Breaking the Silence

Website for the American Mental Health Counselors Association's Breaking the Silence initiative to address mental health stigma.

A Perfect Storm: Biological, Behavioral, Social and Environmental Factors Affecting Women’s Mental Health

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By contributing blogger Joel E. Miller

Whether you call them individual cells in meteorological terms or clusters in a mathematical context, it is clear – based on new research from different disciplines – that women are facing a perfect storm of factors and issues that significantly raise the risk of developing mental illnesses, especially depressive and anxiety disorders.

New research and studies also highlight that there are critical high risk periods during a women’s life where mental health disorders are more likely to occur.

The past decade has seen increased emphasis on women’s mental health and sex/gender differences in the federal sector and in the research community. However, several new factors have come to light that require us to take a more holistic approach to addressing the mental health needs of women across the life span.

In this report we do not cover all of the factors impacting women’s mental health, but we do review key recent findings with the goal of developing priorities in improving diagnosis and treatment, reducing stigma, and implications of the recent findings across many parts of our society.

We conclude with a discussion on the connection between mental health problems affecting women and stigma.


We first look at biological and developmental factors, by focusing on postpartum depression. (see our related post entitled “Not all Mother’s Days Are Happy: A reminder this Mother’s Day that millions of women suffer with postpartum depression.”)

Postpartum depression affects approximately one in seven women each year. Yet the exact causes of this debilitating disorder are not entirely known.

To date, social science and medical researchers believe that the hormonal, physiological, and identity changes of new motherhood contribute to a woman’s vulnerability—but we still don’t know enough.

Maternal depression can create problems for their children that can continue into adolescence. Adolescents with a history of exposure to maternal depression have higher rates of major depression and other disorders such as anxiety, conduct disorders and substance abuse disorders. This is of particular concern because depression that begins early in life is associated with a greater severity of illness and a higher risk of suicide and other violent behavior than later onset depression.

The annual cost of not treating a mother with depression (in lost income and productivity alone) is $7,200. [Note: If you extrapolate that out to 800,000 mothers each year that means the annual cost of untreated maternal depression in the U.S. is $5.7 billion dollars.]

Depression is a particularly serious problem for lower-income mothers, since it can create two generations of suffering, for the mother and her children.

Women during their childbearing years account for the largest group of Americans with depression.

Over 55 percent of ever-depressed women have their first episode of depression during their first postpartum year.

Despite the frequency of depression among new mothers, large numbers of affected individuals may not be identified as having a treatable condition, and only 15 percent obtain professional care.

For many women, pregnancy awakens a surge of emotions, including anxiety, tearfulness, and irritability. Indeed, unknown to many pregnant women, postpartum mood symptoms often begin during pregnancy. Sadly, according to Postpartum Progress, 85 percent of women never receive the psychological help that they need after giving birth.

A recent call to action seeks to change this pattern, namely, the United States Preventive Task Force (USPTF) recommended that all women receive mental health screenings during pregnancy, not just after giving birth.

In support of early diagnosis, a study published in the March 2016 edition of the Journal of Behavior Therapy and Experimental Psychiatry states that mood instability – particularly when related to a woman’s self-esteem – may help predict postpartum depression (PPD).

This groundbreaking study screened women for depression during pregnancy and after delivery. The results indicated that a woman’s frequent fluctuations in self-esteem, especially during the second and third trimesters, are related to higher instances of her becoming depressed postpartum. This is one of the first research studies to exclude women who were previously depressed, shedding light on the factors that contribute to postnatal depression.

While our society portrays childbirth as a uniformly joyous event, the transition to parenthood is a stressful life change. As a matter of fact, a scientific theory called the diathesis-stress model demonstrates why women become more vulnerable to depression during stressful life events, including infertility, pregnancy, and childbirth.

For many women, pregnancy awakens a surge of emotions, including anxiety, tearfulness, and irritability. Due to a convergence of biological and social factors, prolonged stress makes it easier for women to develop negative beliefs and attitudes. Such stress can lead to women to ultimately believe they are “bad mothers,” and that they are “failing at motherhood.” Over time, these negative cognitions can also perforate a woman’s self-esteem.

New research can help guide counseling options. We now know that new mothers who struggle with self-esteem instability may respond better to cognitive behavioral therapy or mindfulness-based cognitive therapy. Both of these therapies help women examine how negative thoughts and feelings impact behavior.

For pregnant women and their families, it’s essential to get accurate and timely information about how to handle maternal mental-health concerns. There are many online resources, such as the Mind Body Pregnancy, Postpartum Progress and Postpartum Support International, that can educate women about pregnancy and postpartum mood concerns. These sites also provide directories of maternal resources, including psychiatrists and psychologists who specialize in perinatal mental health.

Now that there are a bevy of resources available, pregnant women and mothers no longer have to suffer without an end in sight. These combined services can help pave the way for women to receive early screening and counseling – two interventions that can reduce the length of maternal suffering.


The second area in this perfect storm confluence is discrimination in the workplace, specifically, the impact of wage gaps on mental health. (see our related post entitled “Beyond the Glass Ceiling: Wage Gaps and the Increased Depression and Anxiety in Women“)

According to the U.S. Census Bureau, the median woman’s earnings are 79 percent of the median income of men.

Now we know that the wage gap between American women and men is a significant reason why women have higher rates of depression and anxiety, according to a new study by the Columbia University Mailman School of Public Health’s Department of Epidemiology,

Their research revealed that women with lower incomes than men with similar levels of education and experience were about 2.5 times more likely to have major depression than men. But, women who had incomes similar to their male counterparts didn’t have a greater risk of depression than men.

The author’s findings show that some of the gender disparities in depression and anxiety are due to the effects of structural gender inequality in the workforce and beyond. The findings show that the social processes that sort women into certain jobs, compensate them less than equivalent male counterparts, and create gender disparities in domestic labor have psycho-social consequences.


A third area affecting women’s mental health falls into the category of social stressors. (see our related post entitled “Mother and Child – and – Elderly Reunion: Childbirth, Maternity Leave and Depression in Older Women“)

Currently, the U.S. is the only industrialized country in the world that does not guarantee paid parental leave.

There is considerable evidence now that paid parental leave can have a significant positive effect on the health of children and mothers and can have major benefits down the road. There can be mental health effects of having job-protected, paid leave after the birth of a child. In one study, women who took longer than 12 weeks maternity leave reported fewer depressive symptoms, a reduction in severe depression and improvement in their overall mental health.

Maternity leave benefits are an example of a government intervention that affects women at a critical stage in their lives and has the potential to generate positive health externalities. The U.S. has mandated non-paid maternity leave policy aimed at employers for 12 weeks, but employers have wide discretion in implementing the policy and all employers with less than 50 employees are exempt from the measure. Twelve weeks is a drop in the bucket. Research has shown that it takes women a full year to recover psychologically from the upheaval of bringing a child into the world. British women are offered up to 39 paid weeks off to adjust to this tremendous life transition.

Now we know, based on new research that beyond any potential benefits on employment, families and child outcomes, maternity leave entitlements also have important benefits in regard to women’s mental health in the long-run by reducing the long-term consequences of stress and mental health disorders associated with the experience of childbirth.

A strand of literature in epidemiology has shown that the birth of a child is a stressful life event that carries a new role for mothers, potentially generating an imbalance between the demands from multiple roles. This is often accompanied by a sudden change in hormone levels around childbirth.

New mothers are at increased risk for a range of serious psychiatric disorders such as postpartum depression, posttraumatic stress disorder, anxiety disorders, obsessions of child harm, and postpartum psychosis. The prevalence of post-partum depression is exceptionally high in the weeks after delivery: it is estimated that between 10-15 percent of mothers experience depression in the postpartum period.

Reducing depression in the period around childbirth, maternity leave benefits can lead to enduring benefits in long-term mental health. Maternity leave entitlements have spillover effects on the mental health of women decades after delivery.


Another issue that significantly affects women’s health falls into a broad category of trauma, violence, and abuse. (see our related post entitled “Addressing Intimate Partner Violence: A Public Health and Mental Health Imperative“)

Some call emotional abuse “soul murder”.

Moreover, emotional abuse includes neglect, which is sometimes called the “violence of silence”.

Intimate partner violence (IPV) is a multifaceted public health issue that has gained much attention over the last year, especially as the National Football League addresses some of its players’ violence charges.

The issue, of course, is not about football or football players. The bigger issue is that domestic violence affects one in every four women — according to statistics from the National Coalition against Domestic Violence. The group notes that 1.3 million women are victims of assault by an intimate partner each year; 85 percent of all domestic violence victims are women; and the women at greatest risk of non-fatal intimate partner violence are between 20 and 24 years of age.

Intimate partner violence is a serious, preventable public health problem that affects millions of Americans. The term “intimate partner violence” describes physical, sexual, or psychological harm by a current or former partner or spouse.

There is a lot to learn about how to prevent IPV. We do know that strategies that promote healthy behaviors in relationships are important. For example, programs that teach young people skills for dating can prevent violence. These programs can stop violence in dating relationships before it occurs.

We also know that there are best practices in treating women and men who have been victims of IPV and for those who have been the perpetrators of such violence.

Moreover, the facts and the statistics cry out for a public health and mental health response to the IPV problem.

Nearly 3 in 10 women in the United States have experienced rape, physical violence, and/or stalking by an intimate partner and reported at least one impact related to experiencing these or other forms of violent behavior in the relationship (e.g., being fearful, concerned for safety, post-traumatic stress disorder (PTSD) symptoms, need for health care, injury, contacting a crisis hotline, need for housing services, need for victim’s advocate services, need for legal services, missed at least one day of work or school).

On average, 24 women per minute are victims of rape, physical violence, or stalking by an intimate partner in the United States – more than 12 million over the course of a year. Among victims of intimate partner violence, more than 1 in 3 women experienced multiple forms of rape, stalking, or physical violence.


Perfect Storm Factors and Stigma Issues

We have identified several factors ranging from social stressors to unique biological issues that impact the mental health of women.

Depression and anxiety disorders affect among women and girls across the life span based on many factors. And to make matters worse, there is profound discrimination and stigma of women and girls who live with mental health issues.

Stigma is compounded by factors such as sex and gender, culture, race, ethnicity, poverty, age, and locality. Women and girls have an increased level of suffering from mental health issues, associated with issues of family responsibility, poverty, employment, and access to mental health services. Women and girls face unique risks at specific developmental stages (adolescence, pregnancy, post-partum, menopause, elderly years, etc.).

The need to integrate mental health issues in settings where women and girls naturally congregate to seek care and services should be a major policy and program priority to help achieve positive outcomes.


Key anti-stigma messages that need to be conveyed through public education activities aimed at women include:

  • Having a mental disorder is not your fault and not something of which to be ashamed.
  • It takes strength to reach out for help.
  • Counseling works.
  • Early intervention and identification promote greater success.
  • It is important to distinguish between depression and normal sadness.
  • Building knowledge helps to enhance access to identification and intervention.
  • There is no health without mental health.


Key priorities include:

  • Addressing the increased risk of victimization for all women.
  • Addressing the discrimination and lack of social acceptance that women with mental disorders face
  • Internal barriers to seeking and receiving mental health care such as shame and guilt.
  • Addressing negative images of girls and women, particularly among minority women, in television, magazines, and film-related media.
  • The need for additional research on the economic impact of maternal mental illness on family health outcomes.



Chatterji, P. and Markowitz, S.  (2012) Family Leave After Childbirth and the Mental Health of New Mothers. The Journal of Mental Health Policy and Economics. 15: 61-76.

Mitchell, C., Notterman, D., Brooks-Gunn, J., Hobcraft, J., Garfinkel, I., Jaeger, K., … McLanahan, S. (2011). Role of mother’s genes and environment in postpartum depression. Proceedings of the National Academy of Sciences of the United States of America, 108(20), 8189–8193.

Draft Recommendation Statement: Depression in Adults: Screening. U.S. Preventive Services Task Force. July 2015.

Postpartum Progress. (n.d.). The Symptoms of Postpartum Depression and Anxiety (in Plain Mama English). Retrieved from Postpartum Progress:

Correll, J., Benard. S., (2007 March) Getting a Job: Is There a Motherhood Penalty?, American Journal of Sociology, Vol. 112, No. 5 pp. 1297-1339 The University of Chicago Press

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Avendano, M., et al. The Long-run Effect of Maternity Leave Benefits on Mental Health: Evidence from European Countries. Netspar Discussion Papers. 2013.

Stewert, D., et al. Postpartum Depression: Literature Review of Risk Factors and Interventions, University Health Network Women’s Health Program Prepared for Toronto Public Health, October 2003.

Dagher, R., McGovern, P.. & Dowd, B. Maternity Leave Duration and Postpartum Mental and Physical Health: Implications for Leave Policies. J Health Polit Policy Law. 2013.

Dahl, G., Loken, K., Mogstad, M. & Salvanes, K. What Is the Case for Paid Maternity Leave? National Bureau of Economic Research, Inc., NBER Working Papers: 19595. 2013.

Doucet, S., Dennis, C., Letourneau, N. & Blackmore, E. Differentiation and Clinical Implications of Postpartum Depression and Postpartum Psychosis. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 38, 269-279. 2009.

Fiske, A., et al. Depression in Older Adults. Annu Rev Clin Psychol.; 5: 363–389.  2009.

Avendano, M., et al. The Long-run Effect of Maternity Leave Benefits on Mental Health: Evidence from European Countries. Netspar Discussion Papers. 2013.

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