EIGE-2021 Gender Equality Index 2021 Report: Health
Gender differences in mental disorders begin early in life
Mental health disorders are defined using international diagnostic criteria, such as the those in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) (American Psychiatric Association, 2020), or the International Classification of Mental and Behavioural Disorders (WHO, 2020e). Large-scale meta-analyses have identified mood complaints, including depression, anxiety and substance use disorders (SUDs), as the most common mental health conditions among adults (Baxter et al., 2013; Steel et al., 2014) .
Depending on how they manifest, mental illnesses are often broadly classified as either internalising or externalising disorders. Internalising disorders are characterised by thoughts and emotions within oneself and include mood disorders and anxieties. Externalising disorders are primarily denoted by actions in the external world, and include SUDs and attention-deficit hyperactivity disorder (ADHD). Across the EU, women have consistently higher rates of internalising disorders, for example depression, anxiety, phobias, and suicidal thoughts and attempts. Men self-report twice as high levels of externalising disorders, such as alcohol abuse, ADHD, and conduct and drug-use disorders (Boyd et al., 2015).
Mental health disorders among children and youth
According to WHO, half of all mental health conditions begin by 14 years of age, but most are undetected and untreated (WHO, 2020c). Mental health disorders are one of the most common sources of disease burden in children and young people, particularly adolescent girls (Baranne and Falissard, 2018). WHO estimates that between 10 % and 20 % of adolescents globally experience mental health conditions, making it critical to investigate causes of poor mental health and to intervene as quickly as possible during childhood and adolescence.
Gender-specific data on pre-school children’s mental health is scarce. More evidence on gender differences is available 10-19-year-olds. Boys are generally more affected by autism, particularly Asperger’s syndrome, anxiety and conduct disorders, while girls tend to suffer from anxiety, conduct disorders and depression (Baranne and Falissard, 2018).
Among children and adolescents aged 6–17 years and 5–17 years, the prevalence of ADHD and conduct disorders is estimated at around 5 % and 3 %, respectively (Wittchen et al. 2011). Boys are three times more likely to be affected by both ADHD and conduct disorders than girls. The prevalence of common mental health disorders among adolescents, for example depressive and anxiety disorders, is estimated at between 25 % and 31 %, depending on the diagnostic criteria, with girls more affected (S. A. Silva et al., 2020). Regarding overall self-reported mental health, 10 % of boys and 14 % of girls aged 11 years in 28 European countries noted ‘feeling low’ more than once a week, on average (OECD, 2018). These figures rise significantly with age; gender differences become more pronounced, with 29 % of girls aged 15 years saying they felt low, compared with 13 % of boys the same age.
Mental health disorders among adults
Analysis of GBD data shows that in 2019 36.7 million women and 34.1 million men aged over 20 years in the EU suffered from mental disorders. These figures represent 20 % and 18 % of the total adult population of women and men, respectively.
There are important gender differences in prevalence rates for internalising and externalising mental health disorder, Figure 31, based on GBD data, shows the distribution of internalising mental disorders in women and men across countries. In all EU countries, the proportion of adults with mental disorders, excluding SUDs, is higher among women than among men. Prevalence rates among women range from 20 % or higher in Portugal, Spain and Greece to 12 % in Poland. The difference between countries is lower for men , ranging from 16 % in Portugal, Ireland and Greece to around 11 % in many eastern European countries (Figure 31). The highest prevalence of mental disorders among women and the greatest gender gaps are in western European countries. This does not mean that the mental health burden is lower in eastern Europe. The results are influenced by access to mental healthcare and stigma related to seeking professional help, both of which can vary across countries. As shown in Figure 31, women in northern and central European countries turn to mental healthcare professionals more often than women and men elsewhere.
Older age groups are at risk of specific types of mental disorders, such as dementia, with Alzheimer’s disease accounting for between 60 % and 70 % of all dementia cases (Mielke, 2018). An estimated 5 % of people aged 60 years or older in the EU suffer from dementia, and women are about 1.6 times more likely to be affected than men (Wittchen et al., 2011). This gender gap is partly due to life expectancy, as women live longer than men. Dementia is less common in eastern Europe than in the rest of Europe (Wittchen et al., 2011) because of women’s comparatively lower life expectancy in eastern Europe. However, it is not yet clear whether women have a higher risk of dementia than men after accounting for differences in life expectancy. While some risk factors are more common among women, such as depression and lower educational levels, others are more prevalent among men, including sleep apnoea (Mielke, 2018). This means that it is possible that the gender gap in dementia is partly determined by sex differences, and not only by gender inequalities.
Gender differences in mental disorders
As mentioned above, mental illness tends to manifest differently in women and men, with the distinction between internalising and externalising disorders particularly relevant.
GBD data reveals that the prevalence of depression in the EU is 1.7 times higher in women than in men (Figure 32), while anxiety disorders are twice more prevalent among women. Gender differences in eating disorders are even higher, with almost three times more adult women than men suffering from this illness. The gender gap is reversed in cases of SUDs, which are 2.1 times more prevalent among men. This is consistent with earlier findings on internalising mental health disorders being more common among women and SUDs being more common among men.
Depression is the most widespread mental illness in the EU (Wittchen et al., 2011). Some scholars estimate it to be about twice as prevalent among women as among men (Kuehner, 2017; Van de Velde et al., 2013; Wittchen et al., 2011; Yu, 2018). For women, one in 10 of all healthy life years lost is lost because of depression. For men, it is roughly one in 20.
Men are more likely to suffer from alcohol, opioid and cannabis dependence, with men-to-women ratios of 3.3:1, 1.4:1 and 2.5:1, respectively. Alcohol use disorders make up the greatest mental health disease burden among men (Wittchen et al., 2011). However, some recent research suggests that the gender gap in SUDs may be narrowing, especially among adolescents (Thibaut, 2018).
Gender-specific mental health disorders have different impacts on health status. Overall, poor mental health contributes to the overall burden of disease, including NCDs.
While the percentage of healthy life years lost that is attributable to mental disorders is almost the same for women and men aged over 20 years in the EU – 9 % and 8 %, respectively – the proportion of healthy life years lost as a result of SUDs is higher among men. On average, 37 % of all healthy years lost through SUDs are lost from alcohol or drug abuse. Figures are highest in the Baltic countries, Denmark and Poland, at more than 50 %. In contrast, SUDs account for only 13 % of all healthy years of life lost among EU women overall. This share differs across EU countries. It ranges from 24–25 % in Estonia and Poland, to less than 10 % in southern European countries and the Netherlands. This is consistent with the analysis of men’s premature mortality being disproportionately impacted by alcohol and substance abuse (Table 3).
Gender norms and relations impact mental health
Research in various parts of the world connects the level of gender inequalities in society with their impact on individual women’s mental health. Using measures for women’s political participation, economic independence, employment and SRHR to assess levels of gender equality, Chen et al. (2005) found that low gender equality scores were associated with higher levels of depressive symptoms in women. The link was particularly notable among certain groups of women – younger, unmarried and non-white. Similar findings in the EU by Van de Velde et al. (2013) showed that macro-level gender equality supported good mental health for women and men. Some groups were affected more than others by certain aspects of gender equality. Research in various parts of the world connects the level of gender inequalities in society with their impact on individual women’s mental health. Using measures for women’s political participation, economic independence, employment and SRHR to assess levels of gender equality, Chen et al. (2005) found that low scores were associated with higher levels of depressive symptoms. The link was particularly notable among certain groups of women – younger, unmarried and non-white. Similar findings in the EU by Van de Velde et al. (2013) showed that macro-level gender equality supported good mental health for women and men. Some groups were affected more than others and by certain aspects of gender equality.
Other research in Europe also argues that the gender gap in mental health over the life course is affected by a country’s gender equality levels, measured by the Global Gender Gap Index. For example, the mental health of older women in gender-unequal countries is worse than in more gender-equal countries (Bracke et al., 2020). This could suggest that the effects of disadvantage, such as being a woman in a gender-unequal country, accumulate over a lifetime and result in more pronounced health inequalities. This is consistent with previous research linking rigid gender norms with poor levels of cognition in old age (Bonsang et al., 2017).