Throughout a woman’s life, sex and gender can affect both her likelihood of developing mental health conditions, and the course, prognosis and treatment response to those conditions. Key influences on women’s mental health include genetic and epigenetic factors, gender-linked stresses and traumas, and reproductive cycle stages. Helping female patients understand these influences can help them manage potential stressors or symptoms throughout their lives.
We should start by briefly mentioning terminology. Colloquially the terms “sex” and “gender” are used interchangeably. However, I use “sex difference” to refer to biologically-based differences between males and females and “gender difference” to refer to culturally-based differences (with or without biological influence). These two categories are interrelated. Societal gender roles can amplify small sex differences and these influences can accumulate across a lifespan.
There are gender differences in the prevalence of many mental health conditions. For example, women are almost twice as likely to experience depressive and anxiety disorders as men. This divergence begins in mid-puberty and persists until menopause. In some cases, genetic susceptibilities influence these gender differences and may be further compounded by epigenetic influences – environmental effects on a developing fetus, such as maternal stress, nutrition or exercise, that determine which genes are expressed.
Impacts on mental health can occur before birth. Experiencing severe, prolonged maternal distress in the womb can be a key influence on a person’s subsequent mental health. People with mothers who were severely distressed during pregnancy are at higher risk for mental health problems, regardless of their mothers’ postpartum symptoms.
Also, coping style is thought to be a way that gender influences the propensity for mood disorders. Rumination (directing attention toward negative feelings and thoughts) is more common in girls, and problem solving and distraction are more common in boys. Of these two styles of coping, rumination confers a higher risk of depression.
Beginning at about age 13, the prevalence of depression rises in girls and is about twice that of boys. This is influenced in part by gonadal hormone fluctuations. Some gender-linked stressors and traumas tend to emerge after puberty and influence the trajectory of mood disorder in women. These include adverse sexual events, intimate partner violence, unintended pregnancy, perinatal loss, and gender harassment and discrimination.
It is also during this post-puberty time that women become eligible to join the military. Compared to male service members, female service members experience increased risk for certain challenges. For example, military service women are three times more likely to be single parents if they have children. They are five times more likely to have a partner who is also eligible for deployment. They are more likely to get divorced, and less likely to find a new partner after divorce. Additionally, female active-duty service members tend to face more stress with parenting transitions and conflicts between their military roles and societal gender role expectations.
The perinatal period is an especially high-risk time for new onset or recurrence of psychiatric disorders. Active-duty service women face extra challenges during this time. The rate of unintended pregnancy is higher among service women compared to the general U.S. population. In some cases, pregnancy-related biological changes may pose challenges to adherence to active duty workplace policies, such as physical fitness standards. Though advances such as extended maternal leave indicate movement in a positive direction, more focus is needed on meeting the needs of service women during the perinatal period.
Perimenopause is a hormonal transition culminating in menopause, which is the absence of a menstrual cycle for at least one year. During perimenopause, sex hormone levels are more variable and less predictable, and the risk of depression more than doubles. Increased variability of estrogen and other sex hormones around women’s baseline levels correlates with developing depressive symptoms during perimenopause. This hormonal variability may interact with stress to influence mood. Perimenopause occurs during the time when mid-life transitions may further compound the occurrence or recurrence of depression. Key examples are relationship transitions, caregiving transitions, and health and aging transitions. Women are more likely to be widowed, and after a mid-life divorce, less likely than men to find a new partner. Furthermore, women are three times more likely to help aging parents with activities of daily living, and may also be caring for children.
Understanding life-long influences on women’s mental health is helpful for women themselves and for the providers who care for them. Women who learn that they are more physiologically vulnerable to certain stressors or during specific time periods may be motivated to self-manage these challenges by maintaining physical activity, developing healthy eating patterns and food choices, cultivating social and spiritual support, and expanding their repertoire of coping strategies. Military health care providers can be attuned to these vulnerable time periods and stressors, ask their patients about these issues (e.g., social supports during times of transition, gender-based work-related challenges, hormonal changes, etc.), and address them when caring for women. For women who may need treatment, providers can optimize use of pharmacotherapy during times of reproductive transition and use psychotherapy to target the most relevant influences and concerns.
Learn more about a woman's mental health throughout her lifespan in my presentation from the National Departments of Veterans Affairs and Defense (VA/DOD) Women’s Mental Health Mini-Residency and see the VA mental health and women veterans website for additional resources and information.
Miller is the medical director of women’s mental health at the Edward Hines Jr. VA Hospital, and a professor of psychiatry at Loyola University Stritch School of Medicine. She does clinical work, teaching, curriculum development, program development and research in the field of women’s mental health.
The views expressed in Clinician's Corner blogs are solely those of the author and do not necessarily reflect the opinion of the Psychological Health Center of Excellence or Department of Defense.