolescence. Third, psychological symptoms and inflammation tend to emerge together and relate to one another beginning in childhood. For example, internalizing and externalizing symptoms at age 8 are associated with inflammatory biomarkers at age 10, with some research showing pronounced associations among those who have childhood adversity. Fourth, inflammation may have a stronger relationship to depression among women than men, according to observational and experimental evidence.
It is possible to shift biological processes implicated in the development of inflammation and depression, she said. For example, a large study of African American families showed that 8 years after being enrolled in a 7-week psychosocial intervention, youth had significantly lower levels of inflammation relative to the control group, a difference mediated through improved parenting, and the intervention had a positive effect on depressive symptoms.11 Furthermore, in a systematic review of 17 randomized controlled trials or quasi-experiments, interventions designed to improve relationships or social conditions improved cortisol levels for children at high risk (i.e., experiencing a parent death or living in foster care) such that levels were similar to those of low-risk children.12
Slopen indicated that research needs to pay more attention to sensitive periods in development, moderators of early indicators of risk that go beyond individual-level factors, and age-appropriate interventions that target key aspects of the environment to have an impact on depression in women.
MENTAL HEALTH OVER THE LIFE COURSE: LATER LIFE
Joan Girgus (Princeton University) reported on a review of research examining gender differences in unipolar depression among people aged 60 and above.13 Historically, said Girgus, little attention has been paid to gender differences among the elderly; of the 85 studies identified by the review, about 72 percent were published in the past 10 years. About 81 percent of the 85 studies showed either that elderly women scored higher than elderly men on dimensional measures of depressive symptoms or had significantly higher rates of diagnosed unipolar depression. Girgus approvingly noted that most of these studies, which included participants from 34 countries and 6 continents, were conducted with population rather than convenience samples.
However, Girgus went on to note that although these studies establish the existence of a gender difference in depression in the elderly, they say little about how the magnitude of the gender difference compares to that observed at younger ages or on the reasons for this gender difference. In some cases, the causes may be similar—for example, negative life events, coping styles (particularly rumination), interpersonal orientation, or lack of social support. In other cases, the causes may stem from circumstances that arise more often in the lives of elderly women—for example, widowhood, living alone, poor health, financial strain, and caregiving.
Girgus suggested improvements for the research, such as creating finer-grained reporting of age effects after age 60 in order to assess how the magnitude of gender difference may change through later life, and research on the causes of the gender difference in depression in the elderly. Girgus noted that in order to determine whether a given variable is a cause of a gender difference in depression, three questions should be asked: (1) Is there a gender difference in depression in the group being studied? (2) Is there a gender difference in the hypothesized contributing variable? (3) Is there a clear predictive relationship between the gender difference in the hypothesized contributing variable and the gender difference in depression?
Karen Lincoln (University of Southern California) said that information about gender differences in mental health disorders is even more limited for older African Americans. The best
11 Miller, G.E., Brody, G.H., Yu, T., and Chen, E. (2014). A family-oriented psychosocial intervention reduces inflammation in low-SES African American youth. Proceedings of the National Academy of Sciences, 111(31), 11287-11292.
12 Slopen, N., McLaughlin, K.A., and Shonkoff, J.P. (2014). Interventions to improve cortisol regulation in children: A systematic review. Pediatrics, 133(2), 312-326.
13 Girgus, J.S., Yang, K., and Ferri, C.V. (2017). The gender difference in depression: Are elderly women at greater risk for depression than elderly men? Geriatrics, 2(4), 35.
data available on the prevalence of disorders come from the National Survey of American Life, according to which lifetime disorders (including lifetime substance disorders) are more prevalent among older African American men than women; mood disorders, however, are more prevalent among older African American women than men.14 According to another study, said Lincoln, older African American men were more likely than older white men to go from being “not depressed” to “depressed” and “depressed” to “death,” while there were no such differences between older African African women and older white women.15 Lincoln indicated that, compared to whites, older African American adults were overall less likely to be diagnosed, more likely to have higher rates of depressive symptoms over time, more likely to have higher rates of recurrent and chronic major depressive disorder, likely to have more fluctuations in depression course, less likely to receive effective care and management of their illness, and likely to have more severe symptoms and disability.
Lincoln noted several limitations in the research, including small sample sizes and inadequate measurement of heterogeneity among older African-American women. She indicated that she has examined heterogeneity by extending existing published research to look more closely at group differences, at variations in the endorsement of items on research measures, and at life-course trajectories and risk profiles. Lincoln concluded by presenting a conceptual framework for understanding the cumulative effects on the mental health of older African-American women based on demographic factors (i.e., race, socioeconomic status, age, relationship status), risk factors (i.e., early life adversity and psychosocial stress), resilience factors (i.e., social ties and health behaviors), and physical health conditions and accelerated aging (observed in older African Americans). Lincoln also proposed creating biopsychosocial risk typologies for identifying patterns of risk and resilience factors.
MENTAL HEALTH CARE AND POLICY
Chloe Bird (RAND Corporation) discussed how gaps in knowledge about women’s health have resulted both from a long history of excluding women from research studies and from untested assumptions about the ways women and men may be similar or different. She said that researchers could do several things in order to have better knowledge for practice and policy. First, conceptual models of sex and gender could be improved to consider diversity in each category, as well as biological and social influences (as discussed earlier). It is also important, according to Bird, to consider how sex and gender differences can be confounded or amplified over time; for example, women both earn less and live longer, and as a result they are more likely to end up as caregivers, widowed, and living in poverty in old age. Social policies may worsen the situation. Social Security, for example, provides men and women a standard cost of living adjustment that may be considered to under-adjust for women who, on average, live longer than men. Second, according to Bird, researchers need to examine their assumptions or long-standing beliefs since these can either lack an evidence base or be based on limited information obtained from animal studies or only certain demographic groups. This requires examining more of the population, assessing whether findings vary across groups and determining the mechanisms that underlie group differ ences. The relatively small amount of research on depression in older women (reported earlier by Girgus) is a case in point; Bird indicated that certain populations are often studied because they are the less complicated—for example, they have no comorbidities or may be younger and healthier—and the findings are inappropriately generalized to groups (such as older women or women of color) who are less frequently studied. Bird proposed that journals report findings by gender in electronic appendices in order to provide a better understanding of gender differences.
Christine Grella (University of California, Los Angeles) described gender differences in the comorbidity of substance use and mental
14 Ford, B.C., Bullard, K.M,, Taylor, R.J., Toler, A.K., Neighbors, H.W., and Kackson, J.S. (2007). Lifetime and twelve-month prevalence of DSM-IV disorders among older African Americans: Findings from the National Survey of American Life. American Journal of Geriatric Psychiatry, 15(8), 652–659.
15 Barry, L.C., Thorpe, R.J., Pennix, B.W.J.H, Yaffe, K., Wakefield, D., Ayonayon, H.N., Satterfield, S., Newman, A.B., and Simonsick, E.M. (2014). Race-related differ ences in depression onset and recovery in older persons over time: The Health, Aging, and Body Composition Study. American Journal of Geriatric Psychiatry, 22(7), 682-691.
health disorders that are evident early in life and persist throughout the life course. She argued that these differences underlie a perception within the substance use field that women are more difficult to treat, and they point to the need to design substance use treatments that are more effective for women. For example, according to data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), men have a greater lifetime prevalence of substance use disorders by a ratio of 2 to 1, but women are more likely to have mood and anxiety disorders and greater comorbidity with substance use.16 Grella presented a robust finding from research—depression tends to precede alcohol disorder for women, whereas the order is reversed for men. She said that data from the National Survey of Drug Use and Health also show that females progress faster from first use of a substance to having a substance use disorder during adolescence and have higher prevalence of prescription medication disorders, while marijuana use disorder is more prevalent among males.
Systems of treatment, Grella said, are not designed to be responsive to gender differences in substance use severity that result from the greater comorbidity of substance use and mental health disorders among women. According to data from NESARC, women seek help for substance use disorders less often than men. Pessimism about treatment is one of the reasons women give for not seeking treatment; other reasons include stigma, finances, fear, and structural barriers. The reasons varied by race/ethnicity and type of substance (i.e., alcohol versus drugs); for example, African American women were more likely than other women to cite structural barriers and treatment pessimism as reasons for not seeking help for alcohol problems.
Grella said that, according to 2012 data from the National Survey of Substance Abuse Treatment Services, only about one-third of programs reported offering “special services” for women that included access to domestic violence- and trauma-related services, pregnancy and postpartum services, and child care and child live-in capacity. Yet, said Gella, studies indicate that women-focused treatment programs (such as women-only residential programs) that are more likely to provide services addressing women’s needs show better retention and improved outcomes related to drug use, criminal behavior, incarceration, and family reunification—despite the fact that women in these programs tend to have more severe problems than those in mixed-gender programs.
Jeanne Miranda (University of California, Los Angeles) began with a brief perspective on the state of measurement and intervention research. Questionnaires for measuring depression and related medication and psychotherapy work fairly well across gender and ethnicity groups, she said. Tailoring care for reading level, income, and population relevance is important, but tailoring beyond that appears to offer little additional benefit. Miranda argued that attention is needed to the contexts within which women and minorities live and the impacts of policies on their lives. Minorities in the United States experience racism, sexism and misogyny, and homophobia and transphobia, which have indirect effects (through stress, segregation, and poorer education) and direct effects (through the inequitable distribution of medical resources) on mental health. Miranda presented statistics showing higher rates of disorders, discrimination, and bullying for LGBT populations; and higher rates of suicide, homelessness, foster care, and detention for sexual- and gender-minority women.
Access to health care is also an important factor, according to Miranda. Miranda said that although the number of uninsured has decreased, 11 percent of women remain uninsured, with the rates being highest for Native Americans and Latinas. Child care and transportation also affect access, and poverty is another major factor: women are more likely to live in poverty, with higher rates among African American, Latina, and Native American women. Miranda shared her view that researchers advocate for the repeal of discriminatory public policies that have been shown to negatively affect the mental health of women and minorities, such as the “war on drugs” and policies that increase income inequality, prohibit gay marriage, and target undocumented immi-
16 Conway, K.P., Compton, W., Stinson, F.S., and Grant, B.F. (2006). Lifetime comorbidity of DSM-IV mood and anxiety disorders and specific drug use disorders: Results from the National Epidemiologic Survey on Alcohol and Related Conditions. Journal of Clinical Psychiatry, 67(2), 247-257.
grants. Miranda further expressed her opinion that women’s mental health could be improved by providing access to universal health care to address chronic care needs; fostering better outreach to minority women and sexual- and gender-minority populations in order to provide them with necessary care; and developing services that meet the needs of sexual- and gender-minority youth, which would include physician extenders (i.e., lay health workers) to screen, educate, and follow up with patients who need care. The clinical workforce would also benefit from more diversity, Miranda said, presenting data that show that Latinos and especially African Americans are under-represented.
Jennifer Glass (University of Texas at Austin) discussed the relationship between work/family policies and women’s mental health and well-being. She said that research shows that, although employment and marriage are protective factors for women in the United States, motherhood has no effect or negative effects on depression, anxiety, happiness, and perceived health. An important factor, according to Glass, may be the context of motherhood in the United States, which includes more births that are mistimed or unplanned than in other industrialized countries and a rising proportion of nonmarital births that presents a higher risk of single motherhood. Another factor needing attention, she continued, is the “second industrial revolution”17 and the way in which this economic shift may be interacting with motherhood in the United States to make children and families more vulnerable. One example of this vulnerability, according to Glass, was the fact that the proportion of children primarily dependent on the earnings of their mothers had risen to 40 percent by 2014.
Glass said that four labor market trends deserve monitoring because they are worsening outcomes for families and for mothers in particular: (1) an increase in work hours in full-time employment, (2) an increase in the number of “mother breadwinners,” (3) an increase in erratic work hours and 24/7 availability demands; and (4) large wage and benefit penalties for less than full-time work. Policies in the United States are not responding to the changing economy, she said, while European and other English-speaking countries have enacted a number of different policy reforms consistent with their views about the value to society of relieving pressures on families, which may affect fertility rates, happiness, and well-being. Glass suggested that studies are needed to test models of how different work/family policies do or could affect women’s mental health.
GROUP REPORTS AND DISCUSSION
Participants met in breakout groups to consider needs for research, practice, and policy. Jason Schnittker (University of Pennsylvania) shared his group’s discussion of health care research. First, he said, much has been known for a while about women’s mental health, and a challenge lies in how best to communicate this information and connect it to the needs and values of policy makers and stakeholders. Second, while measures to assess mental health are well-developed, measures of risk and protective factors known to affect mental health, such as resilience, are also important to have. Third, with respect to methods, according to Schnittker, datasets need to be able to capture diversity in the population and within categories such as nativity and race/ethnicity. Large samples would also be useful to study intersecting group identities. Longitudinal designs with repeated measures would allow researchers to learn more about the processes that underlie group differences, and some data collection may need to begin early in life, and perhaps include multiple generations. In order to produce better research and improve women’s mental health, it is necessary to move beyond individual-level analyses. In this vein, more attention to multilevel processes, including eco-social and cultural factors (such as sexism and the policy environment), could be beneficial. Fourth, said Schnittker, more needs to be known about specific groups such as LGBT populations and pregnant and postpartum women who have historically been excluded from research.
A participant suggested that the National Institutes of Health (NIH) policy on the inclusion of women in research be implemented more fully and guidance provided to grant reviewers to
17 According to Glass, the “second industrial revolution” is characterized by the rise of the service sector, mechanization and the outsourcing of production, weakened job security and the rise of temporary and contract employment, increasing wage inequality, diversification of work hours and work schedules, and heightened skill requirements for jobs.
ensure that applicants have adequately considered and addressed sex or gender differences in the articulation of scientific premises and research designs. Another participant said that the NIH policy should define as “novel” any research that proposes to study a problem in a new population neglected in past research, and it was suggested by another participant that grant-making organizations could fill gaps in knowledge by requesting that researchers include sex and gender analyses in proposals, such as for community-based needs assessments.
Several participants, each in turn, also suggested the following actions: studying how biological and social processes interact to affect mental health over the life course; including the further collection of biological data; adding questions or modules related to mental health in national health surveys such as NHANES and NHIS; acquiring intergenerational data sources that could allow multiple generations to be tracked prospectively in order to study mental health risks; gathering information on how factors, such as income, racism, and sexism, may contribute to public health costs; and ensuring that the tools being used for measurement are assessing the same constructs across the lifespan. A participant also advocated for increased attention to women’s mental health and trauma following disasters, as well as adolescent and young women’s mental health as a precursor to and consequence of human trafficking.
Jennifer Payne (Johns Hopkins School of Medicine) reported that the breakout group discussion on health care practice revolved around issues of access, such as low Medicare reimbursement rates discouraging many psychiatrists from taking new Medicare patients. Payne said that the group also discussed the value of delivering mental health care more creatively and of considering approaches, such as lay providers, medical homes, and mother-baby units.
Hortensia Amaro (University of Southern California) recounted her group’s discussion of health care policy, starting with the importance of recognizing the broad effect that factors such as stigma can have on communities and the larger population. Policies likely to increase stigma should to be avoided, she said, and care taken when invoking the role of mental illness in, for example, debates about gun control. Second, for the purpose of informing policy, it may be appropriate to reframe research questions and approaches in terms of community wellness, as opposed to focusing on individual pathology. Third, said Amaro, mental health researchers ought to communicate research to policy makers in ways that speak to policy makers’ values, interests, and motivations (e.g., having a functioning workforce). A meeting participant pointed out that Canada provides “knowledge dissemination” funds as part of research grants to assist researchers in this type of outreach.
One participant noted that mental health problems are associated with a wide range of social stressors in domains that go far beyond health, such as education funding, work/family balance, distribution of wealth, racism, and housing. Another participant pointed to a need for budgetary and collaboration mechanisms that could enable federal agencies, such as Departments of Education, Labor, Transportation, and Health, to pursue joint research and policy activities to influence the multiple factors that affect people’s mental health; the participant went on to suggest that the issue may be of interest to the bipartisan Committee on Evidence-Based Policymaking.
Debra Umberson (University of Texas at Austin) concluded the workshop by noting that participants had shared an incredible amount of knowledge on the subject of women’s mental health and that the workshop made apparent the need to connect all this knowledge in order to produce a more coherent understanding of women’s mental health across the life course.
WORKSHOP PLANNING COMMITTEE: Debra Umberson (Chair), University of Texas at Austin; Hortensia Amaro, University of Southern California; Lisa F. Berkman, Harvard University; Bridget J. Goosby, University of Nebraska–Lincoln: Jennifer L. Payne, Johns Hopkins School of Medicine; Jason Schnittker, University of Pennsylvania; and STAFF: Malay K. Majmundar, Study Director; Mary Ghitelman, Senior Program Assistant.
DISCLAIMER: This Proceedings of a Workshop—in Brief was prepared by Melissa Welch-Ross, rapporteur, as a factual summary of what occurred at the meeting. The statements made are those of the rapporteur or individual meeting participants and do not necessarily represent the views of all meeting participants; the planning committee; the Committee on Population; or the National Academies of Sciences, Engineering, and Medicine. The steering committee was responsible only for organizing the workshop, identifying the topics, and choosing speakers.
REVIEWERS: To ensure that it meets institutional standards for quality and objectivity, this Proceedings of a Workshop—in Brief was reviewed by Rina Repetti, Department of Psychology, University of California, Los Angeles; and Debra Umberson, Population Research Center, University of Texas at Austin. Kirsten Sampson Snyder, National Academies of Sciences, Engineering, and Medicine, served as review coordinator.
SPONSORS: This workshop was supported by the U.S. Department of Health and Human Services, Office on Women’s Health. For additional information regarding the meeting, visit http://nas.edu/WomensMentalHealth.
Suggested citation: National Academies of Sciences, Engineering, and Medicine. (2018). Women’s Mental Health across the Life Course through a Sex-Gender Lens: Proceedings of a Workshop—in Brief. Washington, DC: The National Academies Press. doi: https://doi.org/10.17226/25113.
Division of Behavioral and Social Sciences and Education
Copyright 2018 by the National Academy of Sciences. All rights reserved.