Second prize essay winner of our Mind the Research Gap Student competition in partnership with WHAM, written by Lucy Pritchard, MRes student in Neuroscience at the University of Bristol.
"Lucy chose an often neglected space in female health - that of brain health - and specifically discussed the gap in PTSD care for female individuals and what can be done to address this healthcare challenge"
Issue: The Brain Health Gap
There is a clear sex and gender gap in outcomes for brain health disorders across the lifespan, with strikingly negative outcomes for women. The Brain Health Gap is a term that refers to the inadequate attention and funding afforded to research on women’s mental health. The result: our understanding of female brain health is insufficient and contributes to expensive long-term treatment costs.
Between 1977 and 1993, women able to have children were banned from participating in cell,
animal and human clinical studies (Liu & Mager, 2016). This was prompted by the belief that female hormones made women expensive and difficult to study. Consequently, little research exists on female-specific symptoms that brain health issues create, while the largely false belief that men and women are the same still dominates the literature.
Even when women are included in research, the data is rarely analysed for gender differences. Throughout the life course, women experience the changes in sex hormones (i.e., oestrogen, progesterone, and androgens) induced by pregnancy and ageing. Neuroscience and clinical research have not sufficiently incorporated sex and gender-based differences to understand female-specific disease development, or the subsequent treatment considerations (Beery & Zucker, 2011). More research is needed to understand the modifications hormone changes have on behaviour, cognition, sleep and mood in women.
Two-thirds of worldwide Alzheimer’s disease patients are women, and dementia has become the leading cause of death for women in England and Wales (Snyder et al., 2016). Despite these disproportionate statistics, research focused on understanding this disease specifically from a gender perspective is limited. Another example of this is Post Traumatic Stress Disorder (PTSD). Around 10% of women suffer with PTSD sometime in their lives, compared to only 4% of men (National Centre for PTSD, 2019). This statistic alongside numerous research studies suggest females are twice as likely to experience PTSD than their male counterparts, despite being exposed to proportionately fewer traumatic events then men (Seedat, Stein & Carey, 2005).
Prior research regarding gender differences in PTSD has generally focused on prevalence and
symptom expression, neglecting to explore why women develop more PTSD symptoms than men and the potential underlying neural basis for these differences (Irish et al., 2011). Women’s symptoms are often overlooked, dismissed, or misdiagnosed due to poor understanding of female-specific symptoms (Thompson & Blake, 2020). All of which result in striking health inequalities in diagnosis, and subsequent treatment and outcomes for women. In the case of PTSD, women tend to experience a greater symptom burden, longer course of illness and have worse quality-of-life outcomes than men.
Should we be concerned?
Inequalities within research have dramatic knock-on effects for wider society. 60-80% of primary caregivers are female and relied heavily upon by children, partners and elderly relatives (Sharma, Chakrabarti & Grover, 2016). By failing to effectively treat women for any health condition (physical or mental), the rest of the population relying on them will also suffer. This can give rise to further problems such as lack of attendance at school/ work, increased family tensions, and the exacerbation of current and/ or facilitation for more mental health problems.
From an economic standpoint, the WHAM Report (Women’s Health Access Matters) shows that high network countries cannot afford inaction. Designed to study the impact of accelerating sex- and gender-based health research, the report found that funding is dramatically disproportionately allocated to research projects focused on women’s health. They also found that increasing this investment generates millions back into the economy. In the case of Alzheimer’s Disease, doubling investment in research focused on women pays for itself three times over, with a 15% higher return than general research.
How can this be addressed?
To close the brain health gap, we must identify, quantify, and understand the mental health issues facing women, with the goal of identifying data-driven levers for change. Closing this gap will have wide reaching positive outcomes and will stem, in part, from greater investment in gender-centric clinical research. There is also a need for greater investment in female-identifying entrepreneurs and companies, those that can empathise and provide support by focusing on neglected areas of health such as menopause, fertility, trans health, and postpartum depression. The WHAM report is promoting change in how institutions and organizations approach sex and gender in health research, by providing evidence that Women’s health is an economic issue we can’t afford to ignore.
Understanding how women react differently to stress and what causes this increased vulnerability to PTSD is vital to support more targeted and effective treatments and interventions. Increasing female representation across research and beyond will develop our knowledge and help us to take better care of women’s health. A growing understanding of the psychobiological alterations in PTSD is facilitating the development of improved pharmacological and psychosocial treatment options. Recent randomised controlled studies suggest that female gender may be associated with better response rates to pharmacotherapy. Thus, the use of SSRIs and anti-adrenergic agents in treating trauma-exposed women should be explored in greater depth to ensure we maximise the elevated benefits (Ipser & Stein, 2012).
The OECD are working on a neuroscience-inspired initiative to support and encourage greater investment in female-focused research (OECD, 2021). As awareness around the Brain Health Gap and wider research inequalities increases, more steps are being taken to support new research, producing more accurate scientific data on women’s brain health for the future. Advances in healthcare show promise to move away from the one-size-fits all treatment model, towards personalised medicine tailored to the needs of the individual (aided by big data and AI). In order to take this step, we must account for sex and gender differences across disease, or risk never reaping the full benefits of this potential break through.
References
Beery, A. K., & Zucker, I. (2011). Sex bias in neuroscience and biomedical research. Neuroscience & Biobehavioral Reviews, 35(3), 565-572.
Ipser, J. C., & Stein, D. J. (2012). Evidence-based pharmacotherapy of post-traumatic stress disorder (PTSD). The International Journal of Neuropsychopharmacology, 15(6), 825-840.
Irish, L. A., Fischer, B., Fallon, W., Spoonster, E., Sledjeski, E. M., & Delahanty, D. L. (2011). Gender differences in PTSD symptoms: an exploration of peritraumatic mechanisms. Journal of anxiety disorders, 25(2), 209–216. https://doi.org/10.1016/j.janxdis.2010.09.004
Liu, K. A., & Mager, N. A. (2016). Women's involvement in clinical trials: historical perspective and future implications. Pharmacy practice, 14(1), 708. https://doi.org/10.18549/PharmPract.2016.01.708
OECD. (2021). New Approaches to Economic Challenges. 22/03/2022. https://www.oecd.org/naec/
Seedat, S., Stein, D. J., & Carey, P. D. (2005). Post-traumatic stress disorder in women. CNS
drugs, 19(5), 411-427.
Sharma, N., Chakrabarti, S., & Grover, S. (2016). Gender differences in caregiving among family-caregivers of people with mental illnesses. World journal of psychiatry, 6(1), 7–17.
https://doi.org/10.5498/wjp.v6.i1.7
Snyder, H. M., Asthana, S., Bain, L., Brinton, R., Craft, S., Dubal, D. B., ... & Carrillo, M. C. (2016). Sex biology contributions to vulnerability to Alzheimer's disease: A think tank convened by the Women's Alzheimer's Research Initiative. Alzheimer's & Dementia, 12(11), 1186-1196.
Thompson, J., & Blake, D. (2020). Women’s experiences of medical miss-diagnosis: How does gender matter in healthcare settings?