In an illuminating conversation with Indian Abroad, Prof. Jayashri Kulkarni, a leading figure in women’s mental health, shared insights from her extensive career and pioneering research. Her journey began in a psychiatric ward, where she witnessed firsthand the unique mental health challenges faced by women. Over the years, Prof. Kulkarni has observed significant evolution in the field, particularly in acknowledging women’s distinct mental health needs.
The recent COVID-19 pandemic, she noted, intensified these challenges, especially for women trapped in violent circumstances, resulting in a necessary shift towards telehealth services. Prof. Kulkarni advocates for a transformative approach to psychiatry, emphasizing the need for objective diagnostic tests to reduce the subjectivity in current practices.
With recent accolades, including the 2024 RANZCP Senior Research Award, she highlights the growing focus on women’s mental health and outlines effective strategies for early intervention, particularly in addressing societal violence against women. Moreover, she challenges conventional diagnoses such as Borderline Personality Disorder, emphasizing the critical influence of trauma on mental health outcomes.
A strong advocate for the representation of women in psychiatry, Prof. Kulkarni recognizes the existing barriers while celebrating the shift towards shared childcare responsibilities. She also underscores the essential role of public education in combating stigma and improving perceptions of mental health, reinforcing the importance of research and effective treatment in advancing this mission.
Question: Your work has been pioneering in the field of women’s mental health. What initially drew you to focus on this area, and how have you seen the field evolve over the years?
Prof Kulkarni: Initially my interest in women’s mental health began when I was a young doctor and worked on a psychiatry ward that was dedicated to the treatment of chronic mental ill health in women. Meeting these women encouraged me to listen to their stories and understand their histories in more detail. I then decided to conduct research in the area of women’s mental health, in particular the area of hormones and women’s mental health in order to improve outcomes for women. There has been slow evolution in the field but nonetheless women’s mental health is now achieving more recognition as a field in its own right. I am very hopeful that the next decade will bring considerable innovations for women.
Question: The COVID-19 pandemic has exacerbated mental health issues for many women. What specific challenges have you observed, and how have you addressed these through your research and clinical practice?
Prof Kulkarni: The COVID pandemic meant that we had to provide clinical practise via telehealth. This raised challenges in particular for therapeutic work with women who had experienced violence and were ‘locked down’ in a violent household currently. It was a difficult time but nonetheless we managed to learn more about delivering key therapy through telehealth and we were also able to provide a good service for women who lived very far away from our centre. We used some of these principles to continue our qualitative research at this time.
Question: You have called for a revolution in psychiatry, starting with research. Could you elaborate on the key areas where you believe transformative changes are most urgently needed?
Prof Kulkarni: My major concern in psychiatry practice today is that we do not have objective biomarkers or tests to be able to make consistent, objective and verifiable diagnosis. Unlike other parts of medicine, we do not have tests that assist in the clinical diagnosis and the specific treatments for the condition. This means that diagnoses in mental health are really subjective and a matter of the clinician’s experience and particular favoured areas of work. It is an important next step for psychiatry research to develop high standard objective diagnostic tests to enable individual tailored treatments. Also, it is important that more brain research is done to develop a better understanding of why particular mental illnesses occur and to develop more targeted brain treatments. Of course, each patient experiences different presentations of mental illness because of their own psychology and social world but nonetheless it is critical that we recognise that mental illnesses are in fact brain conditions. This is the revolution that I’m calling for!
Question: Your research has emphasized the importance of tailored treatments for women’s mental health. How do biological, social, and psychological factors uniquely impact women, and how are these factors incorporated into your treatment approaches?
Prof Kulkarni: Women experience mental ill health differently to men. This has not been recognised and it has created further problems for women to receive adequate treatments for their conditions. Women experience far more violence than men and their responses to violence, particularly if it occurs in early life, shapes and determines their lifelong mental ill health. Added to this is the power differential in many societies where women struggle with a lack of power, finances and influence that means their needs are often overlooked. Added to this are the specific biological factors eg: gonadal hormone impact on brain neurochemicals & neurocircuitry that produce typically female mental illnesses such as premenstrual depression, antenatal mental ill health and menopause related depression. Hence women who have mental ill health require consideration of the integrated biopsychosocial factors.
Question: You recently received the 2024 RANZCP Senior Research Award and the Ian Simpson Award. What do these recognitions mean to you, and how do they reflect the current state of psychiatry, especially concerning women’s mental health?
Prof Kulkarni: I feel very honoured to have received 2 awards from the Royal Australian New Zealand College of Psychiatry in 2024. Much more than the personal honour and glory, I see these awards as recognition of the research and clinical focus on women’s mental health. I believe that formal recognition by the learned college is critical as a means of support moving forward, to make women’s mental health both a national and global priority.
Question: With women being significantly more likely to experience conditions like depression and anxiety, what do you believe are the most effective strategies for early intervention and prevention in these cases?
Prof Kulkarni: There are many effective strategies for both early intervention and prevention for women experiencing depression and anxiety. Chief among these is the need to address domestic and other violence in all our societies. There are many programmes operating to educate even young children about mutual respect between the genders as well as increased policing and judiciary powers to deal with violence against women in a legal way. These external societal laws will hopefully change the notions generated in patriarchal societies that women are ‘second-class citizens’, hence their views, and needs are not as important as men’s. Older cultures, where male dominance is inherent over generations need to change attitudes and recognise women as equals in every way. This takes time and needs a whole community approach. If such attitudinal change can be achieved, then violence against women will decrease, which in turn will improve women’s mental health.
However, while we have embarked on such a major societal shift, we must not forget the women who are already suffering mental illnesses that are related to violence in their lives. So as well as prevention, we must develop new treatments and services for the women experiencing mental ill health.
Question: Your work has challenged conventional diagnoses such as ‘Borderline Personality Disorder.’ How do you believe the field should approach complex conditions like this, and what role does trauma history play in these cases?
Prof Kulkarni: The term ‘Borderline Personality Disorder’ is a highly stigmatising diagnosis. It has connotations of personal inadequacy and ignores the ever-present history that many of the women with the condition have of terrible emotional, physical and sexual abuse. In many ways the term and the sense of nihilism that it engenders in clinicians has led to very poor outcomes for this large female population. Trauma is a critical factor in the development of the symptoms such as deliberate self-harm, mood fluctuations, rage, and anxiety that are the hallmarks of BPD. We can better understand these symptoms as reactions to various traumas. When we do this, we are immediately more likely to be compassionate and pursue trauma therapy treatments which often have good outcomes for this patient population. Understanding the role of trauma in BPD, (and trauma defined broadly is always present if inquired about), is a big step forward in empowering the patient and removing the unhelpful stigma of a personality disorder diagnosis. I believe that psychiatry needs to move away from diagnosing borderline personality disorder and work harder to understand the role of trauma in early life in women, in a biological, psychological and social sense.
Question: As an innovator in psychiatry, what are some of the most exciting developments you see on the horizon for mental health treatment, particularly in terms of integrating neuroscience and new technologies?
Prof Kulkarni: I believe that there are many exciting developments on the horizon for mental health treatment. In particular, the developments in neuroimaging, neurobiology, neuroimmunology give us hope that we can understand the brain aspects that are involved in particular mental illnesses. For example, we are working currently with particular brain circuitry alterations that appear to set off anorexia nervosa. Identifying this circuit gives us the opportunity to utilise state of the art brain stimulation techniques to then modify the particular neurobiology involved. There are many examples like this when neurobiology can be harnessed to provide better understanding and better targeted treatments. We can learn from our neurology colleagues as well as other medical specialties who have made advances in many diagnostic and therapeutic areas. There are also some exciting artificial intelligence technologies that may provide useful new treatment modalities for different mental health conditions.
Question: You’ve been a strong advocate for increasing the representation of women in psychiatry and related fields. What are the barriers women face in these careers, and what steps can be taken to support and empower them?
Prof Kulkarni: Women in psychiatry and related fields are still facing the difficulties of trying to juggle careers and personal life. However, it appears that there is a greater acceptance of the joint responsibilities for childcare between parents of all genders and their extended support systems. This may well herald a new era for women, who in the past have had the major responsibility for child rearing. Of course, each professional woman will need to make her own decisions about her work- life balance. Nonetheless it is important that women psychiatrists engage fully in their careers for as long as possible. With more women in powerful positions, there is more likelihood of change in the overall approach to patient care, with women patients needs being better understood and catered for. Support in the workplace is needed to enable all clinicians, researchers and the women experiencing mental illness to feel worthy to express their views.
Question: Mental health awareness has grown significantly, yet stigma remains. What role does public education play in changing perceptions, and how can professionals like yourself further this mission?
Prof Kulkarni: It is interesting that stigma remains for some mental health conditions but not others. Depression and ADHD appear to be much less stigmatised than the badly stigmatised conditions of BPD and schizophrenia. If we consider why this is the case, then we can learn more about how to destigmatize all mental health conditions. I think that where there are effective treatments (and usually these are easy to deliver medications that have observable impact) then the stigma is decreased. Hence the answer to destigmatisation appears to be better treatments and better understanding of the cause of the illness – to remove the sense of the ‘unknown & untreatable’, which engenders fear and stigma. So, the answer again lies in good research that provides treatments that can then be delivered for people with mental illness and accompanying education about the condition. Professionals like me have a role to play in both the research and the public messaging about the condition.
