Aged just 17, I got sick. The kind of sick doctors can’t diagnose using a blood test or a scan; the kind of illness that’s talked about in whispers, behind closed doors, if it were even talked about at all.
It started on my first morning back to school after a blissful summer. I clearly remember walking through the school hall and everything suddenly seeming grey and bleak.
Today, I know this was my first experience of the terrible weight of depression.
At the time, though, I didn’t recognise the darkness for what it truly was, which wasn’t helped by the rapid onslaught of ailments seemingly contained in my body, not my mind.
Headaches, stomach aches, irritable bowel syndrome, insomnia and panic attacks: all these physical symptoms crept into my life one at a time. I couldn’t get on buses or trains or go into any other place where I felt confined, because my panic revolved around my intense nausea and a fear of vomiting.
‘Headaches, stomach aches, irritable bowel syndrome, insomnia and panic attacks: all these physical symptoms crept into my life one at a time,’ says Misty Pratt
I visited specialists who pressed on my abdomen and stuck a scope down my oesophagus, on the hunt for a physical cause of my tummy troubles. All tests came back negative for serious illness.
‘You need to reduce stress,’ one doctor said, and I nodded in agreement, unsure how to do that. My body’s internal smoke alarm was beeping, but I couldn’t find the source of the fire.
I took to popping Zantac, a medication used to reduce stomach acid, every time I felt the familiar stab in my abdomen.
Soon it was a daily habit. My weight dropped rapidly and I began to isolate myself. Schoolwork was the only thing tying me to some sense of normality.
My depression lasted for years. Eventually I ended up taking antidepressants.
At first, the drugs helped — but the positive effects soon wore off, leaving me with side-effects like an involuntary twitch and a diminished libido, which thankfully resolved after I painstakingly weaned myself off the medication.
By the age of 35, I had received five different diagnoses from five different doctors.
What started as ‘panic’, became ‘generalised anxiety’, then morphed into an eating disorder, was revised as ‘cyclothymia’ — a condition that shares many similarities with bipolar disorder — and culminated in a bout of ‘postpartum mood disorder’.
Indeed, my mental illness lasted through my two pregnancies — my first at 29, my second three years later — and beyond, as my children grew into beautiful young girls.
And the cause of all this?
At first I presumed it was, as the phrase puts it, ‘all in my head’, some kind of genetic legacy gifted to me by my paternal grandmother, who suffered from manic episodes.
I had witnessed them from the age of five. She would have grandiose ideas, like falling in love with someone she barely knew, or make epic shopping sprees that tallied in the thousands. On other occasions, she experienced complete breakdowns and lost the ability to speak.
Later, I learned the curse of mental illness had touched the lives of at least two other women in my family tree, both following childbirth. My paternal great-grandmother stayed in a so-called ‘nursing home’ after the birth of her third child.
Even more tragic was the story of my grandmother’s sister, who died by suicide shortly after the birth of twins.
I suppose I also thought it was a ‘woman thing’, or some sort of chemical imbalance in my brain that just needed ‘righting’.
But today I know, thanks to years of research — both in my job as a health researcher and also by speaking to mental health experts and other sufferers — that women’s mental illness is far more complex than these two often-cited explanations would make you think.
Indeed, many scientists believe the minute intricacies of our female bodies, the complex ebb and flow of our hormones — not to mention the pressurised, multi-tasking world in which women live and work — are absolutely vital to unpick if we are ever truly to tackle female ‘problems of the mind’.
Yet as one professor of psychiatry — Jayashri Kulkarni, a specialist in women’s mental health at Monash University, Australia — told me wearily, ‘psychiatry remains primitive’ in how it diagnoses and treats problems like mine.
You might wonder why I am writing so specifically just about women here. It’s because I’m far from alone. As one of the first doctors I saw as a teenager said, while sighing and shaking his head: ‘Why are so many girls dealing with things like this?’
The reality is that women make up the bulk of mental health patients. Today, women are three times more likely than men to experience common mental health problems.
In England in 2014, one in six adults had a common mental health problem; about one in five women and one in eight men.
While rates of severe mental illness have remained steady over time, and don’t differ much by gender, more common disorders, including depression and anxiety, certainly reflect a gender difference.
Women are approximately twice as likely as men to be diagnosed with depression, according to data published in 2011.
Adapted from All In Her Head: How Gender Bias Harms Women’s Mental Health, by Misty Pratt, to be published by Greystone on June 6
It’s also notable that half of all serious mental illness begins in adolescence — and girls far outweigh boys among the diagnosed.
Between the ages of 12 and 17, more than 36 per cent of girls develop depression, compared with less than 14 per cent of boys. And once mental illness begins in adolescence, it often persists throughout a person’s adult life.
Add to this the fact that statistics show when a woman presents at her doctor’s office with complaints of anxiety or a depressive mood, she is also almost twice as likely, compared with men, to be prescribed psychotropic medication, such as antidepressants — and you can see we have a problem.
Finally, once a woman is on medication, research seems to indicate that it’s hard to stop taking them. In a study in 2017, researchers in Sweden found it was twice as common for women as for men to use antidepressants when they were not currently depressed.
These findings suggest women are being overtreated with these drugs.
Surely, given all the amazing medical advances that are possible in our technologically proficient age, we can do better than our current method of treatment — doling out antidepressants, and crossing our fingers that they do the trick?
Part of the problem, sadly, is that we often still treat women, medically, on the same basis as we do men, ignoring glaringly important differences between us.
One 2016 report in The Lancet Psychiatry cited some of these differences as including: women’s diminished stress response (we are more likely to release less cortisol during stressful events, which is associated with a higher risk of subsequent depression even after the event has passed); the fact that women are more likely to have lower self-esteem and higher risk for rumination (meaning being stuck in a cycle of negative thoughts) and body-related shame — and also that women suffer higher rates of traumatic childhood experiences, such as physical and sexual abuse.
Yet the thresholds and treatment of mental health issues are not gender specific.
And aside from diagnosis, clinical research to study the effectiveness of antidepressants and their potential harms has, historically, mostly been in male animals and adult male humans — which means that much of what we know about their side-effects relates to the male body.
Little wonder, perhaps, that one 2020 report in the journal Biology of Sex Differences found worrying implications for how women process standard prescribed doses of antidepressants.
‘Among patients administered a standard drug dose,’ the report said, ‘females are exposed to higher blood drug concentrations and longer drug elimination times than males.
‘This likely contributes to the near doubling of adverse drug reactions in female patients, raising the possibility that women are routinely overmedicated.’
Dr Liisa Galea, a world-renowned neuroscientist, now at the Centre for Addiction and Mental Health in Toronto, Canada, found that only five per cent of studies from neuroscience and psychiatry journals in 2019 used an appropriate analysis for the discovery of possible sex differences in the outcomes.
When women are included in trials, variables such as hormonal contraceptives, menstrual cycles (which means differing responses to medication at different points in our cycles), pregnancy, childbirth and menopause have been found to affect treatment outcomes.
But these variables sometimes lead researchers to exclude women from participating in research altogether, in the belief that it’s just too difficult to incorporate them in their findings.
This is despite the fact that, as Dr Galea tells me: ‘Pregnancy and postpartum do create a perfect storm for mental health disorders, because we see the same kind of biomarkers occurring during those stages that we see in mental health problems.’
In depression, there is a reduction in volume of the hippocampus, a part of the brain that’s involved in memory, for instance.
As Dr Galea points out, the same reduction occurs in pregnancy and postpartum.
Other major changes in this same timeframe affect our immune system, stress hormones and metabolism — all in ways similar to what we see during an episode of major depression.
This gender bias in the diagnosis and treatment of women’s mental illness just further medicalises natural processes in our bodies and pathologises our emotions.
Those pesky wombs and changing hormones affect our moods — of course they do! — but that shouldn’t automatically lead doctors to focus on women’s emotions and dole out antidepressants and ignore other serious health issues that may be going on.
Part of the answer, surely, must be in precision medicine, rather like that we are seeing in cancer care and cardiology.
‘We need the ECG for the mind,’ says Kulkarni, referring to the test that checks heart function by measuring its electrical activity. Indeed, it seems there are in fact ways emerging to define what type of mental health disorder women have.
Professor Kulkarni identifies different types of depression based on factors such as hormonal changes or a history of trauma, which would impact the stress response system and thereby change brain chemistry over the long-term.
Other researchers have studied blood tests that could identify whether a person was experiencing a depression associated with inflammation in the body. Meanwhile, research suggests that more than 50 per cent of the variance of antidepressant response and tolerability is genetically controlled.
New genetic tests — embryonic though they are — show some early promise in predicting antidepressant treatment response and remission rates.
Taken together, these advancements provide hope for those women who have found antidepressants have not been the ‘happy pills’ we were promised.
But the missing piece of the puzzle, as I can testify, is that women desperately require holistic care, as well as sound biologically based medical care — particularly at moments of hormonal change, such as adolescence, pregnancy and menopause.
It’s at times like these that overburdened women can feel TATT — ‘tired all the time’. But this feeling of being worn out is all-too-often diagnosed as anxiety or depression.
When this happens, treatment solutions may prove ineffective, leading to worsening symp- toms or an abandonment of treatment altogether.
That’s because treatment for mental illness generally centres on therapy and medication, while treatment for burnout needs more practical solutions — such as time off work to rest; negotiating different working hours with an employer or encouraging basic self-care, such as getting a good night’s sleep and taking exercise.
There is even evidence that women should try to see that some bumps in the road could, in the end, be positive for our mental health.
According to Dr Galea, the structural changes we see in the brain during puberty, pregnancy and menopause ‘might even be better for you’, she says.
For instance, research on brain changes that occur during adolescence shows that grey matter in the prefrontal cortex begins to thin.
This is an important process of pruning unwanted neural connections in the brain, while the connections that remain are strengthened.
In pregnancy, brain volume changes may help us to feel more bonded to our babies.
And images of our brains during menopause have shown changes in its structure, neural connectivity and energy metabolism which have the potential to make women more vulnerable to mental health issues — or, instead, make us more resilient to change and better able to adapt.
All these changes are likely serving a functional purpose, helping us transition into the next stage of life.
For me, making peace with my moods and coming to the realisation that there’s nothing I need to ‘fix’ about myself helped me to recover.
But long term, it’s only with more research dedicated specifically to women’s bodies and minds — in all their complex glory — that we may ever fully tackle the idea that our mental health woes really are just ‘all in our heads’.
Adapted from All In Her Head: How Gender Bias Harms Women’s Mental Health, by Misty Pratt, to be published by Greystone on June 6, £18.99. © Misty Pratt 2024. To order a copy for £17.09 (offer valid to June 8, 2024; UK P&P free on orders over £25), go to mailshop.co.uk/books or call 020 3176 2937.