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open minds: better mental health care

An ideal mental health system would include medication when necessary, but also therapy, peer support and a recognition of the social circumstances that lead to illness, says psychologist Dr. Marina Morrow.

This is part of a series on improving mental health research, diagnosis and treatment. Join the conversation on Twitter with the hashtag #OpenMinds

Poor Jan. She's one of those "unmarrieds with low self-esteem," who never found the right man. On a recent cruise, the purser had to take her sad, solitary picture because she had no one else to hold the camera. Her diagnosis: 35, single and "psychoneurotic." Her fix: Valium. "You probably see many such Jans in your practice," reads the full-colour advertisement, published inside the cover of the Archives of General Psychiatry in June, 1970, as a direct overture to psychiatrists by the manufacturers of the now-famous sedative. Never mind that the list of warnings and side effects – including confusion, slurred speech, insomnia and rage – are as long as the sales pitch. "Should these occur," the ad blithely advises, "discontinue drugs." Otherwise, dose that spinster's sadness away.

If only this were a Mad Men-esque historical artifact. Even today, women appear four times more often than men in antidepressant advertising, often gardening or blissfully sleeping – and always thin – because, apparently, a pop of Prozac means never having to work (out) again. In 2013, antidepressants, sleeping pills and all variety of Valiums were a growing $1.4-billion market in Canada, and it's still the Jans – and Jessicas and Jaydas – who pop two-thirds of them.

Women are, quite literally, getting the prescription that's available more often than the treatment they need. Canada's mental-health system leans heavily on medication to solve its problems, even when science finds treatments such as psychotherapy equally, and in some cases more, effective – without physical side effects. This bias hinders women getting proper help in multiple ways. For starters, the research on how drugs affect female patients is less robust: While drug companies flog pills to women, most of their clinical trials have been dominated by men (and even lab rats are mostly male). The disorders most commonly diagnosed in women – depression, anxiety and insomnia – are also the ones most likely to respond to therapy, an approach that women are significantly more likely than men to prefer over drugs. The long wait lists for publicly funded therapy further disadvantages poor women and those working without benefits, who suffer higher rates of mental illness. For them, evidence-based treatment is too often a luxury reserved for the Housewives of Rosedale.

"Women aren't getting access to the range of care they need," says Dr. Marina Morrow, a Simon Fraser University psychologist who studies gender and mental health. An ideal system, she says, would include medication when necessary, but also therapy, peer support and a recognition of the social circumstances that lead to illness.

The debate about women and mental health

Women's experiences tend to highlight what's wrong with the mental health care system because they end up in care far more often than men – though the reason why is heavily debated. The prevalence of depression and anxiety in women is about twice that of men (who have higher rates of substance abuse), but is that because women are actually sicker? Or are their more frequent visits to the doctor more likely to turn up a mental health problem, slotting them into Jan territory, whether legitimately or not?

Research has yet to pin down the influence of sex and gender, says Dr. Sonia Lupien, director of the Centre for Studies on Human Stress at the Institut universitaire en santé mentale de Montréal – in part, because until the last decade these potential differences haven't been studied. Women, for instance, are 10 times more likely than men to admit to being stressed on self-reporting surveys, according to Lupien. On the other hand, she says, even men who say they aren't stressed have much higher levels of stress hormones. So are women protected from the biological effects of stress because they talk about it more, and if so, doesn't that support talking therapy as a valid treatment?

Mental illness among women is also linked to culture and circumstance; many experts believe societal roles, family stress, poverty and trauma also contribute uniquely to female rates of mental illness. A recent study that followed more than 1,000 British mothers over a decade found that those who experienced physical spousal abuse were twice as likely to develop depression and three times more likely to have psychotic symptoms in mental illness, as mothers who weren't victims of violence. There is also new science suggesting that depression may factor differently into women's physical health, particularly heart problems. In both cause and effect, the case for early and appropriate intervention in women's health is clear.

Seeking help with treatment

In research focus groups, Lupien says people often say they want to go to therapy but can't afford it. "If you have a single mom making $40,000 a year, raising three kids, you are not going to ask her to go see a psychologist for $200 [an hour]," Lupien says. Instead, she tries to educate people on what to look for in a psychotherapist so they don't waste their money.

With money a top consideration for governments too, Canadian researchers are testing cost-effective ways to deliver therapy. For instance, a New Brunswick pilot project offered 12 weeks of peer support to women with postpartum depression. At the end of the program, only 12 per cent were still depressed. But when it came to funding the $142,000 annual budget for a full-scale program, the province balked.

"Women told us, 'I would have been hospitalized if you hadn't been there helping me,'" says Dr. Nicole Letourneau, a University of Alberta researcher who led the project. The cost of providing peer support would be roughly half the amount of the average hospital stay for a woman with postpartum depression, says Letourneau – not counting the benefit for families and early-childhood development. "I think we are totally missing the mark."

This isn't about clearing out the medicine cabinet – drugs work for many people. But there are compelling reasons why women should be angry about their lack of treatment choices. Mental illness tends to peak during child-bearing years – and for about 15 per cent of women, postpartum – when drugs aren't recommended, or patients aren't keen to take them.

Adverse side effects of drugs

Women are also more likely than men to be prescribed antidepressants and sedatives as seniors, putting them at higher risk of adverse side effects. Because clinical trials haven't always considered sex differences, less is known about how body mass and hormones alter responses to drugs. In 2013, for instance, the U.S. Food and Drug Administration recommended that women receive a lower dose than men of the sleeping pill zolpidem – also known as Ambien – because of stronger side effects that raised the risk of next-morning car accidents. That rare, sex-specific finding came two decades after the drug first hit the market. (Health Canada followed suit with a similar announcement in January, 2014.)

In fact, sleeping pills are a clear example of the negative side effects – and poor cost management – of short-changing therapy as a treatment alternative.

Insomnia, a chronic problem suffered by one in 10 Canadians, is diagnosed twice as often in women as men. It has a circular relationship to mental illness: People with it are five times more likely to have anxiety and depression, and having it makes you more likely to be depressed and anxious.

According to Dr. Cara Tannenbaum, the Montreal-based scientific director of the CIHR Institute of Gender and Health, a short dose of cognitive behavioural therapy (CBT) with a focus on sleeping strategies is an effective treatment. In studies, it's been found to work as well as medication – and for years, in the most prestigious scientific journals, sleep researchers have been making the scientific case for CBT as a drug alternative, especially for seniors. In a 2006 article, published in Canadian Family Medicine, Quebec researchers analyzed 15 years of studies and concluded that therapy adapted to insomnia should be the "recommended treatment" for seniors.

But most patients are never offered CBT, says Tannenbaum, instead they often get benzodiazepine, a common drug prescribed for sleep. (Ativan is the bestseller in Canada.) These drugs are a $336-million market in Canada. Approximately 30 per cent of Quebec seniors alone have a prescription, second only to France among OECD countries, Tannenbaum says. Although men and women diagnosed with insomnia are equally likely to get drugs as treatment, among those taking them over the age of 65, two-thirds are women – in part because female patients are diagnosed more often.

But since seniors have slower metabolism, the drug takes longer to clear their system. It can be difficult for patients to stop taking them because of withdrawal symptoms. They can also cause dangerous side effects such as dizziness and cognitive impairments. They have been linked to higher rates of falls and fractures among seniors, which cost the Canadian health-care system more than $2-billion a year. A 2005 meta-analysis in the British Medical Journal concluded that for seniors, the "benefits may not outweigh the risk."

Adding to those concerns, a 2014 article, also published in the BMJ, by a team of Canadian and French researchers using a large Quebec sample of patients, suggested an association between long-term use of benzodiazepine medication and an increased risk of Alzheimer's.

Not only is therapy arguably safer and more effective, it's also the cheaper choice, according to a 2015 study by Canadian and U.S. researchers, led by Tannenbaum. Upfront, it may cost a little more (though less if delivered in groups), but it saves on costly and debilitating falls and hip fractures. "There remains no sound justification," the authors concluded, to prescribe drugs without first trying therapy. "The caveat is that treatment should be accessible and affordable to all, otherwise older patients will be deprived of safer evidence-based therapies for insomnia."

A yet-to-be-published analysis by Tannenbaum and Dr. Vakaramoko Diaby, an assistant pharmacy professor at Florida A&M University, estimates that if even 20 per cent of seniors with insomnia received CBT instead of medication, the cost-savings to the system could be in the hundreds of millions – based on the potential falls that would be avoided.

Tannenbaum has recently penned a stern letter to Quebec's health minister to make this point. "That's the most transformative part of the research," she says. "What are we going to do about it? The way we fund therapies in Canada does not make sense right now."

For women, the current situation risks poor outcomes for some of their most common health problems. In a system favouring medication over the best-evidence psychotherapy, treatment-as-usual makes sense neither from a financial perspective, nor for a health-care system seeking to deliver patient-centred care.


'Anger of the blood'

Does depression cause heart disease in younger women? At the very least, it's a warning sign.

The American Heart and Stroke Foundation recently recommended that depression be listed as a risk factor for heart disease. This partly stems from some anxiety-inducing research suggesting an association between depression in women under the age of 55 and higher rates of heart attacks, as well as higher rates of death following surgery.

Heart disease is rare among young women, but when a heart attack occurs, young women die at higher rates, even with medical intervention. Since young women are less likely to be included in randomized trials, there's been little research, until recently, into finding a possible explanation.

One answer may lie in the minds of patients.

An international study published last month in the Journal of the American Heart Association followed 3,572 young patients with acute myocardial infarction for four years, at hospitals in the United States, Spain and Australia. Researchers found that 48 per cent of women reported a history of depression, twice as many as the men in the study. At the time of admission to hospital, women were also significantly more likely to report acute depressive symptoms. A separate U.S. study, also published this spring, assessed depression in patients receiving an angiogram and found that young women with depression were more likely be to diagnosed with coronary artery disease than men or older women.

This doesn't prove that depression causes heart problems in women, only that there is an association that scientists don't yet understand. Depression is linked to smoking, poor diet or lack of exercise, factors that contribute to health problems – although even when researchers adjusted for these facts, an increased risk remains. Depression also has physiological side effects on hormone and cortisol levels, and has been found to increase inflammation, causing what one of the study authors, Dr. Amit Shah, an epidemiologist at Atlanta's Emory University, described as "anger of the blood."

Antidepressants may also play a role, he suggests. It's possible that women respond differently to stress; a recent study that tested stress reactions in young women found a higher reduction of blood flow around the heart than men given the same test.

But what to do about it? Pyschotherapy and drugs have been successful at treating the depression of heart patients. They've been proven to improve the outcome of the patient's heart disease – suggesting the question is more complicated.

The Centre for Addiction and Mental Health has purchased advertisements to accompany this series. The organization had no involvement in the creation or production of this, or any other, story in the series.

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