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Time is up: Psychiatrists urged to abandon ‘gender blind’ approaches and prioritize women’s mental health

Women’s mental health needs took center stage in a ‘provocative’ keynote address by Professor Jayashri Kulkarni, professor of psychiatry at Alfred and Monash University, this year Congress of the Royal Australian and New Zealand College of Psychiatrists.

Dr. Amy Coopes reports Kulkarni’s keynote below, with a strong message to improve women’s mental health care by following a biopsychosocial approach.

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Amy Coopers writes:

Women’s mental health must become a real priority, with a growing chorus of lived experiences demanding that we “fix this and fix it now”, using holistic approaches that appreciate the unique biological and social determinants including violence, power and inequality.

That was the message of a resounding and “deliberately provocative” speech 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 Psychiatristsannual convention in Sydney.

Kulkarni, from the Monash Alfred Psychiatry research center in Melbourne, set his speech firmly in the current historical moment, highlighting recent regressive movements on abortion rights in the United States with the putative pushback from Roe vs. Wade and – closer to home – the raising of voices such as Brittany Higgins and Grace Tame as evidence of a growing sense of injustice.

Despite the fact that women made up more than half of the population, the mental health system continued to sell them short on several fronts, including diagnosis, drivers and treatment, Kulkarni said.

She pointed to a unique “gender-blind” approach that fueled “righteous anger” against psychiatry and its supporters.

Not getting it right has a huge social and economic cost, she warned, with an estimated 47 per cent of Australian women suffering from mental health issues in their lifetime and a price tag running into the billions.

Professor Kulkarni at #RANZCP2022. Photo by Alison Barrett


In psychiatry, Kulkarni said a woman’s problem usually begins at the time of diagnosis, a process she described as subjective at best and which too often overlooked or failed to consider trauma, including the difficulties of attachment that were “very traumatic to the developing brain”.

She denounced the “diagnostic nihilism” and victim-blaming inherent – most notably – in the personality disorders space, where she said severe and chronic trauma, including attachment issues, were common. .

Up to 80 to 90 percent of women diagnosed with borderline personality disorder (BPD), for example, have had trauma in their history, she said.

The condition had significant overlap in terms of genetic factors with mood disorders and schizophrenia and was determined by environmental interactions, with a combination of inherent vulnerability and mistreatment resulting in a stress response that triggered pathophysiological processes unsuitable.

A biological causal hypothesis posited that early stressors, including insecure parental attachment, lead to cortisol dysregulation and glutamatergic (or neuroexcitatory) overexpression, with perceptual and reactive disturbances and effects on self-esteem that were contributing to relationship difficulties, Kulkarni said.

The adrenal and gonadal systems – the so-called HPA and HPG axes – have also been implicated, with links to polycystic ovary syndrome, premenstrual syndrome and dysphoric disorder (PMS/PMDD) and worsening of symptoms at the menopause, she added.

Kulkarni described sex hormones – estrogen, progesterone and androgens, including testosterone – as “powerful neurobiological substances,” as evidenced by the proportion of women with PMS (40%) or PMDD (10-15%), which she referred to as rapidly cycling “brain hormone disorders.”

The links between sex hormones and depression in women are well established, Kulkarni told the meeting, with mood effects being one of the most common reasons for discontinuation of oral contraceptive pills in women. three out of four Australian women who have tested it in their lifetime.

Kulkarni said that multiphasic preparations (where the ratio and dose of estrogen to progestogen are adjusted throughout the cycle) were worse than monophasic pills (a standard ratio and dose throughout), and that there was only one neutral pill on the market.

Implantable contraceptives such as Implanon and Mirena also had strong associations with depression, Kulkarni said.

Affective disorders during perimenopause were also an underappreciated and mismanaged phenomenon, she noted, with depression rates 16 times higher among women aged 48 to 52, and this group is only second. than among men aged 84 and over in terms of the suicide rate in Australia. .

This was, in large part, attributable to “chaotic gonadal hormonal changes” at this time of life, Kulkarni said.

Hormonal influences

Understanding these hormonal influences and the unique neurobiology of mental health disorders in women is important because it has opened up new, understudied avenues of treatment, Kulkarni told RANZCP delegates.

She gave the example of a promising trial of memantine – a glutamate-blocking drug commonly used in Alzheimer’s disease and other neurological conditions – in women diagnosed with cluster B personality disorders, with a good effect on impulsiveness and self-harm.

On the hormonal front, Kulkarni said psychiatry is still testing the science, with psychiatrists more likely to prescribe an antidepressant for menopausal mood instability, despite mounting evidence of better clinical response in these women to treatment. replacement hormone (HRT) and the movements of general practitioners and obstetrician-gynecologists in this direction.

At the population level, it was not a small group, and she said it was important to get good treatment, not only for the women themselves, but also in the interests of mental health. of their teenage children.

Taking a conservative “wait and see” approach to perimenopausal depression was no longer good enough, with the transition to menopause typically taking 10 to 12 years, meaning these women were doomed to more than a decade of unnecessary suffering, a she added.

Kulkarni is to launch a new unit called HER (Health Education Research) Center Australiaa collaboration between The Alfred, Monash and Cabrini Health to improve and increase research on women’s mental health, including the neurobiology and etiology of disorders.

She advocated for reforms that went far beyond biomedical, pointing to the emergence of new female-focused psychotherapies like feminist empowerment theory and the creation of single-sex inpatient units as significant shifts in the right way.

However, she said the latter needs to be made much more widely available in the public system so that women can perform trauma-informed work safely and in privacy.

Kulkarni advocated for the reform of diagnostic categories in psychiatry that have negatively impacted and stigmatized women, giving the example of complex PTSD in place of less nuanced characterizations like borderline personality disorder. “Names matter,” she said.

She also described as disappointing and insufficient the ranking of mental health as the fourth priority in the National Strategy for Women’s Healthstating that it was vital to “make women’s mental health a real priority, and listen to women with lived experience telling us to fix this, and fix it now”.

Above all, she said these reforms should be co-designed with women with lived experience and should take into account biological (hormones, differences in drug metabolism, neural networks and genetics), psychological (impact conditioning and gender roles) and social (violence, power imbalances, poverty, gender wage inequality) determinants.

“We have a long way to go,” Kulkarni said.

From Twitter

Read Coopes’ thread on Professor Jayashri Kulkarni’s keynote address here.

Read the Croakey News thread (by Alison Barrett) about Kulkarni’s keynote here.

Selection of #RANZCP2022 tweets

The experiences of women on the other side of psychiatry, as clinicians, also featured prominently at the RANZCP conference. Read the tweets collected from these sessions below.

Dr. Amy Coopers was in virtual attendance at the RANZCP Congress for the Croakey Conference News Service. Follow her on @coopesdetat for his Congressional Tweets, with additional coverage via @croakeynews and @wepublichealth.

bookmark this link to see all of our conference coverage, join the conversation on Twitter at #RANZCP2022 and follow the Twitter #RANZCP2022 listing.

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