Women's mental health: Prof Jayashri Kulkarni public lecture

Women's mental health: Prof Jayashri Kulkarni public lecture

Professor Jayashri Kulkarni is Director of the Monash Alfred Psychiatry research centre (MAPrc) within the Central Clinical School (CCS) of Monash University. In 2015 she gave the annual public lecture hosted by CCS on “Women's mental health: It's getting tougher”. See more:
* Q&A session https://youtu.be/KOrSQaTfhBI
* Australian Women's Mental Health Consortium announcement https://youtu.be/_YoPKpAZ9Lo
* MAPrc http://www.maprc.org.au/
* CCS http://www.med.monash.edu.au/cecs/

thank you is all round first of all thank you very much to central clinical school to steve jane for inviting me to give this use public lecture thank you so much to the people in central clinical school julie of each where are you there you go Thank You Julia to you to dusty and so many of the people in central clinical school to the people who are Manning the cameras and so on it's fantastic that you put so much effort into this this public lecture but to my dear friend and colleague Dame Quentin Bryce thank you thank you thank you for so many things thank you for coming down here today braving Melbourne traffic and public on a Friday evening but thank you so much for all that incredible work that you've done in the past that you're currently doing and that I'm sure you're going to do in the future for the women of Australia you are undoubtedly a national treasure and we all salute you we all love you and we want to keep working with you thank you again for a brilliant talk okay women's mental health is everyone's business now I really want you to keep that in mind as we go through the talk tonight I might even get you to chant it from time to time but I really need you to remember that statement because this is not secret women's business it's not women's business for women women's mental health is everybody's business here are some statistics I can't help it I'm an academic I need my stats but you know that in Australia and these are figures from the National Survey of mental health and well-being 2007 now a little bit old but the data still stands in Australia 43 percent that's 3.5 million women had experienced mental illness at some time in their life 22 percent of Australian women compared to 18 percent of men had experienced symptoms of a mental disorder in the 12 months prior to this survey 18 % of women compared to 11 percent of men experienced anxiety disorders 10% of women compared to five percent of men experienced mood disorders like depression and here's an awful figure as well 15 to 30 percent of women report depression after childbirth now the eating disorders numbers are difficult to get because it's hard to actually capture the data about various dieting and various other types of eating disorders but we know clinically that women experience eating disorders far more than men and the deliberate self-harm figures are twenty times greater for women than men now mental health just like other areas in health is gendered unfortunately we tend to think of a patient as a patient as a patient or even worse we tend to think of a patient as a 70-kilogram man as the stereotypical patient but there is a gender aspect to mental health and when we think about it what comes up is that men and women have different patterns of mental illness and other forms of distress they are subject to different risk factors and vulnerabilities there are a number of different theories that have been put forward to try to explain the prevalence and differences in mental health problems I like to go to the bottom of this slide which is a biopsychosocial approach now it's basically saying we need an integrative approach if we think about the bio or the biology we're talking about those things that happen in women's bodies combine that with women's personality or psychological aspects combine that with women's lives or the social theories that impact on women if we look more specifically we know that in the biology we have hormone impacts we have gender differences in drug metabolism systems we have differences in brain circuitry we have differences in genetic transmission of conditions in the psychology we know that psychiatric illnesses can present very very differently in men and women because of gender differences in psychological responses and defense mechanisms socially as Dan Quentin has referred to we are very much aware of the impact of violence poverty gender inequities in wages power and social roles that impact on women's mental health currently unfortunately friends mental health in women or women's mental health is not a national priority that's going to be one of our goals is to create a national priority to improve women's mental health it really is not good enough that we are ignoring sometimes the impacts in the way forward for women because improving women's mental health is intimately tied to improving her well-being and productivity but also the next generations outcomes and the mental health of her family as well as our general community women's mental health is everyone's business now I am a clinician and I am a researcher so I'm going to tell you four different women's stories these are real stories but obviously I have changed the names and it's not the real picture in order to preserve confidentiality Mr stared out of her window she gaze down into the courtyard and she loved doing this because down in the courtyard was a swing the swing was a little bit rusty now and the seat was a bit broken but it brought back memories for her of when she was four years old and she could sit on that swing and she would kick her legs up in the air and try to move as far forward as she could she'd laugh and she'd tell her dad that she was going to touch the sky he laughed as well these were good times Emma recalled them with great joy but that was five years ago here she is at age nine and life is not good for Emma her father is not there and she misses him but she also misses her mother who is physically there but somehow not quite there and then there's Jeff Jeff moved into their house about two years ago Emma hates Jeff she hates the way he looks at her she hates the way he talks to her most of all she hates the smell which is that of beer it's there all the time Emma got into her bed and she could hear outside her bedroom door screaming and crying and a loud thud her heart started beating faster and faster and her breathing sped up as she saw the doorknob slowly start to move she smoked the beer smell gets stronger and stronger she burrowed underneath the dinner as much as she could but he staggered into her room and into her bed let's fast forward ten years Emma stared at herself as a 19 year old in the mirror she didn't really recognise the woman who stared back out at her she was more than a hundred kilos in weight she had hair on her face she felt terrible about the way she looked she felt even worse about the way she felt about everything inside was this cauldron of rage of hatred but she didn't really know where to focus it she felt absolutely terrible about herself she constantly felt that she needed to be punished because she was a bad person she looked down at her forearm and she noticed the slashes on her wrist that she had done over many years Emma felt bad she felt like a bad person she stared in the mirror and thought what is there for me in this world now Emma's story unfortunately is very common and as Dane Quentin said with the increasing epidemic of domestic violence family violence we in our clinic which is held on Thursdays at the Alfred are seeing more and more Emma's at younger and younger ages emma has a diagnosis of borderline personality disorder let me tell you about this condition it's got a ridiculous name the dsm-5 which is the psychiatric Bible call this condition borderline personality disorder I mean what an absolutely useless term if you try to tell somebody that they have borderline anything the first thing that comes back is well do I have something or do I not have something typical psychiatrist you can't make up your mind and then if you tell someone they have a personality disorder I mean the personality think about it that's what is you that's what makes you a unique human being if you tell somebody that that which is unique is disordered you know you're writing them off they may as well not exist so borderline personality disorder which is a term from 1938 is still with us is hated by consumers and is absolutely useless in terms of having any therapeutic kind of alliance with the person that we're trying to empower and build up to get over the horrible traumas in her life so in our clinic and also in conjunction with people who are a wonderful service spectrum within Victoria which is dedicated to this condition we we meet regularly and we have decided that even though dsm-5 has this official terminology that our unofficial terminology is complex trauma disorder why as I've Illustrated with Emma's story there is a trauma behind what she's experiencing the symptoms that people feel with this condition are vague and diffuse and that makes it difficult because they have deep feelings of insecurity there are there's a fear of abandonment a fear of loss there's rage there's anger there's a fragile sense of self there's dissociation which is where there's a split in themselves and they sometimes feel like you know they're watching their life rather than living their life there is self-harm and it can have a mortality there is persistent impulsiveness and confused contradictory feelings people with this condition it's a mimicker of other conditions which makes it difficult to diagnose because they might have anxiety or mood disorders or may even experience psychotic symptoms from time to time importantly and this is something we're trying to educate our colleagues in primary primary health is that these symptoms can get into abeyance in the 30s and 40s but then my goodness it erupts with a vengeance back in the 50s and that's not well understood but it is another set of time when a woman can go through this living hell the condition is complex it's hard to diagnose because of all these different symptoms what causes this condition Emma's case is illustrative I chose that case because it is very very much indicative of what we're seeing in our clinic 85% of cases described early life trauma of many types sexual physical trauma loss trauma many different traumas but there is a trauma there's early life deprivation often with loss of and disruption of primary care from the primary caregiver who is often mother there's early life privation in the worst cases where there has been no real maternal of a primary care and that's in 85% of cases now of the of the whole group 75% of the sufferers are women so you can see why I'm caught up in the women's mental health area of trying to advocate and get something done for MS of this world 15 percent of cases there's no discernible trauma and there are genetic factors we think at play now along with if it's not an you know it's not bad enough to have all those psychological issues along with that these women also have obesity diabetes infertility abnormal menstrual cycles chronic fatigue fibromyalgia and also have an increased susceptibility to infections in general so glandular fever is common and so on why is this all going on here's a simplistic diagram my apologies to the biologists in the audience but we have the stress here and in chemists a so you obviously realize what the stress is and you have a threatening situation that leads to changes in the hormone output so there are increased elevation of cortisol hormone which is a stress hormone it doesn't more than that but it is synonymous with the stress hormone this this hormone goes up and and stays up we all have cortisol fluctuations but in particular in chronic stress and particularly in a child who can't make head or tail out of this terrible set stress this hormone goes up the hormone has many effects in many other places in the brain here is an example and I'll explain what happened here this was an experiment where people were given cortisol and this is their verbal memory performance so specific tasks when they were given that extra cortisol they performed very badly in in verbal memory so this is going on in the brain of these people and women particularly children girls who are who are stressed that they actually have great difficulties with learning with new memory because of the stress having an impact through the hormone and it continues on as the stress continues on now I want you to memorize this immediately and I'll test you on it later but here we have the cortisol releasing hormone and I the only thing I want to tell you about this is basically as I said it impacts on the reproductive hormone axis so this actually does it start to explain a bit about why women are more sensitive to it and also why we have all those other changes the infertility changes the issues with premenstrual exacerbation of this condition and so on because there's a biology behind this that is interacting constantly and chronically with the psychology and the social aspects so if you if you think about it what we have is we have trauma abuse of whatever type and then that goes on to cause the ongoing biological and psychological damage which then goes on to create chronic stress disorders which then impact adversely on self-harm right were causing self-harm but with rage and that impacts on relationship and work issues so relationships fall down work performance or school performance falls down and then you can almost see that there's a reit Ramat izing because now we've got someone who hasn't got any support in terms of relationship now you've got someone who hasn't got any finance and again that's reach Ramat izing so this horrible cycle can go round and round and this is ladies and gentlemen what we're facing with the downstream effects of family violence and physical violence against women our research has taken this this particularly difficult condition but but we feel very strongly about trying to get something done so we're looking at new treatments and we're developing new treatments for girls women and also men who experience chronic traumatic disorder so a complex trauma disorder the hormone treatments we're looking at particularly for women but we're also looking at new clinical approaches by linking the trauma with biological changes we're also as I said on a campaign to rename this condition we're working in special psycho therapeutic techniques and we're also doing a of Education of General Practitioners and other health professionals and also the general public to try and get less stigma for people who have this condition and a better outcome overall I'm going to talk now about a different set of conditions and this is hormones and mental illnesses in women this is a story of Sharon Sharon found herself at 3 o'clock in the morning lying on the bathroom floor with her cheeks pressed up against the bathroom tiles the tiles were cool this was a great relief for her because she just felt so hot with these flushes running through her system and as she was lying there with her face up against the bathroom tile at 3 o'clock in the morning she reflected what a strange place for a 50 year old to be in she thought about her day what a horrible day she'd had she was a director of the large company and she'd been at work as usual but she just felt that in the last few months she's really struggling really struggling hard to keep up with her work things that came easily to her she juggled four or five different tasks effortlessly and now she was really having to think hard about each thing she was convinced that the people at her work we're talking about her behind her back and saying oh you know the old girls had it she's past it maybe we ought to get a new director and then worst of all when she left work she couldn't remember where she'd kept her car finally she found her car she got in and to drive home she had a major panic attack while she was on the road first time ever in her life she had everything heart racing feeling sweaty couldn't think it was awful when she got home her husband and two adolescent sons started to ask her about what's for dinner and she felt really annoyed that they couldn't notice that she was going through hell she also felt that in the last few months basically this is happening more and more that there were more fights there were more bra they just didn't get that she was going through something what was going wrong with her she just wasn't the sharon that she used to be in fact she couldn't remember the last time she had a good belly laugh Sharon is experiencing what we call peri menopausal depression peri around or associated with the menopause my good friend Janet Mitchell Moore and Jane Fisher from the gene Hale Center focus a lot on on this particular area as well as other issues but it is an issue that is not well recognized and not well known in our general community and we lose many many women to this condition there's a very high incidence of first-time-ever depression in this age group in this middle-aged age group these are the women of course who are the mainstay of senior staff in nursing profession and other professions these are women who have great responsibilities to bring up the adolescent children who may have responsibilities for their elderly parents so a real linchpin in our community but there are women who have passed histories of depression have done really well and then they relapse at this time there is a 16 fold increase in depression in 42 to 52 year old women that's huge you know it 16 times increased risk of depression in this group so we think this is obviously due to the decreasing or declining hormone function that starts to begin from the age of 43 brain changes occur well before body changes and that makes it difficult to pick this particular type of depression so the brain changes in the depression and anxiety can happen up to five years before there are hot flushes when everybody knows what's going on the fluctuations in estrogen in fact appear to cause this depression the symptoms are plummeting self-esteem paranoid ideas aggression disconnection no libido irritability and agitation weight gain despite sensible eating and ex sighs poor sleep which then becomes compounded by hot flushes and has its own repercussions memory and concentration changes and panic and anxiety none of its pleasant as you can see in our research center we spend a lot of time working on new treatments but we're also working on trying to get recognition of this condition so that it doesn't become that thing which nobody knows what to do about we are working with in a clinical trial we've got some interesting excellent results there's an NH and MRC supported clinical trial using a safer amount of short-term hormone treatment we also work with a different antidepressant approach some of the standard antidepressants the SSRIs Prozac is one of them can actually make this condition worse and that's an issue that we need to get the knowledge out there about my very dear friend and colleague dr. Rosie Worsley who works with me in this in the clinic it brings her endocrine expertise to our work and it's an interesting combination of psychiatrist and endocrinologist seeing patients together we tackle the physical health we look at the whole person because we're tackling weight gain wine consumption now it's really significant that we have this issue where you know in many of our clients we find that they quite often will be drinking three or more glasses of red wine per night why because this is a self medication attempt to deal with anxiety to deal with depression to de-stress after a day's hard work and the worst thing is of course that has many many of its own side effects and see Kweli I was talking about this to a group of nurses and again senior nurses often experience this and they were telling me that they often drink or the women in the room many of them said they often drink quite a lot of red wine per night they tried to reassure me and said we only drink the good stuff though didn't reassure me this is an issue that we need to tackle in our clinic we also work with the complementary medicines because many women do use and have some faith in their complementary medicines no good us going don't do that what we need to do is work with the with the women we're seeing so we have learned about complementary medicines and work alongside the other medicines as well in other research we've been working with hormone interventions for many years and here's his a description of some of the papers that we've published in particular looking at estrogen in the treatment of schizophrenia as an interesting way of actually looking at the gender aspects in schizophrenia and then doing something that is a targeted approach in schizophrenia I want to now talk to you about pregnancy and mental illness Jenny's story jenny was 21 when she was first diagnosed with schizophrenia after her diagnosis it took about four or five years to stabilize Jenny's mental state many different medications were tried hospitalization after hospitalization and eventually a medication was found that suited Jenny and actually took control of her symptoms so she didn't any longer have the voices talking to her constantly and talking about her as well also the sense that she had that people were trying to hurt her disappeared when she was taking the medication Jenny did very well she was able to recover from her psychosis and she did so well that she was able to go to work she began work in a menswear department in a in a big department store and it really enjoyed her work selling shirts and ties she met Peter who became her boyfriend and later on living partner so Jenny and Peter were quite happy she did not however tell Peter about her past history when she was 28 Jenny developed a Jenny Jenny became pregnant it was an unplanned pregnancy but it was a wanted pregnancy she had still been taking her medication and when she went to her general practitioner he said to her that because there was no information about this medication safety in pregnancy that she should stop taking the medication because otherwise her unborn baby may have a whole lot of side effects so Jenny complied and she stopped taking the medication within four weeks the voices were back the delusional thinking and being paranoid about people around her had returned peter was horrified because he had no idea that she'd had this illness and of course now this was back and it was absolutely awful unfortunately Jenny's condition meant that she had to be admitted to hospital and in hospital there was another whole problem because the staff in the hospital also didn't know how to treat Jenny's symptoms because there was no evidence for what to do with the new medications so she was treated with a combination of old medications which only partially contained the symptoms so she was still unwell and could not be discharged so Jenny stayed in hospital for a long time she got to 36 weeks of pregnancy and it was decided that she should have a cesarean section to deliver her baby so she had a cesarean section under a general anesthetic the baby was a little flat but okay but needed to care in a special care nursery the baby was transferred to another hospital now Jenny had a general anaesthetic so she didn't actually see the baby before the baby was transferred her baby daughter she was admitted to the psychiatric ward and there for the next three or four weeks she started to gain ground she did well again because they put her back on the medication that had stabilized her in the first place so she did well and she achieved the level of mental health that she'd had before but she hadn't seen her baby Peter had been awarded custody of the child now in Victoria the custody of an unborn child can be given away from the mother if the mother is deemed to be unfit and that's exactly what happened in Jenny's case so the custody of the child went to Peter and he and the baby moved to a new address and he did not tell Jenny where they were moving the psychiatric staff engaged a number of legal practitioners advocates social workers everybody working together to try to get Jenny access for her child to see her child to have involvement with her child but as we all know the wheels move slowly in these systems Jenny became increasingly desperate to see her baby daughter who she had not seen and was now 12 weeks old she became increasingly depressed that's understandable she hadn't seen her child Jenny was treated out of hospital by the community treatment team they went to do a home visit they found her dead and she left a pink jumpsuit with a letter attached to it that said dear Chloe this is the name I chose for you I'm sorry but I will never see you have a good life your loving mother Jenny colleagues in medicine and health profession in general know that sometimes our patients stories touch us to a point where you just have to do something you really can't let go of that particular case because you absolutely feel tormented that something needs to be done and it needs to be done now that's what Jenny's case has done it has done for me to me I was involved at the end stage in supervision of the of trying to actually get some of the root cause analysis done for this patient which is to work out where did things go wrong and what happened is in my thinking it was very clear that the part that really went astray was that no one had the medication information and safety about how to treat this pregnant woman who needed treatment that we didn't ever have that that information and it was not available worldwide so in 2003 spurred on to do something about Jenny and to prevent further Jenny's I set up the National Register of antipsychotic medications in pregnancy called n ramp this is a this is a survey a quick a quick glimpse of the participating centers around the country and my very dear friend and colleague Heather Gilbert who runs this study we've received enormous support from colleagues all around the country and what we've done is collect demographic and collect a lot of data on the women who have to have needed antipsychotic medications in pregnancy because our aims in this study is to examine and report on psychiatric medication safety during pregnancy to improve the treatment options for people who do need this kind of medication and to formulate evidence-based guidelines and to export best practice to the country and the world to assist clinicians and their patients in making informed consent decisions about medication and to raise awareness of improving health outcomes for both mother and baby I'm thrilled to report that in fact we've had several publications now we routinely receive calls emails both Heather and I from people in Australia and from overseas to ask us because we have the only database in the world that has this information which would surprise you because you'd think by now that surely there's there's something going on about this but I can tell you that in fact the only work done in this area is it's a sort of the standard registers which is where you just look for congenital malformations or you know where the limbs and malformed like in the thalidomide story that's not the problem with these medications but what we need to be able to say is are these medications safe for the child's development in terms of learning progress at school in the future and so on so we will continue to labor on with the study which is continuing and a whole range of outcomes are coming from this work here is a picture of a real woman who has given us permission to use her slide use her photo and she's been in the study and has three beautiful children as you can see who are very very healthy and doing very well and we're very grateful to Mariska for being an ambassador for the enwrapped study and she has talked about her story in public on many occasions and will continue to do so my last story Tara Tara found herself in the check out of Safeway screaming at the checkout chick with torrents of abuse and foul language coming out all about the cost of a bunch of bananas so this was something that really shocked Tara herself it shocked everyone around her and it shocked her boyfriend who had never heard Tara use such language in the 18 months that they'd been together what was going on with her he noticed that in the last three or four months that in fact she really hadn't been herself at all they'd moved in together into a lovely apartment last year and they had great fun decorating it they had people over for dinner they went out to the movies they were really enjoying life Tara was working as a marketing executive and doing very well Tara herself over the last five months kept noticing that she just didn't have any joy in her life the joy had disappeared and increasingly she was irritable absolutely prickly about not much at all and if somebody's made a comment she often had a missed perspective on that comment and kind of jumped down her throat like she was doing it Safeway for no apparent reason she went to see her local doctor and she said to a local doctor you know ever since I went on that brand of pill or a contraceptive pill things have not gone well he said well I think you should look at your relationship you might be having difficulties there you might be having difficulties at work and another time when she went to see the another person working in that practice he said just pull up your socks and get on with it there's nothing wrong with you we saw Tara and we see many terrors in Oakland and in fact one of the things that we were able to do was we changed her oral contraceptive pill type and within a week Tara came back to see me especially to let me know that she'd been at Luna Park they've gone on the roller coaster at the height of the roller coaster she'd thrown her arms up in the air and she said I felt exhilarated the joy is back her boyfriend said she's back and it was one week what's going on here 75% of Australian women report using a contraceptive medication at some time this is great the oral contraceptive pill has given women you know control over their reproductive life which is a very good thing however the discontinuation of hormonal contraceptives is often due to the mood side effects and that is extremely common but not well documented not well understood and not well publicized when we look at it in the pill is estrogen and progesterone and of course estrogen and progesterone affect many brain chemicals the neurotransmitter systems involved in mood regulation so it's not surprising to think that the pill could be a really potent effector of mood what does the literature tell us well not much even though the pills been in use worldwide and being used by millions of women for nearly 50 years we still don't have any way of predicting which women are likely to experience adverse effects on the oral contraceptives adverse effects on their mood and which pill is not likely to do that so over many years now we've been were conducting work looking at mood or depression and the oral contraceptive pill and we are continuing to conduct this research I'm going to get to the punchline very quickly because people might want to know what we're what we am advocate but from our studies basically ongoing and in clinical practice and we found that the low dose estrogen pill is not good for depression yes and Yasmine seemed to create Tasmanian Devils out of komm women and that's not good some of the progesterone in the pill there are bad for mood but worst of all are the progesterone only pills and particularly the straw the Implanon that's implanted under the skin in vulnerable women can create a depression where there wasn't one so we need to be very mindful of these things multiphasic pills that go up and down worse than the ones that have a standard sort of dose and so far dr. Worsley and I really we're not working for Zoli but this is the pill that we seem to be saying is the best of a bad bunch although it does still create a bit of weight gain and acne we're still waiting for a good pill and one that doesn't have mood impact and the difficulty is that see this is again a stigma in terms of mood effects are not considered in often the actual trials and the impact that the pill has it's seen as sort of you know minor but as we know it can be very very major and detrimental on the quality of life I don't have another 48 hours to tell you about the other projects that we're conducting but we are looking at estrogens and more recently looking at a specific type of brain estrogen in women with schizophrenia and Menma schizophrenia – we're also looking at hormone treatments for women with bipolar disorder we're continuing our work in menopause and anxiety disorder we're continuing our work in trying to improve women's safety in our inpatient wards around the country we're educating GPS and other clinicians on the assessment of domestic violence my very dear colleague dr. Jasmine Gregg has developed a toolkit which is very very much simplifying how do you assess for domestic violence and that's been rolled out for general practitioners she's now working on one for mental health practitioners as well along with the neuro the brain stimulation team at ma Parsi and dr. kate who is in the audience paul Fitzgerald who's the deputy director of map RC is a world expert in brain stimulation and we are looking at projects that's typically focus on women for this area again I couldn't possibly let them do stuff that's not gender focused many many many other projects in women's mental health here's my mighty mighty team I am so so grateful so thankful and so happy to have such a wonderful group of people to work with and I can't have the whole team here because it's like sort of herding frogs that we couldn't get everybody in the room at the same time but the the people that I work with are from different disciplines Heather Gilbert is a nurse with 40 years of experience as a midwife dr. Rosie Worsley wearing the red jacket red is our theme color rosie is an endocrinologist and a senior research fellow in women's mental health jasmine Greg who's the blonde haired woman in the back is a cognitive psychologist and has done a PhD in that area and is is brilliant in terms of the work she does and of course any who's on the in the far your left is the coordinator for women's mental health team my very great thanks also to mr. Anthony D Castella who's in the audience who's the manager of ma Posse and he was one of those frogs that jumped off the scale when we were trying to get this photo done but he's a he's a manager and lifelong friend and has been instrumental in in the work that has been done in MAPP RC and the women's mental health team I'm also very grateful to Simons to frac she who's the director of psychiatry at the Alford and he has been very supportive in terms of the clinic and and registrar's rotate rotating through the clinic so that we can teach the next generation as well we're proud of the fact that we won an award in 2012 for our clinic work and we hope to go on to do bigger and better things because the cost of mental illness in women is enormous that's just the straight economy of this is breathtaking that due to depression and anxiety lost productivity directly by Australian women costs us 22 billion dollars per year that's before we start to add in the costs of of treatments lost earnings the loss of effective parenting of children the divorce costs and the loss of care of elderly and so many other factors this is a hugely costly illnesses group that we cannot afford as a society and that's before I even begin to touch on the human cost where to from here Dane Quentin outlined several things but we need to also remember that one size does not fit all I love the pink and blue brain let's think about the pink and blue brain because this is really important that we have specific approaches for women's mental health and some of the things that were mentioned by Dane Quentin we want to strongly shout an echo that culture changes that's needed we need to pursue women's health and mental health agendas very vigorously we need to provide women focus treatments hence need more research dollars we need research to then underpin practice advocacy we need to address safety privacy and treatment across issues for women with mental ill-health we need to have more white ribbon programs to deal with the violence issues and of course we need to pursue the gender equity in pay social responsibility and equity domains is a big agenda there and we need an integrated tailored approach from many disciplines to make this happen I hope you join me in this let's make women's mental health a national priority thank you friends for your attention

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