Action Steps for Improving Women’s Mental Health

May 2009

Table of Contents

• Executive Summary
• Vision
• Objectives
• Why Action Steps for Improving Women’s Mental Health?
• Methodology
• Rationale for Action
• Summary
• Actions
• Conclusion
• Appendix A: Detailed Conceptual Framework
• Appendix B: Women’s Mental Health Resources, Products, and Tools
• Endnotes
• Glossary

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Executive Summary

Since the publication of Mental Health: A Report of the Surgeon General in 1999, an increasing body of evidence from the research base, public policy analysis, consumer advocacy, and health care practice has underscored the critical importance of mental health to the overall health of women—and to our Nation as a whole. Many advances have been made in our understanding of mental illnesses, effective treatments, and promising approaches for promoting mental health, resilience, and fulfilling lives for those living with mental illnesses. A key component of this progress has been the increased understanding of the critical role of gender in the risks, course, and treatment of mental illnesses. New research findings also have pointed to the effectiveness of a growing array of treatment options for mental illnesses and of a new model of treatment that is recovery-oriented, strengths-based, and includes the active participation of individuals in their treatment. The recent advances in the science and practice of women’s mental health provide an unprecedented opportunity to address the burden of mental illnesses on women’s lives and increase the capacity for recovery. However, for this knowledge to be effective, it must be translated into tangible actions that can promote change and support progress to improve the mental and overall health of our Nation’s women and girls. Thus, this report proposes the following actions:

• Promote the widespread understanding that women’s mental health is an essential part of their overall health.
• Improve the interface of primary care and mental health services for women.
• Accelerate research to increase the knowledge base of the role of gender in mental health and to reduce the burden of mental illnesses in both women and men.
• Increase gender and cultural diversity in academic research and medicine.
• Support efforts to track the mental health, distress, and well-being of women and girls in national, State, and large community-based surveillance systems.
• Decrease the amount of time it requires to translate research findings on women’s mental health into practice.
• Recognize the unique prevalence of trauma, violence, and abuse in the lives and mental health of girls, women, and female veterans. Address their effects and support promising new approaches that enhance recovery.
• Address the cultural and social disparities that place women at greater risk for certain mental illnesses by including considerations of these disparities in diagnosis and intervention and by investigating ways to increase cultural competence in treatment approaches.
• Promote a recovery-oriented, strengths-based approach to treatment for women promulgated by the recommendations of the President’s New Freedom Commission.
• Build resilience and protective factors to promote the mental health of girls and women and aid recovery.
• Meet the mental health needs of girls and young women as part of overall health care.
• Incorporate gender issues and considerations in emergency preparedness and disaster planning, including mental health issues.

The Action Steps for Improving Women’s Mental Health represent a collaborative effort of women’s health experts across multiple agencies and offices of the U.S. Department of Health and Human Services (HHS) including the HHS Office on Women’s Health, Office of the Surgeon General, Substance Abuse and Mental Health Services Administration, Office of Minority Health, National Institute of Mental Health, National Institute on Drug Abuse, Indian Health Service, and Office of the Assistant Secretary for Policy and Evaluation. Its purpose is to spur positive changes. The hope is that policy planners, healthcare providers, researchers, and others will take up its suggested actions and help translate them into reality. In this way, we can promote improved mental health and a healthier future for the women and girls of America.

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Vision

The Office on Women’s Health’s Action Steps for Improving Women’s Mental Health are based on a vision of optimal mental health and well-being for women and girls in the United States. They use a public health approach that addresses the mental health needs and concerns of women and girls and incorporates the newest advances in prevention and treatment. Thus, these Action Steps seek to integrate mental health into mainstream health, promote positive mental health and resilience, and advance access to quality services that are recovery-focused and women and family-centered.

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Objectives

The purpose of these Action Steps is to spur positive changes through tangible actions. Those actions are meant to advance the overarching goal of the Office on Women’s Health's Mental Health Initiative, which is to improve the mental health of girls and women in the United States. The actions put forth in this report also represent realistic steps toward the achievement of specific objectives that can further efforts to advance this goal. The objectives include:

• Increasing the understanding of the importance of improved mental health for women and girls in our Nation
• Reducing the personal, economic, and societal tolls of mental illnesses
• Expanding the accessibility of quality mental health services for women and girls
• Increasing the number of activities that promote mental wellness in culturally competent and gender appropriate ways
• Expanding the knowledge base and use of evidence-based practices to address mental health issues affecting the lives of women and girls
• Increasing the ability of women and girls to promote their own mental health and foster resilience in the face of distress, adversity, and mental illness

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Why Action Steps for Improving Women’s Mental Health?

The 1999 publication of Mental Health: A Report of the Surgeon General provided a comprehensive review of advances in genetics, behavioral sciences, and neurosciences affecting the mental health of Americans.¹ The report highlighted the evidence base that has led to effective treatments for mental illnesses; encouraged individuals to seek treatment; and called for a societal resolve to address the fears, misunderstandings, and stigma associated with mental illness through increased research and educational outreach.

Since the publication of that report, a growing body of evidence has underscored the important influence of gender differences in the prevalence, course, and burden of mental illnesses. A parallel body of research has demonstrated the profound influence of mental health on physical health and survival. Studies from the world of business and economic analysis have highlighted the enormous costs of mental illnesses on American society, and research has shed new light on the long-term consequences of intergenerational risks and effects associated with mental illnesses (e.g., depression) or family dysfunction (e.g., abuse or neglect). Additional findings have elucidated the impact of trauma, violence, and abuse on the development of mental illnesses, particularly as they affect girls, women, and female veterans. Research also has pointed to the effectiveness of a growing array of treatment options for mental illnesses and of a new model of treatment that is recovery-oriented, focuses on building individual strengths and resilience, and includes the active participation of individuals in their treatment.

The evidence from recent research has carried implications for the well-being of all Americans but has particular significance for the health and well-being of women. Women not only suffer disproportionately from a number of mental illnesses but also they often serve as caretakers for those suffering from mental illnesses, make many of the health decisions in the family, and play a critical role in perpetuating or breaking the intergenerational effects of mental illnesses.²

The HHS Women’s Mental Health Initiative has drawn from the latest research; Surgeon General publications on related mental health topics;^3,4,5,6 resources and publications from other HHS agencies, and on the input of experts from the consumer, research, advocacy, health care professional, and policymaking communities. Building on the existing research base, the initiative has been addressing the burden of mental illnesses on women across their life spans through efforts to reduce stigma and discrimination, bring mental health into mainstream health, promote treatment and recovery, and support greater gender and cultural diversity in mental health research and practice.

The HHS Women’s Mental Health Initiative has been sponsored by the HHS Office on Women’s Health (OWH) and has been developed as a collaborative effort with women’s health and mental health experts from the National Institute of Mental Health, the Substance Abuse and Mental Health Services Administration, the Office of Minority Health, the National Institute on Drug Abuse, the Indian Health Service, the Office of the Assistant Secretary for Planning and Evaluation, and the Office of the Surgeon General. The purpose of the HHS Women’s Mental Health Initiative has been to explore questions related to the importance of gender-based differences in mental health; how the science and focus of women’s mental health issues have evolved since the publication of the Surgeon General’s Report on Mental Health; and what gaps remain in our understanding of women’s mental health issues.

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Methodology

In order to address its purpose and assess the current understanding of issues affecting the mental health of women and girls, the HHS Women’s Mental Health Initiative included several background research and information-gathering activities (a more detailed description of each of these activities is included in Appendix A):

• A concept mapping activity to define and depict key women’s mental health issues. Issues were identified, ranked according to both their importance and potential for action, and organized according to common themes. The themes were arranged in a conceptual framework (presented in brief below and more fully in Appendix A), which offers a visual representation of how women’s mental health issues are grouped and interrelated.
• Leadership interviews with 25 high-level individuals representing governmental, provider, and consumer organizations. Respondents identified current, critical women’s mental health issues and gave feedback to refine the conceptual framework developed through the concept mapping exercise.
• Facilitated discussions in three cities with diverse groups composed of consumers, providers, and local government staff. Participants identified and examined key mental health issues concerning women and girls and added further suggestions and comments to help shape the conceptual framework of mental health issues affecting women and girls.
• A literature review targeted to find the most recent and relevant articles on the mental health of women and girls and limited to U.S.-based studies and reviews published in prominent, peer reviewed journals or by Federal agencies since the 1999 release of Mental Health: A Report of the Surgeon General.
• An invitational workshop on women’s mental health with presentations and break out group discussions involving experts from the consumer, academic, advocacy, health insurance, health care delivery, program management, and public policy communities.

The following conceptual framework reflects the concept mapping exercise and additional refinements from the leadership interviews and facilitated discussions. It depicts the major issues associated with women’s mental health, capturing protective and resilience factors and the individual, environmental, and system-based factors that affect the mental health risks, diagnosis, treatment, and challenges for women and girls. A visual illustration of this conceptual framework is presented below. A more detailed depiction of the conceptual framework is presented in Appendix A, which shows all of the issues that were identified as being highly important and having the greatest potential for action.

Conceptual Framework of Issues Affecting the Mental Health of Women and Girls

Full Image Description for Conceptual Framework of Issues Affecting the Mental Health of Women and Girls: At the center of the image are a woman and a young girl holding hands inside an oval labeled Mental Health of Women and Girls. A ring around this oval is labeled Protective and Resilience Factors. Outside of this ring is a thicker ring of sorts that is divided into three segments labeled System Based, Individual, and Environmental. Each of these segments represents a set of issues affecting the mental health of women and girls. The System Based segment contains three ovals: one labeled Health Systems Issues; one labeled Treatment, Access, and Insurance; and one labeled Identification and Intervention Issues. The Individual segment contains two ovals: one labeled Biological and Developmental Factors and the other labeled Specific Mental Disorders. The Environmental segment contains two ovals: one labeled Trauma, Violence, and Abuse and the other labeled Social Stress Factors and Stigma.

Key Themes and Issues

The findings and recommendations of the HHS Women’s Mental Health Initiative underscore the continued importance of key cross-cutting themes from the 1999 Surgeon General’s report on mental health, starting with the persistent need to combat stigma and the associated prejudice and discrimination that affect individuals with mental illnesses and their families. The report also highlighted the need to expand cultural competence across mental health research, training, and services; reduce disparities in mental health access and treatment; and encourage treatment. In addition, a number of new issues have emerged regarding the burden of mental illnesses: the importance of gender-based differences; effects of trauma, violence, and abuse; the mental health of female veterans; lifespan and intergenerational issues; and the need to include patients as active participants in their own treatment and recovery plans. These themes and issues constitute the rationale for action described below.

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Rationale for Action

Burden of Mental Illnesses

Recent findings from the World Health Organization and the National Comorbidity Survey suggest that the burden and prevalence of mental illnesses in both men and women are enormous and far ranging. On a global scale, four of the six leading causes of Years Lived with a Disability (YLD) are associated with mental illnesses, including major depression, alcohol use disorders, schizophrenia, and bipolar disorder. In developed countries, mental illness is second only to cardiovascular disease as a cause of lost years of healthy life.⁷ In addition, mental and substance use disorders represent the top five causes of disability among people ages 15–44 in the U.S. and Canada.⁸ In the United States, mental illnesses are estimated to affect 46.4 percent of Americans at some point during their lifetimes⁹ and to cost the Nation billions of dollars each year in direct health costs, lost wages, decreased productivity, relapse, and suicide. For example, estimates indicate that depression alone costs our Nation $83 billion a year, and another $63 billion is associated with the costs of anxiety disorders.^10,11 Direct treatment costs for mental health and addictive disorders have been calculated to be $104 billion, and an estimated 217 million days of work are lost each year due to these disorders.⁸

Persistence of Stigma

The stigma surrounding mental health and mental illnesses is strong and persistent.^1,12 It perpetuates prejudice against individuals living with mental illnesses and those close to them. Stigma and fear of discrimination prevent people from recognizing the signs of mental illnesses, understanding the prevalence of mental illnesses, and comprehending the importance of mental health to overall health. They also isolate individuals with mental illness, discouraging them from speaking up about mental health concerns and from seeking treatment. Stigma remains particularly pronounced among racial and ethnic minorities, older adults, and individuals living in rural areas.¹ Stigma seems to have its roots in fear—fear of the unpredictable or strange nature of mental illness or of an association between mental illness and violence—and in a widespread misperception that mental illnesses are a sign of personal weakness or poor choices.^1,8

The 1999 Surgeon General’s report underscored the importance of combating stigma and its negative influences by spreading the understanding that mental illnesses are indeed real illnesses, and that like many other diseases they can be treated effectively. The report also highlighted the need for continued social science research to develop and evaluate new approaches for disseminating information about advances in mental health treatments to help combat stigma and potential discrimination.¹ Evidence suggests that promoting a better understanding of the pervasiveness and importance of mental illnesses and putting a personal face on the stories of mental illness are both effective strategies for reducing stigma.¹³ Thus, there is a continued need to advance treatment options for mental illnesses, ensure that findings are rapidly transferred to practice, and promote effective strategies to combat stigma and discrimination.

Rates of Mental Illnesses: Gender Differences

Although overall, men and women experience mental illness at similar rates, some mental disorders occur more frequently in women than men (see Figure 1).⁹ For example, women are nearly twice as likely as men to suffer from major depression, which is associated with problems such as lost productivity, higher morbidity from medical illness, greater risk of poor self-care or poor adherence to medical regimens, and increased risk of suicide.^14,15 Perinatal depression affects an estimated 8–11 percent of women during pregnancy and 6–13 percent of mothers in the first postpartum year.¹⁶ Women are three times more likely than men to engage in non-fatal suicidal behavior (e.g., taking an excessive dose of sleeping pills), though less likely to use a lethal method (e.g., firearm) and die by suicide.^17,18

Figure 1: Rates of Mental Disorders for Women and Men

Full Image Description: Rates of Mental Disorders for Women and Men (Women vs Men, respectively). Anxiety disorders 36 vs 25%, panic disorders 6 vs 3%, phobia 16 vs 9%, PTSD 10 vs 4%, obsessive compulsive disorders 3 vs 1%, major depression 20 vs 13%, impulse control disorders 22 vs 29%, substance abuse disorders 14 vs 26%, bipolar disorders 1.4 vs 1.3%, schizophrenia 1 vs 1.3%. Source: Kessler, RC, Berglund PA, Demler O, Jin R, Merikangas KR, Walters EE (2005).

Rates of anxiety disorders are two to three times higher in women than men; this includes post-traumatic stress disorder (PTSD), which affects women more than twice as often as men.⁹ Women represent 90 percent of all cases of eating disorders, which carry the highest mortality rate of all mental illnesses.¹⁹ Eating disorders frequently are associated with other psychiatric disorders, such as depression, substance abuse, obsessive-compulsive disorder, and social phobia.^20,21,22 In contrast, men are more likely than women to suffer from impulse control disorders and from substance use disorders.

In some cases prevalence rates are similar between men and women, but there are notable differences in the treatment or course of particular mental illnesses. For example, the rates of schizophrenia and schizophreniform disorders in men and women are similar (1.0 and 1.26 percent, respectively), but the disorder has a later average age at onset and appears to be less severe in women compared with men.²³ Similarly, although the rates of bipolar disorder are nearly equal for women and men (1.4 and 1.3 percent, respectively) the onset tends to occur later in women, and they are more likely than men to experience a seasonal pattern of the mood disturbance, depressive episodes, mixed mania, or rapid cycling.²⁴ Women with bipolar disorders also are more likely than men to experience comorbidity, particularly thyroid disease, migraine, obesity, and anxiety disorders, whereas men are more likely to experience a co-occurrence of substance use disorders.²⁴

The disproportionate prevalence of particular mental illnesses in women is all the more important in light of the fundamental links between mental health, overall health, and social well-being. For instance, in the case of major depression, the disorder can precipitate chronic disease or be exacerbated by the presence of chronic disease.²⁵ Individuals with depression are at greater risk of developing diseases such as cancer or cardiovascular disease.^26,7 Mortality rates from disease increase significantly in people with depression, and there is evidence that treating the depression can improve survival rates for conditions such as heart disease.^27,28 Having depression is associated with risk-taking behaviors such as smoking, abuse, unsafe sex, and not following a prescribed medical regimen.⁷ In turn, rates of depression are higher in people with chronic disease (e.g., diabetes, arthritis, asthma, cardiovascular disorders, cancer, neurological disorders, infectious disease) as are rates of suicide.²⁹ Moreover, there are important cost factors associated with the relationships between chronic health problems and mental illnesses. For example, healthcare costs and use appear to be up to two times higher among diabetes and heart disease patients with co-morbid depression compared to those who do not have depression, and depressed patients are three times more likely to be non-compliant with their medical treatment regimen.^30,31,32 These connections need to be recognized and treated in an integrated manner if treatment is to be fully effective.

Some of the sex-based variation in rates of selected mental illnesses and in the risk, course, or treatment of these disorders may be associated with biological differences between men and women.³³ For example, research has demonstrated that the female hormones, estrogen and progesterone, influence brain function and stress response. Studies of reproductive events such as menstruation, pregnancy, postpartum, perimenopause, and other changes in female hormone levels find that these changes lead to an increase of the occurrence and intensity of symptoms of depression and other mood disorders, such as bipolar disorder and dysthymia.^{34,35,36,37,38}

Investigations of the neural mechanisms underlying the processing of emotionally arousing information also suggest that there may be distinct differences between women and men in the activation of the amygdala, the part of the brain involved in the processing of emotional information.³⁹ Studies that investigate male and female differences in brain volume or structure or those that look at differences in the brains of individuals with and without mental illnesses appear to be inconclusive, suggesting that further research is needed to establish a fuller understanding of how biologically-based brain differences may help inform future pharmacologic and medical treatments for women.^40,41,42

Environmental factors also play a significant role in the risk and prevalence of certain mental illnesses. Some environmental factors may be the result of bias in reporting or diagnosis; for example women may be more likely than men to seek treatment or there may be gender differences in rates of diagnosis for particular disorders. In addition, there are important psychosocial factors from women’s environments that may influence the risk, diagnosis, course, and treatment of mental illnesses in women. Examples of these may include such factors as differences in the ways girls and boys are raised; expectations about male and female roles in the family, workplace, or larger society; the higher rates of abuse experienced by girls and women; the higher rates of poverty or single parenthood experienced by women compared to men; or differences in the positive or negative ways men and women cope with stress and adversity.^43,44

Cultural Effects and Disparities

Individual attitudes and responses to mental illness are highly affected both positively and negatively by one’s family and cultural environment. These environments influence the meaning individuals assign to illness, how they make sense of it, what the causes may be, and how much stigma surrounds mental illness.⁶ In addition, they affect whether individuals will seek help (and from whom), how supportive their families may be, the pathways they take to obtain mental health services, and how well they may respond to different types of treatments.⁶

Use of “cultural disparities” can place women at greater risk for mental illnesses. Factors such as racism, discrimination, violence, and poverty have measurable effects on rates of mental illness.⁴⁵ These effects are coupled with the finding that racial and ethnic minorities are less likely to receive needed services, including mental health services, and more likely to receive low-quality care.⁶ In addition, women who are recent immigrants or refugees may face extra stresses and traumas associated with their immigration experiences. Migration itself is a stressful life event, requiring the need to adapt to a new culture. Women and girls who are refugees may face additional stresses or trauma associated with factors such as turmoil in their home country, long stays in insecure refugee camps or processing centers, or experiences of trauma or violence.⁶ At highest risk are the estimated 50,000 women and children who are victims of human trafficking each year into the United States.⁴⁶ Research suggests that nearly 90 percent of internationally trafficked women rely on drugs or alcohol to cope with their situation, 50 percent report feeling hopeless, 85 percent experience depression, and 31 percent say they have had suicidal thoughts.⁴⁶

Surveillance Systems for Identifying Mental Health Service Needs and Disparities

National, State, and community-based surveillance systems for measuring mental health and distress can provide valuable data to measure the burden of mental illness on men and women, indicate potential mental health needs and disparities (e.g., racial, ethnic, age, and gender disparities), and track progress over time.⁴⁷ The State-based Behavioral Risk Factor Surveillance System (BRFSS) provides continuous population data on the mental health perceptions of adult women in every State, the District of Columbia, Puerto Rico, the Virgin Islands, and Guam^48,49 This complements State-level records-based data on mental health status. The value of these data for decision-making and population research in women’s mental health is poised to increase now that a set of depression, mental illness, and stigma measures has been added to this surveillance system. Data resources could be even further enhanced with the addition of brief, validated measures of mental health and well-being to ongoing national surveillance systems such as the National Health and Nutrition Examination Survey (NHANES) and the National Health Interview Survey.

Trauma, Violence, and Abuse

The research literature has increasingly focused on the relatively high prevalence of trauma, violence, and abuse in women’s lives and their effect on women’s mental health and overall well-being. Findings from the National Violence Against Women Survey indicate that 17.6 percent of women compared to 3.0 percent of men report having experienced a completed or attempted rape in their lifetime, and 24.8 percent of women compared to 7.6 percent of men report being raped or physically assaulted by an intimate partner.⁵⁰ Thus, women are six times more likely than men to report being a victim of rape or attempted rape, and they are three times more likely than men to suffer from sexual or physical intimate partner violence. Data also show that violence and abuse in women’s lives begin early in the lifespan. For example, women are five times more likely than men to report being a victim of sexual abuse in childhood.⁵⁰

Effects on Female Veterans

One of the newly emerging areas of research regarding women’s experience of trauma, violence, and abuse concerns the effects of military service and combat on female veterans. A number of factors are combining to generate greater interest in this area including the growing numbers of women in active duty; increasing rates of male and female soldiers returning from the conflicts in Iraq and Afghanistan who are being diagnosed with mental disorders such as PTSD, generalized anxiety, or depression; and findings suggesting that female veterans are at higher risk of PTSD and sexual abuse than either their non-combatant counterparts or male veterans.^51,52

Recent figures suggest that the proportion of returning soldiers and Marines who have had a positive screening for mental disorders is 17 percent, nearly twice the rate observed before deployment.⁵³ Additional research investigating differences in PTSD rates between men and women in the military suggests that female veterans may face a higher risk of PTSD than their male counterparts, with rape being the most common cause of onset.⁵⁴ National surveys suggest that from 13 to 30 percent of women veterans experience rape during their military service, increasing their risk of PTSD and associated problems such as poorer overall health functioning, depression, and substance abuse.^54,55 Researchers conclude that these findings point to a need for regular screening of women veterans for sexual trauma and PTSD to promote early detection and intervention. They also recommend increased efforts to ensure that female veterans obtain needed treatment services in a timely fashion along with greater research to better understand the specific nature of violence against women in the military and identify effective prevention and treatment measures.

Association with Other Health Risks and Problems

Having a history of violence, trauma, or abuse is associated with increased risk of depression, PTSD, panic disorder, and a tendency toward risky behaviors, such as smoking, binge drinking, cocaine use, self-injury, unhealthy weight control, risky sexual behavior, and serious consideration of suicide.^56,57,58,59 In addition, evidence from the neurobiological and other sciences shows that chronic or recurrent exposure to the stress associated with maltreatment can lead to potentially irreversible changes in the interrelated brain circuits and hormonal systems that regulate stress.⁶⁰ Strong and prolonged activation of these stresses, in the absence of any buffering relationships, leaves children who experience them vulnerable to a range of physical and other health problems throughout life, including mental health problems.^61,62 Preventing abuse and trauma before it occurs—by creating safe, stable, and nurturing environments— is essential for buffering these stresses.

Recent research is increasingly investigating the correlation between the co-occurring mental health and substance use disorders in women with a history of sexual or physical trauma. Studies on this issue find that from 55 to 99 percent of women in substance use treatment report a history of trauma, as do 85 to 95 percent of women in the public mental health system, with the abuse most commonly having occurred in childhood.^63,2,64,65 However, these associations are not always recognized, and thus they are not successfully treated through trauma-integrated approaches that address the mental and substance use disorders and the underlying histories of victimization. The research literature reflects the promise of new trauma-based psychosocial educational empowerment group interventions for women that, in addition to individual and drug therapies, help to promote recovery and restore social trust and involvement. When the connection between trauma and substance use is missed, however, the risks of treatment failures, suicide, incarceration, revictimization, and repeated use of social and health services are increased.⁶⁶

Disaster Planning and Response

Another issue that has been the basis of recent research and concern among mental health experts is that of the traumatic effects of catastrophic events on women’s mental health. Lessons from Hurricane Katrina and other large-scale disasters suggest that women may be more vulnerable than men in the face of these events.^{67, 68,69,70} In the United States, as in the rest of the world, women and children constitute 75 percent of people displaced by catastrophies of natural or human origin; women also are more vulnerable than men to reproductive health problems (e.g., premature delivery, unmet needs for sanitary hygiene supplies) resulting from disasters and post-disaster conditions, at higher risk of being abused, and face greater family responsibilities.^71,72 In addition, women face higher rates of depression and report higher rates of post-disaster stress symptoms.^72,73 Lessons from disaster experiences reveal that response planning and interventions are made more timely and efficient when they integrate an understanding of gender differences in needs, vulnerabilities, responsibilities, capacities, and coping strategies.^68,74 These findings suggest a need to incorporate gender considerations into emergency preparedness planning, training, and response.

Life Span and Intergenerational Issues

Mental illnesses, including those that disproportionately affect women such as depression and anxiety disorders, are often chronic or recurrent. They may influence women’s lives across the life span and those of their families across generations. Findings from the National Comorbidity Survey indicate that mental illnesses in both men and women often begin at a young age, with half occurring before age 14 and three-fourths by the age of 24.⁹ If left unrecognized or untreated, mental illnesses that occur in childhood frequently persist into adulthood.⁷⁵ In addition, they may lead to conditions such as more risk taking behaviors, low self-esteem, and school failure that can set forth a downward spiral of poor outcomes that reduce an individual’s quality of life and ability to meet his or her full potential.⁵ Indeed, research on child and adolescent mental health indicates that no other illness has such damaging effects on children as does mental illness.⁷⁶

These findings are important for young and adolescent girls, who appear to be at increased risk compared to their male peers and to adult women of being a victim of abuse, developing an eating disorder, experiencing depression or anxiety, or engaging in suicidal behavior.⁷⁷ They also underscore the importance of prevention and early intervention in stemming the risks of mental illness and the associated health and social problems later in life. Thus, one strategy is to try to prevent abuse and trauma before they occur by creating safe, stable, and nurturing environments for children, youth, and families.

In addition, early intervention for children with mental illnesses has been shown to effectively address health and behavioral concerns; shorten and lessen the disabling course of illness; reduce unnecessary pain and suffering; and help promote greater resilience, self-esteem, and school achievement.¹² Early intervention and appropriate treatment also reduce the risk in children of developing co-occurring mental or addictive disorders.

Research on the prevalence and effects of co-occurring disorders among children and adolescents indicates that the problem affects a substantial number of youth, and that if one of the disorders is not treated, both generally tend to become worse. As a result there is an increased risk of further problems (e.g., unemployment, poverty, incarceration, suicide, medical problems, social separation) later in life.⁷⁸ However, there is evidence to suggest that girls may be less likely than boys to be identified as having a mental disorder. Thus they may be more likely than their male peers to miss the opportunity for early intervention and treatment.⁵

In addition to the effects of mental and behavioral disorders in children, there is considerable evidence to suggest that mental illnesses can persist in an intergenerational cycle.^79,80 For example, maternal depression increases the risk of depressive symptoms in children, particularly those who are very young, and it may lead to poorer health and developmental outcomes for children.⁸¹ Having a family member with mental illness also carries the risk for both children and adults of increased stress, greater financial burden, social isolation, and exposure to stigma and discrimination.⁷

The long-term effects of exposure to trauma or abuse in childhood also correlate closely with increased lifetime risks of mental illness and serious health problems in adulthood.^82,83 This may be of particular concern for girls and young women due to their higher vulnerability to physical and sexual abuse; indeed, data from the National Violence Against Women Survey indicate that nearly 55 percent of women report having been raped or physically assaulted, often during childhood.⁸⁴

Conversely, evidence suggests that environmental enrichments (e.g., positive parenting, social supports, early recognition and treatment of mental health concerns) can help break the intergenerational cycle of mental disorder or abuse and lead to changes in brain activity, with potential, positive, long-term intergenerational effects.^85,86,87,88 Thus, researchers note that appropriate treatment along with the promotion of healthy psychological states and resilience before, during, and after exposure to adverse childhood events can help promote lifelong mental health for girls, women, and their children.⁸⁸

Resilience and Protective Factors

Resilience means the personal and community qualities that allow individuals to rebound from adversity, trauma, tragedy, threats, or other stresses, which may be caused by psychological distress, specific mental illnesses, or adverse environmental events. It also includes the ability to bounce back from difficult experiences and to go forward in life with a sense of mastery, competence, and hope.

The family and other interpersonal connections in women’s lives may play an important role in building resilience and offering protection from mental illness. Early evidence suggests that social support systems, a stable family life, an abuse-free upbringing, optimism, positive role models, and self-identity build resilience and serve as protective factors for girls and women against mental illnesses.^89,90 Similarly, interventions such as peer support and self-empowerment groups may hold the promise of boosting resilience to help prevent mental illnesses or serve as an adjunctive therapy to help treat mental illnesses, and thus merit further research.^91,92

Recovery-Oriented Treatment

One of the key messages of the Surgeon General’s report on mental health regarded the well-documented variety and efficacy of mental health treatments, even for the most severe mental illnesses.¹ In addition, treatment is very cost-effective in terms of workforce participation and productivity.⁹³ Yet national surveys indicate that most individuals with mental illnesses do not receive treatment.^94,95 For many, this is in part associated with a lack of understanding that a variety of effective treatments exist and that recovery is possible. Other factors also contribute to lower rates of treatment use including stigma and the fear of discrimination, lack of access to treatment services, cost and payment issues, and lack of treatment options that are gender appropriate or culturally competent.

Recent advances in mental health treatment, supported by the recommendations of the President’s New Freedom Commission on Mental Health, have broadened the definition of treatment to include patient involvement, a focus on healthy self-development, and access to a range of quality mental health services.¹² They also have called for a transformation from a model focused primarily on acute care to one that incorporates long-term recovery, with an emphasis on building resilience, facilitating recovery, and including active participation on the part of individuals with mental illnesses and their families.⁹⁶ The aim of this new model is to promote the patient’s ability to live a fulfilling and productive life despite a mental illness and to have a reduction or complete remission of symptoms. For women with a history of trauma, violence, or abuse, there is promising evidence that the most effective treatments are those that are gender-specific, coordinated, multitargeted, and multimodal.⁹⁷ The research evidence suggests that there is clearly a need for more research on optimal treatment strategies, including combination therapies, holistic and integrated approaches, and combining preventive interventions with treatment for periods of risk (e.g., perinatal period) or for women at potential risk for co-occurring disorders.⁹⁸

Integration of Mental Health and Primary Care

Evidence indicates that primary care providers are critical in helping to recognize mental illnesses among women.⁹⁹ Indeed, many individuals with mental illnesses are diagnosed through primary care physicians and other general medical providers, both within the public and private health care systems.¹⁰⁰ For example, 42 percent of those with clinical depression and 47 percent with generalized anxiety disorder are diagnosed by a general medical provider, and more than half of those treated for depression (52 percent) are treated by a primary care or other general health provider.^101,102 This is particularly important for women, who are at higher risk for both of these disorders.⁹ Women also are more likely than men to visit a primary care physician, representing nearly 60 percent of all visits to primary care providers and averaging more than 363 visits per 100 persons per year compared to 266 visits for men.^103,104

Data also show that a majority of Americans receive behavioral health services from primary care providers and that primary care providers prescribe the majority of psychotherapeutic drugs for both adults and children.^8,105 The ability to receive mental health services in a primary care setting can help reduce the fear and stigma associated with mental illnesses. The concern has been raised, however, that the impetus for this trend may be more frequently associated with financial and health insurance factors rather than treatment considerations, and that the primary care setting may not necessarily be the optimal one for treatment due to such constraints as time available, provider expertise, and reimbursement issues.^8,106 This suggests a need to more effectively integrate mental health treatment across primary and specialty care services, potentially with simple screening tools that can be easily adopted in the primary care setting, the ability to refer patients to appropriate services, and the expansion of evidence- based models for delivering mental health services in primary care. For example, early results from demonstration programs funded by the Health Resources and Services Administration’s Bureau of Primary Health Care and other State and private entities show promising results for treating depression or anxiety with short visits in primary or community care clinics in a way that improves access and helps to reduce stigma.¹⁰⁷

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Summary

Since the publication of the 1999 Surgeon General’s report on mental health there has been greater recognition of the role of mental health in the overall health of individuals and of our Nation. Many advances have been made in our understanding of mental illnesses, effective treatments, and promising approaches for promoting mental health, resilience, and fulfilling lives for those living with mental illnesses. A key component of this progress has been the increased understanding of the critical role of gender in the risks, course, and treatment of mental illnesses. However, for this knowledge to be effective, it must be translated into tangible actions that can promote change and support progress to improve the mental and overall health of our Nation’s women and girls.

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Actions

Advances in the science and practice of women’s mental health in recent years provide an unprecedented opportunity to address the burden of mental illnesses on women’s lives and increase the capacity for recovery. They suggest multiple areas for action.

Action: Promote the widespread understanding that women’s mental health is an essential part of their overall health.

The importance of mental health issues on women’s health and in women’s lives has remained largely unrecognized, both within the medical community and among the general public.¹ In addition, there are important connections between mental illnesses and other diseases, such as heart disease and diabetes, that are easily missed when mental and overall health are not considered together. By not approaching these conditions in an integrated fashion, the efficacy of disease management programs for individuals with co-morbid medical and mental illnesses may be compromised.

To increase the understanding of mental health issues, address stigma, and help reduce health disparities, there is a need to develop and disseminate information on gender-specific mental health issues across the life span in both rural and urban settings and in ways that are culturally competent.

To address potential discrimination against individuals with mental illness, there is a need to disseminate information about relevant civil rights laws and the agencies that enforce these laws, including the HHS Office for Civil Rights, the Equal Employment Opportunity Commission, the Civil Rights Division of the Department of Justice, and the Office of Fair Housing and Equal Opportunity in the Department of Housing and Urban Development.

Action: Improve the interface of primary care and mental health services for women.

The gap between mental health and other health services exacerbates issues of stigma and decreases the likelihood that women will obtain diagnostic and treatment services for mental illnesses.¹ Primary care providers and others who regularly interact with women are well-placed to help bridge this gap and to incorporate mental health issues into their health screenings and discussions. This is particularly important for conditions that disproportionately affect women (e.g., depression, history of trauma, anxiety disorders) or periods in women’s lives when they may be at higher risk (e.g., early adolescence, perinatal/postpartum period, menopause, aging, or with diagnosis of a major medical condition requiring extended care).

To achieve this goal, however, there needs to be increased focus on the training and continuing education of primary and general health care practitioners to recognize mental health risks, including genderbased differences. Further strategies include the implementation of systematic screening procedures to identify mental health and substance use disorders and expansion of systems that can link those in need with appropriate mental health services, supports, or diversion programs. The expansion of collaborative care models (combining care from primary care providers and behavioral health specialists) in primary health care settings and greater reimbursement rates for these services by both public and private health insurers also have been cited as critical to promoting the integration of primary and mental health services.¹² Educating consumers to look for and ask for more integrated systems of care can also be an important factor.

Action: Accelerate research to increase the knowledge base of the role of gender in mental health and to reduce the burden of mental illnesses in both women and men.

The last decade of research has highlighted the importance of biological factors (e.g., hormonal fluctuations, psychotropic drug response, brain structure), psychosocial factors (e.g., gender roles, socialization, social status), and artifact (e.g., diagnostic bias, gender differences in seeking treatment) on women’s mental health. In addition, a growing body of research is beginning to shed light on issues of race, ethnicity, and culture as they relate to mental health.

The Federal action agenda for mental health care titled, Transforming Mental Health Care in America Federal Action Agenda: First Steps,⁹⁸ underscores the continued need to further develop the knowledge base in understudied areas, including quality and access gaps facing racial and ethnic minorities, the impact of trauma and violence on the mental health of women and children, and long-term and other effects of psychotropic medications. In addition, a targeted review of recent literature on women’s mental heath issues undertaken as part of the HHS Women’s Mental Health Initiative suggests the need for randomized, controlled clinical studies in order to compare different treatment modalities, to explore the efficacy of individual treatment components, and to determine best practice treatments for women with differences in risk factors or presentation of symptoms.³⁴ Specifically, the literature review reveals that researchers point to the need for more studies to investigate:

• Basic biological and behavioral male/female differences, including animal models, neuroimaging, and genetic studies to increase understanding of the neurobiological underpinnings of mental illnesses and addictive disorders
• Effective pharmacotherapy for women and girls (using female study subjects)
• Specific psychotherapeutic approaches that are effective in women
• Successful treatment approaches for pregnant and postpartum women that minimize impacts on fetuses and infants
• Biological differences between men and women with mental illnesses
• Biological differences between women who develop disorders and those who demonstrate resilience
• Gender-based risk factors and treatments for specific disorders (anxiety disorders, mood disorders, eating disorders, schizophrenia, addictive disorders, etc.)
• Gender-based preventive interventions for specific disorders (eating disorders, depression, substance abuse, etc.)
• Potential gender effects or differences in the effectiveness of programs and interventions to reduce the stigma or discrimination associated with mental illnesses
• Gender differences in the etiology, course, and high-risk periods for mental illness
• Potential gender differences in the risks, prevalence, and effective treatments for mental disorders among male and female veterans, including the effects of rape and sexual trauma on women in the military.

Action: Increase gender and cultural diversity in academic research and medicine.

The growth of women in academic medicine has been slow; women represent just one-third of medical faculty members in the U.S. and are still highly underrepresented among associate and full professors in academic medical institutions.¹⁰⁸ The greater participation of women, including women of color, in academic research is important to ensure that the research base reflects gender, racial, ethnic, and cultural diversity not only in the types of topics that are being researched but also in the interpretation of the findings.¹⁰⁹ Advances in our understanding of gender and cultural diversity must be integrated into the training of health care professionals and staffing of academic research institutions. Several national efforts to promote greater gender and cultural diversity in academic health institutions and among health professionals currently are being sponsored by the HHS Office of Minority Health, HHS Office on Women’s Health, the NIH Office of Research on Women’s Health, and the Substance Abuse and Mental Health Services Administration. Areas of focus in these programs include promoting and investigating cultural competence and the representation of women in behavioral health care education, training, and research; issues such as recruitment and retention of women, including minority women; availability of bilingual trainees; integration of gender into research, training, and practice; and the development of cultural and linguistic competence in clinical practice. However, further efforts need to be undertaken to ensure that the voice of gender and cultural diversity is clearly present in academic research.

Action: Support efforts to track the mental health, distress, and well-being of women and girls in national, State, and large community-based surveillance systems.

The ability to track the mental health status of our Nation’s women and girls is vitally important for identifying current mental health service needs and disparities, including those related to gender, age, race, and ethnicity.^110,111,112 It is also critical for guiding the allocation of resources and assessing the effectiveness of interventions and policies. The improved surveillance of girls’ and women’s mental health will require the development of brief, validated measures of mental health and well-being that can be included in ongoing surveillance systems that currently emphasize physical health and injury. Examples of these include the National Health and Nutrition Examination Survey (NHANES), the National Health Interview Survey, the State-based Behavioral Risk Factor Surveillance System (BRFSS), and the Youth Risk Behavior Surveys (YRBS). Population level data, particularly those gathered at the community level, can provide needed information for prevention research that complements clinically-based research.

Action: Decrease the amount of time required to translate research findings in women’s mental health into practice.

Research suggests that it can take from 15 to 20 years for evidence-based practices to be translated into the everyday delivery of mental health services and activities.¹¹³ Moreover, there is a shortage of research on what works to actually change practice. Thus, many individuals are not benefiting from new evidence-based treatments, preventive interventions, or practices—including those that may be more suitable for women and girls. This points to the continued and urgent need to harness research and transfer it effectively into usable methods and modalities that can be implemented in real-world settings to improve care. Examples of areas in which practice may lag behind research include the development of new medications and potential gender-based differences in their effectiveness, behavioral therapies that may be more appropriate and effective for girls or women, multi-systemic therapy, parent-child interaction therapy, family psycho-education, assertive community treatment, and collaborative treatment in primary care.¹²

Action: Recognize the unique prevalence of trauma, abuse, and violence on the lives and mental health of girls, women, and female veterans. Address their effects, increase prevention efforts, and support promising new approaches that enhance recovery.

The National Violence Against Women Survey indicates that there is a high prevalence of abuse in women’s lives, both in absolute terms and relative to the rates experienced by men. The unique prevalence of trauma, violence, and abuse in women’s lives is important in and of itself and because of the close correlation between being a victim of abuse, having a mental illness, and having a substance use disorder.¹¹⁴ Thus, researchers recommend screening girls and women, including female veterans, more widely for histories of trauma, abuse, and violence—particularly if they present with depression, substance use, or eating disorders. The results of recent research on rates of rape and associated PTSD among women in the military also suggest a need for increased screening and treatment for trauma and abuse in that population.^115,54 Evidence indicates that integrated treatment approaches that address both trauma histories and co-occurring mental or substance use disorders are more effective, especially if they give the patient a voice in her own treatment.¹¹⁶

The research literature related to trauma, violence, and abuse focuses heavily on the prevalence and characteristics of these experiences in the lives of girls and women. Less attention is paid, however, to potential interventions for women and girls who have been or may be at risk for being abused or to possible differences in the effects of different forms of abuse on their mental health. Researchers recommend that future studies include more measures of the effects that traumatic experiences have on women in particular; collect longitudinal data to infer temporal and causal relationships; and develop evidence based interventions to stem the effects that abuse, trauma, and violence have on mental and other health outcomes.^117,118

Action: Address the cultural and social disparities that place women at greater risk for certain mental illnesses by including considerations of these disparities in diagnosis and intervention and by investigating ways to increase cultural competence in treatment approaches.

One of the gaps in the research literature is the lack of information on how risk factors and treatment approaches for mental illnesses among women and girls may differ according to race, ethnicity, and culture. The National Institute of Mental Health’s Five-Year Plan for Reducing Health Disparities calls for the inclusion of populations of women who have not been well represented previously in clinical trials and investigation of diseases and conditions within particular female populations.¹¹⁹ Recent literature on women’s mental health issues suggests that there is only minimal focus in the scientific literature on considerations of cultural competency, racial and ethnic differences, and disparities affecting the mental health of diverse women and girls. Specifically lacking are studies addressing issues of race, ethnicity, and culture with sufficient sample sizes, rigor, or statistical power to provide generalizable findings.

Action: Promote a recovery-oriented, strengths-based approach to treatment for women promulgated by the recommendations of the President’s New Freedom Commission

Most individuals with mental illnesses do not receive treatment due to a widespread lack of understanding that, in most cases, effective treatment options exist, recovery is possible, and treatment is cost-effective.¹²⁰ The message of hope for most women with mental illnesses that is advanced by researchers, planners, and the recommendations of the President’s New Freedom Commission on Mental Health is that they can be active partners in their recovery and build resilience.^12,121 It is a message that needs to be conveyed more broadly to providers, planners, and members of the public and translated into practice. Thus, there is a continued need to promote services and treatments that are geared to give individuals with mental illnesses and their families meaningful choices about treatment options and providers. In addition, care should be focused on coping with challenges, facilitating recovery, and building resilience, not merely on managing symptoms of the disorder.¹²

Action: Build resilience and protective factors to promote the mental health of girls and women and aid recovery

Effective prevention and mental health promotion may reduce the risk or recurrence of all but the most severe mental illnesses. There is a call from researchers and program planners to increase the amount of research, including gender-based research, to further the understanding of internal (e.g., optimism, positive self identity) and external (e.g., societal roles, cultural supports) protective factors, interventions that build self-esteem and improve well-being, and other wellness enhancing programs as well as preventive interventions for specific disorders.^122,123,124 In addition, according to the World Health Organization, there exists a wide range of evidence-based preventive programs and policies that can help reduce risk factors, strengthen protective factors, decrease psychiatric symptoms and disability, and potentially prevent the onset of some mental illnesses.¹²⁵ Activities to build resilience and protective factors also have been shown to improve mental health, contribute to better overall health, and generate long-term social and economic benefits, yet much remains to be learned about the gender-specific effects of preventive and promotive interventions.^91,93 There also are challenges related to disseminating and translating evidence-based prevention activities into practice in a timely manner and to making effective programs and policies widely available.

Action: Meet the mental health needs of girls and young women as part of overall health care.

Most mental illnesses and addictive disorders begin in childhood and, if left untreated, will put children at risk for further health problems, school failure, poor self-esteem, and the adoption of risk-taking behaviors. In addition, childhood and the teenage years are the time when girls may be at higher risk of physical, emotional, or sexual abuse, as well as depression, eating disorders, anxiety, substance use (especially the nonmedical use of prescription psychotherapeutics), or even suicide. Thus, early detection and treatment of girls’ mental health needs and disorders are critical for bringing them the supports and treatments they need and help ensure that problems do not worsen or have negative long-term consequences on their personal development and life potential.

In addition, childhood and adolescence are a prime time for laying a healthy foundation for social, cognitive, and emotional development. It is a key period in which to help build resilience and positive A recovery-oriented and strengths-based approach is one that focuses on increasing the ability of individuals with mental illnesses to successfully cope with life’s challenges, facilitate recovery, and build resilience. mental health habits through activities and individuals that develop self-esteem, promote positive connections and role models, and help girls resist bad influences and trust their own judgment.

Action: Incorporate gender issues and considerations in emergency preparedness and disaster planning, including mental health issues.

The increased vulnerability faced by women in times of catastrophe is not well integrated into community- based disaster mitigation, planning, and exercises. Thus, it is important to ensure that women and issues of gender are included in emergency preparedness planning to address the unique health and mental health needs of women, including their increased risk of depression, anxiety disorders, being abused, and having to face additional family and practical difficulties.⁵³ Women also should be included in discussions among primary distributors of emergency and medical supplies. Considerations of gender differences and needs in emergency preparedness apply not only to local, regional, and national planners but also could involve national associations, university researchers, advocacy groups, the public media, and other stakeholders.

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Conclusion

Today, we face an unprecedented opportunity for action regarding women’s mental health. Following the recommendations of the President’s New Freedom Commission and of the Federal action agenda for mental health, our Nation is in the process of transforming mental health care in America. Indeed, mental health services are in the process of becoming more focused on resilience, recovery, and the active participation of individuals in their own mental health promotion and treatment. The importance of gender-based differences in the risk, etiology, and treatment of mental illnesses is more clearly understood than ever before. These advances set the course for continued progress in our understanding of the unique issues confronting the mental health of women and girls, and they lend urgency to our ability to translate increased knowledge and evidence-based methods into daily practices that can improve health outcomes. The purpose of these Action Steps for Improving Women’s Mental Health is to spur positive changes. The hope is that policy planners, healthcare providers, researchers, and others will take up its charges and help translate action into reality. In this way, we can promote improved mental health and a healthier future for the women and girls of America.

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Appendix A: Detailed Conceptual Framework and Methodology

Full Image Description of Detailed Conceptual Framework and Methodology: At the center of the image are a woman and a young girl holding hands inside an oval labeled Mental Health of Women and Girls. A ring around this oval is labeled Protective and Resilience Factors. Outside of this ring is a thicker ring of sorts that is divided into three segments labeled System Based, Individual, and Environmental. Each of these segments represents a set of issues affecting the mental health of women and girls. The System Based segment contains three ovals: one labeled Health Systems Issues; one labeled Treatment, Access, and Insurance; and one labeled Identification and Intervention Issues. The Individual segment contains two ovals: one labeled Biological and Developmental Factors and the other labeled Specific Mental Disorders. The Environmental segment contains two ovals: one labeled Trauma, Violence, and Abuse and the other labeled Social Stress Factors and Stigma.

From each of the seven outer ovals, a dotted line connects to a detailed description. The descriptions are as follows:

Health Systems Issues

• Lack of information on safety dosing and effectiveness of medications during pregnancy and lactation.
• Inclusion of women in clinical trials and pharmaco-kinetics slash pharmaco-dynamics of drugs.
• Inadequate emphasis on women’s mental health issues in academic curricula for physicians and other health care professionals.
• Side effects of medication.
• The role of hormone therapy in symptomatic peri-menopausal women.
• Family planning and women with major mental illness.

Treatment, Access and Insurance

• Access to appropriate care through primary care providers and mental health specialists.
• The effects of racial and ethnic disparities in health service access and delivery on mental health status.
• Lack of parity for mental health care coverage.
• Insurance coverage.
• Better access to treatments for adolescent depression, anxiety disorders, and eating disorders.
• Access to gender-appropriate diagnostic and treatment services.
• The lack of culturally and linguistically competent providers and treatment materials.
• Competing demands for women that limit their ability to access care; EG, caretaking of children and older relatives.

Identification and Intervention Issues

• The importance of consumer and provider empowerment, self-determination, and choice in mental health treatment.
• Models for transitioning women from institutions to re-entry into family community living.
• Preventive interventions for the most common and disabling disorders, such as major depression and anxiety.
• Depression and anxiety that go undiagnosed and therefore untreated.
• The need for screening depression, anxiety, and other common mental disorders in primary care, schools, and other settings.
• The need to implement the comprehensive nationwide program for suicide prevention previously described in the National Strategy for Suicide Prevention.
• The lack of support and care options for female older adults.
• Complementary and alternative medicine in relation to self-treatment of mental disorders.

Protective and Resilience Factors

• Coping skills for stress and emotional issues.
• Enhancing resilience factors such as active coping and assertiveness in girls to prevent emotional problems.
• Lack of knowledge about mental health well-being versus signs and symptoms of mental health problems.
• The relation of physical activity to depression or anxiety treatment.
• Mentoring and positive role modeling.

Biological and Developmental Factors

• Understanding basic neurological sex differences.
• The need for increased effort to relate biological and genetic mental health research to epidemiological differences in prevalence and course of mental disorders.
• Sex differences in treatment response, both efficacy and side effects.
• Factors contributing to the emergence of gender differences in mental disorders in adolescents.
• Gender differences and the effects of psychotropic medications.
• The neurobiology and physiology of sex differences in social behavior and attachment.
• Understanding the biological bases of normative sex and gender differences.
• How the developmental phases of young females affect their mental health status as women.

Specific Mental Disorders

• Substance use and abuse: alcohol, tobacco, illicit prescription use and other drugs.
• Loss, depression, and anxiety across the life span.
• Peri-natal depression and anxiety and its effects on the family.
• Adolescent depression and anxiety and suicide.
• The impact of race, ethnicity, culture, class, sexual orientation, and age on the expression of symptoms.
• The relationship between depression and anxiety and other negative mood states and substance abuse, especially smoking.
• Recognition of enduring effects of depression and anxiety.
• Co-morbidity of depressive disorders: depression, anxiety, mood disorders, substance abuse including smoking, eating disorders, harming oneself, and suicide.
• The impact on children of parental institutionalization: psychiatric, correctional, and military deployment.
• Understanding why women are more prone to suicide attempts than men.
• The interaction of mental disorders with other illnesses, both as cause and consequence; EG, cardiovascular disease and diabetes.
• Eating disorders.
• Obesity and body image issues.
• Research on serious mental illness in women.
• Gender differences in course, patho-physiology, and treatment response in mental disorders.
• Post-traumatic stress disorder.
• Bipolar disorder.
• Schizophrenia.
• Personality disorders.
• Dissociative disorders.

Trauma, Violence, and Abuse

• The effects of early trauma; abuse, neglect, loss of a parent; on the development of depression and anxiety in women, especially African-American women.
• Sexual violence against girls and women.
• Childhood abuse, whether physical and-or sexual, and the long-term effects.
• Domestic violence in heterosexual and same-sex relationships.
• Emotional abuse at any age.
• The effects of bullying, teasing, and sexual harassment in school.
• Gender discrimination, sexual harassment, and violence in the workplace.

Social Stress Factors and Stigma

• Increased risk of victimization for all women.
• The extent to which lower socioeconomic status and-or immigration status relates to health.
• The discrimination and lack of social acceptance that those with mental disorders face.
• Internal barriers to mental health care such as shame and guilt.
• Negative images of women and girls, 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.

The conceptual framework depicted above was developed and refined based on a multi-step process, which included the following activities:

• A concept mapping activity to define and depict key women’s mental health issues. This activity was based on input from 245 mental health experts, including individuals who had taken part in the development of the Surgeon General’s report on mental health, experts identified by those authors, and members of the Surgeon General’s Expert Working Group on Women’s Mental Health. They included representatives from the voluntary sector, academics, government planners, policymakers, and health care providers. Each participant was asked to complete the following statement: “A specific issue that is relevant to the mental health of women and girls is...” This activity generated 107 issues, which were then rated by the respondents according to the issue’s level of importance and potential for action. Those issues that were rated highly both in terms of importance and action potential were then plotted and grouped according to common themes. These themes were in turn organized into a conceptual framework, which offers a visual representation of how the themes and issues of women’s mental health are grouped and interrelated.
• Leadership interviews with 25 high-level individuals representing governmental, provider, and consumer organizations. Interviewees were selected from a database of experts developed by OWH and included individuals who had expert-level knowledge of women’s mental health; were members of an underrepresented group based on race, ethnicity, or age; and could offer a fresh perspective on the topic of women’s mental health. Interviewees shared what they saw as current, critical women’s mental health issues and offered feedback on ways to refine the conceptual framework developed through the concept mapping exercise.
• Facilitated discussions in three cities with diverse groups composed of consumers, providers, and local government staff. Participants identified and examined key mental health issues concerning women and girls and added further suggestions and comments to help shape the conceptual framework of mental health issues affecting women and girls.
• A literature review focused on the most recent and relevant articles on the mental health of women and girls and limited to studies and reviews published in prominent, peer-reviewed journals that occurred inside the United States and were published since the 1999 release of Mental Health: A Report of the Surgeon General. Prominent publications also were gathered from Federal Agency Web sites and the sites of other major mental health organizations. The literature search gathered information in areas that received limited coverage in the 1999 report, including gender differences in mental health and the ways in which women and girls experience mental health issues. Topics included specific mental illnesses; protective, resilience, and risk factors; biological and developmental factors; environmental factors; trauma, violence, and abuse; and intervention and treatment systems issues. Studies were particularly abundant in areas such as depression, substance use disorders, perinatal mental health, trauma and abuse, and gender-specific risk factors for mental illnesses. One hundred eighty documents were included in the review and analysis.
• An invitational workshop on women’s mental health with presentations and breakout group discussions involving experts from the consumer, academic, advocacy, health insurance, health care delivery, program management, and public policy communities. Breakout groups addressed specific mental health topics that had been identified in the conceptual framework of issues affecting the mental health of women and girls. Participants made suggestions regarding the development of products and materials that could help advance knowledge, understanding, and action around these issues.

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Appendix B: Women’s Mental Health Resources, Products, and Tools

This section provides an annotated listing of useful products and tools currently available as resources from the Federal Government and the private sector related to the mental health of women and girls. Links to non-Federal organizations do not constitute an endorsement of any organization or product by the Federal Government, and none should be inferred. All links and Web sites were verified in April 2008.

Federal Government Resources

Administration on Aging

• Healthy IDEAS: Evidence-Based Disease Self-Management for Depression. The Administration on Aging Evidence-Based Disease Prevention Grant Program includes Healthy IDEAS (Identifying Depression, Empowering Activities for Seniors). This program incorporates four evidence- based components into the ongoing service delivery of care management or social service programs for older individuals in the home environment. The components include screening and assessment, education for clients and family caregivers, referral and linkages to appropriate health professionals, and behavioral activation. The project targets a diverse older population at risk for unrecognized or under-treated depression. There is additional information and a toolkit for local organizations wishing to implement this program.

Agency for Healthcare Research and Quality

• Programs and Tools to Improve the Quality of Mental Health Services. The Agency for Healthcare Research and Quality (AHRQ) has a broad portfolio of mental health research. This report focuses specifically on AHRQ-funded research that has led to the development of programs, methods, and tools for evaluating and improving the of mental health services and improving the education of mental health professionals. Topics covered include depression, schizophrenia, adolescents at risk for suicide, quality assessment, and professional education.

Centers for Disease Control and Prevention

• Live Well, Live Long Module on Mental Wellness for Older Adults. These materials provide health promotion strategies and materials developed by the American Society on Aging through a cooperative agreement with the Centers for Disease Control and Prevention. The module offers a proactive approach, seeking out and encouraging behaviors that contribute to mental wellness among older adults. They also help individuals identify and address depressive symptoms and anxiety early. The modules contain background information on depression and anxiety; information about who in a given community can help create mental-wellness programs; and how, when, and where it can be done. Specific class and presentation outlines and tips for preparing programs are also included.
• CDC Health Related Quality of Life Web site Prevalence Data Page. This Web site now provides annual State-based prevalence and trend data for women’s perceived mental health and distress from 1993–2005.
• Rape Prevention and Education (RPE) Program. CDC’s Injury Center offers technical assistance to help State health departments and sexual assault coalitions more effectively use funds received through the Violence Against Women Act. The funds — designed to enable States to educate communities about sexual violence and develop prevention programs — support educational seminars, hotlines, training programs for professionals, the development of informational materials, and special programs for underserved communities. With CDC’s support, States and Territories have strengthened their infrastructures to address sexual violence and implemented prevention and education programs.
• National Sexual Violence Resource Center (NSVRC). This Resource Center identifies and disseminates information, resources, and research on all aspects of sexual violence prevention and intervention. The NSVRC Web site features links to related resources and information about conferences, funding, job announcements, and special events. Additional activities include coordinating national sexual assault awareness activities; identifying emerging policy issues and research needs; issuing a biannual newsletter; and recommending speakers and trainers. Contact NSVRC toll free at 877-739-3895, access the Web site, or email them.
• The National Youth Violence Prevention Resource Center. This is a “one-stop shop” for information on youth violence prevention, sponsored by the Centers for Disease Control and Prevention. It offers resources and tools (e.g., checklists, fact sheets, curricula, statistics, hotlines) to youths, parents, members of the media, and different types of professionals who interact with youth on preventing all forms of violence ranging from bullying to suicide, substance abuse, and gang violence. A toll-free hotline is available 9AM–6PM EST at: 1-866-SAFEYOUTH (1-866-723- 3968).
• Screening Inventory for Intimate Partner Violence and Sexual Violence in Healthcare Settings. This inventory provides information on screening tools for intimate partner violence and sexual violence victimization for use in healthcare settings. Psychometric information (e.g., validity, reliability) is provided for each measure when available.
• Choose Respect. This initiative is designed to help adolescents form healthy relationships and to prevent dating abuse before it starts. It is a national effort designed to motivate adolescents to challenge harmful beliefs about dating abuse and take steps to form respectful relationships. According to recent research from CDC, one in 11 adolescents reports being a victim of physical dating violence. Even more startling, adolescents who report experiencing dating violence are also more likely to report binge drinking, suicidal behavior, physical fighting, and current sexual activity. Choose Respect reaches out to adolescents, ages 11–14, to reach them when they are still forming attitudes and beliefs that will affect how they are treated and how they treat others. The initiative also connects with parents, teachers, youth leaders, and other caregivers who influence the lives of young teens.
• Sexual Violence Prevention: Beginning the Dialogue. Sexual Violence is a serious public health problem with extensive short- and long-term health consequences. Sexual Violence Prevention: Beginning the Dialogue identifies concepts and strategies that may be used as a foundation for planning, implementing, and evaluating sexual violence prevention activities.
• Measuring Intimate Partner Violence Victimization and Perpetration: A Compendium of Assessment Tools. This compendium provides researchers and prevention specialists with a set of assessment tools with demonstrated reliability and validity for measuring the self-reported incidence and prevalence of intimate partner violence victimization and perpetration. Although the compendium includes more than 20 scales, it is not intended to be an exhaustive listing of available measures. The information is presented to help researchers and practitioners make informed decisions when choosing scales to use in their work.

Food and Drug Administration’s Office of Women’s Health

• Depression Medicines to Help You. This fact sheet is designed as a userfriendly guide for consumers to help them talk to their doctor or pharmacist about antidepressant medications.
• Free Health Information: Depression. This fact sheet provides a short description of the causes and signs of depression.
• Antidepressant Use in Children, Adolescents, and Adults. This informational Web site from the FDA Center for Drug Evaluation and Research provides links to information on the use of antidepressant medications.
• Potentially Life-threatening Serotonin Syndrome with combined use of SSRIs or SNRIs and Triptan Medications. This Web page presents a public health advisory related to the potential dangerous effects of combining antidepressant medications with medications used to treat migraines.
• Treatment Challenges of Depression in Pregnancy.This public health advisory presents information from a study illustrating the potential risk of relapsed depression after stopping antidepressant medication during pregnancy. In addition, it reports new findings regarding the increased risk of persistent pulmonary hypertension in newborns of mothers who used a SSRI antidepressant in the second half of pregnancy.

Health Resources and Services Administration

• Knowledge Path: Postpartum Depression. This knowledge path offers a selection of current, high-quality resources about the prevalence and incidence of postpartum depression, identification and treatment, impact on the health and well-being of a new mother and her infant, and implications for service delivery. Produced by the Maternal and Child Health Library, the knowledge path includes information on (and links to) Web sites, electronic and print publications, databases, and online discussion groups. It is intended for use by health professionals, program administrators, policymakers, researchers, and women experiencing postpartum depression and their families.
• Bright Futures for Womens Health and Wellness Initiative – Mental Health Tools. The aim of this initiative is to help adolescent girls and adult women achieve better physical, mental, social, and spiritual health by encouraging healthy practices through active partnering with their health providers and communities. Based on the latest research and the input of Federal experts and non-Federal mental health experts, tools and materials for consumers, clinicians, and communities have been developed to promote mental health and wellness among adult women and adolescent girls. Three concepts are threaded through these materials to promote mental wellness. These include appreciating yourself, finding balance and purpose in life, and connecting with others. The tools will be available in limited supply through the HRSA Information Center at 1-888-ASK-HRSA.

National Institute of Mental Health

Accessing Services

• Getting Help: Locate Services. This section, located on the NIMH Web site, provides information on where to find help with mental health issues.

Anxiety

• Anxiety Disorders. A detailed booklet that describes the symptoms, causes, and treatments of the major anxiety disorders, with information on getting help and coping.
• When Worry Gets Out of Control: Generalized Anxiety Disorder. An easy-to-read booklet on generalized anxiety disorder that explains what it is, when it starts, how long it lasts, and how to get help.
  A Spanish version is also available.
• When Fear Overwhelms: Panic Disorder Easy to Read. An easy-to-read booklet on panic disorder that explains what it is, when it starts, how long it lasts, and how to get help. (in press as of January 2008).
• Post-Traumatic Stress Disorder. An easy-to-read pamphlet on posttraumatic stress disorder that explains what it is, when it starts, how long it lasts, and how to get help. (in press as of January 2008).
• Always Embarrassed: Social Phobia (Social Anxiety Disorder). An easy-to- read booklet on social phobia that explains what it is, when it starts, how long it lasts, and how to get help.
  A Spanish version is also available.
• When Unwanted Thoughts Take Over: Obsessive-Compulsive Disorder. An easy-to-read booklet on Obsessive-Compulsive Disorder (OCD) that explains what it is, when it starts, how long it lasts, and how to get help.

ADHD

• A Look at Attention Deficit Hyperactivity Disorder. An easy-to-read booklet with personal stories of attention deficit hyperactivity disorder (ADHD) - includes a checklist of symptoms and tips on getting help.
• Attention Deficit Hyperactivity Disorder. A detailed booklet that describes the symptoms, causes, and treatments, with information on getting help and coping.

Autism

• Autism Spectrum Disorders (Pervasive Developmental Disorders). A detailed booklet that describes symptoms, causes, and treatments, with information on getting help and coping.

Bipolar Disorder

• A Story of Bipolar Disorder (Manic-Depressive Illness). Does This Sound Like You? An easy-to-read booklet with a personal story of bipolar disorder - includes a checklist of symptoms and tips on getting help.
  A Spanish version is also available.
• Bipolar Disorder. A detailed booklet that describes symptoms, causes, and treatments, with information on getting help and coping.
• Child and Adolescent Bipolar Disorder: An Update from the National Institute of Mental Health. A fact sheet that describes the symptoms and treatments of bipolar disorder in children and adolescents.

Borderline Personality Disorder

• Borderline Personality Disorder: Raising Questions, Finding Answers. A brief overview that focuses on the symptoms, treatments, and research findings.

Children and Adolescents

• Helping Children and Adolescents Cope with Violence and Disasters: What Parents Can Do. A booklet that describes what parents can do to help children and adolescents cope with violence and disasters.
• Teenage Brain: A Work in Progress. A brief fact sheet about the developing teenage brain.
• Antidepressant Medications for Children and Adolescents: Information for Parents and Caregivers. (online only).

Depression

• Depression. A detailed booklet that describes symptoms, causes, and treatments, with information on getting help and coping.
  A Spanish version is available.
• Women and Depression: Discovering Hope. A detailed booklet that describes the symptoms, treatment, unique factors related to women, and getting help for depression. (in press as of January 2008).
  A Spanish version is available.
• Depression: When the Blues Won’t Go Away. An easy-to-read book let on Depression that explains what it is, when it starts, how long it lasts, and how to get help.

Eating Disorders

• Eating Disorders. A detailed booklet that describes symptoms, causes, and treatments, with information on getting help and coping.

Schizophrenia

• Schizophrenia. A detailed booklet that describes symptoms, causes, and treatments, with information on getting help and coping.
  A Spanish version is available.

National Institute on Alcohol Abuse and Alcoholism

• Alcohol Alert. No. 62: Alcohol–An Important Women’s Health Issue (2004). Considering that about one-third of American women report regular alcohol consumption and 2.3 percent, or 2.5 million women, meet the criteria for alcohol dependence, it is clear that research to better understand the effects of alcohol in women is critical. This issue of Alcohol Alert summarizes some of the most practical implications for women across the lifespan to come from that research.
• Alcohol Alert. No. 50: Fetal Alcohol Exposure and the Brain (2000). This bulletin presents new data on the prevalence and nature of the neurobehavioral problems associated with alcohol use during pregnancy, explores potential mechanisms underlying alcohol-induced damage to the developing brain, and discusses prevention research.
• Alcohol Research & Health. Women and Alcohol: An Update (Volume 26, Number 4, 2002). This issue focuses on the many aspects of alcohol use by and its effects on women.
• Drinking and Your Pregnancy. This brochure answers commonly asked questions about alcohol and drinking while a woman is pregnant.
  A Spanish version is available.

National Institute on Drug Abuse

• A Collection of NIDA Notes Articles That Address Women and Gender Differences Research. This collection covers a wide range of issues and includes such topics as the relationship among victimization, violence, and drug abuse in women; issues affecting drug treatment for women; drug use during pregnancy; and gender differences in drug effects and patterns of drug use.
• NIDA Women and Gender Differences Research Program. This program promotes drug abuse research focusing on the study of women and gender differences. Data from laboratory, field, and clinical research are beginning to show gender differences in biological factors in drug abuse, the progression and initiation to drug use and abuse, the antecedents and consequences of drug use and abuse, and in drug abuse prevention and treatment.
• Broad-based NIDA-wide research program on women and sex/gender differences in drug abuse.

Office for Civil Rights (HHS)

• Office for Civil Rights Web Site. This site offers access to information and fact sheets on numerous issues related to patient privacy and civil rights, including special protections for individuals with disabilities, such as mental illnesses. Fact sheets on multiple topics are available in English, Spanish, Tagalog, Vietnamese, Korean, Russian, Polish, and Chinese.

Office of Minority Health

• Office of Minority Health Resource Center Web Site. This site presents information on the latest news, treatment information, and publications regarding issues such as minority mental health, mental health and cultural competence, and the mental health of individuals in rural and isolated areas. A toll free information line is also available with English and Spanish speaking operators at: 1-800-444-6472.

Office of Research on Women’s Health

• The Science of Sex and Gender in Human Health. This on-line course represents a collaborative effort between the National Institute of Health’s Office of Research on Women’s Health and the Food and Drug Administration’s Office of Women’s Health. This site was developed for researchers, clinicians, and members of academia to gain a basic scientific understanding of the major physiological differences between the sexes, the influences these differences have on illness and health outcomes, and the implications for policy, medical research, and health care. Unless otherwise noted, the content on the site is in the public domain and can be duplicated. The site currently offers one course titled, The Basic Science and the Biological Basis for Sex-and Gender-Related Differences. The course includes six lessons, each of which will take from 20 minutes to an hour to complete. Taking the course is free and continuing education credit can be awarded for successful completion of the course.

Office on Women’s Health

• GirlsHealth.gov. A Web site created to help girls (ages 10–16) learn about health, growing up, and issues they may face. It focuses on health topics that girls are concerned about and helps motivate them to choose healthy behaviors by using positive, supportive, and non-threatening messages. The site gives girls reliable, useful information on the health issues they will face as they become young women and tips on handling relationships with family and friends, at school and at home.
• BodyWise. Fact sheets and other resources for adolescent girls regarding body image, healthy eating, fitness, and illnesses and disabilities.
• WomensHealth.gov. This site provides information about a broad range of issues that affect women’s health. The mental health pages discuss frequently asked questions; offer information on specific mental health issues and target audiences; feature mental health events; and present links to the best organizations, hotlines, and publications related to women’s mental health issues. Fact sheets (PDF Format) on eating disorders and obesity are available. A toll-free information line is available 9AM–6PM, Monday through Friday at: 1-800-994-9662 or 1-888-220-5446 (TDD)

Substance Abuse and Mental Health Services Administration (SAMHSA)

General

• Helping Children Exposed to Substance Abuse, Mental Illness, and Violence. The lead story in SAMHSA News (vol. 10, No. 2) reports on SAMHSA’s Cooperative Agreement to Study Children of Women with Alcohol, Drug Abuse, and Mental Health Disorders Who Have Histories of Violence. The study seeks to identify models of care for the field that will prevent or reduce the intergenerational perpetuation of violence, substance abuse, and mental illnesses and reduce the effect of violence in the lives of children whose mothers have co-occurring mental and addictive disorders and histories of trauma.
• Starting Early Starting Smart (SESS) Training Package to Foster Nurturing Parent-Child Relationships. (PDF Format) This training package, available through NCADI, is designed to prepare family service workers and their supervisors to nurture strong parent-child relationships through the use of video. Developed through collaboration between SAMHSA and Casey Family Programs, the SESS initiative supports the integration of substance abuse and mental health services into primary health care and early childhood settings in which children ages 0 to 6, their families, and their caregivers are served. The complete four-module training package includes two VHS tapes, a CD with a PowerPoint presentation, and a notebook-ready facilitator manual with a detailed outline and materials for each of four training sessions.
• Answers in the Aftermath: A Guide to Mental Health Concerns for Victims of Violent Crime. This brochure describes the after affects of trauma, including PTSD. It offers information on how to begin the healing process following a traumatic event and has a list of resources for further help.

Center for Substance Abuse Treatment

• Approaches in the Treatment of Adolescents with Emotional and Substance Abuse Problems (TAP 1). (PDF Format) Volume I in this series addresses the needs of adolescents with substance abuse problems and makes practical recommendations for the implementation of effective treatment methods.
• Assessment and Treatment of AOD Use/Abuse in Adolescents: A Two Day Training Curriculum. This curriculum is designed for addiction counselors and other helping professionals who come into contact with adolescents. The curriculum includes facilitative communication skills, adolescent diversity, legal issues in adolescent alcohol or other drug assessment and treatment, the assessment process, and treatment recommendations. The purpose of this 2-day workshop is to consolidate the information presented in this self-paced training manual and present it through brief lectures in tandem with experiential group exercises. Before implementing the 2-day workshop, the facilitator should read and complete the exercises in the self-paced training manual in order to gain a thorough understanding of the material to be presented in the workshop. This curriculum package is based upon TIPs manuals 31 and 32.
• A Training Manual: TIPs on Assisting Service Providers to Appropriately Respond to the Needs of the Pregnant and Substance-using Woman and Her Alcohol/Drug-exposed Infant. It is essential that professionals and care providers be adequately trained to detect a client’s substance abuse problem and the characteristics of a child exposed in utero to alcohol and/or drugs. It is equally important that professionals and care providers be knowledgeable about what constitutes appropriate intervention and treatment for the needs of the addicted pregnant woman and her alcohol or drug-exposed child. This training is orchestrated to provide a compendium of information addressing the special needs of these populations. A teaching outline is provided to serve as a guide through the information. This curriculum package is based-upon TIPs manuals 2 and 5.
• Combining Alcohol and Other Drug Abuse Treatment with Diversion for Juveniles in the Justice System (TIP 21). This TIP covers substance abuse treatment-focused diversion program goals, diversion program collaboration, and juvenile diversion to substance abuse treatment planning.
• Empowering Families, Helping Adolescents: Family Centered Treatment of Adolescents with Alcohol, Drug Abuse and Mental Health Problems (TAP 6). (PDF Format) This report describes issues, treatment models, and steps necessary to implement a family-centered approach to adolescent treatment.
• Identifying Substance Abuse among TANF-Eligible Families (TAP 26). (PDF Format) As a result of Welfare Reform in 1997, State and local governments have new requirements, such as time limits, for moving families from welfare to work. For some families, the transition has been difficult, and one of the complicating factors is chemical abuse and dependency. Temporary Assistance for Needy Families (TANF) applicants and participants are reluctant to admit problems with substance use because of the stigma associated with it, fear of sanctions, and referral to child welfare authorities. This publication addresses these and related issues and helps TANF administrators to understand the issues involved in identification of substance abuse among this population.
• Improving Treatment for Drug-Exposed Infants (TIP 5). Guidelines and standards of care in monitoring and evaluating programs treating drug-exposed infants are examined in this report.
• Integrating Substance Abuse Treatment and Vocational Services (TIP 38). This publication introduces vocational services and resources and presents clinical issues related to integrating vocational services into a substance abuse treatment plan. It also discusses policy and funding, and a legal chapter explains the recent regulation that affects employment and substance abuse disorder treatment. This TIP is intended for providers of substance abuse treatment services. However, it also can be of use to vocational rehabilitation staff, social service workers, and all who are involved in arranging for and providing vocational and substance abuse treatment services.
• Navigating the Pathways - Lessons and Promising Practices in Linking Alcohol and Drug Services with Child Welfare (TAP 27). This TAP offers a unique perspective on ways to bridge the divide that too often prevents child welfare and substance abuse agencies from effectively working together to help children and families affected by substance abuse. Using a 10-element framework to measure the capacity of agencies to work as partners on the substance abuse needs of child welfare services clients, this TAP describes seven sites from around the Nation that have implemented programs for families in the child welfare system with substance use disorders.
• Pregnant, Substance-Using Women (TIP 2). This report defines guidelines that reflect state-of-the-art scientific and clinical knowledge on effective treatment practices and care for pregnant addicts.
• Prevention Alert: 25% of U.S. Children Are Exposed to Household Alcohol Abuse (April 18, 2003). Developed by CSAP, Prevention Alert is a twice-monthly feature on a topic of urgency in the substance abuse prevention field that is distributed to prevention specialists.
• Screening and Assessing Adolescents for Substance Use Disorders (TIP 31). Substance use can disrupt a young person’s ability to meet developmental tasks and impair identity development, a central theme of adolescence. This TIP presents information on identifying, screening, and assessing substance use in adolescents. Since adolescents differ from adults physiologically and emotionally, it is important for professionals who come into regular contact with youth to recognize the signs of substance use. The TIP focuses on the most current procedures and instruments for detecting substance abuse among adolescents, conducting comprehensive assessments, and beginning treatment planning.
• Substance Abuse Treatment and Domestic Violence (TIP 25). Designed for treatment providers, this TIP presents an introduction to domestic violence. It offers providers information about the role of substance abuse in domestic violence - among both men who batter and women who are battered. Useful techniques for detecting and eliciting such information are supplied along with ways to modify treatment to ensure victims’ safety and to stop the cycle of violence in both parties’ lives. Legal issues are discussed and a blueprint is provided for an integrated system of care.
• Substance Abuse Treatment and Family Therapy (TIP 39). This TIP addresses how substance abuse affects the entire family and how substance abuse treatment providers can use principles from family therapy to change the interactions among family members. The TIP provides basic information about family therapy for substance abuse treatment professionals and basic information about substance abuse treatment for family therapists. The TIP presents the models, techniques, and principles of family therapy, with special attention to the stages of motivation as well as to treatment and recovery. Discussion also focuses on clinical decisionmaking and training, supervision, cultural considerations, special populations, funding, and research. The TIP identifies future directions for both research and clinical practice.
• Substance Abuse Treatment for Persons with Child Abuse and Neglect Issues (TIP 36). Child abuse and neglect pose an increasingly recognized and serious threat to the Nation’s children. Research suggests that adults with histories of child abuse and neglect are at high risk for developing substance abuse disorders. Compounded with these problems is the increased likelihood of substance-abusing parents abusing their own children. By most accounts, substance abuse contributes to almost three fourths of the incidents of child abuse or neglect for children in foster care.
• Substance Abuse Treatment for Persons with Co-Occurring Disorders (TIP 42). This TIP provides information about new developments in the rapidly growing field of co-occurring substance use and mental illnesses and describes the state of the art in the treatment of people with co-occurring disorders. The TIP contains chapters on terminology, assessment, treatment strategies and models, and an overview of specific mental illnesses and cross-cutting issues such as suicidality and nicotine dependence. The TIP’s appendices provide additional information on topics such as specific mental illnesses, emerging models of treatment, common medications, screening and assessment instruments, dual recovery mutual self-help programs, and other resources for consumers and providers, as well as confidentiality issues.
• Substance Abuse Treatment for Women Offenders, Guide to Promising Practices (TAP 23). Services for women offenders are fragmented or absent all across the country, and funds are scarce for developing the comprehensive networks of community services that women need. Many new programs to treat women have been started or are planned in correctional systems across the country. This guide describes many such promising and creative strategies.
• Treatment for Alcohol and Other Drug Abuse: Opportunities for Coordination (TAP 11). This publication contains an exhaustive review of the need for and benefit of systemic coordination among State, legislative, public health, criminal justice, and social service entities in order to provide a continuum of comprehensive treatment services.
• Treatment of Adolescents with Substance Use Disorders (TIP 32). This TIP presents information on substance use disorder treatment for adolescent clients. Adolescents differ from adults physiologically and emotionally as they make the transition from child to adult and require treatment adapted to their needs. In order to treat this population effectively, treatment providers must address the issues that play significant roles in an adolescent’s life, such as cognitive, emotional, physical, social, and moral development as well as family and peer environment. The TIP focuses on ways to specialize treatment for adolescents, as well as on common and effective program components and approaches being used today.
• Welfare Reform and Substance Abuse Treatment Confidentiality: General Guidelines for Reconciling Need to Know and Privacy (TAP 24). This report provides alcohol and drug agencies, substance abuse treatment providers, and welfare officials with guidance in resolving issues related to the confidentiality of patient/client information.

Center for Substance Abuse Prevention

• Alcohol Use Among Girls (2000). This SAMHSA fact sheet contains information on prevalence of alcohol use in girls, some risk factors for girls who use alcohol, and why males and females respond differently to alcohol.
• CSAP Substance Abuse Resource Guide: Children of Alcoholics (2000). This guide lists resources and organizations that can provide help to children of alcoholics (both adults and children, along with their parents) and prevention, treatment, and intervention professionals.
• CSAP Substance Abuse Resource Guide: Violence Against Women (2000). This resource guide presents recent research findings and information on the relationship of alcohol and substance abuse to violence against women, include battering, murder, stalking behaviors, rape, and sexual assault.

Nongovernment Resources

American Foundation for Suicide Prevention

• This organization sponsors multiple educational and suicide prevention activities. The key theme of its youth suicide prevention campaign is: “Suicide Shouldn’t Be a Secret.” The campaign includes public service announcements featuring real teens who have lost a friend to suicide. The Foundation also has an online registry of evidence-based programs and practices in suicide prevention aimed at providing objective and reliable information to decision-makers seeking to select suicide prevention programs to implement in their schools or communities.

Center for Addiction and Mental Health

• Women: What Do These Signs Have in Common? Recognizing the Effect of Abuse-Related Trauma. (PDF Format) A brochure for self-assessment for the signs of trauma from abuse.

Depression and Bipolar Support Alliance (DBSA)

• Taking Care of Both of You: Understanding Mood Changes After the Birth of Your Baby. Topics include defining postpartum depression, treatment options, and how to stay healthy.

Gender and Disaster Network

• The Gender and Disaster Sourcebook. This sourcebook addresses the link between gender and disaster risk. It presents lessons learned in the field of disaster preparedness and response regarding gender differences and gender-related factors and shows how this knowledge can be applied in practice to reduce risk and improve response outcomes in disaster events.

Geriatric Mental Health Foundation

• A Guide to Mental Wellness in Older Age: Recognizing and Overcoming Depression. This depression recovery toolkit aims to help consumers, in partnership with their health care providers, to identify and treat late-life depression.

Hogg Foundation for Mental Health

• Cultural Competency: A Practical Guide for Mental Health Service Providers. (PDF Format) A comprehensive guide to providing culturally competent mental health services. Includes a definition of cultural competency and information on building rapport, failures in the cross-cultural therapeutic process, conducting culturally sensitive assessments, evaluation of culturally related syndromes, and other challenges.

National Alliance on Mental Illness

• What Families Should Know about Adolescent Depression and Treatment Options: A Family Guide. (PDF Format) This guide discusses the causes and symptoms of adolescent depression. The brochure outlines current options for treatment and the risks of not treating adolescent depression, and it offers resources for families to become effective advocates for their child in determining the appropriate treatment.
  There is a toll-free information line at: 1-800-950-NAMI (1-800-950-6264); TTY: 1-888-829-0500. Spanish-speaking operators are available.

National Center for Victims of Crime

• The National Center’s toll-free Helpline, 1-800-FYI-CALL, offers supportive counseling and practical information about crime, victimization, and trauma in both English and Spanish. The center offers special resources for adolescents, individuals affected by Hurricane Katrina, and those affected by the attacks of 9/11. Also available are referrals to local community resources, social service systems, and legal support and advocacy.

National Council on Aging

• NCOA Model Health Programs Toolkits: Healthy IDEAS for a Better Life. Healthy IDEAS (Identifying Depression, Empowering Activities for Seniors) is a community depression program designed to detect and reduce the severity of depressive symptoms in older adults with chronic health conditions and functional limitations. The program incorporates four evidence-based components into the ongoing service delivery of care management or social service programs serving older individuals in the home environment over several weeks.

National Mental Health Consumers’ Self Help Clearinghouse

• This clearinghouse works to foster consumer empowerment through its web site, up-to-date news and information announcements, a directory of consumer-driven services, electronic and printed publications, training packages, and individual and onsite consultation. It maintains an extensive library of information on topics such as peer counseling, deinstitutionalization, fundraising, involuntary treatment, patient rights, using the media, and many others. Clearinghouse staff and resources are available to help consumers organize coalitions, establish self-help groups and other consumer-driven services, advocate for mental health reform, and fight the stigma and discrimination associated with mental illnesses. The clearinghouse strives to support consumer involvement in planning and evaluating mental health services and to encourage providers and others to accept people with psychiatric disabilities as equals and full partners in treatment and in society.

National Mental Health Association

• Depression in Women. This fact sheet about women and depression includes information on prevalence, contributing factors, and treatment.
• Postpartum Disorders. This fact sheet about postpartum disorders includes information on causes, symptoms, and treatment.
• Tips on Healthy Parenting for Mothers with Depression. (PDF Format) This fact sheet on parenting for women with depression includes valuable parenting tips.
• What to Do When Depression Enters a Relationship. This fact sheet on dealing with depression in a relationship includes steps for overcoming depression and keeping a relationship healthy.

Society for Women’s Health Research

• Fact Sheet on Sex Differences in Mental Health. This sheet offers information on sex differences in the rates and etiology of several mental disorders, including depression, schizophrenia, Alzheimer’s disease, and stress disorders.

Additional Tools to Promote the Psychological, Emotional, and Spiritual Wellness of Women And Adolescent Girls

Assessment Tools

• Beck Self-Concept Measure. Measures competency, potency, and self-worth of youth. Sample statements include “I like myself” and “I do things well.”
• HardiSurvey III. Measures hardiness. Sample statements include “By working hard, you can always achieve your goal.” This item is copyrighted and cannot be adapted.
• How Resilient Are You? Measures resiliency (how people react to difficulties). Sample statements include “I adapt quickly, I’m good at bouncing back from difficulties.”
• Mindfulness Attention Awareness Scale. Measures mindfulness (how aware people are of what they are doing). Sample statements include “I rush through activities without really being attentive to them.”
• Oxford Happiness Questionnaire. A broad measure of personal happiness. Sample statements include “Life is good” and “I find beauty in some things.”
• Satisfaction with Life Scale. Measures life satisfaction in general. Sample statements include “In most ways, my life is close to ideal” and “I am satisfied with my life.”

Tools for Adults

• Authentic Happiness. A Web site that contains a series of assessment tools available for free to registered users. One of these tools is the Signature Strengths Inventory.
• Freeze Frame, One-Minute Stress Management (Institute for HeartMath). This tool focuses on teaching a technique to control and more effectively respond to stress. Researchers have found that this technique reduces blood pressure and stabilizes heart rhythms, and users report a sense of calm and guidance in their decisionmaking. This tool focuses more on controlling and dealing effectively with day-to-day stressors to improve overall quality of life as opposed to avoidance of negative outcomes like depression.
• Hardiness Institute for Performance Enhancement and Leadership Training. This Web site primarily exists as a commercial site to encourage target audience members to purchase tools offered by this organization. Such tools, including assessments, evaluation materials, and training materials are designed to strengthen performance effectiveness.
• Positive Psychological Interventions That Increase Happiness. (PDF Format) (Seligman, Steen, and Peterson). The authors describe and test five potential interventions to increase happiness. Each intervention is theorized not only to cause a temporary increase in happiness but also to be able to produce long-term gains in happiness. The interventions themselves range in content.
• Introducing Resilience (Natural Health Perspective). A Web site that contains a description of resiliency and why it is important. The site contains links to numerous articles on resiliency, including information on how to develop resiliency and a short quiz to measure how resilient you are.
• Self-Esteem Games(McGill University). This Web site contains computer games designed to improve players’ self-esteem. The games are based on research showing that those with low self-esteem have a tendency to focus on negative outcomes and are more sensitive to negative feedback.
• The Science of Happiness(Time Magazine). This special issue of Time is exclusively devoted to the latest research on mental health and wellness. The issue includes an overview article on what makes people happy, as well as articles on the biology of joy, laughter, marriage and happiness, religion and happiness, resilience, and happiness at work. Included are eight tips for increasing happiness.
• The Tree of Contemplative Practices (The Center for Contemplative Mind in Society). This Web site is devoted to encouraging people to develop their contemplative minds (i.e., the ability simply to “be”). The wellness tool of particular interest on this site is the tree of contemplative practices, which visually depicts the development of one’s inner awareness as well as a connection to spiritual things without focusing on any one religion or faith.
• Wellness Guide (University of California, Berkeley). Provides information on a variety of topics related to wellness and well-being. The section on emotional health talks about how emotional health is related to overall health, and it discusses relationship issues, mental illness, disaster, and violence.

Tools for Adolescents

• Empower Me! 12 Sessions for Building Self-Esteem in Girls (Raica-Klotz). Empower Me! is designed as a guide for counselors/involved parents to help girls aged 11-14 to build self-esteem. The 56- page booklet contains comprehensive information to lead 12 sessions on self-esteem with a small group of girls. Each session includes activities and information to help girls identify stressful situations in their lives and how to overcome these situations. Sessions focus on issues such as discovering yourself, understanding relationships with other people, understanding your feelings, thinking about how the relationships you see in your family and images in the media impact your understanding of self, learning to say no, identifying stressful life situations, and understanding your own talents and skills.
• Hardy Girls Healthy Women. This Web site is run by a nonprofit organization in Maine and is dedicated to promoting resources to help communities support adolescent girls. The goal of the site is to serve as an organizing point for resources (including lists of available articles and books) and for local programs and activities to support girls. The site has a strong focus on promoting wellness, creating safe places (e.g., places where girls can share and learn without being judged), and overcoming negative stereotypes about girls. The site promotes hardiness and seeks to develop and promote ways for girls to overcome stressful events and become more resilient. It advocates the creation of hardiness zones, within which girls can thrive. This organization actively has created such zones in the local community and has created regular programming opportunities for girls to experience such zones.
• Penn Resiliency Program (Adaptive Learning Systems and The University of Pennsylvania). This project provides 10 sessions for youth to help them develop skills to become more resilient. The program was originally designed for at-risk youth but has been shown to benefit all youth. Benefits include positive influences on exploratory style, problem-solving ability, self-esteem, self-efficacy, hope, and general health. The 10 sessions focus on links between thoughts and feelings, thinking styles, alternatives and evidence, evaluating thoughts and de-catastrophizing, discussion of conflict, assertiveness and negotiation, coping strategies, social skills training, decisionmaking, and social problem solving.
• Positive Psychology and the Cultivation of Character Among Youth (Positive Psychology for Youth Project). This tool is designed as a positive intervention for youth. It consists of twenty 80-minute lessons for 9th graders, administered as part of the general language arts curriculum at intervals of approximately every 2 weeks. The lessons are designed to nurture positive character development, positive emotion, and citizenship in high school students. The tool is grounded in positive psychology research. The three main foci of the lessons are positive emotions, identifying and using signature strength, and meaning and purpose in life.
• Raising Confident and Competent Girls (Wellesley College Center for Research on Women). This program focuses on bringing research on girl’s self-esteem to teachers and parents to help them support adolescent girls better. A 36-page manual provides full details for trainers. The manual also includes an additional 50-pages of supporting materials, including handouts, overheads, research reports, and a detailed appendix. This training is provided to teachers and parents in a 3-hour training session. The main points of the training are that teachers need to have high expectations for all students, support girls’ aspirations, show girls how to reach their goals, tell girls if they must reveal confidential information (e.g., if girls tell them about an abusive situation, explain that they must report this information before doing so), and support parents in their efforts to raise girls.
• Uniquely Me! The Way to Be (Girls Scouts). The tools consist of a 24-page booklet for girls aged 8–10, as well as two 28-page booklets for adolescent girls aged 12–14. The main points of these materials include appreciating yourself for who you are, thinking about and setting your own values, dealing with peer pressure, and setting appropriate life habits (e.g., getting enough rest/exercise and eating a healthy diet). The materials also help girls to identify potential negative influences in their lives (e.g., media portrayals of girls as too thin) and learn how to counteract these forces.

Tools for Communities

• The Organization of Hope: A Workbook for Rural Asset-Based Community Development (Asset-Based Community Development Institute). This tool is designed for rural community leaders and encourages such leaders to take a “glass half full” view on rural community development. The premises of the workbook are that rural communities have many existing assets in the way of people, places, and resources and that the key to community development is to integrate these assets and build on their collective strengths. The 120-page booklet contains a simple model built around inventorying existing assets, getting others involved, and building enthusiasm to address community-level problems.
• THRIVE: Community Tool for Health and Resilience in Vulnerable Environments (Prevention Institute). THRIVE is designed to help communities identify health disparities and work to improve community health. For example, the tool assists community leaders in identifying the building blocks of healthy communities; e.g., parks, community gathering places, quality schools, and available social services. In addition to this community assessment tool, THRIVE also includes training materials and guidelines to translate assessment results into local policies, programs, and priorities. THRIVE has a woman-focused section, but this section is somewhat narrow and focuses on health as opposed to mental wellness.

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Endnotes

1 U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health (1999). Mental health: a report of the Surgeon General, Rockville, MD: U.S. Department of Health and Human Services.

2 U.S. Department of Health and Human Services, Office on Women’s Health (April 2002). A century of women’s health: 1900-2000. Rockville, MD: U.S. Department of Health and Human Services. Available at: http://www.4woman.gov/timecapsule/century/index.htm.

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Glossary

Mental health is characterized by mental functions that result in productive activities, fulfilling relationships with others, and the ability to adapt to change or cope with adversity.

Mental illness refers to all diagnosable mental disorders, i.e., conditions characterized by alterations in thinking, mood, and/or behavior.

Recovery implies the reduction or complete remission of symptoms and the ability to live a fulfilling and productive life despite a mental illness or addictive disorder.

Recovery-focused services go beyond the treatment of symptoms to emphasize ways to build resilience and facilitate recovery.

Patient and family-centered services are those that are informed by the needs of individuals affected by mental illnesses and their families, who are integrated as active participants in treatment and recovery.

Perinatal depression encompasses major and minor depressive episodes that occur either during pregnancy or within the first 12 months following delivery.

Anxiety disorders are characterized by a disabling, excessive, or irrational dread of everyday situations. They include generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, post-traumatic stress disorder, and social phobia.

Eating disorders may take the form of excessive reduction of food intake or overeating, possibly combined with excessive exercise and extreme concern about body shape or weight.

Substance use disorder refers to the abuse of or dependence on alcohol, illegal drugs, or prescription medications.

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