Women’s mental health needs took center stage during a “provocative” keynote address by Professor Jayashri Kulkarni, professor of psychiatry at Alfred and Monash University, at this year’s conference. Congress of the Royal Australian and New Zealand College of Psychiatrists.
Dr. Amy Coopes reports below on Kulkarni’s keynote address, with a strong message to improve women’s mental health care following a biopsychosocial approach.
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Amy Cooper writes:
Women’s mental health must become a real priority, with a growing chorus of lived experience demanding that we “fix this and fix this now,” using holistic approaches that appreciate unique biological and social determinants, including violence, power and inequality.
This was the message of a resounding and “deliberately provocative” keynote address 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 conference in Sydney.
Kulkarni, from Melbourne’s Monash Alfred Psychiatry Research Center, placed her talk firmly in the current historical moment, pointing to the recent regressive moves on abortion rights in the United States with the alleged rollback of roe vs. wade and, closer to home, the elevation of voices like Brittany Higgins and Grace Tame as evidence of a growing sense of injustice.
Even though women made up more than half the population, the mental health system continued to underestimate their needs on multiple fronts, including diagnosis, drivers and treatment, Kulkarni said.
He pointed to a “one size fits all” ‘gender blindness’ approach that was fueling “righteous anger” against psychiatry and its advocates.
Failing to get it right had a huge social and economic cost, she warned, with around 47 per cent of Australian women experiencing mental health problems in their lifetime and a price tag in the billions.
Diagnosis
In psychiatry, Kulkarni said a woman’s problem usually began at the time of diagnosis, a process she described as subjective at best and too often overlooked or neglected trauma, including difficulties with coping. attachment that were “very traumatic to the developing brain.
He denounced the “diagnostic nihilism” and victim blaming inherent in, in particular, the personality disorders space, where he said severe and chronic trauma, including attachment problems, were prevalent.
Up to 80-90 percent of women diagnosed with borderline personality disorder (BPD), for example, had trauma in their history, he 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 maltreatment triggering a stress response that triggered maladaptive pathophysiological processes.
A biological hypothesis of causality postulated 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 cognitive function. 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 ovary syndrome, premenstrual syndrome and dysphoric disorder (PMD/PMDD), and worsening of symptoms in menopause, he added.
Kulkarni described the sex hormones (estrogen, progesterone, and androgens, including testosterone) as “powerful neurobiological substances,” as evidenced by the large proportion of women suffering from PMS (40 percent) or PMDD (10-15 percent), which she labeled rapid-cycling “brain hormone disorders.”
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 stopping the oral contraceptive pill among three out of four women. Australians who tried it in their lives.
Kulkarni said that multiphasic preparations (in which the ratio and dosage of estrogen to progestin are adjusted throughout the cycle) were worse than monophasic pills (a standard ratio and dosage), and that there was only one neutral pill in the mood in the market.
Implantable contraceptives like Implanon and Mirena also had strong associations with depression, Kulkarni said.
Mood disturbance during perimenopause was also an underrecognized and poorly managed phenomenon, she noted, with rates of depression 16 times higher among women ages 48 to 52, and this group second only to men ages 84 and older in terms of of completed suicide rates in Australia. .
This was due, in large part, to “chaotic gonadal hormonal changes” at this point in life, Kulkarni said.
hormonal influences
Understanding these hormonal influences and the unique neurobiology of mental health disorders in women is important because it opened up new, under-researched avenues of treatment, Kulkarni told RANZCP delegates.
He 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 effects on impulsivity and self-harm.
On the hormonal front, Kulkarni said psychiatry was still testing the science, and psychiatrists were more likely to prescribe an antidepressant for menopausal mood instability, despite mounting evidence of better clinical response in these women. to hormone replacement therapy (HRT) and the measures of GPs and obstetricians. -gynecologists in this direction.
At the population level, this was not a small group, and she said it was important to get the right treatment, not just for the women themselves but also in the interest of the mental health of their teenage children.
Taking a conservative ‘wait and see’ approach to perimenopausal depression was no longer good enough, as the menopausal transition typically takes 10-12 years, meaning these women were consigned to more than a decade of unnecessary suffering, he added.
Kulkarni will 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 aetiology of disorders.
She advocated for reforms that went far beyond the biomedical, highlighting the rise of new female-focused psychotherapies, such as feminist empowerment theory, and the establishment of single-gender inpatient units as important changes in the right direction.
Though she said the latter needed to be much more widely available in the public system so that women could do trauma-informed work on safety and privacy.
Kulkarni advocated reform of diagnostic categories in psychiatry that negatively impacted and stigmatized women, giving the example of complex PTSD rather than less nuanced characterizations such as BPD. “Names do matter,” she said.
He also described as disappointing and insufficient the ranking of mental health as the number four priority in the National Women’s Health Strategystating 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 that these reforms had to be co-designed 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 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) on Kulkarni’s keynote address here.
Women’s experiences on the other side of psychiatry, as treating physicians, also featured prominently at the RANZCP Congress. Read the collected tweets from those sessions below.
Dr. Amy Coopes attended the RANZCP Congress virtually for the Croakey Conference News Service. follow her on @coopesdetat for his tweets from Congress, with additional coverage via @croakeynews Y @wepublichealth.
Marker this link To see all of our conference coverage, join the conversation on Twitter at #RANZCP2022 and follow the Twitter #RANZCP2022 ready.
