ITALIAN NATIONAL PUBLIC HEALTH


“Azienda Sanitaria Locale Napoli 1”

(Local Health Unit)




Clinical Psychology, Psychotherapy, Research and Training Centre

director: E. Reale



 Strategies for Implementing GBA

in mental health field


Elvira Reale and Vittoria Sardelli




  Berlin,  June  8,  2001




Magnolia Centre

Our out-patients Centre is a public health care Centre specialized in women's mental health problems.

The team is made up of psychologists, a psychiatrist, a medical doctor specialised in homeopathy, a sociologist, nurses. The Centre exemplifies the possibility of carrying on, within the Public Health System, activities of gender oriented Prevention, Treatment, Research and Training.

We have been treating  women for more than twenty years.

Up to now, about 6.000 women have been treated in our mental health service, and 1503 women have been treated in the last five years (1996-2000).

From an epidemiological point of view, this population corresponds to the general female population of Italy. It consists mainly of adult married women, with children.

Main symptoms are anxiety, depression, and/or psychosomatic troubles. In recent years the demand for care has been growing, also from younger women, aged between 15 and 44.

Our statistics are consistent with international ones.

International Data on Depression and other mental disorders

    International statistics show that mental disorders (particularly depression, anxiety, eating disorders) are prevalent and rising among women within the general population.  Depression, specially, is the main cause of burden diseases in women between 15 and 44 years of age: Unipolar Major Depression takes 1st place in  ten leading causes of female burden of disease (Source World Health Report 1999, Database).

Research has highlighted that children's mothers and girls are at the highest risk of depression. The prevalence rates, in depression are between 2 and 3 times higher in women than in men.

Female adolescents run a much higher risk of disease compared to boys, and in some cases, like eating disorders, the rate for women goes up to 9: 1 (90% of the total cases).


Why do so many women suffer from mental disorders?



The answer from the traditional medical  world


¨                  In terms of research, even though it is difficult to prove genetic, hormonal and personality structure hypotheses the research is mainly oriented to evaluate the correlation among women's mental pathologies, particularly depression, hormonal, biological and personality factors.

These research projects are carried out with large financial support and with the contribution of pharmaceutical industries, which are profit oriented. The out comes of psychosocial research lead to a different explanation of the higher morbidity in women compared to men, but this kind of research does not have  adequate financial support.

The traditional projects do not yet study the interconnection of many relevant factors: being married and having children; lack of trust toward the partner; lack of social support; low self-esteem; violence, battering and dependency.

¨                  In clinical practice we find sexual prejudices: the fact that mental illness, particularly depression is more widespread among women, is considered by the majority of psychiatrists  as related to female biology (hormonal fluctuation and so on) and personality traits (passivity, low self-esteem, dependency).

Treatments for women, compared to those for men, are more traditional: pharmaceutical treatment is prevalent, at times associated with psychotherapy.

Treatments in a mixed environment (both in or out clinic) do not fulfill women’s needs: often they are involved in an abusive relationship with a violent male, for they do not appreciate sharing a common therapeutic space with men.

Women, compared to men, are objects of longer medical and pharmaceutical treatments, and run a high risk of becoming chronic cases.

This data on longer therapies for women might be due to a lower effectiveness of pharmaceutical treatment, which seems to miss the goal more frequently compared to men in terms of improving women’s health.

¨                  About prevention, existing studies have not developed indications for acknowledging risk factors and protective factors in everyday life, to be used in prevention campaigns.

Prevention should have priority in any health system, for any pathology, yet in the field of mental illness we notice a lack of interest in developing studies and indications toward primary prevention. Such a lack of interest damages women in a special way, since they  get mentally ill more frequently than men and are much more exposed to risk factors in their environment.

Inappropriate prevention (often overlapping treatment) is connected to the recommendation to begin drugs assumption as early as possible, i.e., at the first symptom, even during adolescence; to avoid interruptions and to continue psychodrugs assumption for long periods of time.

¨                  As for the organization of services few Mental Services are focused on women: most services ignore women’s health needs in this field and are not equipped to deal with them. In health programmes there are no indications to lower female rates of mental illness; there are no gender-oriented health activities for risk groups such as adolescent girls or employed women with family commitments and children (overload).

In synthesis: mental health services seem to correspond to men’s needs. They are oriented toward “returning the person to his activities, in order to take up interrupted activities” without observing if these interrupted activities are the very cause of discomfort and disease.


Gender based Analysis (GBA) Proposal


v      Mental Health Research

In the field  of Mental Health Research the GBA highlights  the necessity of:

-          collecting data by sex, and showing the results according to this distinction;

-          using case-control samples;

-          including patients of both sexes;

-          relating the different variables to the sample divided by sex.

In the field of pharmacological research, it is necessary to acknowledge the biological difference between women and men.

In the field of clinical research it is necessary to set up new and specific therapeutical tools for women focusing on the link between illness and  everyday life.


v      Clinical Practice

It is necessary to integrate and modify the traditional ways of working by the elaboration of :

-          diagnostic protocols able to point out the pathogenic pathway which leads to mental illness.

-          Sex specific protocols for pharmacological treatment and recommendations that suggest caution in dosages for women. Particular Recommendations against psychodrugs assumption in the years of growth.

-          Treatment protocols apt to:

-        guide health care providers in singling out the causes undervalued by women themselves;

-    give suggestions apt to help women to lighten the burden of responsibilities and to assume styles of behaviour more suitable to individual wellbeing.


v      Prevention

According to GBA, primary prevention should focus on environmental and social-relational factors. These are factors on which it is possible to intervene before the overload of "pressure" becomes a psychic pathology.

Prevention should be gender sensitive and mainly addressed to the most vulnerable subjects: female adolescents and women (in the range 15-44).  

ü       Prevention in Age 15 - 44  

1. In Adolescents

·         Early adult role playing for supporting mother

·         Study and hobbies lowering

·         Peer relationship reduction

·         Trust only in parents

·         Skills unrecognised

·         Conditioned planning for the future

·         Feeling unwell.


2. In adult women

§         Increasing family work (work characterised by care for others and lack of self-care) connected to lack of “gratitude”

§         Unrecognised tiredness as connected  to family work

§         Decreasing personal interests and activities

§         Decreasing/lack of support

§         Lack of confidence in extra-family relations

§       Low self-esteem connected to undervaluation by others (family-social context).


v      Mental Health Services

                It is necessary to direct health services towards:

-          prevention and therapeutic activities for women;

-          offering women specific services.

Three types of activity or services for women:

1.                    The first type relates to preventing specific situations of distress.

2.             The second type of service is addressed to women who have already begun to develop an illness and manifest symptoms, and who have already had psychiatric treatment.

3.             The third type relates to setting up "women's refuges" (women in distress and violence situations).


Strategies for GBA Implementation


Until now we have evidenced bias and gaps in the mental health field (research, clinical, prevention, services)  and we have also evidenced in the light of GBA the corrective actions for women friendly psychiatry and psychotherapy. 

                Really the actions to modify scientific theories and clinical practice cannot be led by single persons, alone, or by gender oriented single groups. It is necessary involve in this plan Women Associations, University Researchers,  professionals who treat women  with mental disorders in different European Countries.

For these reasons we propose a new European network on women mental health made up of gender oriented technical groups and women/consumers associations.

These groups will be able: