Social factors that support women’s mental health
Women are encouraged to become competent at relationships, and as a result are better than men at seeking help and dealing with the causes of their distress. They also tend to be better able to give and receive help from each other. Women who have strong family support, autonomy, and access to material resources that allow choice are better protected against developing mental health problems.
Physical and mental health interactions
Physical and mental ill-health are linked in both men and women. People with chronic physical illnesses are at greater risk of developing mental health problems, particularly depression, while those with mental health problems are also more likely to have physical illnesses, such as heart or respiratory problems.
MEDICALLY UNEXPLAINED SYMPTOMS
A range of physical problems are considered by doctors to be the physical manifestation of mental health problems, otherwise known as ‘conversion symptoms’ or ‘somatisation’. These include irritable bowel syndrome, fibromyalgia, and chronic pelvic pain. Studies show that medically unexplained symptoms such as these are two to three times more likely in women than in men. Research shows that a high proportion of people with such problems have experienced trauma, abuse or violence.
UNRECOGNISED PHYSICAL ILL-HEALTH
An equally serious problem for women in mental distress is the lack of recognition for physical illnesses, because symptoms of physical illness may be wrongly seen as ‘imagined’ or psychosomatic. Research suggests that women with mental health problems are more likely than other groups to have physical complaints disregarded, and requests for services denied. Studies have found that women with mental health problems have significantly more undetected medical problems than men, and that women with bipolar disorder (manic depression) are three times more likely than men to have undiagnosed medical problems.
Treatment and services
Department of Health guidance on mainstreaming women’s mental health has pointed out that women ultimately want services to adopt a ‘whole person’ approach to their care, treatment and rehabilitation, to value their strengths and abilities, and to recognise their potential for recovery, in the context of holistic assessment and care planning. Many areas of women’s mental health are now also covered by guidance from the National Institute for Health and Clinical Excellence (NICE).
ANXIETY AND DEPRESSION
Too often, a diagnosis of anxiety or depression leads to medication as the first or only treatment option. Women with these issues have repeatedly asked for better access to talking therapies, and for opportunities to learn new skills and coping strategies. These preferences are reflected in current NICE guidelines for the treatment of both anxiety and depression, which state that talking therapies are the most likely treatment to produce lasting benefits, especially when combined with other forms of social support and self-help. Government investment in the Improving Access To Psychological Therapies programme has increased the availability of short-term therapies such as cognitive behaviour therapy (CBT) via primary care. Pilot programmes show that over 60 per cent of those accessing this CBT are women, and that the intervention shows some positive results in reducing levels of depression and anxiety.
Talking treatments, including family therapy and CBT, are widely advised for women with eating disorders. NICE guidance on treatment for anorexia advises structured and symptom-focused inpatient admission as a last resort, with psychological treatment rather than behaviour modification. However, a lack of specialist eating disorder services across large areas of England and Wales means that local services often fall short of national standards.
For women who self-harm, NICE recommends full assessment of physical, psychological and social needs, by a professional with suitable training and in an atmosphere of respect and understanding. Treatment choices should include counselling and therapy. Women who have self-harmed severely should be referred to psychiatric services for further assessment, treatment and support, or taken into hospital in an emergency.
A study by an Asian Women’s group reported that a wide range of services is now on offer for young people across the UK, but there is still a need to evaluate which approaches really work, so that they can be widely adopted. Young women want a variety of options, including support for self-help techniques such as distraction – which includes a wide range of activities, from watching TV to gardening or flying a kite.
BORDERLINE PERSONALITY DISORDER
For women diagnosed with BPD, NICE recommends that a clearly structured, comprehensive multidisciplinary care plan that includes short- and long-term goals is agreed with the client. The care plan should include psychological treatments of at least three months’ duration, and plans to manage crises. No medications are specifically recommended for BPD. NICE and other agencies recommend a range of treatment options, including structured talking treatments, and medication for specific symptoms, such as transient psychotic episodes.
Women clearly benefit from support before and after childbirth. One study shows that counselling for women who are depressed when pregnant may help to prevent problems for the family after the baby is born. Other studies show that health visitors can provide valued listening and support to new mothers, and that individual, group and family support and counselling can help mothers to cope with postnatal depression and parenting problems.
NICE has produced guidance on perinatal (ante- and postnatal) mental health, which recommends that health professionals look out for those most at risk of developing a mental disorder, and ask questions to detect problems, such as depression, as early as possible. This ensures that psychological treatment can begin as early as possible if needed, within one month of initial assessment, and no longer than three months afterwards.
NICE guidance recommends that clinical networks are developed in each region to ensure that services for mothers and infants are better coordinated, and that help is available quickly when needed.
TREATMENT FOR WOMEN DIAGNOSED WITH SEVERE MENTAL ILLNESSES SUCH AS SCHIZOPHRENIA
Experts have argued that gender-aware treatment for women with diagnoses such as schizophrenia should mean doctors taking more account of women’s practical and emotional needs and their social roles as partners, mothers, and professionals or employees. Women may need therapy and support focused on maintaining or re-establishing their roles, and perhaps will do better if they can receive help that does not separate them from their children, but helps them to cope better with parenting.
WOMEN WHO HAVE EXPERIENCED ABUSE OR VIOLENCE
Guidance has been developed to help health professionals work with women who may be experiencing mental disorders as a result of abuse, violence or trauma. The first step is to ask questions to find out about these experiences. Some studies show that, despite guidance, many staff do not do this well, perhaps because of a lack of training and experience.
The World Psychiatric Association recommends that women who have been sexually abused and those who have strong preferences for female healthcare staff should be accommodated whenever possible, and emphasises that the evaluation of mental health problems in women must consider the full context of their lives, as distress often has social origins. Diagnoses should not be stigmatising, and the role of violence and discrimination in the genesis of mental health problems in women requires special consideration.
SERVICES FOR WOMEN IN PRISON OR SECURE HOSPITALS
Women in prison who have mental disorders are rarely transferred to a hospital, but are treated by the NHS within the prison. Substance abuse is treated separately by Counselling, Assessment, Referral, Advice and Throughcare (CARAT). Offending behaviour is treated with CBT.
Treatment for women in secure psychiatric hospitals has been reformed by bringing all women in high secure units to Rampton, which provides a more specialised service. A new service development, Women’s Enhanced Medium Secure Services (WEMSS) aims to provide more local services, offering skilled nursing and psychological therapies, not just incarceration.
General issues relating to medication
SIDE EFFECTS AND INTERACTIONS
Side effects of psychiatric medication that women in particular may find distressing include weight gain and hair loss. In addition, medications can interact with each other in problematic ways, for instance, some medications interact with the oral contraceptive pill.
MOTHERHOOD AND MEDICATION
While medication for antenatal and postnatal depression is an option, NICE guidance says that the risks of anti-depressant medication to the unborn child, or the infant through breast milk, should be explained, and talking treatments and self-help options should be explored.
The issue of medication is particularly important for women with schizophrenia or bipolar disorder who are mothers or who want to become mothers. Healthcare professionals need to work sensitively with women who are already on medication about whether or not it is safe and advisable to take a break from medication, taking into account the additional stresses of pregnancy and parenting, and the amount of support available. If this is considered possible, then experts advise tapering off the dose of medication in order to avoid the risk of damage to the developing foetus.
SAFETY ISSUES FOR WOMEN IN PSYCHIATRIC HOSPITALS
Sexual safety includes freedom from sexual harassment, exploitation, aggression and violence. Women are entitled to feel safe from physical harm or sexual harassment when in a mental health unit; there can be particular issues for women who have experienced sexual abuse or rape.
Separate sleeping, toilets and bathing accommodation for women in mental health units has been policy since 2000, and, according to the National Patient Safety Agency (NPSA), mental health units should be reconfigured to provide either a self-contained, women-only ward or solely single sex wards. Many, though not all, have done this. However, physical and sexual safety for women in mental health units is an ongoing issue, and the NPSA recommends better use of existing guidance and more training for staff to recognise and report incidents such as sexual harassment, taking into account the physical and psychological harm caused.
Improving mental health policy and practice for women
Since the Department of HealthHealth’s report on women’s mental health, policies to improve treatment of women have become part of mainstream work. A number of NHS trusts have developed mental health strategies for women, and, in the light of gender equality duty, many are now further updating and reviewing their policies.
Current priority areas for improvement according to a recent national report are:
- health and wellbeing
- supporting women in their roles as mothers, carers, employees and students
- safety and freedom from threat of abuse or violence
- justice and fairness for women who come into contact with the criminal justice system
- women’s participation, particularly empowering women from BME communities.
Many of the initiatives to improve services for women still have a long way to go, however. Women have been calling for more support for self-help and alternatives to medicalised treatments for many years, but in most cases these alternatives are not well supported financially, and are usually left to the voluntary sector to provide, and therefore not universally available.
Voluntary sector support
The voluntary sector provides many support services for women beyond what is available through statutory services, including information, advice and support and/or counselling, as well as drop-in facilities, befriending and advocacy.
Some groups and organisations operating at local and national levels across the UK focus on the needs of women from particular BME groups. Many of these organisations are staffed by women who share the culture of their service users. Such groups can be useful for social opportunities or for specific services such as information, advice or counselling.
A range of organisations focusing on the needs of lesbians and bisexual women also operate locally and nationally. Most are run by lesbian, gay or bisexual people, and can provide social opportunities or specific services, such as information, advice and counselling. Counsellors or therapists who identify as lesbian or bisexual, or who work for organisations that are positive about LGB issues, can also be found via local organisations and internet as well.