31st October 2023

Gender and Mental Health Basic Principles 

There are many established and stable differences in the epidemiology of mental illness between men and women. For example, it is well known that women have a higher lifetime prevalence of mood and anxiety disorders. Some of these differences can be explained biologically – such as through the neuroprotective effects of oestrogen leading to a later onset of psychosis in women – but overall, the mechanisms for the discrepancy are complex and poorly understood.

Common mental illness

In the 2014 adult psychiatric morbidity survey, anxiety and depression (referred to as common mental disorders) had a lifetime prevalence of 1 in 5 for women, compared to 1 in 8 for men. In the 16-24 age group, women were almost three times more likely to experience a common mental disorder than men of the same age (24% vs 9%).

Proposed reasons for this difference include the differences in sex hormones on mood, women’s blunted response to the hypothalamic-pituitary-adrenal axis, sexual discrimination and increased rates of sexual assault against women. Women also have higher rates of body dissatisfaction, may be more prone to ruminating, and may take on a higher proportion of unpaid work as well as the burden of household labour.

Another theory is that the ways that women express distress are typically labelled as ‘mental illness’, whereas men’s distress is exhibited as antisocial or criminal behaviour. The prison population is majority male, with up to 70% of those requiring mental health support. In keeping with this, antisocial personality disorder is almost three times more prevalent in men than it is in women (4.9% vs 1.8%).

Suicide 

The gender discrepancy in the diagnosis of anxiety and depression may also be due to the concept of masculinity and how men and women access mental healthcare. Expressing anxiety and vulnerability has traditionally been seen as ‘more feminine’. This is reflected in the lower rates of men accessing NHS talking therapies (only 36% of referrals are for men).

Men are also at a significantly higher risk of dying by suicide. 75% of deaths by suicide are male, and these rates have been stable over time for the last 30 years. The causes for this statistic are unknown but may be due to the difficulties faced by men accessing mental health care, the increased rates of substance misuse in men, and the ways in which men traditionally gain esteem. Loss of status and perceived loss of status is a known risk factor for suicide – therefore, loss of job or spouse in middle age or old age could be factors in the peaks in male suicide. The highest risk age for suicide is 45-59 years.

Schizophrenia

As with depression and anxiety, there are several established differences between schizophrenia in men and in women. The onset of schizophrenia in men is, on average, 3-4 years earlier than women, with peak incidence at 20-29 years. Women have a bimodal distribution of symptom onset, with a later incidence peak post-menopause.

There are also key differences in how schizophrenia presents and progresses. Men are more likely to experience more negative symptoms, whereas women tend to have more affective symptoms. It is possible, however, that a symptom such as poverty of speech could be described as a negative symptom of schizophrenia in a man but as a symptom of a depressive episode in a woman.

Outcomes such as homelessness, suicide, remission rates and global scores of functioning are all generally worse in men with schizophrenia compared with women. Gross abnormalities in neuroanatomy (such as reduced volume of the frontal and temporal lobe and increase in right hemisphere gyrification) are more prominent in men.

References

• Li, X., Zhou, W. and Yi, Z. (2022) ‘A glimpse of gender differences in schizophrenia’, General Psychiatry, 35(4). doi:10.1136/gpsych-2022-100823.
• Riecher-Rössler, A. (2017) ‘Sex and gender differences in mental disorders’, The Lancet Psychiatry, 4(1), pp. 8–9. doi:10.1016/s2215-0366(16)30348-0.