Advancing women's mental health: Recommendations from a National Academies of Sciences, Engineering, and Medicine workshop

Abstract

Women make up half the world's population, yet have received relatively little clinical research funding or structural support from major research agencies. Consequently, we know far less about women's health than men's health, including how to prevent and treat conditions such as anxiety and mood disorders that are more likely to occur in women vs. men. To address this issue, the National Academies of Sciences, Engineering, and Medicine recently convened a workshop titled “Essential Health Care Services Related to Anxiety and Mood Disorders in Women,” which aimed to provide short- and long-term recommendations to the United States Health Resources and Services Administration (HRSA) regarding health care services to help improve women's mental health. In this article, we summarize the most actionable and compelling evidence-based recommendations made at the meeting that should be immediately implemented, concurrently by HRSA and other stakeholders, to help reduce lifelong disease risk and promote resilience in women. The recommendations focus on five themes, namely: (i) fund and conduct more women's health research; (ii) provide clinicians with better training and support in women's health; (iii) widen the pipeline for mental health care services and treatments for women; (iv) enact sensible policies supporting women's health and well-being; and (v) strive for better outcomes than the absence of disease using preventative and personalized approaches to addressing women's holistic health and well-being. By pursuing these five aims, we will move one step closer to helping all women thrive.

Introduction

Despite women making up half of the world's population, “those who could become pregnant” have historically been excluded from clinical trials in the United States (1). Indeed, until the 1990s, women and female animals were rarely studied in preclinical or clinical studies, leading to a paucity of data on female biology, a lack of clinical studies on sex differences in human health and disease, and limited investigation into disorders predominantly experienced by females. The 1993 National Institutes of Health (NIH) Revitalization Act required women to be included in NIH-funded clinical trials, but women continue to be under-represented in clinical research studies today (2). Compounding this issue is the fact that women's health research remains grossly underfunded. In 2020, for example, only 5% of research and development funding worldwide was devoted to women's health (3). As a result of these intersecting factors, we presently know far less about how to prevent and treat health conditions that predominantly (or solely) impact women compared with those that predominantly impact men.

Our lack of insight into female health is made more severe by the fact that women are disproportionately affected by many serious chronic disease conditions, including autoimmune disorders (i.e. lupus, rheumatoid arthritis, and multiple sclerosis) and mood-related mental health disorders (4). In fact, a woman's risk for anxiety disorders and depression is at least twice that of a man's starting in puberty and persisting through the menopausal transition (5, 6). There are multiple factors likely contributing to this health disparity, including the dynamics of women's sex-steroid hormone fluctuations across the lifespan, alongside sex-based discrimination and sociocultural influences (7). Further, many women lack access to reproductive health care, which is an additional sex-specific risk factor for mood-related disorders (8). Although researchers have identified many risk factors that increase women's susceptibility to mental health disorders, there are still large empirical gaps in our understanding of the sex-specific mechanisms that drive these disparities. These gaps in women's health research, in turn, affect many issues far beyond our academic understanding of women's health, as they negatively impact both health care quality and health outcomes in women and cripple policy efforts aiming to improve women's health and well-being.

Women deserve health care that is evidence-based and delivered by health care providers who are knowledgeable about women's health and capable of providing effective care. These clinicians need good data and strong policies that support their abilities to provide high-quality care. Likewise, policymakers require guidance on how to enact policies that will enable women, clinicians, and communities to thrive. To that end, the National Academies of Sciences, Engineering, and Medicine (NASEM) recently convened a workshop titled “Essential Health Care Services Related to Anxiety and Mood Disorders in Women,” which sought to provide short- and long-term recommendations to the United States Health Resources and Services Administration (HRSA) regarding women's mental health care services (9). The meeting was organized by Colleen Galambos, Vivian Pinn, Jamille Fields Allsbrook, Joy Burkhard, Jill Emanuele, Tamara Lewis Johnson, Jennifer Leonardo, Heidi Nelson, J. Nwando Olayiwola, and George Slavich, under the direction of Alexandra Andrada Silver, and the stakeholders present included researchers, health care providers, policymakers, payors, community members, and those with lived experience.

The goal of the present article is to summarize the clinical context and key takeaway messages of this meeting. First, we briefly discuss key barriers to accessible and effective mental health care services that impact both sexes. Second, we summarize what is known about the unique biological and social influences that impact women's risk for mood-related disorders. Finally, we describe the most actionable, compelling, and necessary recommendations made at the meeting that should be implemented across multiple sectors including, but not limited to, those within the purview of HRSA, in order to reduce disparities in mood-related disorders between women and men.

Barriers to accessing mental health care

Mental health has a long history of stigmatization. Although there is less stigma surrounding mental illness, seeking help, and receiving treatment today than in the past (10), stigma is still a significant barrier that prevents many people from exploring treatment options that could improve their lives (11). Historically, mental and behavioral health care services were not considered to be essential in the United States and were typically not covered by health insurance plans. That started changing in the 1990s, when the first big step was made to ensure mental health care coverage by commercial payors, but these services were often covered at low rates and loopholes enabled many policies to severely limit mental health care coverage. Enacted in 2010, the Affordable Care Act ensured better coverage and more true “parity” between coverage for services for physical and mental or behavioral health, and as a result, mental health and substance use disorder treatment are now considered essential health care services. Moreover, commercial payors are now mandated to cover these services at similar rates as physical health services.

Despite these immense and vital efforts, the long history of separating stigmatized mental health services from physical health services is still apparent today, leaving many without access to treatment. For example, mental and behavioral health care services are generally reimbursed at significantly lower rates than physical health care services, and have, in turn, dissuaded many providers from accepting insurance rates (12). Relatedly, the demand for mental health care is enormous and far exceeds the number of available providers (13). Finally, access to affordable, in-network metal health care providers is poor across the United States, but especially so in low-income and rural areas (14, 15). Although these barriers preventing the effective provision of mental health care services are true for both men and women, women have much higher rates of anxiety and depression compared with men, thus necessitating a focused examination of factors that uniquely influence women's susceptibility to mood-related disorders (5, 6).

Women's hormones across development

A key factor affecting women's risk for mood-related disorders involves hormonal changes over time (i.e. days and weeks) and across development. Overall levels, and the regulation, of female sex-steroid hormones typically shift across three natural events in a woman's life: puberty, pregnancy, and the menopausal transition (16). These dynamic hormonal changes—namely, in estradiol and progesterone levels—are, in turn, associated with increased risk for developing or worsening several mental health conditions, including anxiety disorders and depression (17).

Beginning during puberty, sex-steroid hormones in women start to fluctuate over time and in particular across the ovulatory cycle. The ovulatory cycle lasts about a month, although this can vary cycle-to-cycle and woman-to-woman, and it has two distinct phases: the follicular phase, which occurs from menstruation to ovulation, and the luteal phase, which occurs from ovulation to menstruation. The follicular phase, during which follicles develop, is characterized by a gradual increase in estrogen levels and relatively low levels of progesterone. During ovulation, which marks the midpoint of a woman's cycle, a surge in luteinizing hormone triggers the release of an egg, estrogen peaks, ovulation occurs, and then estrogen levels drop. The luteal phase follows, during which progesterone levels increase as the egg leaves the ovary. If pregnancy does not occur during this window, progesterone and estrogen levels drop, and the uterine lining sheds during menstruation, marking the beginning of the follicular phase of the next ovulatory cycle. The pubertal transition establishes the onset of elevated risk of depression that persists through the menopausal transition, suggesting that hormonal changes which occur with the onset of cycling are likely mechanistically involved in the increased risk of depression that begins in adolescent girls.

Sensitivity to acute hormonal fluctuations during ovulatory cycles is also known to contribute to premenstrual dysphoric disorder (PMDD) and premenstrual exacerbation (PME) (18), two female-specific mental health disorders. PMDD is characterized by a cyclic recurrence of clinically marked distress during the luteal phase of the ovulatory cycle, with full remission of symptoms 1 week following menstruation. Critically, PMDD is not caused by abnormal hormone levels; instead, it is believed to be a disorder caused by an abnormal sensitivity to otherwise-normal hormonal changes following ovulation (19). For example, it is possible that PMDD is rooted in impaired gamma-aminobutyric acid (GABA) receptor responses to fluctuations of allopregnanolone across the menstrual cycle, which inhibit the typical anxiolytic effects of allopregnanolone signaling in the brain (20). Similar to PMDD, PME is defined as the premenstrual worsening of existing psychiatric disorders before or during menses (21). Although the course of PME is less clearly defined than that of PMDD, individuals generally experience a worsening of their psychiatric symptoms during the late luteal phase, with some reported improvement during the follicular phase. Although this pattern of cycle-related changes in mood is true for many women, some also experience worsening of symptoms at other times of the cycle, such as elevated symptoms of mania during ovulation in those with bipolar disorder (21).

Although the manipulation of sex-steroid hormones by exogenous factors such as hormonal contraceptives can provide myriad benefits for different women (e.g. reproductive autonomy and liberation from hormonally mediated symptoms) (22), the use of hormonal contraceptives is not free from side effects. Indeed, hormonal contraceptives can cause changes in libido, weight fluctuations, and mood swings in many women and more persistent, insidious consequences in others (23). Although high-quality research on the impacts of hormonal contraceptives on women's mental health is sparse, and clinical trials on these topics often suffer from significant design issues (e.g. small sample sizes, survivorship biases, and lack of random assignment to condition), some data suggest that hormonal contraceptive use increases depression risk in some women and is effective in treating depression in others (24). Furthermore, hormonal contraceptives may have consequences that extend beyond mood-related disorders. In one study of 149 women, researchers found evidence that hormonal contraceptive use predicted decreased perseverance across both simple and challenging cognitive tasks, suggesting that the synthetic moderation of hormones by some contraceptives may influence cognition (25). Likewise, the use of hormonal contraceptives has been found to alter brain structure and cortisol signaling in a manner similar to what is seen in rats who have been subjected to chronic stress (e.g. reduced hippocampal volumes, elevated cortisol levels, and altered stress-related gene expression) (26).

A cycling woman's next hormonal transition occurs if she becomes pregnant. During pregnancy, women's bodies experience a dramatic rise in estradiol and progesterone levels that decline rapidly when a woman gives birth. Perhaps surprisingly, mental health disorders are the most common complications of pregnancy and childbirth, with 15–21% of pregnant and postpartum women experiencing perinatal mood and anxiety disorders (PMADs), including anxiety, depression, and bipolar disorder (27). This is twice the rate of other well-known pregnancy complications, such as preeclampsia and gestational diabetes (27).

Beyond influencing the mother's well-being, PMADs can negatively impact children's development during the postpartum period. Compared with children raised by mothers with no lifetime history of depression, those raised by mothers with a history of clinical depression have been found to exhibit lower scores on tests of cognitive, emotional, and behavioral performance (28), and, especially for girls, altered neural and biological reactivity to social stress (29, 30) and an elevated risk of developing depression themselves over the life course (31). These associations are driven in part by the impact that maternal depression has on the developmental environment insofar as it contributes to greater lifetime stressor exposure and the modeling of maladaptive coping patterns, which combine to increase vulnerability for mood disorders in girls during adolescence and across the lifespan (31).

The menopausal transition marks the last hormonal transition of a woman's lifespan. Beginning with perimenopause, women experience menstrual irregularity and declining hormone levels, eventually followed by menopause itself: the formal cessation of menstrual periods accompanied by a marked decline in estrogen, androgen, and progesterone levels (32). This menopausal drop in multiple sex-steroid hormone levels is associated with many physiological and psychological changes. These include sleep disturbances, sexual dysfunction, significant mood changes, brain fog, and the onset or worsening of anxiety and depressive symptoms. Menopause treatment primarily involves hormone replacement therapy (HRT) in which estrogen and progesterone are bolstered to relieve symptoms caused by declining hormone levels. Starting HRT before 60 years old, or within 10 years of menopause and before hormone levels reach their lowest levels, is recommended, as after this time women face increased cardiovascular risk, breast cancer, and possibility of dementia from use of HRT (33).

Although the study of how and why the menopausal transition impacts women's risk for mood-related disorders is still in its infancy, extant research has found that these symptoms can vary widely depending on an individual's sociocultural, environmental, and ethnic background. For example, women exposed to more adverse childhood experiences (ACEs) have been found to have more severe menopausal symptoms, and those living in neighborhoods with greater exposure to pollutants report earlier menopause onset (34, 35).

Social determinants of women's health

Research into these biological and clinical differences has revealed that women face unique social and environmental stressors that lead to high rates of mental health conditions, stress, and trauma in women compared with men. Compared with men, for example, women are more likely to be subjected to bias and discrimination, more often expected to fulfill household caregiving expectations in addition to existing work and life responsibilities, more likely to experience sexual and physical violence, more likely to face poverty and food insecurity, and more likely to be exploited (36–38). The combined and repeated exposure to these intersecting and compounding social and economic adversities increases the risk of chronic disease in women and causes disparities in not just lifespan health but lifelong social, occupational, scholastic, and financial opportunity (39).

These health disparities are especially pronounced in disadvantaged racial and ethnic groups, where structural inequities and systemic discrimination exacerbate vulnerabilities to environmental and social stressors. Further, compounding effects of intersecting identities based on race, gender, and sexuality heighten risk. For example, individuals who identify as LGBTQ+, Black, and multicultural are disproportionately exposed to discrimination and reduced access to appropriate resources, placing them at elevated risk of poor mental health outcomes (40, 41).

ACEs also contribute to female-specific risk for mood-related disorders. Women have a higher incidence of ACEs compared with men, which can contribute to toxic stress physiology that alters development and can contribute to long-term cognitive, emotional, and behavioral problems. Indeed, according to a recent survey by the Centers for Disease Control and Prevention, women are more likely than men to report having experienced four or more ACEs (42). ACEs contribute to higher levels of chronic diseases (including heart disease, autoimmune disorders, and cancer), mental illnesses (including anxiety and depression), and unhealthy behaviors in later life (43). Furthermore, one study showed that women with increased ACE exposure had an increased risk of first onset of major depressive disorder during the menopausal transition (44). Therefore, higher frequencies of ACEs among women contribute to another intersection of potential vulnerability, influencing long-term physical and, therefore, psychological health.

The social roles women tend to fill also impact their risk for mood-related disorders. Throughout a woman's lifespan, but especially in older age, women's disproportionate roles as primary caregivers often result in increased emotional demands, elevated stress levels, and poorer health outcomes (37). Additionally, since women live longer than men on average, they are more likely to experience bereavement, widowhood, and subsequent loneliness (45). The combination of the sustained stress of caregiving, as well as the increased emotional burden of social isolation in later life, places women at heightened risk for experiencing greater amounts of stress, depression, and anxiety, as they age over their lifetime when compared with men (46–48).

Relatedly, women experience a higher prevalence of myriad diseases that are often comorbid with depression. More than 75% of individuals with autoimmune conditions are women, for instance (4). Furthermore, osteoporosis, stroke, and heart disease are more common in women than in men and are often attributable to sex-steroid hormone fluctuations or drop-offs, as occurs during menopause (49–51). Depression is often comorbid with chronic illnesses (52), including those previously mentioned, and mechanistically, it has been proposed that periods of hormonal fluctuations change inflammatory processes, leaving women uniquely vulnerable to developing inflammation-related conditions alongside depression (53–55).

Recommendations to advance women's mental health at scale

As we have summarized above, women experience unique hormonal transitions in their lives that impact their physical and mental health and that can affect their ability to manage life stressors in their environment. At the same time, they are disproportionately impacted by several social and environmental stressors that can set in motion biological changes that promote chronic disease risk across the life course (56–58). Together, these influences result in women being twice as likely as men to experience depression and much more likely to experience anxiety throughout their lives (59, 60). Despite this fact, we have few scalable solutions for addressing the high levels of mental health disorders in women.

To ameliorate this sex-based health disparity, more efforts must be made across multiple sectors concurrently. Below, we synthesize the most actionable, compelling, and necessary expert-consensus recommendations made at the recent NASEM workshop on “Essential Health Care Services Related to Anxiety and Mood Disorders in Women” (see Fig. 1 for a summary of these recommendations). Although some recommendations fall outside of HRSA's scope, meeting attendees made clear that efforts within HRSA alone would be insufficient to address this significant health disparity.

Figure 1.

Recommendations to advance women's mental health. A synthesis of the most actionable, compelling, and necessary expert-consensus recommendations made at the recent National Academies of Sciences, Engineering, and Medicine workshop on “Essential Health Care Services Related to Anxiety and Mood Disorders in Women,” organized into five key themes, namely: (1) fund and conduct more women's health research, (2) provide clinicians with better training and support in women's health, (3) widen the pipeline for mental health care services and treatments for women, (4) enact sensible policies supporting women's health and well-being, and (5) strive for better outcomes than the absence of disease using preventative and personalized approaches to addressing women's holistic health and well-being.

Fund and conduct more women's health research

It is difficult to improve health outcomes for women when we understand so little about basic female biology and the mechanisms through which social experiences are translated into poor health outcomes. Recent efforts to increase women's health funding by ARPA-H (e.g. the sprint for women's health) and the Wellcome Trust (61, 62), for example, have advanced this goal, and it is encouraging that these funders have shifted some focus of their women's health research funding portfolios from primarily fertility-related aims to also investigating women's health outcomes and sex-based health disparities more broadly. However, today, the largest gaps in our understanding of women's health are upstream of health outcomes.

At a basic scientific level, we know very little about how women's sex-steroid hormones influence processes related to stress, health, and disease. This stems from a long history of underfunding of women's health: in 2020, just 5% of global research and development funding was allocated to female-specific conditions, whereby this funding primarily targeted cancer research, continuing the legacy of neglect of endometriosis, menopause, polycystic ovary syndrome, and other major areas of concern for women's health (3). Similarly, persisting stigma around women's health has slowed research progress and compounded funding disparities. For instance, endometriosis affects 10% of women but has long been stereotyped to result from lifestyle choices, leading to chronic underfunding despite its continuing disease burden (63). Consequently, researchers cannot presently make strong, evidence-based recommendations about how to improve the well-being of women during the menopausal transition, how to monitor and treat women for mood-related disorders during pregnancy and postpartum, or how hormonal cycling and hormonal contraceptives influence female adolescent mental health, well-being, and development. Without a sufficient body of evidence from which to draw, health care providers cannot provide optimal care to women and girls, and policymakers cannot effectively promote policies to improve women's health outcomes. This problem must be addressed by multiple sectors, and both public and private efforts to fund women's health research are essential.

Beyond funding these efforts, more researchers studying topics in women's health would accelerate the rate of discovery. For researchers not specifically interested in women's health, collecting data on sex as a biological variable (SABV) and reporting results by sex (as opposed to controlling for sex) will allow researchers to begin to fill the knowledge gaps we have in women's health, which are the result of decades of research being conducted only in males and male animals. Additionally, investigating treatment models for mood-related disorders that are scalable and easily translatable to real-world settings should be a primary goal for all researchers who seek to improve mental health treatment options more broadly. These solutions must be designed for and assessed in diverse research samples to ensure that they do not intensify health disparities they were designed to ameliorate or create disparities where they did not previously exist (see e.g. 64). Clinical psychologists have developed many highly effective treatment models for depression and anxiety; however, experts at the workshop underscored that few are easily scaled and translated to real-world settings, limiting their utility. Likewise, without intentional implementation research, with a specific focus on implantation across diverse communities, evidence-backed therapies discovered by researchers will never reach those in need.

Provide clinicians with better training and support

Health care providers responsible for treating mood-related disorders in women are typically primary care doctors, obstetrics and gynaecology (OB-GYN) specialists, pediatricians, psychiatrists, gerontologists, and mental health practitioners. Oftentimes, doctors in family practice or mental health fields receive almost no formal training on how women's hormones and their fluctuations can impact mental and physical health. Despite this fact, family practice doctors and other primary care physicians are often the providers who are responsible for providing women and adolescent girls with their first contraceptive counseling and birth control recommendations (65, 66). Although OB-GYNs receive more formal training on the dynamics of pregnancy and postpartum, they are not trained to diagnose, treat, and manage mental health disorders, which is striking given that PMADs are the most common complication of pregnancy and childbirth (67). Likewise, medical residents receive very little formal training on menopause, if any, leaving >80% of residents feeling unprepared to treat menopausal women (68, 69).

One approach to address these gaps in the long term is to include additional course content in medical schools that covers these topics, such that the health care providers of tomorrow are better equipped to treat their female patients, both physically and mentally. This has already gained traction within psychiatry, where reproductive psychiatry tracks allow students to become specialists in women's health (70). Further, incorporating SABV through all medical education would begin to illuminate the extent to which many disorders are sex differentiated in prevalence, comorbidities, presentation, and response to treatment. Although additional training could be offered to all current clinicians and health care providers as well, expecting all clinicians to become experts in women's health, mental health, and their own specialty is quite a large demand of a workforce that is already overwhelmed.

Clinicians are overwhelmed in part because of what experts at the workshop called “the medicalization of mental health care,” whereby normal emotional and behavioral phenomena are overdiagnosed as medical conditions or disorders requiring treatment. This “medicalization” is increasing due to the inclusion of mental health care into commercial payor essential services. Although it is clear that mental health care is fundamental to health and well-being, experts voiced concerns that insurance reimbursement policies for mental health services are not reimbursed at sufficient rates, are reactionary instead of preventative, are poorly mapped to periods of elevated risk, and are largely designed around men's health care needs and the standard progression of physical health disorders, without consideration for the unique dynamics of women's health or for the unique dynamics of mental health disorder prevention, disease courses, treatment patterns, and long-term outcomes. Often, psychiatrists providing services for mental health conditions results in the same services being reimbursed at reduced rates, typically reduced by 13–20%, compared with what a nonpsychiatrist specialty doctor would receive (12, 71). The added administrative burdens placed on mental health care providers by payors, combined with low reimbursement rates, result in many practitioners being “out-of-network” with payors, especially in low-income areas and health care deserts (14, 15).

To address the strain on clinicians and the limited access to care, several experts at the workshop suggested policies to support the incorporation of behavioral health services into primary care to increase access to behavioral health service providers. However, it is also important to note that incorporating behavioral health services into primary care puts additional responsibility on overtaxed primary care providers. To support these clinicians, providers need additional lifelong training in behavioral and women's health, more time per patient visit, and tools to facilitate effective clinical decision making.

Beyond more time with patients, health care providers speaking at the workshop consistently stated that they need more reimbursement for mental health care services and more integration of care across specialties. Although we should work toward a more holistic, whole-person, integrated system of health care, one intermediate step is to include care coordination as a reimbursable service, even for patients who do not require complex case management. If care coordination services and routine health check-ins with patients were more easily reimbursable services, care coordinators could monitor patients and help prevent the onset of difficult-to-treat mental health disorders by recommending clinical intervention before a problem takes root. By sending the correct patients to the correct service providers at the correct stages of dysfunction, inefficiencies in health care delivery systems can be reduced, although this alone will not solve provider shortages, which we discuss in the following section. Additionally, because care coordination is not a standard service covered by payors, providers are often unaware of services being provided by different specialties. In older women, this lack of care coordination can result in overmedication and missed indications of mental health symptoms as they arise (72). Overmedication occurs when side effects from one drug are treated by another, often with the medications being prescribed by various specialists across time, resulting in overlapping and interacting effects that decrease quality of life for the patient. Likewise, because many medications can cause side effects similar to depression, a patient may be experiencing and reporting depressive symptoms that are mistaken for drug side effects, such that their depression is left untreated.

Health insurance payor policies, while not always well-aligned with clinician and patient needs and priorities, are at their roots designed to deliver safe, effective health care at scale. To make meaningful change in these systems, payors need evidence that reimbursing increased time with patients, routine checks on complex care cases, care coordination at all levels, and preventative services will reduce health care costs over time. Research focused on the economic benefits of advancing women's mental health is needed to substantiate these demands.

With this in mind, academic and clinical partnerships can be an especially fruitful way to demonstrate the benefits of systemic changes to payor policies. For example, Expect With Me is a group prenatal care model developed collaboratively by researchers and medical professionals to address high rates of preterm birth, low birthweight, and racial disparities in birth outcomes in the United States. This program includes brief individual checkups in combination with facilitated group discussions about pregnancy, childbirth, and wellness while encouraging connection among group members and providing access to online educational resources (73). In an effectiveness-implementation trial in a diverse sample of 2,402 women, when compared with individuals receiving individual care only, Expect With Me patients showed a 58% lower risk of having a preterm birth, 63% lower risk of having an infant born with low birthweight, and 37% lower risk of admission to the neonatal intensive care unit (NICU) (74). Likewise, one workshop speaker, Dr Ebony B. Carter, described EleVATE (Elevating Voices, Addressing Depression, Toxic Stress, and Equity in Group Prenatal Care Women's Collaborative), which is a community-based prenatal care program in St Louis (75). In a pilot sample, women in EleVATE (n = 23) who engaged in the group-based behavioral health techniques had no preterm births, compared with 18% of women in the general population of St Louis (75). Although results are preliminary, as more data become available, a stronger, more compelling case can be made for reform to payor policies by demonstrating that improved health outcomes at reduced costs can be achieved through these types of community-focused, research-grounded initiatives and could be expanded to individuals in other age groups, including during menopause or puberty.

Widen the pipeline for mental health care services and treatments

Although improved training for clinicians and evidence-backed reform to payor policies to support effective clinical services are vital, the current workforce of clinicians is not large enough to manage the problem at hand. This is clear in large cities such as New York, where despite a high number of providers, both providers and patients report that mental health services are inaccessible to most due to workforce shortages (76). Intensifying the workforce shortages, many effective therapeutic treatments for depression and anxiety are designed to be delivered in a one-on-one setting by a highly skilled clinician and are not scalable to meet the demands of the population in need. Widening the pipeline for mental health care services will require a wide variety of practitioners—nurse practitioners, physician's assistants, marriage, couple, and family counselors, masters of social work, and other community health workers—to be a part of the solution, reimbursed for their services, and trained to deliver effective treatments and services.

Providers need more scalable, effective, and evidence-backed solutions in their tool kit. Examples of scalable solutions include group therapy, telehealth, and online support services. Creating, testing, and especially implementing additional scalable solutions in this space is critical. The demand for behavioral health solutions has grown large enough to attract private companies, although commercial payor payment models can hinder growth in the health technology space. Supporting these start-up companies could help accelerate the implementation of innovative solutions that increase the availability and accessibility of services to those in need. However, ethical safeguards must be in place to ensure the efficacy of treatment approaches, given the misalignment of incentives in the private sector with public health needs.

Currently, federal mental health parity acts mandate group health insurance plans to cover mental health and substance use disorder services; however, these mandates have done little to increase the accessibility of such services, resulting in limited mental health care services being available to those who need them most. COVID-era policies for Medicare and many group health insurance plans recently enabled increased access to telehealth services, removed geographic restrictions for providers, and increased reimbursement for mental health services. Many patients have generally reported easier access and reduced stress in accessing care, though experiences are not all positive (77). Although the future of virtual care coverage is currently uncertain for Medicare recipients (78), these policy approaches have demonstrated a potentially promising avenue for extending accessibility.

Various studies have demonstrated the clinical efficacy of telehealth care in vulnerable populations. For instance, in one study examining treatment approaches for veterans with posttraumatic stress disorder, individuals were assigned to receive the same treatment delivered using telehealth or in-person in a traditional office visit. Results revealed no meaningful differences between the groups, with both showing similar treatment effects at follow-up (79). In fact, some patients preferred telehealth visits for mental health treatment due to the sense of security and sanctuary offered by the distance inherent in the modality (80). Thus, with proper implementation, widespread telehealth availability could make a meaningful contribution to increasing the accessibility and ease of mental health care, especially for vulnerable or disadvantaged populations. Beyond the COVID-era policies that expanded care across state lines, some—but not all—states already allow out-of-state providers to practice telehealth in their states through specific registrations (81). By further expanding the ubiquity of this promising technology, the mental health workforce can be made more accessible, expanding access to care for providers and patients alike.

Another approach to ameliorate this problem is to bolster community-based models that include triaged care, similar to models used in grief, substance abuse, and alcohol abuse spaces (82). Beyond just widening the mental health care pipeline, this approach also dramatically increases the likelihood that patients will have access to support from someone who shares elements of their identity, which increases acceptability of treatments, decreases stigma, and improves patient outcomes (83). Further, training a workforce to deliver front-line mental health care services, home health care services, and care coordination services would provide economic opportunity within communities, if appropriately reimbursed. Grounding front-line mental health care services within community-based settings helps to reduce stigma around mental health concerns and improve the cultural acceptability of intervention programs and treatments. For example, “psycho-hairapy” is a creative community-based approach that could help in reducing mental health stigma, especially in Black communities, if effectively implemented (84). In this model, hair stylists and estheticians are taught micro-counseling techniques and given resources on key topics in mental health, empowering them to foster healthy conversations and recommend available resources to others in their communities. To bring other creative solutions similar to this to light, funders such as the NIH could require grant applications to include appropriately compensated community members alongside principal investigators to promote more effective, community-based solutions at each stage of the research process that result in a larger community-based, front-line mental health workforce after the research grants have been completed.

Payors have the power to support the creation of a community-based, front-line mental health care workforce by providing reimbursement for services by this expanded workforce. In this space, population-based payments tied to performance would enable greater flexibility in service delivery and provide more meaningful, outcome-based financial incentives than current fee-for-service models and should be explored. Beyond commercial payors, Medicaid coverage of doulas, care coordination, and community-based mental health care services are key steps, but these services must be covered at reasonable rates. For example, although Medicare does cover some doula services, they do not reimburse these at a living wage, and many services provided by doulas, such as postpartum checkups and extended support, are often not covered (85). One actionable workshop suggestion to grow this workforce of front-line, community-based mental health care providers involves creating student loan forgiveness incentive programs to encourage care providers to accept Medicaid and provide services to marginalized and underserved populations.

Enact sensible policies

“Programs are short-term interventions that create temporary improvements in the wake of challenges. Policies, on the other hand, are covenants we collectively choose to live by, as articulated in legislation and regulation. They inform our socially accepted mores and ethics.”—Reverend Starsky Wilson

While it is illegal in many places, including 26 US states and in the United Kingdom, to separate puppies from their mother before they are 8 weeks old (86), no such laws exist for women and their children. Consequently, one in four American women return to work within 2 weeks of giving birth, almost always citing financial strain (87). The US federal government does not mandate that women be provided with any paid maternal leave, despite guidance from the American College of Obstetricians and Gynecologists that at least 6 weeks should be taken for postpartum recovery (88, 89). Maternal and family leave policies are thus in desperate need of reform.

Although some workshop experts stressed that parent or family leave policies (as opposed to strictly maternal leave policies) should be mandated, workshop experts agreed that at the least, maternal leave policies must be instituted to ensure the health and well-being of mothers and their children. As of the workshop meeting date, 14 states and Washington, DC, had instituted mandatory access to paid family leave; however, several workshop experts felt as though this policy should be mandated by the federal government given strong evidence supporting the multifaceted benefits of family leave policies (90).

Another way that policy reforms could help to mitigate the high rates of mood-related disorders in adolescent girls may be to restrict social media use. Although it is not yet clear if social media use negatively impacts all users and the mechanisms through which using social media can impact mental well-being remain unclear, there is a large body of evidence that finds that social media use in adolescents is associated with anxiety and depression and that these effects are stronger in girls compared with boys (91–93). In December 2025, Australia implemented a national ban on social media use for children under the age of 16 (94). This first-of-its-kind social media policy does not punish those that use social media “underage” but rather requires the social media platforms themselves to regulate the ages of users, imposing large fines on companies that do not take reasonable steps to ensure users are at least 16 years of age. The impact of this policy on adolescent girls’ rates of mood-related disorders should be closely monitored. If effective, such a policy could be implemented in the United States as well, as one way to improve adolescent girls' mental health before the age of 16.

Beyond sensible parental leave and social media policies, the caregiving system in the United States more broadly relies heavily on uncompensated caregiving to fill gaps left by our health care system, the burden of which is primarily born by older women. In 2025, >63 million Americans served as unpaid family caregivers, representing a 45% increase over the past decade (95). If compensated, this work is estimated to be worth >$1.1 trillion (89, 96). Caregivers are primarily older adult women and especially women of color (97). This uncompensated caregiving is stressful, and caregiving stress is tightly linked with accelerated aging, increased dementia risk, and worse mental and physical health (98). Policies requiring payors to provide more straightforward coverage of caregiving and home health services delivered by community members is another opportunity to widen the pipeline for care services that could also reduce the burden of caregiving stress on Americans, and older women more specifically.

Strive for better outcomes through personalized, preventative approaches

The current health care system in the United States is largely designed to treat disease and operates within tight economic margins; however, wellness is not simply the absence of disease. As a technologically advanced, wealthy nation, the United States should strive for a health care system with loftier ambitions. Within a capitalist market, even under conditions of abundance, it is highly unlikely that any system, including the United States' health care system, will exceed the goals it was designed to achieve—when these systems fall short, people suffer from preventable and treatable disease. Instead of accepting a system that only aspires to effectively treat disease, the health care system could be modified to prioritize prevention and well-being before disease is realized. A system designed to promote health, as opposed to one designed to treat disease, would have larger margins of error between suffering and success than the reactionary, disease-focused model currently in use. To realize this possible future, a few preliminary steps should be considered.

First, instead of focusing on treating mental health disorders after they have occurred, clinicians should be incentivized to detect preclinical risk processes and prevent mental health disorders from taking root. In our current reactionary payor model, clinicians who check in or intervene prior to the full onset of a diagnosed mental health disorder are not typically eligible for reimbursement for these services, causing higher payor costs and a much greater disease burden in the long run. Screening for early signs of mental health concerns is critical, especially in at-risk populations. For example, screening for ACEs, a risk factor for nine out of the ten leading causes of death in the United States today (55, 99), during traditional doctor's appointments is now a billable service in California, thanks to the ACEs Aware movement (100). By providing a $29 reimbursement per screening with appropriate referrals for those at elevated risk, providers are incentivized to screen for ACEs and provide referrals or services for those who are at elevated risk. Effective implementation strategies and lessons learned from this movement could be applied to other preclinical risk factors, especially during periods of hormonal changes in women. As mentioned, postpartum depression is the most common pregnancy complication a woman can have, and yet it is not routinely screened for (101). Beyond increased screening, shifting focus to prevention requires increased availability, access, and acceptability of community-based, front-line mental health resources and interventions. Making a more prevention- and resilience-focused mental health care model a reality will be challenging but can be done with governmental policy, private/industry efforts, and payor support.

When prevention fails, treatment becomes necessary. However, the most promising scalable mental health treatment models of tomorrow are not the one-size-fits-all treatments being used today. Personalized and precision medicine approaches that consider whole-person health are showing great promise in clinical studies (102–105). Experts at the workshop highlighted the promise of integrating adaptive, personalized assessments into health care records, which can be used to identify the specific needs of a patient and the therapeutic approaches that an individual is most likely to adhere to and benefit from. For example, if a clinician today has a patient who shows signs of depression, they might recommend cognitive behavioral therapy, interpersonal therapy, mindfulness-based gratitude practices, one of four front-line antidepressant medications, or a handful of behavioral or lifestyle modifications—all of which are evidence-backed depression treatments, but some of which will not be effective “for their specific patient.”

This issue of precision in treatments becomes more important when providers are overburdened. For example, family practice doctors are often tasked with prescribing contraceptives to adolescent girls. There are hundreds of different formulations of hormonal contraceptives on the market today, with emerging research highlighting that not all women and girls respond to all formulations of hormonal contraceptives with the same side effects (23). Beyond effective pregnancy prevention, some contraceptives, in some girls, have a dramatic and potentially lasting impact on their mental health (24). Technological advances with decision aids that help providers find the best contraceptive options for each patient have the potential to dramatically improve women’s and girls' experiences with contraception while also reducing the burden on family practice doctors (106). Similar tools could aid in treating mood-related disorders by primary care physicians as well. With personalized approaches, the number of treatments that patients and clinicians have to cycle through to see results will be reduced, in turn reducing health care costs and demand on clinicians and improving health outcomes, especially when mental health conditions are being screened for and addressed within primary care.

Finally, multiple workshop experts stressed the importance of holistic mental health care services, which foster meaning, incorporate spiritual and community connection, incorporate nature, elevate purpose, facilitate belonging, and inspire connection to a greater purpose than oneself. These are not simply feel-good exercises; rather, they are psychosocial approaches that have been shown to improve mental and physical health, increase resilience, reduce aging, and foster greater meaning, purpose, and joy in life (107–113). We have a solid research foundation to support incorporating meaning, purpose, belonging, and community into standard practices of care—now we need to act upon it.

Conclusion

Now is the time to take women's health seriously. The recent workshop convened by NASEM, titled “Essential Health Care Services Related to Anxiety and Mood Disorders in Women,” provides a strong blueprint for how we can accomplish this by addressing long-standing opportunities in women's mental health research and care. In Fig. 2, we depict what a multipronged approach to ameliorating sex-based health disparities in mood-related disorders could look like. Pursuing the five aims described above and in Fig. 1 will require substantial advocacy, persistence, and expertise, requiring consistent support across multiple sectors. However, the payoff will be immense—namely, a world where women can live healthier, happier, more productive lives, in turn fostering stronger, more resilient communities for all.

Figure 2.

A multipronged approach for addressing risk for mood-related disorders in women and girls across the lifespan. Decreasing the sex-based health disparity in mood-related disorders will require substantial efforts across multiple sectors (see y-axis). Here, we highlight a few key approaches that could be implemented across the lifespan, anchored around key hormonal transitions (see x-axis). Screening for mood-related disorders at each of these hormonal transitions would enable intervention to occur when needed. The most-successful intervention approaches may vary across the lifespan. Here, we suggest focusing on developing and using scalable intervention approaches for adolescents that teach and encourage practicing skills (e.g. emotion regulation), community- and lifestyle-based interventions for adults, and meaning-based interventions for older adults. Educating health care providers about the key hormonal transitions women experience, including hormonal contraceptive effects, depression and anxiety treatment options, premenstrual disorders, and PMADs, and the menopausal transition and hormone replacement therapy (HRT) is crucial for advancing health care parity. Both governmental (e.g. United States HRSA) and payor policy initiatives will be needed as well. Policies that limit social media use in childhood, ensure adequate maternal leave, and compensate caregiving, along with reimbursement of mental health services to prevent the onset of disorder, prior to a diagnosis (Dx), reimbursement of doula services at a living wage, and reimbursement for care coordination have the power to make large, lasting, and meaningful changes in rates of mood-related disorders in women and girls.

Competing interest

The authors declare no competing interests.

Funding

The authors were supported by grant #OPR21101 from the California Governor’s Office of Planning and Research/California Initiative to Advance Precision Medicine. The recommendations and conclusions in this article are those of the authors and do not necessarily represent the views or opinions of these organizations or the National Academies of Sciences, Engineering, and Medicine, which had no role in planning, writing, editing, or reviewing this article, or in deciding to submit this article for publication.

Author contributions

Summer Mengelkoch (Project administration, Visualization, Writing—original draft, Writing—review & editing), Kimya Afshar (Writing—original draft, Writing—review & editing), and George M. Slavich (Funding, Project administration, Supervision, Writing—original draft, Writing—review & editing)