Woman Mental Health-Midlife

Woman’s mental health, is an important issue and easily one of the most neglected domains, especially so for a woman in her middle age full of physiological and psychological turmoil. Mental health problems occur in higher frequency in women in general. Depression is more common in women as compared to men, women are twice as likely to experience anxiety as men and about 60 % of persons suffering from an OCD or a phobia are women. The greater gender predisposition necessitates an in-depth analysis of the biological and environmental factors of women which cause them to be more predisposed to mental illnesses. A recent report on Women of Tomorrow, reported women in India to be the most stressed female population of the world. Overall, the women of the developing nations were found to be more stressed than their sisters in the developed world. This led us to think about the cultural and environmental influences on the disorders, along with attitudes and perceptions of the society in the mental make-up of a woman. The contributing factors discussed in this article need extensive research to help modulate the implicated factors and in turn amount to primordial prevention. This article emphasizes the priorities to be studied in the context of a woman’s mental health, explores deeper issues and interrelationship of multi factorial determinants. Review Article Behere et al.; JPRI, 33(37A): 69-76, 2021; Article no.JPRI.71231 70


INTRODUCTION
Oprah Winfrey once most famously said, "Where there is no struggle, there is no strength." Perhaps this is why women are known to possess an uncanny inner strength that probably comes from a tough journey since the beginning of their lives. Female fetuses have been found to be more resilient than their male counterparts, [1] which might be an early adjustment or preparation for what lies ahead. A woman has to go through changes all through her lifetime. Her struggles can be diminished or magnified depending on how adaptable she is to these alterations. The physical and mental make-up of women is the interplay of her body, mind and surroundings, not to mention the society, culture and education. Gender has been observed to be an important determinant of mental health. It has been estimated that unipolar depression would amount to the second most important contributor of the global disability by the year 2020 and women are predicted to be twice as likely to be affected as compared to the male population [2]. The United Nations projected that , by the year 2025, the world will comprise of a billion people aged 60 years and three fourths of this population will be living in the developing countries, so a billion people would have passed through or would be at the latter half of the middle age.
We live in a youth obsessed culture; it is often overlooked that all elements of a persona do not develop at the prime of youth. Health programmes catering to women have had a narrow spectrum of focus with reproductive health and control of fertility being the priority especially in developing countries like India. The stereotypical perceptions fail to recognize a new way of understanding life that is more apt to benefit others.
Overall, the perception of the middle age is that of pessimism and denial.
History: The works of most influential and renowned theorists has been on the midlife experiences of men. The term midlife crises were coined by Elliot Jaques, the Canadian psychoanalyst while referring to a phase of human development who also described the transition of midlife to be characterized by the resolution of fear of death. It has still not gained recognition as a universal phenomenon and almost fifty percent people view it as a positive phase [3]. The Freudian theory of midlife being the age of thoughts of impending death whereas Jungian followers believe it to be a phase of selfawareness and individuation along with diminished longing for activities of youth but realization of a more meaningful existence. Carl Jung [4]. described the latter half of a person's life as a phase to develop forgotten resources and aspect of self and adapt to the transition, failure of which can lead to consequences such as mental illness, suicide or use of substance. Adventure seeking and questioning one's purpose of existence are typically experienced by females who have a more chaotic shift from the youth during this period. While often questioning the decisions taken as young women, they also perceive themselves with doubt. Feelings of inadequacy at fulfilling expectations of each role played by a woman can surface during this trying period. In Myers Briggs terms, the individual may be unsure about his/her self, and end up seeking feedback and reassurances from sources outside of self. In the psychosocial stages of development described by Erik Erikson [5] he defined middle age to be between 40 to 65 years and in the 1950's gave the psychological conflict of midlife-generativity versus stagnation. George Valliant [6] whose longitudinal research in 1977, followed well educated men and women past the age of 50, taking on social functions and responsibilities describes it as seizing another chance at rebirth, while a year later, Daniel Levinson [7] described the transition (beginning at 40 -45 years approximately), as being characterized by a more realistic picture of oneself and the world after having critically evaluated their successes in meeting the goals of life The literature both empirical and theoretical, inclusive of experiences of a woman in midlife is rather scarce. Some studies also report it to be a culture based perception, being more evident in the west and not so significant in the Indian and the Japanese culture [8]. Feminist psychology has often been critical of such works and the historical perspective of psychological schools of thought centered on the male perspective, keeping the male gender as the norm [9] thus it focuses on incorporating the gender and the manner in which it has an influence on the existing issues, as the pressures and psychological impacts are significantly different for men and women.

Mental health of a middle-aged woman:
In the book , The Foundations of Psychiatry," the authors quote middle age adults as "no longer driven, but now the drivers" [10]. One view suggests that after transitioning through youth full of struggles and striving, late adulthood losses such as health and friends, middle age provides for a greater sense of autonomy and control on one's life.
Mental health is the emotional and cognitive wellbeing, including ability of an individual to balance effectively, lead a holistic life with positive psychology, effort to achieve greater psychological resilience and signifies a successful adaptation to a range of demands [11]. A woman is supposed to have reached her middle age when she has passed the prime of youth and is a step away from old age. The span between the ages of 40 and 60 years is generally considered as the middle age for women [12].
The onset of the middle age or its anticipation itself brings many psychological changes in a female. The youth is characterized by the exuberance of limitless possibilities whereas the middle age brings with it the realization of the finite nature of one's potential. For a female, her physical appearance has a massive role to play in her perception of self. It is highly influenced by the perceptions of her immediate family. This is extremely critical phase in a women's life and is the predictor of her self-esteem, especially as the aging process has just begun. The added burden of shifting roles in the family can also take a toll on women's health. The early adulthood takes up most of her time in adapting to welcome changes such as career prospects, finding a soul mate, experiencing motherhood and starting a fully functional family of her own. Any rest from her tiring schedule is viewed with optimism at this stage. Fulfillment and satisfaction are at its peak during this phase of a woman's life. Entering the middle age, a woman gradually experiences the decreased dependency of her family on her.
The empty nest syndrome is bound to set in typically as the youngest child leaves the nest. The feeling of emptiness is worse for fulltime mothers or stay at home women, as they find themselves suddenly rendered jobless. Unsatisfactory relationship with the husband can also predispose to the loneliness and may give rise to a full blown depressive episode along with feelings of guilt over lost opportunities [13].

PHYSICAL FACTORS
Menopause: It is the last menstrual period followed by absence of menstrual cycles for at least 12 months straight without interspersed cycles or when both of a woman's ovaries are removed or permanently damaged. Perimenopause-It is the period of transition preceding the natural menopause when the changes of menopause commence and the twelve months following the commencement. In some cases, it may last for a period of six years. Post menopause-Comprises of all the years of a women's life following the permanent cessation of menstrual cycles.
The age group within which most females experience menopause is between forty to fiftyeight years with 51 being the average age in the developed world. This occurrence in the middleaged women is characterized by physiological transformation of their body and mind. Menopause which literally means 'the end of monthly cycles' marks the end of the fertility period for women [14]. This plays an important part in the psychology of a woman. It clearly indicates that the latter phase of a woman's life has begun and she has to deal with the emotional changes that the hormonal fluctuations bring with them. Often women attain climacteric at the age of 40 to 50 years and their fertility and sexual activity are at a decline. Women in this age group go through physical discomfort such is menorrhagia, hot flushes, mood swings, insomnia, vasomotor symptoms.

Sexual
Dysfunction: Women usually experience diminished sexual desire and vaginal dryness or discomfort especially during intercourse after menopause. In some cases, dyspareunia or painful sexual intercourse may occur which may further decrease a woman's desire for intimacy. Mucosal atrophy due to estrogen depletion has been implicated as the physiological cause.

Reproductive tract problems:
A good number of women also have problems related to the reproductive tract during this period. Surgical intervention may be required for fibroids, and ovarian masses. Few of them also require a hysterectomy which leads to surgical menopause.

Psychological Manifestations:
The physical change can bring about a mental disturbance. Anxiety features can predominate along with atypical depression, which are at times difficult to differentiate from the physiological basis of mood swings [15]. Stress' is defined as the mental or emotional strain resulting from adverse or demanding circumstances, it is in actually a physiological response for survival of an individual or an organism [16]. For most women 'stress' has become incorporated in the lifestyle and is almost synonymous to being a woman. Prolonged exposure to stressors has been documented to contribute to illnesses such as coronary heart disease, pre mature ageing and also psychosomatic symptoms resulting from internal conflicts which have more likelihood of occurring with the female gender. Stressors have been directly correlated to the development of a full blown depressive episode [17].

Cardiovascular diseases:
The defense of a woman's body against heart disease is weakened after menopause due to the diminished protective effect of estrogen. The rates of women suffering from cardiac illnesses increase and become comparable to that of men's after menopause [18-19].
The Musculosketal system: Osteoporosis is another entity which emerges post menopause as the resorption of calcium from the bones starts at a faster rate and women become more susceptible to fractures and may lead to prolonged hospitalizations.
Obesity: Most middle-aged women struggle with the control of weight. Women tend to put on weight after menopause which adversely affects their overall health adding to the burden of cardio vascular diseases and disorders related to the musculoskeletal system. The rapid gain of weight can also add to the lowering of self-esteem of women [20].

Lifestyle Diseases:
The middle age is the most common phase for lifestyle diseases such as hypertension and diabetes to set in, which in turn have multi system implications.

Malignancies:
The major illness faced during this period is the carcinomas and malignancies which can be attributed to the hormonal changes such as the unopposed action of progesterone. Breast cancers and cervical cancers are on the rise in the pre and peri menopausal age group

CULTURAL DETERMINANTS
Failing to gain universal recognition, the middle age concept has the tendency of being labelled as a cultural artifact having with economic, medical and psychosocial determinants. Nevertheless, the impact of cultural and environmental influences on gender perceptions and health cannot be sidelined. Indian women tend to experience menopause at a younger age than the women in the west. The understanding and support of family is especially of relevance during the fourth decade of a woman's life.Women are overloaded with lifetime stressors while simultaneously fulfilling responsibilities of a daughter, a wife,a mother and her professional role [21]. This is especially relevant in the Indian context where care giving is perceived as a woman's job rather than a shared responsibility. At times she has to battle with the loss of her parents at this age and feelings of guilt or selfblame for not being able to do enough or not having been able to give them enough time can dwell on the psyche of a woman. More often than not, a woman finds herself neglecting her own needs, requirements and ambitions while tending to others.
According to some feminist views of women's health medical discourse strongly influences women's self-definitions and experiences which in turn are influenced by her surroundings and education. A woman's perception for menopause depends on her awareness of the gradual process of alteration of herself that can span up ten years in a woman's life. Though apprehensions are known to exist during pregnancy, for most women it is the most joyful and positive change. This is not so during menopause. As the changes in a woman are not overt the attitude of the woman herself and her support system is that of ignorance. It is a challenging experience and most women are left to deal with it alone, more so, in the developing countries. How women perceive their midlife changes, can be result of the interaction with cultural determinants and may lead her to rework her definition of 'self'. [22][23] Stereotypes and Myths: Ageism refers to the negative attitudes, stereotypes, and behaviors directed toward older adults based solely on their perceived age. Psychiatrist and Gerontologist, Robert Neil Butler coined this term in 1969 to describe pattern of discrimination against seniors with sexist and racist stereotypes [24].
Gender Differences: Although the data in this regard is scarce, some studies have reported the effect of gender impacting beliefs and perceptions of older individuals. Some views suggested a harsher perspective for women as evidenced by a study conducted on stereotyping, which found middle aged and elderly men to be associated with more positive stereotypes than middle aged and elderly women. A study documented higher competency perceptions for males aged 25 to 55 years as compared to their female counterparts, but no such differences in perceptions were noted for men and women beyond the age of 75 years [25]. These revelations point to the requirement future research to elucidate the interaction of age and gender in shaping perceptions, stereotypes , attitudes and behaviour towards middle aged and elderly population [26].
The other myth associated with the middle age, is the apparent 'slowing' of an individual. Any shortcoming or inefficiency in this age is ignorantly attributed to the diminishing capacity of the brain. The constant mockery of one's cognitive capacity may play on the psyche of the individual, causing them to doubt their own abilities at this age. The fact is that midlife scores on cognitive functioning is high in all domains such as verbal ability, numerical ability, reasoning and verbal memory, while the only decline noted between 25 years and middle age is for perceptual speed [27]. Despite this decline, the overall functioning of cognitive abilities is still above their levels at young adulthood [28].

Intervention and Health Promotion:
The aim of intervention and health promotion in the middle age is providing women with the correct information and knowledge about the bodily changes during this period, to help them set realistic and accurate expectations.  Physical Activity: Leisure and non leisure physical activity have been studied to benefit the psychological well being in menopausal age group. It has the added benefit on cardio vascular health and restricts bone resorption [29][30]  Positive Health Behaviors: These initiatives by women make them self-efficacious in health promotion and include positive behaviors such as improved diet, cessation of smoking, consumption of supplements, Yoga and Meditation.  Hormone Replacement Therapy ( HRT) : HRT has is known to be protective against osteoporosis, vasomotor symptoms of menopause, at the same time a rise in certain carcinomas such as Ca Breast and memory dysfunction are its established side effects [31].  Screening Camps: Educational seminars and screening camps can help early detection of cancers. Bone Mineral Density (BMD) testing can catch osteoporosis and relevant interventions help prevent fractures such as fracture neck femur and Colle's which are very common in this age group.  Psychiatric Intervention: Women at late menopause have a higher rate of depressive symptoms and suicidal ideation. Timely psychiatric referrals or intervention for depressive symptoms, anxiety or sexual dysfunction will help better management rather than an ad hoc diagnosis under the umbrella term of 'menopausal symptoms. The sexual problems of women have a tendency of being swept under the carpet. There are approximately forty FDA approved medications for sexual difficulties related to men in comparison to only one such medication for women. There may be changes in appetite, weight or sleep patterns, memory problems or difficulty concentrating. Often there are feelings of worthlessness or inadequacy and a lowered sense of self-esteem.

Psychotherapeutic Interventions:
 Sex role analysis: Women require attaining a refined understanding of the social systems that played a role in moulding behaviours which have been internalized by women through cultural conditioning. This can lead to a critical exploration by a woman's of these behaviours and then they can be equipped to exercise autonomy of the behaviours they choose to abide by or change [32]  Power analysis: This is a technique use to analyze the differential power between a man and woman. Recognition of inequality in power distribution and sexism leading to limiting power of a woman can serve as a medium of empowerment and improved self-esteem [33].  Assertiveness training: The traditional passive role leads to women depriving themselves of reasonable demands. Role play techniques are utilized for assertiveness training.  Cognitive-behavioral therapy: CBT focuses on changing the maladaptive behaviours and cognitive errors in women. But it has been extensively criticized for not taking into consideration the role of society and environmental influences in these learned behaviours and putting the onus completely on the women for their thoughts and behaviours.  Psychoanalytic therapy: This therapy focuses on early childhood experiences and has adapted from traditional psychotherapy. It helps women maintain their individual sense of self. This therapy has been criticized for being culturally obligated and sexist.  Family systems therapy: Focuses on empowering the woman in a relationship and encourages egalitarian relationships [34].

Other Predictors and modifiers of a woman's health:
Other factors influencing a woman's mental health include domestic violence, marital rape and occupational difficulties. An individual's social functioning can be impacted by multiple social identities commonly faced by women in the middle age group [35]. Social support has an extremely important role to play in cushioning a woman from adversaries. Good social and emotional support has been positively correlated with mental health outcomes [36]. Though many women are subject to various forms of sexual and non-sexual violence as children, their effects can be long term and can manifest during any age of life especially when there is increased vulnerability such as in midlife. Child hood violence or trauma can show its psychological effects such as low self-esteem, physical ill health and depression in any age group. [37][38].
The UN declaration of Elimination of Violence against Women rounds it up as any act of gender-based violence That results in or is likely to result in physical, sexual, or psychological harm or suffering [39]. Psychobiological research has lent a better understanding of the toxic effects of stress faced by victims of sexual abuse. The trauma of sexual abuse can have impact on brain development and persistent exposure to severe stress often faced by women, have shown to be related to a decrease in cortical volume and heightened fear responses due to sensitization of the neural pathway [40]. Economic status is a strong predictor of power and hierarchy in the society. Women with a higher economic status have been observed to be having sufficient power to alter and challenge the traditional gender roles [41].

CONCLUSION
There are a variety of views and judgments and yet not a comparable body of research and literature giving a holistic picture of a women's health especially during this stage of a woman's life. Our awareness and knowledge in several areas is lacking and is incorrect owing to the influences of sexism and ageism. These biases have adversely affected the acceptance of woman's needs at midlife by the society at large and the woman herself [42]. The midlife years can be a phase of opportunity for inner growth for a substantial number of people [43][44]. It can be perceived as a time to move in the positive direction from deficiency motivations to growth motivations as described by Abraham Maslow. For women, the problem is graver as personal deficiencies are not their prime concerns, instead they are societal. Social awareness, gender equality at all levels and not merely a glorified feministic agenda, indoctrination along with multimodal strategies are the need of the hour to tackle the neglected issue of Woman's Mental Health in the middle age [45][46].

CONSENT
It is not applicable.

ETHICAL APPROVAL
It is not applicable.