Towards a Better Understanding of Women's Mental Health and Its Indicators

Investigator Name: Dr. Cara Tannenbaum

Project Completion Date: November 2006

Research Category: Research

Institution: Centre de recherche de l'Institut universitaire de gériatrie de Montréal

Project Number: 6795-15-2003/6380006

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• Part 1
• Part 2
• Part 3
• Part 4

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Summary

There is wide recognition that we need to better understand the determinants of women's mental health in Canada. To do this, valid and reliable gender-sensitive markers of mental health are needed to monitor and track the effectiveness of interventions aimed at improving mental health and illness for all Canadians. Our project mission is to clearly communicate three key points 1. that sex differences in mental health need to be reduced, 2. that absolute rates of mental illness for both men and women need to be reduced, and 3. that distress may be a trigger to illness, therefore preventive approaches to distress need to be implemented to reduce mental illness.

Our findings are divided into four parts. Part 1 documents a preventive approach to mental illness by addressing key social determinants. Part 2 critically compares and contrasts three mental health indicators that could be used to gauge the mental health status of adult men and women in Canada in response to the programs and policies described in Part 1. Part 3 brings to the fore the rationale for and importance of certain gender considerations crucial to planning and appraising mental health initiatives. Part 4 underscores the importance of data quality in mental health information, especially for vulnerable or under-represented Canadian subgroups who experience mental illness.

Part 1: Using data from 15,889 men and 19,347 women aged 18 years and older who participated in the 2002 Canadian Community Health Survey on Mental health and Well-being (CCHS cycle 1.2), our analyses revealed that higher levels of distress are associated with inadequate social support, lower income levels, unemployment, physical inactivity, lower educational attainment and single parenthood. Except for unemployment, all of these determinants have a greater impact on distress in women than men.

To alleviate distress and subsequent mental illness, policies and programs need to reduce these root causes of mental distress. For example, to improve social support housing and community outreach programs are needed, especially for widowed older women and the poor. To reduce the gender wage gap, increased income support and leave for care giving workers and the working poor are required. Investment in high quality child-care programs would alleviate stress in working parents and single mothers and fathers. Other strategies to reduce distress include part-time job opportunities for working and single parents and fostering affordable and accessible physical activity programs in a safe environment for women and men.

Part 2: At the current time, there is no adequate health indicator being used to monitor and track mental health for women and men in society. We present validity data on three new potential mental health indicators: psychotropic drug use, physician billings for mental health visits, and self-reported symptoms (not just diagnosis of mental illness). Annual self-reported rates of psychotropic drug use were 8% for women compared to 4% for men, however, these medications were often prescribed for conditions other than mental health symptoms. The proportion of annual claims made by physicians for mental health visits was 25% for women and 18% for men. These numbers underestimate mental illness as only 87% of adult women and 75% of adult men access a physician per year and need to be adjusted. Twenty percent of women and 14% of men admit to feeling depressed or anxious. However, the questions posed in the survey do not take into account cultural interpretations, and many people are reluctant to reveal their symptoms. We concluded that each indicator contributes valuable information on mental health but is deficient in some way. Preliminary discussions with Statistics Canada suggested a preference for the physician diagnostic reporting indicator (which shows an adjusted 20% population prevalence of mental health symptoms for women and 14% for men). The proposed electronic medical health record in Canada would greatly facilitate the use of these indicators and eliminate some of their short-comings.

Members of the Advisory Board questioned whether it was realistic to try to identify a gold standard indicator for mental illness. Given the complexity of the issues, they suggested that the indicators be combined. If used together, they will provide a more robust picture of mental health.

Part 3: Our gender-based analysis strategy revealed differences in expressions of distress, treatment patterns for mental health symptoms, and health-care seeking for men and women. Gender differences in distress translated into similar differences in mental health disorders, with 11% of women compared to 10% men experiencing at least one mental health disorder during a 1-year period. In absolute terms, this is a relatively small difference. However, important differences exist in the spectrum of mental health problems according to sex. Women are more likely to suffer depressive and anxiety disorders, while men are more likely to abuse illicit substances, gamble and engage in criminal activities. In the Canadian Community Health Survey Cycle 1.2 10% of women reported anxiety and depressive disorders compared to 6% of men. Only 1% of women reported substance abuse (alcohol and drug use), compared to 4% of men.

In all age groups, women reported higher levels of distress than men. The highest levels of distress were noted in younger age groups but the gender gap was most significant in older adults. Reasons for the discrepancy among older adults require further investigation, but include issues of widowhood, social isolation, higher rates of disability, and a higher prevalence of compromised socio-economic status among older women.

The ways in which men and women deal with distress appear to differ. Women are more likely than men to seek help from a health care professional and to accept - or be prescribed - pharmacological treatment for their symptoms. In fact, twice as many women than men (12% vs. 6%) in the Canadian Community Health Survey Cycle 1.2 reported consulting a health care provider in the past year for emotional problems. Women were also twice as likely as men to report taking psychotropic medication (18% vs. 10% of those reporting the highest levels of distress).

If there were equity in the provision of psychotropic drugs to men and women, then distress patterns should account for gender differences in prescribing patterns. This does not appear to be the case, and it is not clear whether these differences reflect inappropriate care. Differences may reflect a positive bias in favour of treating women's mental distress, or a negative situation with over-prescribing to the detriment of women's health. The promotion of psychotropic drugs directly to physicians as well as to consumers through direct-to-consumer advertising may be distorting the doctor-patient role and leading to unnecessary medical treatments for normal life events.

It is well-recognized that the use of psychotropic drugs is not without risk, especially in elderly women. Effects on memory, heart problems, and an increased risk of falls, hip fractures, and motor vehicle accidents, are but a few of the potentially dangerous side effects of these medications. Adverse drug interactions are particularly common with these classes of medications, and may lead to inadvertent hospitalization.

In light of an unknown risk-benefit ratio and possible inappropriate utilization of psychotropic drugs, we again emphasize a preventative/public health approach that targets the root causes of women's anxiety and depression. Important social policies should be focussed on reducing known correlates of anxiety and depression such as social isolation and marginalization, gender income inequity, caregiving responsibilities, lack of physical activity, and employment opportunity. Investment in non-pharmacological treatment of depression and anxiety is recommended, such as increased availability of group and individual counselling services and psychotherapy. Additionally, our legislators must enforce the current prohibition of all industry-sponsored advertisements of prescription drugs to the public, and must ensure the provision of independent, unbiased and publicly-financed information on prescription drugs to Canadians.

Part 4: Recommendations to improve mental health data information and quality include negotiations with Statistics Canada to 1) increase the sample size for minority and immigrant populations in future mental health surveys; 2) revise the questionnaire to include broader determinants of mental health and more comprehensive, validated measures of distress, mental health symptoms and disorders; and 3) make more transparent the reasons why certain questions were selected for the survey. Better information technology in Canada is required. Advisory Board Members also stressed the importance of data linkage among provincial and federal data sources. Longitudinal follow up will ensure the ability to evaluate the effects of policies on certain measures of mental health. The Advisory Board, while sensitive to privacy issues, also felt that Statistics Canada and other government departments in possession of health data should allow greater access to the data by qualified health researchers as is the case in the USA and the United Kingdom; this has the potential to improve the health of Canadians.

A knowledge transfer plan is in place to create bridges with the Canadian Mental Health Commission, interested government stakeholders, Statistics Canada, mental health researchers, mental health advocates, health care professionals and consumers for dissemination of these findings and recommendations.

The views expressed herein do not necessarily represent the views of Health Canada