2. gender gaps in mental health

It seems like all evidence produced until now in this field didn’t have any  effects in the assessment of women’s mental health as a priority problem. We notice the lack of attention toward women’s mental health and the absence of an integrated gender approach

1.      in health policies choices;

2.      in empirical research, epidemiological and statistics, in etiological research and in the research regarding the effectiveness of drugs;

3.      in clinical practices, diagnosis and treatment;

4.      in prevention;

5.      in health education.

1.      Health Policies

Health policies show a deep lack of attention toward women’s health. As examples we want to mention what is considered to be priority

As examples we may mention mental health priorities highlighted by Who and the Italian Ministry of Health.

- Health 21 in "Target 6 - Improving Mental Health" does not indicate the emergency is also around women:

"by the year 2020, people’s psychosocial wellbeing should be improved and better comprehensive services should be available to and accessible by people with  mental health problems"[1].

- The Italian health planning does not mention women issues, as in the following schema ( table 8):

2. The research

In the majority of European states we do not have governmental research programmes for women's mental health.

2.1. The research around aetiology and risk factors

Against all evidence research is mainly oriented to evaluate, in principal way, the correlation between depressive pathology and hormonal and biological factors.

These research projects are carried out with large financial support and with the contribution of pharmaceutical industries, which are profit oriented. Psycho-social research which have contributed to most significant explanation of different rates of depression between women and men do not have adequate financial support.

Mainstream  research projects are still problematic because do not study yet the interconnection of many relevant factors: being married and having children; lack of trust toward the partner; lack of social support; low self-esteem; violence, battering and dependency.

Such investigation are not able to offer an etiological model to explain the shift from risk to mental illness among women.

2.2. Pharmacological research

Even though women are greater consumers of drugs there are no studies around differences in pharmacological response among women and men. Experimentation around the effectiveness of drugs is focussed mostly on men and results are often undifferentiated on a gender bases. So women do consume more drugs, with less effectiveness and safety, with respect to men - who are over-represented in clinical and pharmaceutical trials.

2.3. The research on diagnosis criteria and psychiatric treatments

§         Diagnosis

Psychiatric diagnosis is mostly oriented toward symptoms. Life conditions aren't considered aetioopathogenesis.

This allows researchers and health care providers to avoid discussions around psycho-social and environmental causes, which are those mostly connected to the explanation of female mental disease.

 Even though women get most of depression diagnosis, psychiatric handbooks[2] do not keep into account the severity of their symptoms from their point of view, since both severity and social relevance are measured with male parameters.

So, typical women's depression marked by "sense of uselessness and incapacity; lack of desire in all fields; block of activities; death drive; unawareness of being into depression" do not constitute indicators of gravity since are not associated with social disfunctioning or higher rate of suicide.

In addition there is another un-acknowledged criterion of gravity related to the effects of a woman's mental disease upon her family life and in particular her children.  Recent investigations highlighted mother's depression among negative events in adolescence.

§         B. Treatment

At the level of treatment there are no investigations around new method of intervention aimed to

-         observing everyday life (home work, in primis) and behavioural styles;

-         changing in everyday organization and response styles connected to disease perception.

Researchers and health care providers do not have high expectations toward women. A rehabilitation enabling women to fulfil mother/wife role expectations seem to be considered enough as an achievement. So, rehab programmes are weak and do not include social skills improvement and personal resources channelling, aimed to elevate self-esteem (whose lack is an important ingredient in the genesis of depression).

3.      Clinical practice

In clinical practice we encounter sexual prejudice: the greater diffusion of mental illness, particularly depression, among women, is considered by the majority of psychiatricians as related to female biology (hormonal fluctuation and so on) and psychology (passivity, low self-esteem, dependency).

Treatments for women are comparatively more traditional: pharmaceutical treatment is prevalent, at times associated with psychotherapy.

Women are chosen as targets of innovative psycho-rehab treatments in a lesser extent than men. Such treatments are focussed on male needs toward social skills and productive work.

Treatments in a mixed environment (both in or out clinic) do not fulfil women’s needs: often they are involved in an abusive relationship with a violent male, for they do not appreciate to share a common therapeutical space with men.

Women, with respect to men, are taken care for longer time, are object of longer pharmaceutical treatments and take an higher risk in becoming chronic cases.

This data around longer therapies for women might be due to a lower effectiveness of such treatment, which seem to miss the goal more frequently compared to men in terms of improving women’s health.

4.      Prevention

Existing studies did not develop indications for acknowledging risk factors and protective factors in everyday life, to be used in prevention campaigns.

Prevention should have priority in any health system, for any pathology, yet in the field of mental illness we notice a lack of interest in developing studies and indications toward primary prevention. Such a lack of interest damages women in special way, since they are the majority and have many risk factors in their environment.

Improper prevention (often overlapping treatment) is connected to the recommendation to begin drugs assumption as early as possible, i.e., at the first symptom, even during adolescence; to avoid interruptions and to carry out drug assumption for long periods of time.

5.            Training

Training programmes do not fit women’s needs. Such programmes do not keep gender differences into account neither in terms of the greater incidence of mental disease nor in terms of educating the medical profession to identify psycho-social risk factors in women’s everyday life.

Training of mental health providers is supported mainly by the pharmaceutical industry, for it shows a greater interest in pharmacological treatment, instead working toward prevention.

6.         The organization of services

Mental services focussed on women are very few: most of services ignores women’s  health needs in this field and do not wonder around them. In health programmation there are no indication to lower female rates; there are no gender-oriented health activities for risk groups such as adolescent girls or women with job and family commitments or with  children.

In synthesis: mental health services seem to correspond to men’s needs, are oriented toward “giving back the person to his activities, in order to restore interrupted activities” without observing if these interrupted activities are the very cause of discomfort and disease.

3.         priorities

We believe the field of study and research, as well as the field of clinic, are provided with evidences which, up to now, did not result in coherent acts and correcting measures do make clinical treatments and prevention appropriate adapted for women. The measures to be proposed may well be defined in the light of the present state of development of research and of its clear contradictions and gaps. At this stage, it is necessary to work out Directions, Guide Lines and Recommendations useful for the acknowledgement, selection and adoption of appropriate behaviours, both at the clinical and at the research level.

1.         The collection of epidemiological and statistical data

Given the importance, in order to build up more reliable risk maps, of having data divided into sex, recommendations to all the European countries to adopt the following measures are necessary:

-         standardization of data surveying procedures concerning the personal and social typology of the women who come to mental health services;

-         collection of data divided into sex, and presentation of the results according to above distinction. 

2.                  The research

2.1  The research on  etiological and risk  factors:

Recommendations apt to integrate the gender point of view in the research evaluation criteria are considered necessary.

Highly reliable is considered research:

-         using case-control samples;

-         including patients of both sexes;

-         relating the different variables to the sample divided by sex.

It is right to adopt measures to implement researches apt to offer better results in the perspective of primary prevention.

Researches aimed to:

a.       the analysis of risk factors in daily life and in the environment;

b.      standardization of the main pre-morbid risk factors in female mental  illness, particularly the risk of: family work overload, stress and violence;

c.       elaboration of a survey protocol for the gathering of risk factors of mental illness;

d.      development of a multicentric European programme on the interaction of the main psycho-social risk factors.

2.2  The research in the field of pharmacology

In this field, it is necessary to acknowledge the difference between women and men in pharmacodynamics, and in pharmacokinetics.

 Pharmacological research should  assume the goals to improve the efficacy and the safety for women of pharmacological products  through:

a.                  removal of  the obstacles to the inclusion of women in clinical and pharmacological trials;

b.                 data collection trough mix male and female samples;

c.                  analysis of data divided by sex.

2.3  Research on new diagnostic criteria and tools

It is necessary to modify the diagnostic criteria about the measurement of the social seriousness of discomfort by including the gender point of view. More precisely, the evaluation of seriousness of mental disease could be done on the basis of  the perception of impairment and not only on the basis of objective evaluation in terms of social disfunction.

            The integration of the gender point of view should be assumed also in the research of new methodologies and new therapeutical tools.

New and specific therapeutical tools for women are necessary, focusing on the link between illness and everyday life, and particularly on the following conditions:

a.       the external as well as family work;

b.      the use of  verbal, psychological and physical violence in both  external and family relationships;

c.       the educational training to pattern of dependence.

3.                  The clinical practice: diagnosis and treatment

It is necessary to integrate and modify the traditional ways of health working.

a.            Diagnosis

Diagnostic protocols should be widened and should point out the pathogenic route. That is, they should point out the concrete and visible stages of symptom and discomfort developing within everyday life.

b.                  Pharmacological Treatment

It is necessary to predispose sex specific protocols for pharmacological treatment. Evidences on weight and pharmacodynamic difference should produce recommendations that suggest caution in dosages, lower dosages than for men. Moreover, as long as research is not carried out on both sexes, it is important to investigate, directly from the woman herself, about the side effects produced by pharmaceutical products.

c.                  Clinical, Medical and Psychological Treatment

The treatment should take into account the evidences brought up by research and in particular of  psycho-social risks. It should put the woman to the centre with her every day life difficulties.

All types of intervention should take into account two main factors:

-         that many women suffer in daily life of: loneliness, separation, widowhood,  unemployment, lack of economical supports , children burden, violence, etc.

-         and that many women suffering of anxiety, depression, don't speak about their everyday life difficulties, and don't recognize oppression, violence, fatigue and tiredness. 

So it is necessary to work out protocols apt to:

-         guide health care providers in singling out the causes undervalued by women themselves;

-         give suggestions apt to help women to lighten the burden of responsibilities that  benefits others and to assume styles of behaviour more suitable to the individual wellbeing (and benefits herself).

Moreover, homogeneous groups should be set up they should be made up of women sharing, with different symptoms, common life problems, such as: teen ages and post-teen ages, married women with children, separated women etc.

The psyco-social rehabilitation action should be organized around women's needs. The experience with women suggests that these groups may be successfully oriented toward the re-discovery of abilities, expertises and desires for long years set asides and that, instead, can be recovered and included in a personalized and creative social rehabilitation programme.  

4.                  Prevention

A good prevention is one able to single out risk factors, to start up from them the corresponding protection factors and to transfer them in to appropriate information.

Primary prevention  should be  focused on environmental and social-relational factors.  These are factors on which it is possible to intervene before that the overload of pressures becomes a psychic pathology.

As well as any other action and measure, prevention should be gender sensitive and mainly addressed to most vulnerable subjects: female adolescents and women (in the range 15-44).

Prevention consists primarily on giving a correct and wide information on the processes involved in becoming ill and, in the opposite direction, on the protecting factors.

It is addressed to three typologies of subjects:

-         The directly concerned persons, that is the target groups represented, as far as psychic pathology is concerned by women in general and particularly by teen ages and young women with family responsibilities.

-         The contact groups, that is teachers and parents in the case of teen ages, family members in the case of adult women.

-         Health practitioners and specialists in mental health.

We consider important to organize a specific training programme on behalf of general practitioners and other social-health workers, aimed at:

-         reducing drug-abuse;

-         stimulating a medical and psychological approach apt to explain the connection   between illness and everyday life  (house work and violent pressure from the family context).

5.                  Services

            It is necessary to direct health services towards:

-         preventing and therapeutic activities for women;

-         offering women specific services

The main thing is all health care providers work with a gender perspective.

Three types of activity or service for these women:

1.         The first type attends to prevent specific situations of distress.

The main goals are to give correct information on links between daily life and mental disease and to transfer means to:

-         fight  stress, fatigue e tiredness before they become a pathology;

-         overcome  the  pattern of subordination  and dependence;

-         react against family violence and psychological maltreatment.

In These services could be organized:

a.   the listening-centres,  the training-stages, the social and psychological support-groups, ecc.  Each initiative would be addressed to women with specifical problem:

-    Women who have given up working  after maternity,

-    Women having difficulties in social relationships, in organizing both housework and  extra-familiar work;

-    Women  ill-treated, abused, alcoholic women, etc.

b.     Programmes for health education with a view to:

-            Increasing  women ability   to communicate and express themselves emotionally; 

-            Increasing the ability of analyzing their life-style;

-            Improving their image and their self-esteem;

-            Reducing the risks of symptoms of mental pathologies.

2.         The second type of service is addressed to women who have already begun to develop an illness and manifest symptoms, and who have already had psychiatric treatment.

            There women could be encouraged to understand the way in which their daily lives have led them to illness. Work method should be different from that traditionally adopted in psychiatry.

            The specialised services should offer practical help and necessary support by creating a concrete alternative to hospitals and to psychiatric cures.  

            These services have the following goals:

-   to reduce or to eliminate the use of specific therapeutical means, such as hospitalization,  drugs, or any other strategy that tends to impede or delay the comprehension of the concrete and tangible causes of their illness;

-                               to consider the symptoms of mental illness as signs of unbearable life conditions;

-                               to create a new life-style for women's benefits in keeping with their interests,  aptitudes and emotions.

3.         The third type attend  to setting up "women's refuges"

Today, in spite of hospitalization, it his right to consider as a therapeutical tool non medical care places for women with psychological  problems.

            They could go there spontaneously for receiving psychological support in their daily lives.

            So they could make as stop of daily life stressors.

6.                  European Initiative

We propose the organization, at European level, of a net-work aimed to improve a mental health system oriented on women's problems.

Goals of this net-work can be the following:

-         Co-ordination and Promotion of actions focused on women mental health problems.

-         Promotion of European Guide-lines and Recommendations.

-         Promotion of Services and Projects activities oriented on women's needs.

-         Co-ordination and promotion of activities aiming to improve knowledge about gender differences in different fields such as care and treatments, risk factors research, prevention in every day life.

-         Development of culture skills based on new approaches and methods to influence women health prevention, diagnosis and treatments.

-         Development of training and information contents regarding gender difference in mental health.

-          Improving international exchanges of knowledge and experiences.