Christina P.C. Borba, PhD, MPH

About 1 in 4 individuals around the world will develop mental illness at some point in their lifetimes. Women are impacted at a higher rate than men, with 1 in 5 women experiencing a prevalent mental illness (eg, anxiety, depression) versus only 1 in 8 men.

 Perhaps this imbalance is not surprising, given that women’s mental health throughout history and around the globe has commonly been attributed to different versions of 

 (uterus), intimately connecting mental illness with what has for millennia defined an essential and exclusive aspect of the female gender.

Today, across different countries and in different settings, there continue to be gender differences in the utilization of mental health services and the treatment provided.

For example, a significant predictor of being prescribed psychotropic drugs is simply identifying as a woman.

 Furthermore, specific mental health-related risk factors that disproportionately affect women include pressures created by their multiple roles; gender discrimination and associated factors of the pay gap; and increased rates of poverty, hunger, malnutrition, domestic violence, and sexual abuse.

 However, these statistics and figures do not portray the more narrative data of global women’s mental health.

To address this, we unite here to explore the lessons we have learned from personal and clinical experiences, and the challenges that remain in treating mental illness in patients who identify as female. We are a group of women from different ethnic heritages and cultures, working together in a psychiatry department at the largest academic safety net hospital in New England. Given that 32% of our patients do not speak English as a primary language in this diverse patient population, we have gained insight into how mental health is perceived by women from around the world. While there are cultural nuances, there are also shared universal themes contributing to women’s poor mental health, such as prohibitive cultural views that do not acknowledge mental health, 

, cultural defense mechanisms (eg, denial), and alternate explanations (“crazy,” somatization, religious punishment) that target and can ultimately cause lack of access to timely and effective diagnosis and treatment in women.

Some cultures have a prohibitive view of mental health, from ignoring that it exists to discounting it as a necessary component of wellbeing.

 Kushani Patel, DO, shared her unique perspective: “As a first-generation Indian immigrant who moved from India at an early age and lived most of her life in the United States, I can give the perspective of growing up in a family and Indian community here where mental health is often discounted and seen as not real.”

Sonal Jain, DO, also shared her experience: “As a South Asian female who identifies as a second-generation Indian-American, I have struggled to engage in mental health services despite training as a psychiatrist. In high school, there were moments where I would develop racing thoughts, palpitations, and nervousness, but was unable to identify this as anxiety. Mental health was simply not discussed in our community. The idea of seeking out formal mental health services was daunting; [it] felt “wrong” and intimidating… 

How would I even do that? [Would] I worry my family if I did?

While rarely discussed, South Asians—defined as individuals descending from the areas of Nepal, India, or Pakistan—are experiencing high rates of untreated mental health disorders.

South Asian female immigrants have a higher rate of depressive disorders, self-harm, and suicide than South Asian males, due to acculturative stress, gender roles, domestic violence, collectivist culture, and limited understanding of mental health services.

A similar prohibitive view toward mental health is experienced within Chinese culture. Per Lucy Lan, MD, MBA, a Chinese American immigrant, mental illness is associated with shame and disregarded, seen as contrary to “saving face” for one’s family and community. Resultant mental health issues and psychiatric disorders overall are thus typically not acknowledged. In general, rates of mental illness are likely grossly underreported in research literature and official government records in China, and in communities with Chinese heritage abroad. Of the statistics that are published, the effects of female gender discrimination, institutionalized from traditional 

, still exist; however, they appear to be slightly lessened due to the effects of the Communist government policy that women are equal to men.11 Nevertheless, significant inequalities still exist, such as women occupying fewer psychiatric hospital beds and in general receiving fewer health care resources than men.

 Mental health is still a taboo subject, for both genders, within Chinese and other East Asian communities.

Given the large extent to which culture of familial origin may affect one’s acknowledgement of mental illness, it makes sense for providers to ask patients how their culture views mental illness in general and specifically in women. This information is invaluable in understanding the wider sociocultural context of how a woman might view her illness, and how she ultimately copes with it. It is also important for us clinicians to understand our own biases, especially when there are clinical symptoms with unique presentations with cultural nuances that differ from ours.

Some cultures associate mental illness with stigma and cope via multiple defense mechanisms.

 Per several Haitian patients, mental health symptoms are overall discounted with statements such as “crazy, shameful, hide it, just deal with it.” Katherine Crist, MD, a fourth-generation descendent of Irish Catholics immigrants, recently spoke with a 25-year-old Haitian, Catholic, female patient who presented to the emergency room with psychosis. This patient had been struggling with auditory hallucinations, bizarre thought content, and inability to take care of herself for several months. Crist said, “When I asked about prior mental health treatments, she stared at me blankly and said, ‘my mother prays for me.’”

Religiosity in the Haitian approach to mental health is not so different from that of other cultures. In reflection, Crist recalled a discussion with her uncle, a Catholic priest from Minnesota, who encouraged religious treatment for churchgoers suffering from severe mental illness. “Each of these stories helped me to realize that a core issue continues to be believing women’s experience with mental illness and treating them equitably,” Crist said.

There is an opportunity for clinicians to show interest in and respect for patients’ faith-based world views while providing mental health education in order to build a therapeutic alliance and inadvertently combat stigma of mental illness.

Somatization of mental health symptoms is prevalent across many cultural and ethnic groups.

 Patel recalled caring for a 28-year-old Somalian female, “Mrs Caledon,” on the consult psychiatry service who presented to the hospital multiple times for persistent nausea and uncontrolled movements. This patient found it very difficult to accept and understand her diagnosis of psychogenic nonepileptic seizures, especially in relation to her severe childhood sexual trauma. Mrs Caledon explained that it was also difficult to discuss such a diagnosis with her family.

A somatic understanding and explanation of mental illness is especially common in the Latinx female community.

Anxiety and depression show up as abdominal pain, nausea, and 

. Lan’s 32-year-old Colombian patient who was suffering from acutely elevated anxiety and depression in the context of domestic violence presented to the emergency department many times for chest pain and nausea. She believed she was suffering from cardiac emergencies and found it culturally difficult to acknowledge the possibility of panic attacks.

We suggest approaching somatization with empathy, sharing with the patient that there is strong scientific evidence for mind-body connection and that their experience is normal.

 For example, for patients who feel anxiety with gastrointestinal manifestations, we have found it helpful to explain that this is logical, given that there are more nervous cells in the gastrointestinal tract than in the central nervous system and there is a well-known gut-brain connection.

Patients with anxiety are more likely to be open to mental health treatment, as they tend to feel their interpretation is acknowledged.

Of note, there is active research in elucidating how significant biological differences between male and female brains affect cognitions, behaviors, and how our existing treatments work in light of emerging evidence. Providers should make an effort to learn how differences in female anatomy, biochemistry, and pharmacokinetics affect our understanding of women’s mental health.

Many of our female patients and their female family members expressed a sense of mental burden secondary to gender discrimination within their culture of origin. For example, Lan shared how this affects her 59-year-old Haitian female patient, “Mrs Louis,” who said, “It is not right, the way we were brought up—hit and screamed at for the smallest thing. My brothers weren’t, but that is the way it is in Haiti. My sister and I were the girls and had to do everything, take care of everyone, and not talk back… I got married so I could get away.”

Mrs Louis noted that she was encouraged by her sister, also an immigrant, to seek psychiatric care. Her primary goal of treatment was to gain confidence in “standing up to myself, to my parents, to my brothers, even to my sister. I have to learn how to say no.” Yet despite the painful, chronic conflict with her family, this patient’s parents live with her, and family is a large part of her identity and daily life.

Similarly, per Patel, gender discrimination and societal pressure of women’s roles play a significant factor in women’s health in the South Asian community. Patel noted that many females in the Indian community, particularly middle-aged and elderly women, carry out the traditional Indian concept that women—not men—are largely and solely responsible for taking care of the household at the cost of caring for their own mental health. This concept is largely explained by collective culture, where the emphasis on family cohesion and interdependence is emphasized over the individual.

Literature shows that collectivist culture and gender roles in the South Asian community can also lend themselves to increased risk of depressive disorders amongst South Asian females.

 Increasing training in ideas such as acculturative stress and gender roles within society and improving understanding amongst mental health professionals may be ways to overcome this barrier.

Women-focused mental health is not one-size-fits-all. As per the preceding narratives, there are many different factors that result in how a woman makes sense of and approaches her mental wellbeing, nuanced by ethnic, cultural, socioeconomic, and traumatic experiences. Yet despite these differences, there are many shared themes within women’s mental health across the world, such as stigma, lack of resources for treatment, and shared risk factors for mental illness.

 As providers, we have an opportunity to be inclusive of and sensitive to female patients with different world views, especially of the mind-body connection, which is more representative of how most of the world makes sense of mental illness.

While there is a dearth of and need for evidence-based treatments for how to best approach women’s mental health with cultural nuance, our clinical experiences suggest simply asking patients how they make sense of their mental health symptoms: “What does this mean to you?” This basic approach opens the door to an infinity of possibilities, inclusive of cultural and gender differences. It is imperative that we listen; we may be the sole individual willing and able to lend an ear to a woman with mental health needs. Do not hesitate to ask questions from a humble position of wanting to better understand a context that differs from your own. More than ever, we as providers are uniquely positioned to make a significant impact on our female patients’ mental health—thereby positively affecting their families and communities at large.

 are residents in psychiatry at Boston University Medical Center/Boston University School of Medicine in Boston, MA

 is Vice Chair of Research for the Department of Psychiatry at Boston Medical Center and Associate Professor at Boston University School of Medicine in Boston, MA.

This article was initially published by our sister publication Psychiatric Times.

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This diverse group of women came together to explore the challenges in treating mental illness in patients who identify as female.

Christina P.C. Borba, PhD, MPH

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