Women’s mental health needs took centre stage during a “provocative” keynote by Professor Jayashri Kulkarni, Professor of Psychiatry at The Alfred and Monash University, at this year’s Royal Australian and New Zealand College of Psychiatrists Congress.
Dr Amy Coopes reports below on Kulkarni’s keynote, with a strong message to improve care of women’s mental health by following a biopsychosocial approach.
Bookmark this link for ongoing reports from the Congress.
Amy Coopes writes:
Women’s mental health needs to be made a real priority, with a growing chorus of lived experience demanding that we “fix this and fix it now”, using holistic approaches that appreciate the unique biological and social determinants including violence, power and inequity.
This was the message of a resounding and “deliberately provocative” keynote on women and mental health by Professor Jayashri Kulkarni, who is an internationally renowned expert on hormones and psychiatry, at the recent Royal Australian and New Zealand College of Psychiatrists’ annual congress in Sydney.
Kulkarni, from Melbourne’s Monash Alfred Psychiatry research centre, situated her talk firmly in the present historical moment, pointing to recent regressive moves on abortion rights in the United States with the putative rolling back of Roe versus Wade and – closer to home – the elevation of voices such as Brittany Higgins and Grace Tame as evidence of a growing sense of injustice.
Despite the fact women made up more than half of the population, the mental health system continued to sell them short on multiple fronts, including diagnosis, drivers and treatment, Kulkarni said.
She pointed to a ‘gender-blind’ one-size-fits-most approach that was fuelling “righteous anger” at psychiatry and its proponents.
Failing to get things right came at huge social and economic cost, she warned, with some 47 percent of Australian women experiencing mental ill health in their lifetime and a price tag running into the billions.
Diagnosis
In psychiatry, Kulkarni said a woman’s problem typically began at diagnosis, a process she described as subjective at best and one that too often overlooked or failed to consider trauma, including attachment difficulties that were “very traumatic for the developing brain”.
She decried the “diagnostic nihilism” and victim-blaming inherent in – most particularly – the personality disorder space, where she said severe and chronic trauma including attachment issues were frequent.
Up to 80-90 percent of women diagnosed with borderline personality disorder (BPD), for example, had trauma in their history, she said.
The condition had significant overlap in terms of genetic drivers with mood disorders and schizophrenia and was determined by environmental interactions, with a combination of inherent vulnerability and mistreatment setting in train a stress response that triggered maladaptive pathophysiological processes.
A biological hypothesis of causation posited that early life stressors, including insecure parental attachment, resulted in cortisol dysregulation and glutamatergic (or neuroexcitatory) overexpression, with resulting perceptual and reactive disturbances and effects on self-esteem that contributed to relationship difficulties, Kulkarni said.
The adrenal and gonadal systems – the so-called HPA and HPG axes – were also implicated, with links to polycystic ovarian syndrome, premenstrual syndrome and dysphoric disorder (PMS/PMDD) and worsening of symptoms at menopause, she added.
Kulkarni described sex hormones – oestrogen, progesterone and androgens including testosterone – as “powerful neurobiological substances”, as evidenced by the sheer proportion of women who suffered from PMS (40 percent) or PMDD (10-15 percent), both of which she labelled rapid cycling “brain-hormone disorders”.
The links between sex hormones and depression in women were well established, Kulkarni told the meeting, with mood effects one of the most common reasons for discontinuation of the oral contraceptive pill among the three in four Australian women who trialled it in their lifetime.
Kulkarni said multiphasic preparations (where the ratio and dose of oestrogen to progestin is adjusted across the cycle) were worse than monophasic pills (a standard ratio and dose throughout), and there was just one mood-neutral pill on the market.
Implantable contraceptives such as the Implanon and Mirena also had strong associations with depression, Kulkarni said.
Affective disturbance during perimenopause was also an underrecognised and poorly managed phenomenon, she noted, with rates of depression 16 times higher among women aged 48-52, and this group second only to men aged 84 and older in terms of rates of completed suicide in Australia.
This was, in no small part, attributable to “chaotic gonadal hormonal changes” at this time of life, Kulkarni said.
Hormonal influences
It was important to understand these hormonal influences and the unique neurobiology of mental health disturbances in women because it opened new, and under-researched avenues for treatment, Kulkarni told RANZCP delegates.
She gave the example of a promising trial of memantine – a glutamate-blocking drug commonly used in Alzheimer’s and other neurological pathologies – among women diagnosed with Cluster B personality disorders, with good effect on impulsivity and self-harm.
On the hormonal front, Kulkarni said psychiatry was still trailing the science, with psychiatrists more likely to prescribe an antidepressant for menopausal mood instability, despite growing evidence of better clinical response in these women to hormone replacement therapy (HRT) and moves by GPs and obstetrician-gynaecologists in this direction.
At a population level, this was not a small group, and she said it was important to get treatment right, not only for the women themselves but also in the interests of their adolescent children’s mental health.
Taking a conservative ‘wait and see’ approach to perimenopausal depression was no longer good enough, with the transition to menopause typically taking 10-12 years meaning these women were consigned to more than a decade of unnecessary suffering, she added.
Kulkarni is due to launch a new unit called HER (Health Education Research) Centre Australia, a collaboration between The Alfred, Monash and Cabrini Health to enhance and increase research on women’s mental health, including on the neurobiology and aetiology of disorders.
She advocated for reforms that went far beyond the biomedical, highlighting the emergence of new woman-focused psychotherapies like feminist empowerment theory, and the establishment of single-gender inpatient units as important shifts in the right direction.
Although, she said the latter needed to be much more widely available in the public system so women could do trauma-informed work in safety and privacy.
Kulkarni argued for the reform of diagnostic categories in psychiatry that negatively impacted and stigmatised women, giving the example of complex-PTSD in place of less nuanced characterisations like BPD. “Names do matter,” she said.
She also described as disappointing and insufficient mental health’s ranking at priority number four in the National Women’s Health Strategy, declaring that it was vital to “make women’s mental health a real priority, and listen to women with lived experience who are telling us to fix this, and fix it now.”
Above all, she said these reforms had to be in codesign with women with lived experience and should consider the biological (hormones, differences in drug metabolism, neural networks and genetics), psychological (impact of social conditioning and gendered roles) and social (violence, power imbalances, poverty, gender wage inequity) determinants.
“We’ve got a long way to go,” Kulkarni said.
From Twitter
Read Coopes’ thread on Professor Jayashri Kulkarni’s keynote here.
Read Croakey News thread (by Alison Barrett) on Kulkarni’s keynote here.
Women’s experiences on the other side of psychiatry, as treating clinicians, also featured prominently at the RANZCP Congress. Read collected tweets from those sessions below.
Dr Amy Coopes was in virtual attendance at the RANZCP Congress for the Croakey Conference News Service. Follow her at @coopesdetat for her Tweets from the Congress, with additional coverage via @croakeynews and @wepublichealth.
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