Mental health in women and men : the interplay of biological, psychological, and social-environmental risk- and protective factors in internalizing disorders
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Abstract
Health differences between women and men are rooted in anatomy, physiology, genetics, and hormones. These differences have for a long time been neglected in medical research due to a male default in medicine. For a long time, women were not included or underrepresented in clinical studies causing increased negative health outcomes in women compared to men. Genetic and hormonal differences as well as symptom differences between women and men cause differences in prevalence rates of diseases and outcomes between women and men, which are reinforced by differences in health behaviors. Overall, these factors cause a gender gap in mortality.
The purpose of the current work including four studies was to broaden the perspective on women’s and men’s mental health by examining similarities and differences in risk and protective factors of mental health as well as investigating somatic and lifestyle effects in associations between mental and physical health. The main focus lay on internalizing symptoms (mental health symptoms linked to negative emotionality), comprising mental distress, depression, anxiety, and suicidal ideation. To this end, the work drew on high-quality, prospective community cohorts that provided data satisfying all aspects of the biopsychosocial model as well as large samples that enabled the investigation of comparatively rare outcomes as well as modelling of numerous risk/protective factors from several domains of life, including interaction terms and additional, stratified analyses.
The biopsychosocial model, presuming there is always an interaction between the mind and the body, was used as a starting point for this dissertation. It includes the words bio referring
to biological factors or physiological pathology (genetic determinants), psycho referring to psychological factors such as thoughts, emotions, and behaviors, and social referring to socioeconomical, socio-environmental, and cultural factors. Biological factors causing differences in internalizing disorders between women and men can be found in the regulation of the HPA axis (which is in stressful situations more rapidly activated in women), differences in sex hormones, and differences in inflammation and immune responses. Psychological factors underlying differences in internalizing disorders between women and men are early stress experiences such as childhood adversity or differences in emotion regulation strategies. Social and environmental factors affecting women’s and men’s mental health differently can be seen in family-related aspects (relationships and relationship quality) and economic aspects (e.g., SES), which in combination can also have different outcomes (e.g., double burden for women combining child rearing and employment).
A systematic review of findings of three large, population-based German cohort studies (representing different parts of Germany) on mental health for women and men was conducted. Results revealed higher prevalence rates of internalizing disorders for women (e.g., depression, depressed mood or depression symptoms, anxiety, suicidal ideation, and loneliness). Risk and protective factors for mental health included social factors, lifestyle (e.g., BMI), somatic health (including physical diseases such as diabetes mellitus), and genetic and biological factors. The most evident were the sex-specific risk profiles for depression. For women, more internal risk factors were found (such as loneliness, social isolation, and low social support), but also specific biological factors (lower cholesterol levels and higher leptin levels) were important determinants for depression. For men, more external behavioral risk factors (e.g., physical inactivity and smoking), CVD (i.e., myocardial infarction and stroke), and markers for infection (higher interleukin-6 and hs-CRP levels) were found as determinants for depression. Lastly, socioeconomic and family-related factors influenced mental health status (especially mental distress and suicidal ideation). These findings underline the importance of focusing on sex-specific approaches in mental health research and the development of prevention measures.
In the second study, the focus lay on the association between mental and physical health. This study examined the predictive effect of depression symptoms on the new onset of (chronic) physical diseases (CVD, chronic obstructive lung disease, diabetes, cancer, and migraine) in women and men. Controlling for demographic characteristics and loneliness, in men and women, baseline depressive symptoms were predictive of CVD, chronic obstructive lung disease, diabetes, and migraine, but not of cancer five years later. Additionally adjusting for metabolic and lifestyle risk factors, there was an 8% increase in the risk of chronic obstructive lung disease and an 8% increase in the risk of migraine per point of depressive symptoms. The effect of depressive symptoms on CVD and diabetes was attenuated by metabolic and lifestyle factors and lost significance. Sex-sensitive analyses revealed significant effects of depressive symptoms on chronic obstructive lung disease and migraine for both women and men. Differences were found for CVD and diabetes; trends for the relevance of depressive symptoms for CVD in men (4%; p = .065), and for diabetes in women (5%; p = .077) were
found. These findings underscore the need to implement screening for depression in the treatment of major somatic illnesses. At the same time, depressed patients should be screened for metabolic and lifestyle risk factors and somatic diseases and offered lifestyle interventions.
In the third study, the focus lay on protective factors. It was examined whether social support prevents suicidal ideation over time, whether this association differs for women and men, and whether this association differs for East- and West Germany. More women (8.6%, N = 565) than men (6.2%, N = 417) reported suicidal ideation. In East Germany men were found to report less suicidal ideation than women, no difference between women and men in West Germany was found. Middle or high social support was associated with a lower probability of reporting suicidal ideation five years later after controlling for sociodemographic factors, living situation, and region. The effect was strongest among West compared to East Germans. Men reported significantly lower suicidal ideation than women, but no statistically significant interaction of sex and social support was found (ratio of ORs = 1.00, 95%-CI = 0.73–1.35). Overall, these findings pointed to a strong protective effect of social support for suicidal ideation.
Besides depression and suicidal ideation, anxiety impairs health and well-being and differs strongly in prevalence between women and men. The last study therefore focused on mental distress comprising depression and anxiety and examined temporal trends over a 15-year time span in East- and West Germany. Applying HAPC analyses, significant period and cohort effects were found, with peek values for mental distress in the years 2017 (M = 2.05, SD = 2.42) and 2020 (M = 2.18, SD = 2.31) and for the oldest birth cohort (born before 1946) (M = 1.99, SD = 2.33). Age was negatively associated with mental distress; mental distress decreased by 1.7% with every one-year increase in age, but became insignificant when sociodemographic and socioeconomic factors were considered alongside cohort- and period effects. Over the years, women reported consistently more mental distress than men; significant differences between women and men were found for all survey years. In the main analyses, an interaction effect for sex and region was found. Men in East Germany reported significantly higher mental distress compared to men in West Germany, while women reported
the highest prevalence in both regions. Overall, the effects of age, period, and cohort did not influence differences in mental distress between women and men.
The multiple influences of biological, psychological, somatic, and social and culture factors on mental health and associations between these factors are confirmed by the findings from the studies reported in this dissertation. Biological and genetic factors do not necessarily cause mental health impairments or disorders, but pose a certain vulnerability for developing mental health symptoms or disorders. Strong associations between mental and physical health exist, but differ between women and men. Depression symptoms are predictive of new onset of physical illness, but metabolic and life style factors play an important role in these associations. With regard to resilience, social support poses a protective effect against suicidal ideation for both women and men. Social and regional factors play an important role in mental health within a society, mental distress increases with crises in society. Regardless of this, mental distress is more strongly present in women than men. Hence, biological, psychological, somatic, and social factors can be seen to be interlocked in their associations with mental health, but the exact factors associated with one another, or pathways to health and illness, tend to differ for women and men and seem to be more than solely sex differences.
The existing sex differences seem to be following gendered pathways, they are strongly influenced by gender roles and expression (behavioral norms attributed to women and men in a given society and acting according to these roles) as well as institutionalized gender (distribution of power between women and men in institutions in society which shape social norms and justify different expectations and opportunities for women and men). These gender aspects are reflected in social determinants and promote health differences in women and
men by 1) exposing them to different health risks, 2) causing differences in health behaviors, 3) causing differences in access to health care, 4) an existing bias in healthcare systems. Gender equality would be beneficial for better mental health in both women and men. Future studies should therefore address the health bias in women and men by 1) examining whether women and men report similar of different symptoms for specific mental disorders, 2) sampling women and men from different sociodemographic- and socioeconomic backgrounds to at least partly include gender aspects from the societal and cultural perspective, 3) examining the overall group as well as women and men separately to see if effects for women and men differ or have different effect sizes or to test interaction terms with birth sex. This last point helps to determine 1) what risk- and protective factors are more important for whom, 2) what risk factors are more often present among either women or men, and 3) what risk factors concern only women or only men.