“You cannot separate out the issue of having no reproductive rights from a woman’s mental health”

“Rights, Resilience, Recovery” is a big theme for a big global meeting on women’s mental health, but two years ago in Japan, experts chose Ireland as the next country to stage the global conference for a reason, says Veronica O’Keane, professor of psychiatry at Trinity College Dublin.

“You cannot separate out the issue of having no reproductive rights from a woman’s mental health,” she tells The Irish Times. “Every single woman and girl who travels out of Ireland for an abortion, their mental health will be affected by having to take that trip. And the more vulnerable a person is in terms of their mental health, the worse the trauma is going to be for them.”

Mental health experts were aware that The Eighth Amendment to the Irish Constitution prohibits abortion except in cases where there is a threat to the life of the pregnant woman when they chose Dublin as the venue for the 2017 World Congress on Women’s Mental Health, which runs from March 6th to 9th at the Royal Dublin Society, Dublin.

Orla O’Connor, director of the National Women’s Council of Ireland, who has organised the conference alongside Trinity College Dublin, told The Irish Times that up to 1,000 people working in the area of mental health across the world – doctors, psychiatrists, psychologists –  will attend.

Mental health experts ‘shocked’ by lack of abortion in Ireland

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“We want to make a connection between those working in the area of women and mental health in medical and advocacy settings and to find out what civil society is doing about women’s mental health,” says O’Connor.

So why do women need a dedicated congress on mental health?

“Women and men have different health needs but mental health issues are especially ‘gendered’,” says O’Connor. “Young women, for example, have different mental health needs. They will talk about issues like eating disorders and self-harm. We are not saying that women experience mental health issues more than men, but just that their needs are different, so we need to look at them separately, and we need to look at our services and our policies.”

The lack of research on women and mental health will also be highlighted, says O’Connor. “We need data on women’s mental health. There is very little research on women’s mental health across the life cycle. In Ireland we have a Men’s Health Strategy, but we don’t have a women’s health strategy.”

So what are the mental health issues facing women in Ireland? Prof O’Keane says women’s lives and experiences plot a specific path for their mental health needs.

Childhood

During childhood, up to the age of 12, one of the “main reasons people come to psychiatrists is because of what we call developmental disorders’. You could have an absence of usual developmental milestones, for example speech or play, and that could indicate something on the autistic spectrum.”

The trajectory for the anxiety disorders into adolescence and young adulthood is depression

Girls are less likely to get the autistic spectrum disorders, Prof O’Keane says, but they are more likely to get “anxiety disorders”. An anxiety disorder would typically manifest itself in childhood by school refusal and is one of the main reasons for presentation to a child psychiatrist.

“There are two main areas of what we call psychopathology,” Prof O’Keane says. “Girls are more prominent in the anxiety disorders and boys are more prominent in the autistic spectrum disorders. And the trajectory for the anxiety disorders into adolescence and young adulthood is depression.”

Adolescence

“The most common disorders in adolescent girls are depression and anxiety,” says Prof O’Keane. “Girls can even be suffering with depressing thoughts of suicide for years before they seek help. It usually presents when there is a crisis in terms of deliberate self-harm or suicidal ideation, so it can develop into a crisis when they are brought by their parents to A&E.”

Issues around sexual identity and orientation affect everyone, says Prof O’Keane.

“Food disorders are more common in girls, but they are becoming more common in boys and issues that were considered gender-specific are merging a little bit. For example, with deliberate self-harm, which was overwhelmingly female, males are catching up on females now,” she says.

Girls are much more disposed to depression

“During the developmental years, the rates of suicide among young girls are increasing and the rate of eating disorders in men is increasing, so the gender disparity in mental health disorders is narrowing.

“But there is a very common theme and that is that girls are much more disposed to depression and anxiety disorders. And that carries though to their reproductive years, if you like from their 20s till their early 50s.”

Reproductive years

Rates of depression among adult women are about 2½ times as common as in adult men, says Prof O’Keane. So why are women 2½ times more likely to be depressed than men, we ask.

“Because of the social and biological aspects of being female,” says Prof O’Keane. “Inequality breeds depression, so in any group in society that is relatively disadvantaged, you will have higher levels of depression.

“If you look at people who are disadvantaged socioeconomically, they will have higher rates of depression than the more affluent, socioeconomically advantaged.

“If you look at women as a whole in relation to rights, to human rights and to socioeconomic status, obviously women are poorer, they are more disadvantaged, they have lower rates of promotion to senior positions, they are disadvantaged in terms of their environments and their jobs and they don’t have the same parity of pay.

The other social aspect is that women are subjected to much more violence than men

“So obviously for those reasons alone, you are going to have higher rates of depression among women than among men.

“I think the other social aspect is that women are subjected to much more violence than men. And anybody who is subjected to violence, that group is going to have higher rates of depression.”

Does being a woman mean you are more likely to be depressed for biological reasons? Biological issues are very interesting, Prof O’Keane says, because women are “more biologically and hormonally primed to be in a stressed state than men”.

This is particularly the case during pregnancy, she says. “During pregnancy, women are biologically highly stressed. That makes them much more vulnerable to developing mood disorders. We have just launched a study looking at probable rates of depression among Irish women during pregnancy and we have found probable rates of depression of 16 per cent.”

During the reproductive years, looking after babies comes right after pregnancy comes , says Prof O’Keane.

“I think there is no real focus on mothering and some women cannot mother and we dare not say that. We can’t say that because women do not have a choice in this country about whether they become a mother or not. Therefore, there is an unspoken truth that all women will naturally be good mothers and this is not true,” she says.

Some women become depressed for hormonal and biological reasons and some women become depressed because they have difficulties mothering, according to Prof O’Keane.

It is important to mention that not everyone who is pregnant wants to become a mother - Prof Veronica Keane

“This is something that we are not acknowledging and it is very important when we are looking at depression and women,” she says.

“I don’t think we look at motherhood critically; we look at motherhood in the sense that it is all good, but it isn’t all good and children do get abused and children do get neglected. I think it is important to mention that not everyone who is pregnant wants to become a mother.”

Women’s mental health experts chose Ireland as a venue to stage the global conference for this reason, says Prof O’Keane. “You cannot separate out the issue of having no reproductive rights from a woman’s mental health.

“At the most extreme you could take the examples like Ann Lovett, where a girl dies, like Miss X where she was going to kill herself. So at the most extreme, we will have girls and women who will die from very significant mental health problems related to unwanted pregnancies.

“Then at the softer end of mental health, every single woman or girl who travels abroad for an abortion, their mental health will be affected by having to take that trip. For a resilient woman with means it may not be a trauma at, but for my patients who have a serious mental issue, it is a very big trauma.

“From a mental health perspective, for everyone who needs an abortion in Ireland, it has a deleterious effect on their mental health that we don’t have abortion services available.

"When we bid for this conference in Tokyo two years ago our international colleagues were so shocked by the situation in Ireland, they were actually disbelieving of the fact that Irish women had to go abroad for abortions.

“Our colleagues were so shocked that they wanted to come to Dublin and make ‘Rights, Resilience and Recovery’ the theme for this World Congress on Women’s Mental Health. There is consensus that you can’t have good mental health in the absence of basic rights.”

Psychiatrists are now in the position of making decisions that should be a woman's decision

So what is the effect on women to be reliant on a health service where the choices are restricted?

“We do not have services to offer women,” says Prof O’Keane. “And we have written it into our legislature that this service is going to be provided abroad. Psychiatrists are now in the position of making decisions that should be a woman’s decision, so I now have to certify a woman as appropriate for an abortion or not and I think that should be a choice for a woman to make.”

Older women

Women at this stage can go from being carers for their children to being carers for their family of origin. “The culture is for this care to be managed by women and this is very stressful for women,” says Prof O’Keane.

Does menopause carry a risk of mental imbalance? “Yes.Any period of hormonal fluctuation has a risk of brain disorder because hormones influence behaviour and they influence your mood. Menopause is the same as adolescence, pregnancy and menarche. They would be the periods of time you have the big hormonal fluctuations.

“Of course, you get them during the menstrual cycle and some women do get clear changes in mood during the menstrual cycle, but all women are vulnerable during periods of cataclysmic hormonal change.”

For women 66 and over, Prof O’Keane has good news. Women do a bit better then, she says. “Their cardiovascular status is generally better than men’s and cardiovascular status affects brain disease.”

Balance

Does she think any of the medial or academic professionals at the conference might think that Ireland is right to ban abortion except under limited circumstances?

“No. There is absolute unanimity in this,” Prof O’Keane says. “The International Association for Women’s Mental Health does not consider that abortion is bad for a woman’s mental health. I think the need for so-called balance in any discussion of the matter is deplorable. Why does 5 per cent of the population get 50 per cent of the representation? It is a very fringe view in society in general and in medicine as well.”

Details about the conference can be found at: http://iawmh2017.org/wp/

Women’s mental health in Ireland: facts and figures

According to the Healthy Ireland Survey 2016, one of the largest social surveys ever conducted, higher levels of positive mental health were recorded among men than women.

Depression and anxiety are three times more prevalent amongst women. Some 15 per cent of new mothers in Ireland experience post-natal depression. One in four women experiences some form of domestic or sexual violence in Ireland.

Men are three times more likely to die by suicide than women. More women than men attempt suicide and self-harm.