A Nurse’s Guide to women’s mental HealtH

Michele R. Davidson, PhD, CNM, CFN, RN, holds a PhD in nursing administration and health care policy from George mason University and has practiced in the area of women’s health nursing for more than two decades. she is currently an associate professor of nursing and an affiliate faculty member for the women’s studies Program at George mason University. Dr. Davidson received an associate degree from marymount University and then a baccalaureate nursing of science degree from George mason University in Fair-fax, Virginia. Upon graduation, Dr. Davidson worked in a variety of women’s health set-tings including labor and delivery, postpartum, neonatal intensive care unit, reproductive endocrinology, and inpatient gynecology at Columbia Hospital for women, formerly in washington, DC.

Dr. Davidson completed a master’s of nursing and science from Case western Reserve University and obtained her certification as a certified nurse midwife (Cnm) with a special interest in high-risk obstetrics. she has delivered more than 1,000 babies during her career as a nurse midwife and has treated women with a variety of mental health disorders. she has subsequently developed an interest in postpartum mood dis-orders and women’s mental health issues. she formulated a postpartum depression sup-port group and provided ongoing treatment to indigent women battling postpartum depression. Her doctoral dissertation, “Care of High-Risk women Cared for by Certi-fied nurse midwives,” brought national attention to the potential care that midwives could provide to a high-risk obstetrical population. she received an honorary award from the march of Dimes for her ongoing care to pregnant women.

over her years as a nurse midwife, she has continued to develop an interest in women’s clinical obstetrical and mental health issues, including PtsD, postpartum depression, and postpartum psychosis. she has published more than 50 papers, contrib-uted more than 17 chapters to textbooks, and published an additional 15 textbooks that she has cowritten, including the international bestseller Olds’ Maternal-Newborn Nursing and Women’s Health Across the Lifespan (9th ed.), which is translated into nine lan-guages and used throughout the world.

she is a member of the american College of nurse midwives (aCnm) where she served as past vice president of the washington, DC, chapter and has served as an item writer for the aCnm national Certification examination. she is also an educational affiliate of the american College of obstetricians and Gynecologists (aCoG). she is a long-time member of sigma Theta tau, the International Honor society of nursing. Dr. Davidson holds an additional certification as a certified forensic nurse (CFn) and is a member of the american College of Forensic examiners International (aCFeI). she is also a member of the International society of Psychiatric-mental Health nurses (IsPn) and the marcé society.

In 2002, Dr. Davidson established the smith Island Foundation to provide rural health care education, screening programs, and children’s programming to this small island community in the Chesapeake Bay. she subsequently developed an immersion clinical practicum for students to participate in rural community health on smith Island. she is also the author of the children’s book, Stowaways to Smith Island.

A Nurse’s Guide to women’s mental HealtH

Michele R. Davidson, PhD, CNM, CFN, RN

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To my family, who has taught me the joys of living well, finding inner strength, pursuing happiness and making me believe that happily ever afters

can come true . . .

Nathan . . .For my husband, who has ridden the ride with me through good and

bad and never wavered.

Hayden . . .For introducing me to the wonder of first motherhood, always making

me smile, and enabling me to laugh.

Chloe . . .For showing me the true delight in having a daughter, whose beauty

and strength inspire and delight me every day of my life.

Caroline . . .For bringing sunshine, happiness, and hope to the world, for making

motherhood the thrill of a lifetime.

Grant . . .For showing me that disabilities are just challenges to be celebrated and

proving that love can conquer all.

vii

Contents

Preface ixAcknowledgments xi

seCtioN i: iNtRoDuCtioN to WoMeN’s MeNtaL HeaLtH

1. statistics on mental Health of women 3

2. stressors affecting women 13

3. Role of Culture in mental Illness 27

4. Violence against women 43

seCtioN ii: sPeCiaL PoPuLatioNs iN WoMeN’s MeNtaL HeaLtH

5. Childhood and adolescence 63

6. mental Health for the aging woman 83

7. Physical Disabilities and mental Health 99

8. lesbian and transgender women 111

9. Female Veterans 121

10. women and Forensic mental Health Issues 129

seCtioN iii: CHiLDbeaRiNg aND WoMeN’s HeaLtH issues

11. menstrual-Related Issues 141

12. Infertility and Psychological Implications 149

13. antepartum and Intrapartum Psychological Issues 157

14. Postpartum mood Disorders and lactation Issues 173

viii Contents

seCtioN iV: PsyCHiatRiC issues CoMMoN to WoMeN

15. anxiety Disorders 193

16. mood Disorders 213

17. eating Disorders 233

18. Grief and loss 247

19. Personality and Dissociative Disorders 261

20. schizophrenia 277

21. Psychotic Disorders 287

22. sexual Dysfunction 311

23. sleep Disorders 323

24. substance abuse Disorders 337

Index 349

ix

Preface

I always, always wanted to be a nurse! although I am the only nurse in my fam-ily, nursing surrounded me throughout my childhood. my nursing career began at the young age of 3 with the daily schedule in our household that involved caring for my maternal great uncle who was chronically ill. watching my mother, a “lay nurse,” care for him provided me with the motivation and direc-tion that guided my professional life. we spent many days at hospitals, clinics, and physicians’ offices. since that time, I was inspired to become a nurse.

I recall being mesmerized by the stark, white uniforms and, years ago, the starched hats. It was not until I entered nursing school and had my first obstet-rical clinical that my love for women’s health emerged. The excitement of seeing a birth, holding a mother’s hand, or breathing through contractions with that laboring mom, have always provided a great sense of joy for me. even after years as a certified nurse midwife and having delivered more than 1,000 babies, it has never grown old.

when I began my nurse midwifery practice, I became acutely aware of the issues surrounding women, mental health, and illness. as an advanced practice nurse, not a day passed that I hadn’t provided mental health care services to women in my practice. as I began to research the issue of women and mental health, it was apparent that little had been published on the topic. most mental health professionals engage in the care of the mental illness without respect to gender. The more I studied and treated women affected with mental illness, the more differences I encountered.

as a nurse midwife, most people would assume that the women for whom I cared were all happy and joyous; after all, isn’t having a baby the greatest joy of all? In reality, 25% of the population suffers from a mental illness; many are specific disorders that are more common in women than in men. women have unique biopsychosocial factors that make them more vulnerable to mental ill-ness. many of these mental illnesses can elicit enormous physical, emotional, financial, and social barriers.

mental illness can affect any woman; it knows no racial, ethnic, educa-tional, social, economic, or geographic boundaries. many women have risk

x Preface

factors for mental illness; whereas other women have none. mental illness con-tinues to carry a negative stigma in our society, making seeking treatment dif-ficult. some women may be embarrassed to seek treatment; others may not have the financial resources to do so, and still others may not know they have a men-tal health issue at all.

During my fourth pregnancy, I gave birth to a little boy after my physician failed to come to the hospital to perform an emergency Cesarean delivery de-spite severe fetal distress. my son finally was delivered after a 90-minute delay but suffers from severe cerebral palsy as a consequence of the delay. During the subsequent months, while my son’s brain injury and multiple disabilities were being evaluated, I suffered from several postpartum mood disorders. It was dur-ing this time that I realized the potential depth of postpartum mood disorders and how significantly such disorders can impair one’s family and one’s entire life. During my journey to recover the life I once knew, I experienced a growing passion to become an advocate for women suffering from mental illness. I have had the opportunity to meet many women, both personally and professionally, who struggle with mental illness. I truly believe that nurses make a difference, can be that single voice that is heard, and can change the course of lives. I sin-cerely hope that this book will serve as a resource for all nurses caring for women and to all those nurses who can and do make a difference!

xi

Acknowledgments

This project was truly a labor of love, and like giving birth, I have complete awe for the people who have inspired me along the journey, became my coaches, and partnered with me until the end. I would like to acknowledge and sincerely thank my mother, Geri lewis, whose support and encouragement never waiver; who believes in me no matter what the task; and is always there to provide ad-vice, lend a hand, or a shoulder to cry on through good and bad times. my fa-ther, Harry mcPhee, has provided ongoing encouragement throughout this process.

In 1991, I met and married my husband, nathan Davidson Rn, CFnP, msn, who is perhaps one of the best practitioners I have ever met. nathan’s knowledge, experiences, and guidance have provided a wealth of knowledge that only helped to enrich this project during the year we celebrated our 20th anniversary!

my earliest nursing adviser, Dr. Charlene Douglas, has provided ongoing support since the time I was an undergraduate student at George mason Uni-versity and, 20 years later, remains an inspiring mentor. Dr. Douglas is, without a doubt, the smartest woman I have ever known. she is the quintessential woman, nurse, educator, and friend. when the going gets tough, she gets going! Thank you for years of encouragement, support, and love; I am proud to call you a friend.

I want to thank margaret Zuccarini, my publisher at springer Publishing Company, who wholeheartedly embraced this book from day one and provided the guidance and support to bring it to life. my colleagues at George mason University, school of nursing, have provided support and encouragement throughout the writing process. to the many George mason University nursing students who have enabled me to do what I love every day, thank you! to Dean shirley travis, thank you for your support. mike and angela westbrook and elizabeth “Buffy” Dougherty, Rn, have been friends ’til the end. many thanks to my many neighbors, friends, and adopted family on smith Island, who pro-vided much encouragement and support, specifically the Reverend Rick edmund and ewell United methodist Church!

xii Acknowledgments

many mental health providers have inspired and taught me during these past few years, and to them, I remain forever grateful. Dr. arthur Rosecan is a knowledgeable, caring, and gifted psychiatrist specializing in geriatrics who brings compassion, knowledge, and skill to the field and who I met briefly when our paths crossed several years ago. I remain thankful to have met him. Dr. sharon Furari, a forensic mental health psychologist, offered hope and compas-sion and taught me a great deal during the brief time we collaborated together. Dr. laurence levin, a practitioner in a state mental health facility, has years of experience dealing with forgotten souls, who guided and expanded my knowl-edge base. Dr. Victoria lyle is a forensic specialist who is a generator of hope, a practitioner of caring, and a role model to all psychiatric practitioners. Jennifer Greene, lCsw, continually offered guidance and support. Dr. mohammed nasr taught me the value of patience and that all things will come. Perhaps one of the most compassionate nurses I have ever had the privilege of meeting was a new graduate practicing in a psychiatric mental health field named Rae leach, Rn. Her compassion remains an inspiration, and I think of her almost every day when I teach eager young nursing students. Caroline Chevalier, Katie Huff-man, and Dr. lisa lindley all provided support for this project. Finally, Violet taylor, CPs, provided remarkable insight into this book. Violet, a certified peer specialist, made the experiences of mentally ill women come alive and continues to serve as a role model who embraces recovery in every sense of the word!

During my treatment for postpartal mood disorders, I encountered some amazing young women who were inflicted with mental illness. many of them have suffered for years and some have spent years in and out of mental health facilities. They offered amazing support, encouragement, and befriended me in the darkest of times. I will always be thankful to have met and will fondly remember Jackie spaw and June Rosales.

I will never forget the many women who have entrusted themselves and their families in my hands over the years, you have touched my life in such an intense, positive way, thank you for allowing me to participate in your care, your births, your good times and bad. For the women I have treated for mental illnesses, thank you for never giving up and believing in yourselves.

I cannot thank enough my four beautiful children who have endured much and complained little during their young lives. They have walked with me on this path of life through good times and bad. They have seen postpartum mood disorders firsthand and, as a result, have developed compassion, patience, and hope. my son Hayden, an honor student, has decided he would like to pursue a career path in medicine as a result of seeing how people with physical disabilities and mental illnesses are treated. my daughter Chloe is forever the cheerleader, peacemaker, babysitter, and all around wonderful great big sister. my youngest daughter, Caroline, remains best friends with Grant and believes that, with love, all things are possible. my youngest son, Grant, who has spastic quadriple-

Acknowledgments xiii

gia cerebral palsy as a result of a birth injury, has been our family’s greatest joy and taught us about hope, love, and faith. He has created an environment of laughter, positivity, and strength that we have all grown and strengthened from. It is my hope that, as they grow and mature, they will encounter a world where mental illness is no longer a disease of embarrassment to be hidden and denied. For the brave women that fight mental illness and its stigma, thank you for allowing us to walk this journey by your side.

I

Introduction to Women’s Mental Health

3

1Statistics on Mental Health of Women

Women’s mental health is a great public health concern that includes women of all races, ethnicities, cultures, education levels, sexual orienta-

tions, and socioeconomic statuses. More women are diagnosed with mental health disorders than men. In fact, women are more likely to be diagnosed with a mental health disorder even in situations where men have the same objective scores on standardized testing, and are more likely to be prescribed psychotro-pic medications. It is estimated that 29% of women are treated for mental health disorders compared to 17% of men (World Health Organization [WHO], 2011). Th e diff erence may be because health care professionals may view women as overemotional. Additionally, women may seek treatment of mental health–associated symptoms more frequently than men (Hattery & Smith, 2007). Table 1.1 describes major mental illnesses in women.

Most women with mental health disorders are diagnosed by primary-care providers; for this reason, the need for education regarding screening, diagno-sis, and treatment of the primary-care and advanced-practice nurse is impera-tive. Th e diagnosis of mental health disorders presents a signifi cant challenge when compared to physical disorders because there are no blood tests or neuro-logical scans that can confi rm a diagnosis. Instead, diagnosis is based on clini-cian observation and subjective reports from the patient. Women may underreport mental illness symptoms because of fear, stigma, family values, or cultural factors.

Societal issues play an important role in the diagnosis and treatment of mental health disorders in women. A diagnosis of a mental illness can be stig-matizing even in today’s society and can result in delay or avoidance of treat-ment. Most mental health disorders go untreated and are not identifi ed by health care providers. Women frequently report more somatic complaints rather than specifi c mental health illnesses, such as depression or anxiety.

4 I. Introduction to Women’s Mental Health

Clinical Pearl

Depression is the most common mental health disorder affecting

women.

InequalItIes In Women’s mental HealtH

There is a large body of research showing that gender inequality in society is a leading factor related to the increased incidence of mental illness diagnosis in women. Women’s role in society places them in a more vulnerable state: They are more prone to abuse, rape, and various acts of violence than men (WHO, 2011).

In most societies, women have a tendency to internalize their feelings and emotions, which can lead to specific mental health problems; men, however, commonly externalize their feelings and emotions, leading to syndromes more externally related, such as aggression, substance abuse, alcoholism, and antiso-cial personality disorder (WHO, 2011).

In some cultures women are seen as being inferior to men, a situation far more pronounced in some parts of the world than others. Gender gaps lead to inequality that commonly manifests in psychological ways. Women suffer more stress than men, partly as a result of conflicting societal roles.

Women are also negatively impacted by the health care system. Access to services, prompt and accurate diagnosis when mental health issues are present, financial barriers, and lack of insurance all play roles in women’s mental health care (Figure 1.1). In some countries, it is forbidden for anyone to receive mental health care services, and therefore many women go untreated (WHO, 2011). Biological and developmental factors also play a role.

BIologIcal Factors

Research is just beginning to uncover gender differences in neurobiology, neu-rochemistry, sex steroids, endocrine sex reactivity, and psychosocial stressors that make women more prone to psychological illnesses. Increased levels of pro-

Table 1.1 n Major Mental Illnesses in Women Mental Illness Incidence

Depression Twice as common in women Bipolar Disorder Equal in men and womenAnxiety Twice as common in women Post traumatic stress disorder (PTSD) Twice as common in womenEating disorders Three times as common in womenAutism Four times as common in men but more severe

symptoms in womenBorderline Personality Disorder Twice as common in womenSchizophrenia Equal in men and women; women have later onset

1. Statistics on Mental Health of Women 5

gesterone and estrogen have shown that women develop a greater susceptibility to mental illness during times of hormonal fluctuations, such as puberty, preg-nancy, menstrual-cycle changes, and menopause (Vigod & Stewart, 2009). Al-tough women’s brains are smaller than men’s, women have larger frontal lobes, which are responsible for judgment, language, and problem solving (Surgeon General’s Workshop on Women’s Mental Health, 2005), possibly explaining why some genetically based specific mental health disorders occur more com-monly in women than in men.

statIstIcs on mental Illness

Currently, 26.4% of Americans over the age of 18 are living with a mental health diagnosi s. Of them, 6% are suffering from a major mental illness that r esults in significant impairment and are therefore classified as “chronically m entally ill” (WHO, 2011). “Chronically mentally ill” patients have a major mental illness that impacts work, social, and family interactions and interferes with thought processes.

Chronic mental illness is diagnosed by a licensed medical professional and includes Schizophrenia, Major Affective Disorder, and Posttraumatic Stress

Biologicaland Developmental

Factors

Specific MentalDisordersHealth

Systems Issues

TreatmentAccess

and Insurance

Identificationand Intervention

Issues

Social StressFactors and Stigma

Trauma, Violenceand Abuse

E N V I R O N ME

NT

ALS

YS

TE

M-

BA

SE

D

I N DI V

ID

UA

L

Factors

of Women and Girls

SpecifiDisoth

Issues

TraFFFaacctoorss

of WoW men and Girls

P

rotection and Resilience

Mental Health

Figure 1.1 n Multiple variables, including individual, environmental, and system-based factors can impact women’s mental health care. Source: Surgeon General’s

Workshop on Women’s Mental Health, 2005.

6 I. Introduction to Women’s Mental Health

Disorder (PTSD). Federal law further states that the individual must have at least one documented hospitalization within 2 years as a result of the disorder; have documentation via a standardized test that evaluates mood, thought pro-cesses, and/or impairments with work or family relationships; or have docu-mented symptomology (U.S. Code of Federal Regulations, 1977).

Chronically mentally ill patients have shortened life expectancies by up to 25 years, with poor health practices identified as the main causative factor. Women who meet the criteria for chronic mental illness are more likely to be substance abusers; participate in more high-risk sexual behaviors; have a higher incidence of sexually transmitted infections (STIs), such as HIV infection; and are more likely to participate in survival sex, the performing of sexual acts in return for food, shelter, or money (American Psychological Association [APA], 2010). In addition, these women may be less apt to understand the process of HIV transmission.

cultural DIsparItIes anD mental Illness

The mental health disparities among various cultural groups are not clearly de-fined. It is well documented that minorities experience more mental health disor-ders than their Caucasian counterparts. African Americans are more likely than White Americans to experience a mental health disorder but are more unlikely to seek help for that disorder. While Whites and Hispanics suffer equally from men-tal health conditions, Hispanic women suffer higher rates of depression than His-panic men. Puerto Ricans have significantly higher rates of depression than other Hispanic groups. American Indians and Alaska Natives suffer significantly higher rates of depression and substance abuse. In terms of suicide, Blacks are half as likely to commit suicide as Whites (Office of the Surgeon General, 2000).

The disparity of treatment of minorities related to mental illness is wide-spread. In general, minority populations have less access to mental health services. Minorities are less likely to receive mental health services even when they have been identified as being in need of services. Furthermore, minorities who do re-ceive care often receive poorer quality services, and minorities continue to be un-derrepresented in mental health research. Barriers to care include lack of access, financial considerations, limited availability, and social stigma. Struggles with dis-crimination and racism remain viable barriers to receiving needed services. It is also common for Blacks to be labeled as mentally ill when indeed they are not, particularly with the diagnosis of Schizophrenia (Hattery & Smith, 2007).

DIsaBIlIty From mental Illness

Although more than two-thirds of individuals with a mental illness are defined as having a mental disability, few receive federal benefits as a result. It is esti-

1. Statistics on Mental Health of Women 7

mated that 3.5% of individuals have a mental health disability that results in compensation from the U.S. government. Individuals with a mental health dis-ability are 20% to 30% more likely to be unemployed than individuals without a mental health disability (Social Security Administration, 2010). Mental health disorders are the leading cause of disability in both the United States and Can-ada. Individuals are said to have a mental health disability if they are unable to work or attend school and have limitations on their functioning that impact daily activities. Major mental health disorders that meet these criteria typically include Bipolar Disorder, Major Depressive Disorder, Schizophrenia, Paranoid Personality Disorder, Delusional Disorder and other personality disorders. De-pression is twice as common in women as in men and is forecasted to become the greatest cause of disability by 2020. Nearly half (45%) of individuals with a mental illness suffer from more than one mental disorder (Social Security Ad-ministration, 2010).

Individuals with a major mental illness of long-term duration may receive disability support payments through two federal programs: Social Security Dis-ability Insurance (SSDI) and the Supplemental Security Income (SSI). SSDI is indicated for women who have previously worked and paid Social Security taxes. SSI is for low-income women who have not paid Social Security taxes in the past. SSI beneficiaries are eligible to receive medical services through state-funded Medicaid programs, and SSDI beneficiaries can receive Medicare after a two-year waiting period. Vocational rehabilitation services may also be avail-able to women who receive Social Security benefits.

Clinical Pearl

Women considered to have long-term mental health disorders should

be referred to the local Social Security Office to complete the applica-

tion process. Applicants with legal representation are more likely to

receive benefits than those who apply independently.

gloBal prevalence oF mental Illness

The prevalence of mental illness is not isolated to the United States, although the United States leads the world in the percentage of mental illness within its population. While the incidence of mental illness in the United States is 26.4%, globally it is estimated to be 6.5% (WHO, 2011). This number may not be a true reflection of actual rates, however, because some cultures are more prone to deny mental illness because of the cultural stigma plus a reluctance to confide in researchers studying mental illness in developing countries. Despite barriers to research, it is estimated that worldwide 450 million people have a mental health disorder (WHO, 2011). The most common mental health disorders

8 I. Introduction to Women’s Mental Health

worldwide are anxiety disorders. In countries such as the Ukraine, where hun-ger and unemployment are widespread, depression is the leading cause of men-tal illness. It appears stigma from mental illness is a worldwide phenomenon that crosses all borders. In developing countries, it is estimated that 76% to 85% of individuals with serious mental disorders are untreated compared to 36% to 50% in developed countries (WHO, 2011).

In developing countries, 20% of the patients who solicit physical health services from primary care clinics also have an underlying mental health disor-der (WHO, 2011). It is common practice to avoid seeking help from health care providers of mental illness or for mental-illness–associated symptoms. In some cultures, physicians who diagnose mental health disorders are seen as incompe-tent for not identifying a physical disorder instead.

Worldwide, it is estimated that 80% of the people impacted by civil wars, natural disasters, and displacement are women and children (WHO, 2011). Globally, violence against women is on the rise and is a major contributor to mental illnesses. Women in certain cultures are more likely to be victimized, especially in societies where violence against women is an accepted norm. As mentioned, depression is the leading cause of illness in women and this is true in both developed and developing countries. Depression is the third leading cause of disease worldwide, second only to infections and parasitic diseases. Suicide is the leading cause of death worldwide, with women more likely to at-tempt suicide than men (WHO, 2011).

mental Illness anD comorBIDItIes

Women with chronic health problems have a higher incidence of coexisting mental illness. Heart disease, now the leading cause of death among American women, may coexist with major mental illness. One-third of individuals who have a myocardial infarction also have depression. Individuals with diabetes are twice as likely to be depressed as individuals without diabetes. HIV/AIDS is the leading cause of death worldwide for women during the reproductive years. Women with HIV or AIDS have twice the number of mental health issues com-pared to those without the disease. It is estimated that 50% of individuals with cancer suffer from severe mental health disorders, including Depression, Adjust-ment Disorder, and anxiety (Koester, 2007). Table 1.2 lists the leading causes of death in American women.

HealtH care expenDItures anD mental HealtH

It is estimated that of the total health care expenditures in the United States, 6.2% is spent on mental health and 1.3% is spent on substance abuse disorders

1. Statistics on Mental Health of Women 9

(Substance Abuse and Mental Health Services Administration [SAMHSA] 2010). The majority of mental health treatment in the United States is paid by federal and state agencies in the form of Medicare, Medicaid, and local pro-grams. Private insurance accounts for 4% of the costs. Many mental health consumers are uninsured or underinsured and are members of the working poor or the unemployed. Substance abuse treatment is funded by government sources for 76% of patients, with private insurance covering only 24% (SAMHSA, 2010).

By 2014, it is estimated that the treatment of mental health disorders will cost more than $203 billion per year (SAMHSA, 2010). The majority of spend-ing is allotted to providing medication management to patients; however, it is expected to slow as a result of the greater availability of generic medication. There is also an expectation that the use of inpatient settings will continue to decline in upcoming years. It is estimated that by 2014, substance-abuse ser-vices will cost approximately $35 billion (SAMHSA, 2010). There is an expected shift in expenditures from speciality treatment centers to a community-based treatment model of mental health care as the amount of services being paid for by private insurance companies is expected to continue to decrease.

Mental illness costs are also seen in the workplace. It is estimated there is a $193.2 billion loss in earnings annually resulting from mental health condi-tions (Kingsbury, 2008). Individuals with mental illness earn an estimated 40% less than those without a mental illness, and it is estimated that 5 to 6 million individuals cannot find employment as a result of a mental illness (Kingsbury, 2008). Mental health costs are often not covered to the same de-gree as physical condition by insurance as well, making it more costly for indi-viduals seeking treatment. Many workers do not seek treatment at all because of these limitations.

Table 1.2 n Leading Causes of Death in American Women, All Races, All Ages, 2007Cause Percent*

Heart disease 25.8Cancer 22.0Stroke 6.7Chronic lower respiratory diseases 5.3Alzheimer’s disease 4.2Unintentional injuries 3.5Diabetes 3.0Influenza and pneumonia 2.5Kidney disease 1.9Septicemia 1.5Source: Centers for Disease Control and Prevention, 2007.

10 I. Introduction to Women’s Mental Health

summary

Mental illness in women is a worldwide epidemic that results in major alterations in lifestyle and social relationships. Minority women are more likely to experience mental illness and less likely to have access to quality care to treat it. Mental health disorders are the leading cause of disability in the United States and Canada. While some federal programs assist in providing financial compensation to women with disabilities, often applicants do not receive needed services. Worldwide, de-pression is the third leading cause of mental illness in women. Global issues, such as war and violence against women, make mental illness more common in women. Many women suffer from both physical and mental illnesses; comorbidity is com-mon in women. As more women face mental illness issues, rising health care costs will continue to consume the gross national product of the United States.

Regina Robertson is a 34-year-old African American woman who was diag-nosed with schizophrenia at the age of 19. Regina was attending a local community college and doing well when she began experiencing delusions about her English professor following her around town and home from school. Shortly thereafter, she began experiencing auditory hallucinations. Regina had worked part time at a local clothing store in the mall during her senior year of high school but has not worked since that time nor has she been able to attend school. She attends the county mental health services program where a mental health nurse reviews her medications and treatment management as part of each visit. She currently qualifies for free services based on her lack of income but has no health insurance or other health care services. What services may be available to Regina based on her mental health disability?

Case Study

1. How can nurses identify risk factors in women who may be prone to men-tal illness?

2. How do cultural differences impact the presentation of mental illness?3. How can health care expenditures for the treatment of mental illness be

reduced in the United States?

Questions to Consider

1. Statistics on Mental Health of Women 11

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