| Abstract|| |
Gender is a critical determinant of mental health and mental illness. The patterns of psychological distress and psychiatric disorder among women are different from those seen among men. Women have a higher mean level of internalizing disorders while men show a higher mean level of externalizing disorders. Gender differences occur particularly in the rates of common mental disorders wherein women predominate. Differences between genders have been reported in the age of onset of symptoms, clinical features, frequency of psychotic symptoms, course, social adjustment, and long-term outcome of severe mental disorders. Women who abuse alcohol or drugs are more likely to attribute their drinking to a traumatic event or a stressor and are more likely to have been sexually or physically abused than other women. Girls from nuclear families and women married at a very young age are at a higher risk for attempted suicide and self-harm. Social factors and gender specific factors determine the prevalence and course of mental disorders in female sufferers. Low attendance in hospital settings is partly explained by the lack of availability of resources for women. Around two-thirds of married women in India were victims of domestic violence. Concerted efforts at social, political, economic, and legal levels can bring change in the lives of Indian women and contribute to the improvement of the mental health of these women.
Keywords: Common mental disorder, disorder, domestic violence, mental health, substance abuse, suicide, women
|How to cite this article:|
Malhotra S, Shah R. Women and mental health in India: An overview. Indian J Psychiatry 2015;57, Suppl S2:205-11
| Introduction|| |
Women and men are different not only in their obvious physical attributes, but also in their psychological makeup. There are actual differences in the way women's and men's brains are structured and "wired" and in the way they process information and react to events and stimuli. Women and men differ in the way they communicate, deal in relationships, express their feelings, and react to stress. Thus, the gender differences are based in physical, physiological, and psychological attributes. There are psychological theories that present a gender sensitive viewpoint called as alpha bias, and there are others that are gender neutral representing beta bias. Alpha bias proposes that men and women are different and opposite, and in beta bias differences between men and women are ignored. Alpha bias is seen in psychodynamic theories and therapies where according to Freudian viewpoint, male anatomy and masculinity is the most desired and cherished goal and female anatomy and femininity are seen as a deviation. In contrast, the cognitive theories, behavioral theories, and humanistic-existential theories have beta bias.  Alpha bias could be rooted more in the social conditioning and power structure in the societies.
Gender roles have been culturally prescribed through the prehistoric cultures to the more civilized societies. In hunter-gatherer societies, women were generally the gatherers of plant foods, small animal foods, fish, and learned to use dairy products while men hunted meat from large animals. In more recent history, the gender roles of women have changed greatly. Traditionally, middle-class women are typically involved in domestic tasks emphasizing child care. For poorer women, economic necessity compels them to seek employment outside the home. The occupations that are available to them are; however, lower in pay than those available to men leading to exploitation. Gradually, there has been a change in the availability of employment to more respectable office jobs where more education is demanded. Thus, although, larger sections of women from all socioeconomic classes are employed outside the home; this neither relieves them from their domestic duties nor does this change their social position significantly. For centuries, the differences between men and women have been socially defined and distorted through a lens of sexism in which men assumed superiority over women and maintained it through domination. This has led to underestimating the role a woman plays in the dyad of human existence.
It is necessary to understand and accept that women and men differ in biological attributes, needs, and vulnerabilities.
| Mental Health and Mental Disorders|| |
Mental health is a term used to describe either a level of cognitive or emotional well-being or an absence of a mental disorder. From perspectives of the discipline of positive psychology or holism, mental health may include an individual's ability to enjoy life and procure a balance between life activities and efforts to achieve psychological resilience. On the other hand, a mental disorder or mental illness is an involuntary psychological or behavioral pattern that occurs in an individual and is thought to cause distress or disability that is not expected as part of normal development or culture.
Gender is a critical determinant of mental health and mental illness. The morbidity associated with mental illness has received substantially more attention than the gender specific determinants and mechanisms that promote and protect mental health and foster resilience to stress and adversity. 
Analysis of mental health indices and data reveals that the patterns of psychiatric disorder and psychological distress among women are different from those seen among men. Symptoms of depression, anxiety, and unspecified psychological distress are 2-3 times more common among women than among men; whereas addictions, substance use disorders and psychopathic personality disorders are more common among men. The World Health Organization report  lays out these facts effectively. It has further been suggested that observed gender differences in the prevalence rates originate from women and men's different average standings on latent internalizing and externalizing liability dimensions with women having a higher mean level of internalizing while men showing a higher mean level of externalizing. 
| Women's Mental Health: The Facts (World Health Organization Report, 2001)|| |
- Depressive disorders account for close to 41.9% of the disability from neuropsychiatric disorders among women compared to 29.3% among men
- Leading mental health problems of the elderly are depression, organic brain syndromes, and dementias. A majority are women
- An estimated 80% of 50 million people affected by violent conflicts, civil wars, disasters, and displacement are women and children
- Lifetime prevalence rate of violence against women ranges from 16% to 50%
- At least one in five women suffers rape or attempted rape in their lifetime.
| Common Mental Disorders|| |
Gender differences occur particularly in the rates of common mental disorders (CMDs)-depression, anxiety, and somatic complaints wherein women predominate. Unipolar depression, which is predicted to be the second leading cause of global disability burden by 2020, is twice as common in women. Furthermore, the lifetime risk of anxiety disorders (e.g., generalized anxiety disorder) is 2-3 times higher in females as compared to males. 
Moreover, depression is not only the most common women's mental health problem, but may be more persistent in women than men.  Although depressive symptoms in men and women have generally been found to be similar overall, women are more likely to present with atypical or "reverse vegetative" symptoms such as increased appetite and weight gain. In case of anxiety disorders, females have greater severity of symptoms, have more often comorbid depression and complicated course. 
As across the world, studies in India have shown that CMD such as depression and anxiety are strongly associated to female gender besides poverty. Both community-based studies and studies of treatment seekers indicate that women are, on average, 2-3 times, at greater risk to be affected by CMD.  In light of this convincing evidence that CMD are more common in women, the next most intriguing question is what makes females apparently more vulnerable. Hormonal factors related to the reproductive cycle may play a role in women's increased vulnerability to depression.  Another answer may be that the factors independently associated with the risk for CMD are factors indicative of gender disadvantage. These factors include excessive partner alcohol use, sexual, and physical violence by the husband, being widowed or separated, having low autonomy in decision making, and having low levels of support from one's family. ,, Furthermore, stressful life events are closely associated with the occurrence of depression in vulnerable individuals. During their lifetimes, females are faced with various life stressors including childbirth and maternal roles, caring and nurturing the old and sick of the family. In addition, women are less empowered due to lesser opportunities of education and respectable employment. Moreover, even those who are financially secure fear to cross social lines and therefore too are apparently vulnerable.
| Severe Mental Illness|| |
Although severe mental disorders such as schizophrenia and bipolar disorders are less prevalent than CMD, the chronic course and associated disability make these disorders severe. In addition, the stigma associated with these illnesses has a major impact not only on the sufferer but also on the families. Also, the families are burdened with the care of these patients for almost their entire lives in a great number of cases. Needless to say, the emotional and financial strain on the caregivers may be overwhelming.
There are no marked gender differences in the rates of severe mental disorders like schizophrenia and bipolar disorder that affect <2% of the population.  Gender differences have been reported, however, in the age of onset of symptoms, clinical features, frequency of psychotic symptoms, course of these disorders, social adjustment, and long-term outcome. The clinical features of bipolar disorder differ between men and women; women have more frequent episodes of depression, more commonly have "rapid cycling" and a seasonal pattern of mood disturbances.  Large cross-cultural studies in schizophrenia have shown that "female gender" is associated with a better course and outcome of schizophrenia in the developing countries. Furthermore, females have a later age of onset of schizophrenia as compared to that in males.
Although female gender is associated with a favorable outcome, social consequences such as abandonment by marital families, homelessness, vulnerability to sexual abuse, and exposure to HIV; and other infections contribute to the difficulties of rehabilitation of women. The prevalence rates for sexual and physical abuse of women with severe mental illnesses are twice those observed in the general population of women. In India, the absence of any clear policies for the welfare of severely ill women, and the social stigma further compounds the problem.  Stigma has been reported to be more toward ill women than men and also, women caregivers become the target of stigma. ,
Studies of suicide and deliberate self-harm have revealed a universally common trend of more female attempters and more male completers of suicide. However, in contrast to the data from many other countries, except China, which records the highest female suicide rate, women outnumber men in completed suicides in India, although the gap between them is narrow.  Biswas et al.  found that girls from nuclear families and women married at a very young age to be at a higher risk for attempted suicide and self-harm. The suicide rate by age for India reveals that the suicide rates peak for both men and women between the age 18 and 29 while in the age group 10-17, the rate for the female exceeded the male figure.
In his seminal studies, Emile Durkheim had vividly demonstrated over a century ago, that sociocultural factors are significant determinants of suicide behavior and perhaps these impact men and women differently. In an Indian study, the 1-year incidence of attempted suicide was 0.8%, and seven of these women (37%) had baseline CMDs. CMD, exposure to violence, and recent hunger were the strongest predictors of the incident attempted suicide cases.  A large degree of attempts is as a response to failures in life, difficulties in interpersonal relationships, and dowry-related harassment.  The precipitants for suicide, according to Indian government statistics, among women compared to men are as follows: Dowry disputes (2.9% versus 0.2%); love affairs (15.4% versus 10.9%); illegitimate pregnancies (10.3 versus 8.2); and quarrels with spouse or parents-in-law (10.3% versus 8.2%). The common causes for suicide in India are disturbed interpersonal relationships followed by psychiatric disorders and physical illnesses.  Spousal violence has been found to be specifically associated as an independent risk factor for attempted suicide in women. 
Violence and abuse
According to an eye-opening United Nations report, around two-third of married women in India were victims of domestic violence and one incident of violence translated into women losing 7 working days in the country. Furthermore, as many as 70% of married women between the ages of 15 and 49 years are victims of beating, rape or coerced sex.  The common forms of violence against Indian women include female feticide (selective abortion based on the fetus gender or sex selection of child), domestic violence, dowry death or harassment, mental and physical torture, sexual trafficking, and public humiliation. The reproductive roles of women, such as their expected role of bearing children, the consequences of infertility, and the failure to produce a male child have been linked to wife-battering and female suicide. ,
Sexual coercion is a serious and prevalent concern among female Indian psychiatric patients. Sexual coercion was reported by 30% of the 146 women in an Indian study. The most commonly reported experience was sexual intercourse involving threatened or actual physical force (reported by 14% of women), and the most commonly identified perpetrator was the woman's husband or intimate partner (15%), or a person in a position of authority in their community (10%). 
The consequences of gender-based violence are devastating including life-long emotional distress, mental health issues including posttraumatic stress disorder and poor reproductive health. Common mental health problems experienced by abused women include depression, anxiety, posttraumatic stress, insomnia, and alcohol use disorders, as well as a range of somatic and psychological complaints. Battered women are much more likely to require psychiatric treatment and are much more likely to attempt suicide than nonbattered women.  The cross-sectional data from a recent study, in India showed an association between violence and a range of self-reported gynecological complaints, low body mass index, depressive disorder, and attempted suicide.  In summary, women are subjected to an alarming amount of violence in childhood and adulthood, and the effects of this violence are often profound and long-term.
| Reproductive Health|| |
Mood and behavioral changes have been observed to be associated with menstrual cycle since ancient times. The symptoms such as irritability, restlessness, anxiety, tension, migraine, sleep disturbances, sadness, dysphoria, and the lack of concentration occur more frequently during the premenstrual and menstrual phase. A premenstrual dysphoric disorder consisting of extremely distressing emotional and behavioral symptoms is closely linked to the luteal phase of the menstrual cycle.
Mental disturbances frequently occur during late pregnancy and in the postpartum period. Postpartum blues is the most common and least severe postpartum illness affecting between 50% and 80% of new mothers,  whereas postpartum depression constitutes a major depressive episode with an onset within 6 weeks postpartum in a majority of cases. In India, depression occurs as frequently during late pregnancy and after delivery as in developed countries, but there are cultural differences in risk factors. In a study in rural Tamil Nadu,  the incidence of postpartum depression was 11%. Low income, birth of a daughter when a son was desired, relationship difficulties with mother-in-law and parents, adverse life events during pregnancy and lack of physical help are all risk factors for the onset of postpartum depression. In addition, the postpartum period carries the potential for exacerbation of psychiatric symptoms in women with the preexisting mental illness. Similarly, a recent systematic review  on nonpsychotic common perinatal disorders (CPMD) among women from low and middle income countries estimated that about one in six pregnant women and one in five women who have recently given birth experience a CPMD. The risk is highest among the most socially and economically disadvantaged women. The other important risk factors include gender-based factors such as the bias against female babies; role restrictions regarding housework and infant care; and excessive unpaid workloads; especially in multi-generational households in which a daughter-in-law has little autonomy, and gender-based violence.  Also, menopause is a time of change for women not only in their endocrine and reproductive systems, but also their social and psychological circumstances. It has long been known that menopause is accompanied by depression and other mental disturbances.
Reproductive health factors, particularly gynecological complaints such as vaginal discharge and dyspareunia are independently associated with the risk for CMD. More importantly, gynecological symptoms may actually be somatic equivalents of CMD in women in Asian cultures. 
| Substance Use|| |
Although there are variations between countries, rates of substance abuse - particularly abuse of alcohol, tranquillizers, and analgesics - are increasing around the world.  Women are more likely to attribute their drinking to a traumatic event or a stressor and women who abuse alcohol or drugs are more likely to have been sexually or physically abused than other women.  Significantly more major depression and anxiety disorders are found in females with alcoholism. Thus, the profile of women with substance use problems differs from that in male abusers. However, despite increasing rates, services to assist women are limited. 
| Woman - A Life Cycle of Vulnerabilities|| |
As mentioned earlier, in many of the disorders, social factors and gender specific factors determine the prevalence and course in female sufferers. In fact, the numbers are meaningless without considering the sociocultural factors. Thus, depression, anxiety, somatic symptoms, and high rates of comorbidities are significantly related to interconnected and co-occurring risk factors such as gender based roles, stressors, and negative life experiences and events.
Gender determines the differential power and control that men and women have over the socioeconomic determinants of their mental health and lives, their social position, status and treatment in society and their susceptibility, and exposure to specific mental health risks. A strong inverse relationship exists between social position and physical and mental health outcomes. Hence, the effect of the biological vulnerability is increased by the social disadvantages that women have. Pressures are created by their multiple roles and the unremitting responsibility of caring of others. In addition, gender specific risk factors such as gender discrimination and associated factors of poverty, hunger, malnutrition, overwork, domestic violence, and sexual abuse combine to account for women's poor mental health. There is a positive relationship between the frequency and severity of such social factors and the frequency and severity of mental health problems in women. In addition, severe life events that cause a sense of loss, inferiority, humiliation or entrapment can predict depression.
Furthermore, the expectation about what constitutes illness is gender biased. Thus, the somatic complaints that form the most prominent presentation of CMD may not be taken into account by the care providers. A gender bias more often than not ensures that the symptoms are taken less seriously than they are for men. The impact of mental health problems also shows a gender differential. For example, whereas women are required to be the primary care givers if their husbands were mentally ill, it is themselves who still need to carry on with the role of care giving to the family despite their problems.
The sociopolitical scene in South-East Asia including India in the mildest of terms is bleaker when compared to the Western world. , Wrath of dowry practices, a firm patriarchal family system with the woman having little say, lesser opportunities for education, and employment add to the plight of women. Women's mental health tends to suffer as they are faced with stressors and are ill-equipped to cope with the same.
Furthermore, when a woman becomes mentally ill, services are sought infrequently and late. Rather she is blamed for the illness. The mentally ill woman may be socially ostracized and abandoned by her husband and her own family. Hence, being a "woman" and being "mentally ill" is a dual curse. Even though some authors feel that marriage protects against psychological breakdown, it is not always true. Several studies show that there is greater distress in married women as compared to married men. The birth of a child, abortion or miscarriage, economic stresses, and major career changes are some of the stressful events in married life; many of these are gender specific. 
The responsibility of care for the mentally ill women is often left to her own family than to husband or his family. In a study, of women with schizophrenia and broken marriages, Thara et al. , found that the stigma of being separated/divorced is often felt more acutely by families and patients than the stigma of having a mental illness. Feelings of disruption, loss, guilt, frustration, grief, and fear about the future of their daughter make the caregivers miserable.
| Service Provision and Utilization|| |
Psychiatric epidemiological data cite a ratio of one woman for every three men attending public health psychiatric outpatients' clinics in urban India. Indian state officials view this as "under-utilization" by suffering women, attributing it to the greater stigma attached to women's mental illness that restricts help-seeking in public health facilities and/or to the lower importance accorded to women's health generally. 
Gender heightens the discrepancy between prevalence and utilization. This low attendance is partly explained by the lack of availability of resources for women in the hospital settings. The mental hospitals appear to cater primarily to men in distress, and there is sex-based discrimination in the availability of beds. The male:female ratio for the allotment of beds in government mental hospitals with only service was 73%:27% while those with service, research, and training was 66%:34%. 
| What Needs to be Done?|| |
It is therefore, amply clear that women's mental health cannot be considered in isolation from social, political, and economic issues. A woman's health must incorporate mental and physical health across the life cycle and should reach beyond the narrow perspective of reproductive and maternal health, which is often the focus of our policies.
In the discussion of the determinants of poor mental health of women, the focus needs to be shifted from individual and "lifestyle" risk factors to the recognition of the broader, social, economic, and legal factors that affect women's lives. It is essential to recognize how the sociocultural, economic, legal, infrastructural, and environmental factors that affect women's mental health are configured in the given community setting.
If the efforts to promote women's mental health focus solely on the reduction of individual "lifestyle" risk factors, they may neglect the very factors that bring that lifestyle into being. Moreover, if the individual factors are focused in isolation, ignoring the sociocultural factors, there is an additional risk of placing the responsibility of change on the women alone. However, the truth is that largely the change is beyond their control and lies in the bigger social change. Inadvertently, the failure to change and improvise the mental health may be misattributed to the women.
Education, training, and interventions targeting the social and physical environment are crucial for addressing women's mental health. Identification of significant persons in government departments and other relevant groups in the community, to obtain and document data indicating the extent of women's problems and the burden associated with women's mental problems and the development of policies to protect and promote women's mental health are extremely crucial.
Interventions at various levels aiming at both individual women and women as a large section of the society are essential. These should be implemented at primary care delivery as well on legal and judicial fronts. The primary care providers must be aware of the major mental health problems affecting women, routinely enquire about common mental health problems, provide the most appropriate intervention and support and provide education to the community on issues related to the mental health of women. Women are increasingly joining the workforce, and there is great potential to intervene at this level too.
There are many reasons why women are reluctant to report incidents of assault and abuse to police. These include: A belief that the incident is a "normal" part of life; feeling responsible for the violent incident; intimidation by the partner; fear of reprisal; financial dependence; continuing love or affection for the partner; inability to respond as a result of the psychological and emotional trauma arising from repeated abuse; and intimidation by the whole legal process. Barriers to an effective criminal justice response also relate to the attitudes and beliefs of those people working within the criminal justice system. Taking into account the above, it is imperative to improve the criminal justice response to violence against women. The initiative of Government of India asking citizens to report any incident of domestic violence that they might have witnessed is commendable and may go a long way to provide security to the women.
The more fundamental need is the woman/girl's education. Being educated provides awareness of rights and resources, the capability to fight exploitation and injustice. Education will also lead to better chances of economic independence, which is so crucial.
It is essential to develop and adopt strategies that will improve the social status of women, remove gender disparities, provide economic and political power, increase awareness of their rights, and so on. Although much depends upon the policy makers and planners, but women must also learn to speak for themselves. Women must act as social activists to fight against the social evils, which are responsible for their woes. Women's anti-alcohol movement in Andhra Pradesh where they destroyed the liquor shops to fight drunkenness of their husbands is a historical landmark. Similar movements to fight prostitution, sexual abuse, and domestic violence could be historical leading steps.
In summary, concerted efforts at social, political, economic, and legal levels can bring change in the lives of Indian women and contribute to the improvement of the mental health of these women.
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Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh - 160 012
Source of Support: None, Conflict of Interest: None