Women with Mental Illness: Furthering Awareness and Improving Patient Outcomes

 Mental illness is a disabling condition that has a negative impact on women’s daily lives (Silverman et al., 2015). Mental illness is the leading cause of disability in the United States (National Institute of Health [NIH], National institute of Mental Health [NIMH], 2018).  Mental illness can interfere with women’s ability to function and have stable jobs. In addition, health care disparities exist among women with lower economic status, resulting in inadequate mental health care. Even further, the stigma of mental illness can cause social isolation, leaving women feeling lonely. Reducing bias and providing cost-effective mental health care can enhance mental illness management. Early screening, diagnosis, and treatment of mental illness is necessary to improve the women’s quality of life. The purpose of this paper is to outline the significance, socio-economic aspects, social justice, ethical issues, and plan of action in this marginalized group to enhance awareness and improve patient outcomes.

Background and Significance

 The Diagnostic and Statistical Manual of Mental Disorders, 5^th edition (DSM-V) defines mental illness as a psychological condition that indicates an underlying biological dysfunction that results in substantial distress or disability in the individual. Mental illness (i.e. postpartum depression, anxiety) has a significant impact on women and can cause poor concentration, sleep disorders, diminished energy and disruption of relationships with friends and family (Langan & Goodbred, 2016). The most common types of mental illness in women in the U.S. are anxiety (18.1%) and depression (i.e. postpartum) (6.9%) (NIH, NIMH, 2017). The DSM-V criteria for diagnosing major depression includes at least 5 of the 9 symptoms, which must include depressed mood and loss of interest, over the past two weeks (American Psychiatric Association [APA], 2013). The DSM-V criteria for diagnosing generalized anxiety includes experiencing excessive worry and anxiety for at least 6 months (APA, 2013).                                                                                    In the United States, one out of five women will experience mental health issues in their lifetime (NIH, NIMH, 2017).  In 2016, 4.2% of women in the U.S., age 18 years and older, reported serious psychological distress (i.e. depression, anxiety) in the past 30 days (Centers for Disease Control and Prevention [CDC], 2018). In this group, 9.3% were below poverty level, 9.2% were American Indian/Alaska Native, 3.7% were Hispanic, 3.6 % were Caucasian, 3.6% were African American, 2.1% were Asian, and 2.1% were Hawaiian. In addition, in 2016, 6 per 100,000 women in the U.S. died from suicide (CDC, 2018). In adults with mental illness, more women (48.8%) received mental health treatment than men (33.9%) in 2016 (NIH, NIMH, 2017). In 2014, suicide ranked 11^th highest for the cause of death in Maryland. In the same year, 136 women died from suicide in Maryland (Maryland Department of Health and Mental Hygiene, 2018). In 2017, 16.3% of the Maryland population, or 735,000 total people, were diagnosed with a mental illness (Mental Health America, 2018). 

Socioeconomic Disparities

 Economic status has a significant impact on the development and management of mental illness. Low monthly income and less than a high school education increases the risk of mental illness in women. In a recent article, Zell, Strickhouser, and Zlatan (2018) evaluated the impact of racial disparities and socioeconomic status on mental illness in women. Zell et al. (2018) found that women with lower socioeconomic status had a significantly higher rate of mental illness compared to women with higher socioeconomic status. The development of mental illness in the former group was due to economic distress, unemployment, and dissatisfaction in their housing arrangements and neighborhoods (Zell et al., 2018). 

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 Women with lower socioeconomic status face challenges with managing their mental illness. For example, women are unable to afford their medications, resulting in unstable mental conditions. In a recent article, Lee, Rothbard, and Choi (2016) discussed that patients with mental illness spend approximately $400-$700 per month on medical costs. In addition, Lee et al. (2016) discussed that women with mental illness spend $3588 on medications and $11,399 on total medical costs per year. Even further, Lee et al. (2016) discussed that women with mental illness were more likely to develop comorbid conditions, resulting in higher medical costs.

 Women with mental illness and low socioeconomic status are less likely to pursue and receive adequate mental health care due to health care costs. In a recent article, Cook, Zuvekas, Chen, Progovac, and Lincoln (2017) found that there was a lower rate of mental health treatment initiation in African American and Hispanic women with lower socioeconomic status compared to Caucasian women with a higher socioeconomic status. This disparity was due to lower education, reduced ability to pay healthcare costs, and lower rates of initiation among providers in low-income neighborhoods (Cook et al., 2017). Inadequate mental health treatment initiation suggests a need for culturally-sensitive, economical, and educational interventions to mitigate health care disparities among patients with lower socioeconomic status (Cook et al., 2017; Dolbier, Rush, Sahadeo, Shaffer & Thorp, 2013).

Social Justice

 Women with mental illness face significant discrimination and isolation due to the stigma associated with their condition (Gabbidon et al., 2014). In addition, women with mental illness have difficulty with receiving and maintaining adequate employment, education, training, and intimate relationships (Gabbidon et al., 2014). Consequently, these women experience poverty and societal marginalization, leading to inadequate mental health services and treatments (Gabbidon et al., 2014). Even further, women with mental illness in the racial minority group face further discrimination, leading to further isolation (Gabbidon et al., 2014).

 Patients with mental illness are more likely to receive social security than patients without mental illness due to unemployment and termination from their former jobs. Women with mental illness would like to and would benefit from working, which would improve mental stability (McDowell & Fossey, 2015). In a recent study, McDowell and Fossey (2015) discussed that more than half of the women who were fired from their jobs were dissatisfied with their termination. McDowell and Fossey (2015) discussed that employers often lack awareness of mental illness and accommodations that need to be implemented.                                                                                    Women with mental illness are treated unfairly and disrespected in the work and school environment, resulting in uncomfortable working conditions (Gabbidon et al., 2014). In a recent study, Gabbidon et al. (2014) discussed that women in the racial minority group experienced more psychological and emotional distress, discrimination, and daily isolation than the Caucasian group. Women in the racial minority and Caucasian group reported discrimination in general and mental health care, resulting in decreased motivation to seek further mental health treatment (Gabbidon et al., 2014). The mental illness-related discrimination leads to further health care disparities.

Ethical Issues

 It is a constitutional right for women with mental illness to receive individual treatment without discrimination (National Conference of State Legislature [NCSL], 2017). In Maryland, provider must provide adequate treatment for women with mental illness, despite personal biases (NCSL, 2017). In a recent article, Knaack, Mantler, and Szeto (2017) discussed that women with mental illness feel dehumanized, devalued, and dismissed by health care providers. In addition, women reported that they received inadequate information regarding their medical condition and treatment.

 Providers should develop an individualized treatment plan for the patient to provide adequate mental health care. However, providers may neglect the patient due to their own discrimination or biases (Ross et al., 2015). Negligence is a type of malpractice that omits the obligation of providing adequate treatment for the patient (Hall, Orentlicher, Bobinski, Bagley, & Cohen, 2018). In addition, in a recent qualitative study, Ross et al. (2015) discussed that providers were not providing adequate informed consent when treating mental illness in women. Informed consent is necessary, especially in women of child-bearing age due to teratogenicity of several psychiatric medications.

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 Women with mental illness are not receiving adequate treatment because of inequality in health insurance or lack of financial resources (Rowan, McAlpine, & Blewett, 2013). It is required by law that insurance companies must provide insurance to patients without discrimination (NCSL, 2015). In Maryland, insurance companies must provide equal insurance to patients, whether they have mental health illness or not. Women with mental illness should receive equal opportunities for insurance (NCSL, 2015).

Evidence-based practice

 In daily clinical practice, it is essential to implement informed consent, which includes providing accurate information on risks, benefits, and alternative treatments (Barstow, Shahan, & Roberts, 2018). This author will provide adequate informed consent to women, which will include education on mental illness, treatment options, risks of untreated illness and side effects of medications, especially if they are of child-bearing age (Silverman et al., 2016). Then, this author will request that the patient relays what she understood from the discussion (Barstow et al., 2018). This author will provide a questionnaire to every woman with mental illness to evaluate whether she received adequate education and her needs were met during the office visit.

 This author will implement informed consent and offer treatment options to women of all ethnicities, ages, and socioeconomic statuses without discrimination. This initiative will increase treatment options and mitigate health care disparities. In addition, this author will educate peers in the clinic on the importance of treatment equity for all patients to eliminate barriers to mental health treatments. This author will administer a pre- and post-test to measure providers’ understanding of mental illness and how to prevent discrimination. As a result, women will receive improved patient care and experience reduced discrimination in primary care and psychiatric offices (Barstow et al, 2018).

 This author will implement cost-effective mental health care for women by prescribing medications that are inexpensive, but effective. SSRIs (selective serotonin reuptake inhibitors) have been found to be most effective in treating depression and anxiety in women (Locke, Kirst, & Shultz, 2015). This author will prescribe fluoxetine for women who have anxiety and depression. fluoxetine 10 mg in 30 tablets is $4.00 at Walmart and $5.68 at Harris Teeter (GoodRx.com, 2018). The yearly cost for fluoxetine 10 mg would be $48, which is very inexpensive compared to psychiatric brand medications (Locke et al., 2015).

  Even further, this provider will implement a free health fair for women with mental illness in Baltimore, Maryland, which would include mental health questionnaires (i.e. GAD-7), postpartum depression screening and educational resources (i.e. brochures). In a recent article, Opperman, Hanson, and Toro (2017) implemented depression screening at a community health fair and found that over 25% of patients screened positive for at least moderate depression. The community mental health fair initiative will assist in early diagnosis and treatment options that are cost-effective for patients (Silverman et al., 2015). This author will implement a pre- and post-test to evaluate community awareness and understanding of mental illness. 

Summary

 Mental illness is a leading cause of disability in women in the United States. Women with mental illness experience significant stigmatization and isolation in their communities, jobs, and doctor’s offices.  Women face challenges with having steady jobs due to their mental illness and employer biases, resulting in termination. Providers should offer adequate screening, education, informed consent, and treatment to women with mental illness and should avoid discrimination. It is imperative that providers implement cost-effective interventions to improve women’s access to mental health care. Inexpensive medications and mental health fairs should be implemented to reduce health care costs. It is necessary that providers implement cost-effective and equitable care to women with mental illness to mitigate health disparities and enhance health outcomes on a continuum.

References

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