Surgeon General’s Workshop 

on Women’s Mental Health 

November 30–December 1, 2005 

Denver, Colorado 

This document summarizes the views and issues addressed by invited speakers and discussants at the Surgeon 

General's Women’s Mental Health Workshop. The views expressed in this Report reflect the opinions of the 

individual participants at the Workshop and do not necessarily reflect the official position of the Office of the 

Surgeon General, the Department of Health and Human Services, or other Federal entities. 

Workshop Report 
Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

Table of Contents 

Executive Summary....................................................................................................................................1

Introduction: Background and Purpose of the Workshop ....................................................................3

Day 1 – Morning Sessions..........................................................................................................................4

Welcome, Introductions, and Charge to the Workshop.........................................................................4

About the Surgeon General’s Women’s Mental Health Project .............................................................6

The State of Women’s Mental Health – What We’ve Learned...............................................................9

Breakout Group Sessions........................................................................................................................17

Workgroup 1: Biological and Development Factors .............................................................................18

Workgroup 2: Specific Mental Disorders ..............................................................................................24

Workgroup 3: Trauma, Violence, and Abuse .......................................................................................31

Workgroup 4: Social Stress Factors and Stigma..................................................................................37

Workgroup 5: Identification and Intervention Issues ............................................................................43

Workgroup 6: Treatment Access and Insurance..................................................................................50

Workgroup 7: Health System Issues ....................................................................................................57

Workgroup 8: Protective and Resilience Factors .................................................................................62

Day 2 – Final Session ...............................................................................................................................69

Overview of Themes and Recommendations from the Breakout Workgroup Presentations...............69

Comments from the Workshop Participants.........................................................................................70

Closing Remarks ..................................................................................................................................72

Appendix A: Conceptual Framework ......................................................................................................74

Appendix B: Communiqués and Toolkits: Ideas from Leadership Interviews 

and Facilitated Discussions.....................................................................................................................75

Toolkits for Consumers and Families ...................................................................................................75

Toolkits for Professionals .....................................................................................................................75

Appendix C: Participant List....................................................................................................................76

i 
Surgeon General’s Workshop 

on Women’s Mental Health: Workshop Report

Executive Summary 

The Surgeon General’s Workshop on 

Women’s Mental Health brought together 

experts from the consumer, academic, 

advocacy, health insurance, health care 

delivery, program management, and public 

policy communities to explore sex and 

gender differences

1 in mental health and to address critical 

mental health issues affecting girls and 

women. The goal of this workshop was for 

participants to develop practical and 

actionable recommendations for materials 

(referred to broadly as communiqués) and 

toolkits that could be produced by the 

Surgeon General to advance knowledge, 

understanding, and behaviors regarding 

women’s mental health issues – and 

ultimately to improve the mental health of 

our Nation’s girls and women. 

A rich array of potential messages, 

materials, target audiences, formats, and 

dissemination strategies emerged from the 

day and a half of workshop discussions and 

presentations. Examples ranged from a 

Surgeon General’s Letter to the American 

People, to iPod messages for teens, audio 

materials, story-telling formats, public 

service announcements, messages on 

commonly used products (e.g., diapers), and 

profiles of promising practices or model 

companies that promote mental health. Also 

discussed were ways of identifying and 

harnessing existing resources, such as 

clearinghouses, assessment tools, studies, 

self-esteem-building models, and more. The 

specific ideas and recommendations are 

described within the chapters of this report. 

A series of overarching messages and crosscutting themes pertaining to the mental 

health of girls and women also resonated 

through the sharing of ideas that took place 

at this workshop. These messages and 

themes will serve to inform the development 

of Surgeon General’s communiqués or 

toolkits: 

1 Workshop participants defined the terms sex and gender 

as follows: Sex is a biological construct defined by the 

organs with which a person is born. Gender is a societal 

construct that reflects a person’s sex as it figures in the 

context of cultural, family, and social environments. 

y Women’s mental health is essential to 

overall health. Both mental disorders and 

mental wellness should be integrated as part 

of primary and other health care practice. 

y The disease burden of mental illness is 

enormous. Among developed countries, 

mental illness is second only to 

cardiovascular disease in prevalence and 

causes nearly a fourth of the disease 

burden.2

y Women’s health matters. The last decade 

of research has underscored the importance 

of sex and based differences in the risk, 

prevalence, presentation, course, and 

treatment of mental disorders.

y Mental disorders must be viewed like other 

chronic medical conditions and are highly 

treatable. This message needs to be further 

understood to combat stigma and encourage 

more people to seek the treatment they need. 

In addition, there is a need for a broader 

understanding of the variety of treatments 

available. 

2 Murray CJL, Lopez AD, eds. The global burden of disease 

and injury series, volume 1: a comprehensive assessment of 

mortality and disability from diseases, injuries, and risk 

factors in 1990 and projected to 2020. Cambridge, MA: 

Harvard School of Public Health on behalf of the World 

Health Organization and the World Bank, Harvard University 

Press; 1996. 

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Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

y Mental health must be addressed across 

the life span, from early childhood to the 

later years. The types of risk, prevention 

messages, ways of building resilience, 

course of disease, and treatments vary 

according to age, reproductive events, and 

other life span issues. Thus there is a need 

for materials and messages adapted to 

audiences of different ages. 

y There are ways to promote resilience and 

factors that help prevent mental disorders.

We need to define good mental health and 

promote prevention. This means building a 

wider understanding of protective factors 

that can help girls and women build 

resilience – including for those who 

experience mental disorders – and 

developing effective strategies to translate 

that knowledge into practice. 

y Culture is an important source of resilience 

but also of barriers related to the recognition 

and acceptance of mental health issues.

Girls and women draw great support from 

cultural connections and identity but also 

feel the weight of cultural pressures to 

remain silent about personal issues, not to 

discuss problems outside the family, or to be 

strong. 

y Gender must be integrated into disaster 

training and planning activities. The lessons 

of Hurricane Katrina and other large-scale 

disasters indicate that women are at 

particular mental health risk due to factors 

such as family responsibilities, women’s 

higher rates of poverty, their greater risk of 

depression and anxiety disorders, and their 

vulnerability to sexual abuse and domestic 

violence.3

y The importance of trauma, violence, and 

abuse needs to be recognized by providers, 

researchers, policymakers, and the general 

public. Trauma, violence, and abuse are far 

more prevalent in the lives of girls and 

women than commonly thought – and they 

may lead to serious, long-standing physical 

ailments, co-occurring conditions, and risky 

behaviors that, if left unrecognized and 

untreated, can compromise women’s health. 

3 World Health Organization, Gender and Health in Natural 

Disasters. Geneva, Switzerland; 2005. 

y Recovery from mental disorders or from 

the effects of trauma, violence, and abuse is 

possible. Following the recommendations of 

the President’s New Freedom Commission, 

we need to move toward a health care 

system that is recovery based and consumer 

focused. 

y Health literacy is a public health and 

Surgeon General’s priority. It is critical to 

design communiqués that carry health 

messages in language that people use and 

understand. To be culturally competent, 

materials should be designed with the input 

and participation of target communities, 

which may represent diversity in race, 

ethnicity, age, geographic area, sexual 

orientation, or health status. 

A final message that echoed throughout the 

meeting was the recognition that women’s 

mental health issues touch everyone, either 

directly or through the women they love. 

Recognizing this factor, participants shared 

an enormous amount of energy, expertise, 

and commitment to the workshop effort. The 

rich results of their work are a testament to 

their substantial and considered 

contributions. 

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Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

Introduction: Background 

and Purpose of the Workshop 

The Surgeon General’s Workshop on 

Women’s Mental Health was convened to 

bring together experts from the consumer, 

academic, advocacy, health care delivery, 

health insurance, program planning, and 

policy planning communities to address 

critical issues affecting the mental health of 

women and girls and make 

recommendations for the production of 

Surgeon General’s communiqués4 and 

toolkits. This workshop was part of a 

broader initiative, the Surgeon General’s 

Women’s Mental Health Project, designed 

to explore sex and gender differences in 

mental health and gain a better 

understanding of the role mental health 

plays in the overall health of our Nation’s 

women and girls. The initiative represents a 

joint project of the U.S. Department of 

Health and Human Services (DHHS) Office 

of the Surgeon General, Office on Women’s 

Health (OWH), Office of Minority Health, 

National Institute of Mental Health (NIMH), 

Substance Abuse and Mental Health 

Services Administration (SAMHSA), and 

National Institute on Drug Abuse (NIDA). 

The Women’s Mental Health Project has 

consisted of several background activities, 

which have laid the groundwork for this 

workshop. These have included a concept 

mapping exercise; key-informant interviews 

with mental health experts and leaders; 

facilitated discussions with local providers, 

consumers, advocates, and decisionmakers; 

and a targeted literature review. The 

activities have led to the identification of 

major mental health issues for girls and 

women, which are recognized as being both 

high in importance and in action potential. 

These myriad issues have been grouped 

according to eight different cluster areas, 

encompassing personal, environmental, and 

health care system-related concerns. The 

cluster areas include: 

4 The term “communiqué” was deliberately chosen to 

represent a broad array of potential products and materials. 

y Biological and developmental factors 

y Specific mental disorders 

y Trauma, violence, and abuse 

y Social stress factors and stigma 

y Treatment access and insurance 

y Identification and intervention issues 

y Health system issues 

y Protective factors and resilience 

Each participant in the Surgeon General’s 

Workshop on Women’s Mental Health was 

assigned to a working group addressing one 

of these eight topics. Each working group 

was asked to review and prioritize the issues 

associated with their cluster area. (Note: A 

schematic representation of those areas and 

the issues which fall under them is included 

in Appendix A). They also were given the 

charge of developing recommendations for 

the production of Surgeon General’s 

communiqués and toolkits. For each cluster 

area, participants were specifically asked to 

choose three key priority issues to be 

addressed, describe the key messages, 

suggest a format for a product or toolkit, 

identify the audience, and highlight any 

cultural concerns or other cross-cutting 

issues. 

To set the stage for the workshop 

discussions, participants were offered 

several plenary presentations, including a 

welcome and introduction by U.S. Surgeon 

General Richard H. Carmona. These 

presentations underscored the importance of 

women’s mental health not only to their own 

overall health, but also to the health and 

well-being of those around them and 

ultimately of our Nation as a whole. They 

highlighted the burden of mental disorders 

on the lives and productivity of individuals 

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Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

“We must truly listen to the 

stories women tell – turn to 

women survivors as experts. We 

must replace the question ‘What 

is wrong with you?’ with the 

question ‘What happened to 

you?’” 

– Rene Andersen 

Center on Women,

Violence, and Trauma 

and revealed what we have learned about the 

interplay of sex and gender in the risk, 

course, and treatment of 

these disorders. 

Participants were invited to 

become active partners, 

throughout this meeting 

and beyond, in the 

promotion of a mental 

health system that could 

address the mental health 

issues of women with an 

approach that is more 

consumer focused, 

recovery oriented, and 

focused on integrating all 

aspects of mental health with mainstream 

and primary health care. 

Day 1 – Morning Sessions 

Welcome, Introductions, 

and Charge to the Workshop 

Wanda K. Jones, Dr.P.H., Deputy Assistant 

Secretary for Health, DHHS Office on 

Women’s Health, welcomed the meeting 

participants. She described their task as 

being to develop recommendations for 

concrete products and toolkits that could be 

developed from the Office of the Surgeon 

General to address key mental health issues 

affecting women and girls. Dr. Jones 

explained that each workgroup was 

comprised of a diverse range of participants 

(e.g., researchers, advocates, providers, 

consumers) to ensure that a full range of 

perspectives would be represented. 

Rene Andersen, M.Ed., LCSW, Center on 

Women, Violence, and Trauma, described her 

personal and professional experiences with 

the effects of trauma, violence, and abuse on 

women and families. She told of her own 

experience of growing up in a family that 

appeared to be fun and loving on the outside 

(the “day stories”) but that hid an 

intergenerational cycle of abuse (the “night 

stories”) filled with cries of despair and 

terror. Ms. Andersen told how this history 

led to legacies of 

depression, addiction, 

posttraumatic stress, and a 

host of physical ailments in 

her life and those of her 

siblings. She told of being 

overmedicated and subject 

to many diagnoses and 

treatments – all of which 

overlooked this history of 

abuse for many years. 

Ms. Andersen explained 

that the experience of 

trauma is central to the lives of many 

women and that emotional, physical, and 

sexual traumas are pervasive. She 

emphasized that violence is a social disease 

and not a personal issue. She also stressed 

the importance of helping the victims of 

trauma, violence, and abuse to understand 

that it need be neither unbearable forever 

nor passed from one generation to the next. 

Ms. Andersen offered herself as living proof 

that healing is possible. She noted that there 

are indeed many “rafts in the river” to offer 

help and support, including relationships 

with friends, service providers, recovery 

groups, and the like. 

Everyone knows at least one woman who is 

a survivor of trauma, commented Ms. 

Andersen. She suggested that we must turn 

to women survivors as experts and truly 

listen to the stories they have to tell. She 

called for a fundamental shift in diagnosis 

and treatment founded on the belief that 

everyone can heal and that the question 

“What is wrong with you?” should be 

replaced with the question “What happened 

to you?” 

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Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

“I see this work as more than a 

job. I see it as a tribute to my 

mother and my grandmother.” 

– Richard H. Carmona 

U.S. Surgeon General 

Ms. Andersen concluded by 

inviting the audience 

members to conjure the 

image of one woman in 

their lives who has had to 

survive trauma or mental 

illness. She asked them to 

keep that image close at 

hand during the course of this workshop as a 

reminder of how closely the issues of mental 

disorders, trauma, and violence touch 

everyone directly and through the women 

they love. 

“The purpose of this meeting is to 

bring you all together as parents, 

providers, scientists, consumers, 

and so forth to guide the 

development of these 

communiqués, whatever they end 

up being. I welcome the 

opportunity to argue with you to 

figure out the right path so that 

girls and women will say we got it 

right.” 

– Richard H. Carmona 

U.S. Surgeon General 

Vice Admiral Richard H. Carmona, M.D., 

M.P.H., FACS, U.S. Surgeon General, shared 

his experience of being a high school 

dropout and growing up in an environment 

of poverty and hardships. He spoke of his 

grandmother trying to raise her children and 

grandchildren in Harlem; his father, with no 

high school education, unable to sustain a 

life with four children; and a mother trying 

to instill in her children the value of 

education and knowledge as a way to escape 

poverty. The Surgeon General described a 

childhood living in 

substandard apartments, 

being homeless, and 

moving into the projects 

with 12 people in a tiny 

apartment. He talked about 

the critical roles his mother 

and grandmother played as 

the powerful women in his 

life, who continually 

battled to sustain their 

families despite poverty, 

homelessness, being 

immigrants, alcohol abuse, 

and other difficulties. Their 

continued determination to 

take care of their families, 

he explained, taught him 

about resilience and made 

him keenly aware of the roles women play 

in our society. 

The Surgeon General told 

of how his mother would 

say that men have run this 

world for most of eternity – 

and are running it into the 

ground. She would point 

out that men see the world 

differently from women 

and that women tend to be more conciliatory 

and try to bring people together to resolve 

problems. 

Dr. Carmona turned to the audience of 

workgroup participants and described their 

role as the foot soldiers in the battle to 

address women’s mental health and the 

broader issue of how it fits into their overall 

health. He recognized the risk they face of 

being marginalized by other events of the 

day, but he offered his commitment and 

support. 

Dr. Carmona noted that when he was chosen 

to be the U.S. Surgeon General, the 

President described the primary issue to be 

addressed as that of becoming a Nation that 

embraces prevention, 

health, and wellness – 

because ultimately, we all 

pay the price for poor 

health or health care crises. 

Thus, he explained, 

prevention and 

preparedness are the 

primary areas of focus in 

the Office of Surgeon 

General. 

In the area of health 

preparedness, Dr. Carmona 

stressed the importance of 

being ready in the face of 

emerging infectious 

diseases, such as SARS, 

mad cow disease, and avian 

flu, as well as other natural and manmade 

threats. He pointed to the need to determine 

how to prepare first responders and other 

5
Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

critical support personnel to be ready to deal 

with these issues. In addition, he referred to 

the importance of looking at prevention and 

preparedness at the household level – where 

it is almost universally the women who bear 

the responsibility for taking care of the 

health of the family, making the health 

decisions, and being the family health 

leaders. 

“Those of you taking part in this 

workshop, you are the foot 

soldiers. You run the risk every 

day of being marginalized by the 

events of the day, but I’ll be right 

with you. My commitment is 110 

percent.” 

– Richard H. Carmona 

U.S. Surgeon General 

The Surgeon General also discussed the 

importance of the issue of health disparities 

– noting that he has had 

personal experience with 

these disparities and knows 

firsthand what it is like not 

to go to the doctor for 

years. He underscored the 

need not to lose sight of the 

fact that ours is still a 

nation divided as it relates 

to race and health. We 

should be outraged, he 

suggested, to be living in 

the greatest nation in the 

world but one where not everyone has the 

same health care access and outcomes. 

Dr. Carmona pointed out that we need a 

common currency and language to reach 

into the streets, into the “hood”, or among 

the ranks – and that often those we most 

need to reach are the ones furthest away 

from us. He stressed the need to understand 

that cultural competence is about more than 

just finding a translator – and that we must 

figure out ways to translate the great 

advances we have from science into 

packages that can reach people. One key 

factor in this area, he noted, is health literacy 

– the need to communicate with a language 

and at a level that people can understand. 

This is why, explained Dr. Carmona, every 

time a Surgeon General’s Report is 

published there is also an accompanying 

“People’s Piece” publication that takes the 

key messages and information from the 

report and presents it in a clear manner, 

written at a sixth-grade reading level. 

The reason for convening this workshop, 

noted the Surgeon General, is to help guide 

the development of any document or 

materials to come out of the Surgeon 

General’s Women’s Mental Health Project. 

Dr. Carmona specified that he felt these 

recommendations needed to come from the 

ground up – from the sample of parents, 

consumers, policymakers, advocates, 

providers, scientists, and 

others represented at the 

meeting. The Surgeon 

General said that he 

welcomed the opportunity 

to face arguments and 

disagreements – to figure 

out the right path ultimately 

and come out of this 

together. 

Dr. Carmona concluded by 

re-emphasizing his personal 

commitment to this project and the 

important work of this Surgeon General’s 

Workshop on Women’s Mental Health. 

About the Surgeon General’s 

Women’s Mental Health Project 

Wanda K. Jones, Dr.P.H., Deputy Assistant 

Secretary for Health, OWH, gave a slide 

presentation providing the background of 

the Surgeon General’s Project on Women’s 

Mental Health to help set the context for this 

workshop. Dr. Jones began by pointing out 

the long history of supporting reports and 

documents, starting with the publication of 

Mental Health: A Report of the Surgeon 

General in 1999, which laid the scientific 

groundwork for this project. Subsequent 

supporting documents include: 

y The Surgeon General’s Call To Action 

To Prevent Suicide (1999) 

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Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

y Report of the Surgeon General’s 

Conference on Children’s Mental Health: 

A National Action Agenda (2000) 

y Mental Health: Culture, Race, and 

Ethnicity, a supplement to Mental Health: 

A Report of the Surgeon General (2001) 

y Youth Violence: A Report of the Surgeon 

General (2001) 

y Achieving the Promise: Transforming 

Mental Health Care in America (2003), 

from the President’s New Freedom 

Commission on Mental Health 

She specified the project’s four main 

objectives. The first three include 

identifying the critical issues affecting the 

mental health of women and girls, assessing 

the state of the science, and developing a 

framework for a long-term strategy to 

address the issues. The fourth objective is 

the one most directly related to this 

workshop, namely to develop additional 

supporting endeavors and products to 

increase awareness and activity related to 

these critical issues. 

Dr. Jones described in more detail the 

background activities of the Surgeon 

General’s Women’s Mental Health Project 

that were undertaken to begin to address the 

project objectives and lay the groundwork 

for this workshop. The first of these, she 

explained, consisted of a concept mapping 

activity designed to define women’s mental 

health and develop a conceptual framework 

for addressing the issues that affect the 

mental health of women and girls. It 

involved 245 participants representing 

experts and communities of interest who 

responded to this statement: “A specific 

issue that is relevant to the mental health of 

women and girls is....” Dr. Jones noted that 

this activity generated 107 issues, which 

were then rated according to their level of 

importance and their potential for action. 

The next step, she explained, involved the 

development of cluster areas grouping these 

different issues according to common 

themes, which were in turn organized to 

create a conceptual framework. That 

framework encompasses individual, 

environmental, and systemic issues affecting 

women’s and girls’ mental health. Because 

of the central importance ascribed to 

protective and resilience factors by 

respondents, these were placed at the center 

of the framework. The conceptual 

framework was further refined during the 

process of two additional background 

activities. These included a set of leadership 

interviews with 25 high-level individuals 

representing governmental, provider, and 

consumer organizations along with a series 

of facilitated discussions in three cities with 

diverse groups of consumers, providers, and 

the local government staff. The resulting 

framework is presented below. A more 

detailed version that lists the specific issues 

associated with each cluster area is included 

in Appendix A. 

Conceptual Framework of Issues Affecting 

the Mental Health of Women and Girls 

When the eight cluster area topics emerging 

from this framework were cross-walked 

with the 1999 document, Mental Health: A 

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Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

Report of the Surgeon General, explained 

Dr. Jones, there were clear differences in 

identified priorities, particularly in the 

research base. While issues such as sex and 

gender differences in specific mental 

disorders or developmental factors were 

referenced in the Surgeon General’s Report, 

others such as “trauma, violence, and abuse” 

or “resilience and protective factors” barely 

appeared at all – reflecting the lack of 

research evidence on these important topics 

at the time. 

The Surgeon General’s Women’s Mental 

Health Project’s targeted literature review 

and other background activities revealed 

several changes or developments since the 

publication of the 1999 report. Regarding 

sex and gender differences, noted Dr. Jones, 

there is a growing body of evidence to 

increase our understanding of the significant 

sex and gender differences in the risks, 

prevention, diagnosis, course, and treatment 

of mental illness. She added that we clearly 

need to address these differences not only in 

research but also in social policies and in the 

training of health providers. 

Another major area that has received 

significantly more research attention in 

recent years, said Dr. Jones, is the 

importance and prevalence of trauma, 

violence, and abuse in the lives of girls and 

women. She referenced a new World Health 

Organization (WHO) study that looks at this 

issue and its long-term impacts worldwide.5

Dr. Jones also noted that this evidence 

further underscores the fact that women 

need to be screened routinely for trauma, 

violence, and abuse as part of their regular 

health care. 

One of the important cross-cutting issues to 

emerge throughout the background activities 

was the importance of cultural differences 

and disparities. The issues of culture, race, 

and ethnicity clearly cut across all of the 

areas of the conceptual framework, 

explained Dr. Jones, but the scientific 

literature is sparse. She mentioned recent 

research that investigates both the protective 

factors of culture and potentially deleterious 

effects of acculturation – suggesting that 

culture may weigh more heavily than race or 

ethnicity in terms of our attitudes and 

behaviors regarding mental health and 

mental disorders. 

5 World Health Organization. WHO Multi-country Study on 

Women's Health and Domestic Violence Against Women. 

Geneva, Switzerland; 2005. 

Yet another issue to come up consistently 

and in a cross-cutting way is stigma that 

keeps families in denial and keeps 

individuals from seeking care, said Dr. 

Jones. She pointed to the need for continued 

education and outreach to providers, to 

women and girls, and to the general public. 

Regarding the issue of resilience and 

protective factors, Dr. Jones noted that this 

was clearly a critical topic, in which there is 

so much more we need to know regarding 

both protective factors and successful 

prevention-focused activities. 

Dr. Jones concluded that with the 

combination of the science base, these 

background activities, and the input from the 

members of this workshop, we have the 

potential to create an array of new products. 

These have been identified as Surgeon 

General’s communiqués – a term 

intentionally chosen to be broad to reflect 

the wide array of possibilities. Dr. Jones also 

pointed out that the term brings together 

both the words “communications” and 

“unique.” She presented this as a challenge 

to the workshop participants to debate, 

discuss, and craft creative ideas for ways we 

can communicate important issues affecting 

the mental health and long-term wellness of 

our Nation’s women and girls. 

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Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

The State of Women’s Mental Health 

– What We’ve Learned 

“Why focus on women’s mental 

health? Because sex matters!” 

– Richard Nakamura 

Deputy Director 

National Institute of Mental Health 

National Institutes of Health 

“We are challenging you to help 

us devise ideas for new Surgeon 

General communiqués – a word 

that appropriately combines 

‘communications’ and ‘unique’. 

I invite you to meet that challenge 

here.” 

– Wanda K. Jones 

Deputy Assistant Secretary 

for Health

DHHS Office on Women’s Health 

Richard Nakamura, Ph.D., Deputy Director, 

NIMH, presented the scientific perspective on 

the status of what we have learned about 

women’s mental health. 

Dr. Nakamura emphasized 

that while critical, research 

is only part of the picture, 

and the side that affects 

individuals on a personal 

level is equally important. 

Thus, he noted, the NIMH 

and the Center for Mental 

Health Services (CMHS) 

play complementary roles, 

with NIMH providing the 

research piece and CMHS 

providing the direct service 

that is informed by the 

research. 

The mission of NIMH is to address the 

burden of mental health through research, 

explained Dr. Nakamura. He noted that 

worldwide, this burden is considerable, 

according to data from WHO and World 

Bank, and it is expected to increase. For 

example, the data show that within 

developed countries, major depression is 

second only to heart disease as the leading 

source of disease burden, and for women, it 

is already the number one 

cause of disease burden.

Schizophrenia and bipolar 

disorder are also among the 

top 10 causes of DisabilityAdjusted Life Years 

(DALYs). Depression, 

alcohol and substance 

abuse, and self-inflicted 

injury also constitute major 

causes of disability – and taken together, 

mental disorders account for nearly onequarter of the total disease burden in the 

United States.

Dr. Nakamura explained that though we 

commonly speak of the disability burden 

associated with mental disorders, there is 

also an important elevated risk of death as 

well. For example, he noted that 90 percent 

of individuals who commit suicide have had 

a mental disorder – and we 

know that women are four 

times more likely than men 

to attempt suicide, though 

less likely to die from the 

attempt. This says much 

about the level of pain and 

hopelessness these 

disorders can bring. 

Dr. Nakamura then turned 

his attention to one of the 

fundamental questions of 

this workshop; namely, 

“Why focus on women’s 

mental health?” His simple response was, 

“Because sex matters!” Dr. Nakamura 

elaborated on this point and offered a more 

detailed presentation of the interplay among 

sex, gender, and mental health issues. His 

presentation highlighted the following 

points: 

y There are considerable differences in the 

sex ratios for selected mental disorders, 

with women having much higher rates of 

disorders such as major depressive disorder, 

anxiety disorders, 

posttraumatic stress 

disorder, and eating 

disorders. 

y There are important 

biological differences

related to hormones and 

brain structure that may 

affect mental health risks, 

rates of disorders, and the course of those 

disorders. For example, research has 

demonstrated that estrogen and progesterone 

influence brain function and stress response. 

These findings are interesting given that at 

9
Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

“The continued, effective 

integration of women and 

diversity in academic medicine 

and research is essential for 

ensuring that the research base 

reflects gender, racial, ethnic, and 

cultural diversity – not only 

regarding research topics but 

also in the interpretation of the 

findings.” 

– Richard Nakamura 

Deputy Director 

National Institute of Mental Health 

National Institutes of Health 

puberty, the female-to-male ratio for 

depression rises from 1:1 to 2:1. Some 

women also experience increased 

vulnerability to depression during times of 

reproductive endocrine changes, such as the 

premenstrual, postpartum, and 

perimenopausal periods. There also are sexbased differences in the 

size and structure of the 

human brain. Men’s brains 

are larger than women’s. 

Women’s brains are lighter 

but more complex, with 

proportionately larger 

frontal lobes (attributed to 

executive functions such as 

judgment, language, 

memory, problem solving, 

and socialization).6

y Clearly environmental 

factors play a significant 

role in the risk and 

prevalence of certain 

mental disorders. 

Environmental factors may 

include both artifact (e.g., women may be 

more likely than men to seek treatment, 

there may be diagnosis bias) and 

psychosocial factors (e.g., gender 

socialization, gender roles, lower social 

status, reaction to social cues, experiences of 

abuse, gender-related differences in coping 

mechanisms). 

y There is important overlap between 

biological and environmental factors, 

although the interplay between the two is 

complex. For example, in the gene that 

codes for the serotonin transporter, 

individuals with a short version of that gene 

seem to have a greater vulnerability to the 

deleterious effects of a history of 

maltreatment than do those with a longer 

version of that gene. 

6 Rabinowicz T., Dean D.E., Petetot J.M., de Courten-Myers 

G.M. Gender differences in the human cerebral cortex: more 

neurons in males; more processes in females. J Child 

Neurol. 1999 Feb; 14(2):98-107. 

y There is clearly much still to be learned 

about social and protective factors that 

affect mental health, including the effects of 

race, ethnicity, and culture. For example, 

while we see that the 

overall ratio of female-tomale rates of depression is 

2:1, there are enormous 

differences in range. Rates 

of depression are higher 

among Hispanic and 

Caucasian women 

compared with AfricanAmerican women. 

Similarly, there are 

considerable differences 

among women in rates of 

attempted suicide. 

Although women are more 

likely on average to attempt 

suicide than men, the rates 

of suicide attempts in 

African-American women 

are very low. These differences lead us to 

wonder if there are social or protective 

factors at play and underscore the fact that 

we need to understand more fully what 

happens with groups that do well. 

y New science is rapidly changing our 

understanding of lifetime and 

intergenerational cycles affecting mental 

health – and the extent to which 

environmental manipulations can lead to 

positive changes. For example, recent 

evidence shows that when a mother rat licks 

and grooms her pups, it actually changes 

their brain function and affects how they 

themselves parent, producing pups that are 

better parents.7 This is supported by other 

studies that suggest that environmental 

7 Weaver ICG, Cervoni N, Champagne FA, d’Alessio AC, 

Sharma S, Seckl JR, Dymov S, Szyf M, Meaney MJ. 

Epigenetic programming by maternal behavior. Nature 

Neuroscience. August 2004;7(8):847–854. 

10
Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

enrichments can change the brain and have 

long-term, intergenerational effects – 

potentially through epigenetic effects. 

Dr. Nakamura concluded his presentation by 

pointing to the continued need to integrate 

more women and diversity effectively into 

academic medicine and scientific research. 

He pointed to the slow growth of women in 

academic medicine – representing onefourth of medical faculty members in 1995 

and one-third today, and still highly 

underrepresented among associate and full 

professors in academic medical institutions. 

Dr. Nakamura emphasized that greater 

participation of women, including women of 

color, is necessary to ensure that the 

research base reflects gender, racial, ethnic, 

and cultural diversity not only in the types of 

topics that are being researched but also in 

the interpretation of the findings. 

Like the presenters before him, Dr. 

Nakamura noted that women’s mental health 

issues have a personal side 

that touches every family. 

He dedicated his thoughts 

from this meeting to an 

aunt, who was subjected to 

a frontal lobotomy during 

the 1950s as a treatment for 

her bipolar disorder – and 

shared the hope with the 

workshop participants that 

the continued work of this 

group and others will 

ensure that no one will go 

through that experience 

ever again. 

A. Kathryn Power, M.Ed., Director, Center for 

Mental Health Services, SAMHSA told the 

workshop participants that it is time to 

change the way we think about, develop, 

and deliver mental health services. Ms. 

Power emphasized that the knowledge exists 

now to make real headway toward the goal 

of helping women and girls achieve holistic 

lives of greater self-determination, power, 

and self-dignity. She argued that we know 

from the evidence that recovery is possible 

and that with the right treatments and 

supports, recovery can be the expected 

outcome for every woman and girl in 

America living with mental health 

conditions. 

In order to promote recovery, she added, it is 

imperative that the woman herself become 

the director of her own treatment, since only 

she knows the truth about the conditions of 

her life. It also becomes imperative that we 

move from a model focused on illness, acute 

treatment and symptom mitigation to one 

that is recovery-focused and strengthsbased, since virtually all behavioral health 

conditions will require environmental or 

lifestyle changes as well as biological 

treatments. 

Our current mental health services system, 

Ms. Power argued, has neglected to 

incorporate respect for and 

understanding of the unique 

histories, beliefs, attitudes, 

and value systems of 

culturally diverse 

populations. Our efforts to 

bring all of the relevant 

health and human service 

components to the table to 

address the totality of 

women’s health have been 

haphazard at best – and 

clouded by stigma and 

discrimination. 

“It’s time we harness the power of 

these [scientific] discoveries to 

offer new hope in both treatment 

and prevention for women and 

girls. We have the tools. It’s time 

to put them to use!” 

– A. Kathryn Power 

Director 

Center for Mental Health Services

SAMHSA 

Ms. Power called for an integrated, holistic 

approach to mental health services that cares 

for the whole woman. She described this 

approach as including such things as making 

routine use of self-administered depression 

screening tools at primary care clinics, in 

OB/GYN offices, by breast cancer 

specialists, and in prenatal and birthing 

centers to address unrecognized and 

11
Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

untreated depression. Ms. Power also noted 

that in order to take care of the whole 

woman it is important to take care of her 

children and to help keep them from getting 

caught in a cycle of mental illness 

themselves. She said that a comprehensive, 

family-based approach to prevention works. 

She also noted that there are promising 

treatment strategies for eating disorders that 

use cognitive behavior therapy methods and 

involve family members. 

“What do we know about trauma 

interventions? We know that 

multi-target, multi-modal 

treatment approaches and 

coordinated community 

responses have had the most 

positive impacts.” 

– A. Kathryn Power 

Director 

Center for Mental Health Services 

SAMHSA 

Ms. Power also brought up 

the need to improve 

systems of care for women 

in our nation’s jails and 

prisons, including effective 

interventions around 

parenting and child custody 

issues; services for 

pregnant inmates; and 

services and supports to 

resolve mental health issues 

related to victimization and 

violence. 

As the Director of CMHS, Ms. Power 

explained that one of her personal and 

professional priorities is to open the 

Nation’s eyes to the impacts of trauma on 

women’s lives and to the power of recovery. 

Through the work of its National Center on 

Women, Violence, and Trauma, SAMHSA 

is developing leadership networks to spread 

information about emerging best practices 

and to stimulate local change. In FY 2006, 

the CMHS Women’s Coordinating 

Committee – a group charged with 

promoting the importance of health issues of 

women across SAMHSA – is planning a 

series of activities, including trainings 

focused on the integration of traumainformed services in public health facilities. 

CMHS is making a major investment of 

resources in the issue of women and trauma, 

explained Ms. Power. CMHS’s 

groundbreaking Women and Violence Study 

is a shining example. 

Ms. Power also cited the Kaiser 

Permanente/CDC-sponsored Adverse 

Childhood Experiences (ACE) Study, which 

provides strong evidence of a causal link 

between violence-induced neurological 

damage, the use of self-medicating 

measures, the adoption of health risk 

behaviors, and consequent chronic disabling 

health morbidity and early mortality.8 She 

noted that the ACE Study is just one 

example of the substantial 

body of research 

investigating the impacts of 

trauma, particularly on 

women. Ms. Power 

emphasized that what we 

have learned about the 

pervasive lifelong impacts 

of violence and trauma in 

women and children brings 

urgency to our need to act 

now. 

She supported that 

statement by offering the 

following highlights about 

what is known regarding the impact of 

trauma: 

y Trauma is no longer regarded as an 

anomalous experience. It is increasingly 

seen as a widely prevalent experience of 

public mental health and human service 

recipients.9

y Addressing trauma is increasingly 

recognized as essential for recovery for 

other mental health disorders such as 

substance abuse. Improvement in 

symptoms such as depression and 

8 Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of 

childhood abuse and household dysfunction to many of the 

leading causes of death in adults: the Adverse Childhood 

Experiences (ACE) study. Am J Prev Med. 1998;14:245. 

9 Tjaden P, Thoennes N. Extent, nature, and consequences 

of intimate partner violence: findings from the National 

Violence Against Women Survey. Washington: National 

Institute of Justice and Centers for Disease Control and 

Prevention; 2000. NCJ 181867. 

12
Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

“The Report from the President’s 

New Freedom Commission on 

Mental Health challenges us to 

change the way this nation thinks 

about, delivers, and finances 

mental health care. It calls on us 

to create a new, recoveryoriented national mental health 

system that meets the needs of 

every American living with mental 

illness.” 

A. Kathryn Power 

Director 

Center for Mental Health Services 

SAMHSA 

substance-use disorders 

will not occur without 

integrating a focus on an 

underlying history of 

trauma.10

y A recovery-oriented 

system is not possible if 

we do not integrate 

trauma into mental health 

services. 

y The failure to address 

trauma results in major 

and costly human service 

systems failures, such as 

seclusion and restraint, 

self-injury in adult 

criminal and juvenile 

justice, repeated failures 

to maintain housing or employment, heavy 

use of health care services, and suicide. 

y Childhood physical and sexual abuse 

may lead to harmful coping strategies such 

as dissociation, self-injury, eating 

disorders, running away, and substance 

use that may delay development and create 

a legacy of lifetime disabilities associated 

with chronic mental health problems, 

addictions, and major health problems. 

y The intergenerational and historical 

costs of trauma are being increasingly 

recognized. 

y “Treatment as usual” that does not 

address trauma results in spiraling costs, 

lack of reduction in symptoms and misery, 

and continued cynicism regarding 

recovery on the part of consumers. 

Ms. Power went on to discuss effective 

interventions for trauma. She noted that 

multi-target, multi-modal treatment 

approaches and coordinated community 

responses have had the 

most positive impacts. She 

explained that SAMHSA 

sponsored a five-year 

Women and Violence 

Study, which has provided 

the most authoritative and 

comprehensive view to date 

of what can be 

accomplished in the public 

health system with women 

who have histories of 

physical and sexual abuse, 

who are in need of services 

for both mental health and 

substance-use disorders. 

She explained that this 

groundbreaking study 

featured a traumaintegrated counseling approach that 

addressed both mental health and substanceuse conditions. Findings suggest that 

integrated counseling (e.g. group and 

individual therapy that addressed trauma, 

mental health, and substance-use disorders 

issues) was the key element associated with 

better outcomes, which improved 

significantly over a 12-month period. 

10 Rosenberg SD, Mueser KT, Friedman MJ, Gorman PG, 

Drake RE, Vidaver RM, Torrey WC, Jankowski MK. 

Developing Effective Treatments for Posttraumatic Disorders 

Among People With Severe Mental Illness. Psychiatr Serv 

2001;52:1453-1461. 

Citing the findings and recommendations of 

Achieving the Promise: Transforming 

Mental Healthcare in America, the landmark 

final Report of the President’s New Freedom 

Commission on Mental Health, Ms. Power 

said that she saw our Nation as being on the 

cusp of a new evolution in mental health 

services. Achieving the Promise, she 

explained, calls for the creation of a new, 

recovery-oriented national mental health 

system that meets the needs of every 

American living with mental illnesses. 

Ms. Power warned, however, that this 

change will require true transformation – a 

revolution, as she described it, in how we do 

things, how we think, and how we work 

together. She commented that with this type 

of change, new sources of power emerge 

13
Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

that create a profoundly different system that 

is changed in structure, culture, policy, and 

programs. 

Embedded in transformation is the core 

belief in recovery and the belief that adults 

with mental illnesses can take charge of 

their own lives, their own wellness, and their 

own care, said Ms. Power. It is the belief 

that systems should help children and their 

families build on existing strengths, foster 

resilience, and create promising futures. 

She described her vision of a transformed 

mental health system as one in which: 

y Services for women and girls will 

recognize the complex linkages between 

biology and environment and the role of 

violence and poverty in health conditions 

– and new treatments will grow out of this 

recognition. 

y Culturally relevant, strengths-based 

approaches, which encompass creativity 

and spirituality and address the unique 

needs of refugees and immigrants, will be 

commonplace. 

y The power of technology will be tapped 

to connect women to, and educate them 

about, the wealth of effective recoveryfocused services that are available to them. 

Cooperation and collaboration, noted Ms. 

Power, are the lifeblood of transformation. 

She asked the workshop participants at the 

local, State, and national level to act and to 

advocate for the comprehensive, 

coordinated, consumer-centered mental 

health system that will give women, and all 

Americans, access to the full range of 

services they need to recover. 

In closing, Ms. Power quoted the Americanborn Buddhist nun, Pema Chödrön, “Now is 

the only time. What we do accumulates. The 

future is the result of what we do right now.” 

She called on participants to act, one person, 

one program, one community at a time, so 

that those actions do accumulate and lead to 

a point when recovery is the expected 

outcome for all. She challenged them to 

seize this moment rife with promise and use 

the power of it to transform the lives and 

future of millions of Americans. 

Cheryl Bowers-Stephens, M.D., M.B.A., 

Assistant Secretary for the Office of Mental 

Health, Louisiana Department of Health and 

Hospitals, described her experience of 

leading a mental health care system 

impacted by a severe natural disaster. She 

noted in her presentation that she was 

speaking not only as a person in charge of 

mental health for the State of Louisiana but 

also as a wife, with a husband who is 

Director of Health for the city of New 

Orleans, and as a mother. Through the lens 

of each of these perspectives, Dr. BowersStephens shared the story and lessons of 

trying to meet mental health needs in 

Louisiana before and following Hurricane 

Katrina. 

Prior to the hurricane, Dr. Bowers-Stephens 

explained, she and others had been planning 

strategic objectives for transforming the 

State mental health system to address more 

fully the need for mental health services. 

Pre-Katrina State figures indicated that of 

Louisiana’s 4.5 million people, more than 

900,000 were estimated to have a mental 

disorder – including nearly 180,000 adults 

and 65,000–77,000 children with a serious 

mental illness. Of these, only 46,000 were 

being served by the State Office of Mental 

Health. Thus, even before the storm, there 

was a great unmet need for mental health 

services. 

With warnings that the storm was on its 

way, the Office of Mental Health acted to 

evacuate psychiatric units and hospitals, said 

Dr. Bowers-Stephens. She noted that though 

the public heard mainly about those left 

behind in New Orleans, it is important to 

understand that 1.5 million people were 

evacuated from the city through a huge and 

14
Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

largely successful effort. The Office of 

Mental Health disaster preparedness had 

included disaster response drills, evaluation 

plans, disaster training for employees, and a 

staff callout registry. Prior to and during the 

storm, multiple command centers were 

activated; mobile crisis teams and call 

centers were put into place; Southeast 

Louisiana State Hospital, Charity Hospital 

Acute Unit, and New Orleans Adolescent 

Hospital were evacuated to other systems in 

eastern and central Louisiana; and specialneeds shelters were activated across the 

State. 

Dr. Bowers-Stephens reminded the 

workshop participants that Hurricane 

Katrina was the most destructive natural 

disaster in U.S. history. As a category IV 

storm with winds of nearly 150 miles per 

hour, it ripped apart homes, 

destroyed infrastructure, 

and toppled hundred-yearold trees like saplings. This 

was followed by a storm 

surge of nearly 30 feet, 

which caused levees to give 

way and sent people 

scrambling to rooftops and 

attics in desperate attempts 

to avoid the rising water. 

New Orleans and cities and 

towns across eastern 

Louisiana were devastated. 

The impact of Katrina on 

the State’s mental health 

system was enormous and 

far reaching, and Dr. Bowers-Stephens 

presented some numbers to illustrate its 

severity. She noted the following: 

y An estimated 3.2 million individuals 

were in need of crisis counseling services. 

y More than 1 million registrations were 

submitted for Federal Emergency 

Management Agency assistance through 

local parishes. 

y Among those moderately exposed to the 

destruction, estimates are that 5–10 

percent will experience clinically 

significant mental health issues and an 

additional 5–10 percent will experience 

subclinical issues that still will require 

support. 

y Among those in severely exposed 

communities, an estimated 25–30 percent 

of the population can be expected to 

experience clinically significant issues, 

with an additional 10–20 percent 

experiencing subclinical ones. 

While these numbers are significant, Dr. 

Bowers-Stephens explained that the impact 

of Hurricane Katrina was particularly severe 

for women. She noted that research on 

gender and natural disasters has found that 

women are more vulnerable 

than men in these situations 

and indeed should be 

considered a “special 

population.” This is due to 

a host of historical, social, 

cultural, and societal 

factors, such as domestic 

and economic burdens, 

lower incomes, lower social 

status, male flight, and 

increased risk of violence 

and abuse. In addition, 

women face an interaction 

of biologic and social risk 

factors, such as a higher 

baseline prevalence of 

depression and the risk of 

adverse reproductive events 

(e.g., there were numerous premature 

deliveries during and after Katrina). 

“Women should be considered as 

a special-need or vulnerable 

group during periods of disaster. 

Gender role differences and 

power differentials between men 

and women must be integrated 

into disaster preparedness 

training and planning activities.” 

– Cheryl Bower-Stephens 

Assistant Secretary 

Office of Mental Health 

Louisiana Department of Health 

and Hospitals 

Dr. Bowers-Stephens pointed out that the 

research evidence was indeed confirmed in 

the case of Katrina and its aftermath, where 

women were left behind by men to take care 

of the family, meet immediate survival 

needs, and face the risks of disorganization 

and increased violence that characterized the 

15
Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

post-storm situation in New Orleans. Dr. 

Bowers-Stephens noted that with her 

husband immediately called to the 

Superdome, she herself was left to make the 

family decisions regarding where to 

evacuate with their three children to meet 

both her family and professional 

responsibilities. 

y Institute policies to support the care of 

children. More than 1,000 children were 

listed as missing after Katrina and many 

were separated from their families. 

Predisaster planning must address the need 

to prevent family separations and lost 

children. 

y Teach families to be prepared. 

Incorporate messages into public health 

policies and messages about the 

importance of making emergency plans as 

a family before disaster hits. 

Dr. Bowers-Stephens highlighted the fact 

that there are many important lessons that 

should be drawn from the experiences of 

Hurricane Katrina in terms of emergency 

planning and preparedness. Specifically, she 

offered the following recommendations: Dr. Bowers-Stephens concluded by noting 

that the lessons of Hurricane Katrina must 

serve as a timely reminder of the critical 

need to incorporate gender into emergency 

preparedness planning and training.

y Anticipate postdisaster male flight in 

disaster preplanning, including first 

responder support. Ensure that there are 

special supports for women and families 

(e.g., there were no schools or day care on 

the cruise ships supplied for evacuees in 

New Orleans). 

y Ensure that specific structures, policies, 

and procedures are put into place to 

address postdisaster domestic violence and 

sexual assault prevention and intervention. 

16
Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

y Objective 3: Prepare a series of 

PowerPoint slides highlighting three key 

priority issues from the cluster area. In 

addition, for each key priority issue identify 

the major messages, suggested format, target 

audience, dissemination strategy, funding 

sources, and any overarching cultural 

concerns to be taken into consideration. 

Breakout Group Sessions 

Each participant in the Surgeon General’s 

Women’s Mental Health Workshop was 

assigned to one of eight workgroups. The 

basis for these assignments was not 

associated with individual specialties or 

areas of interest; rather, it was designed to 

ensure diversity and even numbers across 

each of the workgroup topic areas. These 

topic areas reflected the eight “cluster areas” 

identified through the series of background 

activities leading up to the workshop. As 

described above, these activities included a 

concept mapping exercise, key-informant 

interviews, facilitated discussions, and a 

targeted literature review. The breakdown of 

the eight workgroups was as follows: 

Each workgroup was composed of 12–14 

participants and facilitated by two 

individuals, including one Federal 

representative and one expert from the field. 

The facilitators conducted introductions, 

reviewed the workgroup objectives, and 

conducted a prioritization exercise to 

determine the highest priority issues within 

their cluster area. A list of potential 

communiqués and toolkits, based on 

recommendations from the background 

leadership interviews and facilitated 

discussions, was distributed to the 

workgroup members to spur ideas and 

discussions. This list is included in 

Appendix B. 

Group 1: Biological and developmental 

factors 

Group 2: Specific mental disorders 

Group 3: Trauma, violence, and abuse 

Group 4: Social stress factors and stigma 

Group 5: Identification and intervention 

issues 

Group 6: Treatment, access, and insurance 

Group 7: Health systems issues 

Group 8: Protective and resilience factors 

The workgroups were given the task of 

addressing three major objectives. These 

included: 

y Objective 1: Review and prioritize the 

significant issues affecting the mental health 

of women and girls within the identified 

cluster area. 

y Objective 2: Develop practical 

recommendations for the production of 

communiqués and toolkits related to the 

issues of that cluster area. 

17
Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

Workgroup 1: Biological and Developmental Factors At-A-Glance 

Priorities 

1. Understanding the biobehavioral bases for sex and gender differences as related to mental health 

2. Taking a life span approach to mental health – understanding sex and gender differences in etiology, 

course, and high-risk periods 

3. Understanding male and female differences in biobehavioral response to psychotherapeutic and 

behavioral mental health treatment (including side effects, efficacy, and compliance) 

Messages 

y Biobehavioral factors underlie sex and gender differences in the way people think and feel. 

y Biobehavioral differences between men and women are known through a small but growing body of 

research. 

y Greater knowledge will enhance our capacity to understand the etiology, prevention and treatment of 

mental health disorders and inform gender-based prevention and treatment strategies. 

y Early puberty is a high-risk period for specific mental disorders (for adolescent audiences). 

y Research shows that important events and times in a woman’s or girl’s life increase the likelihood of 

developing a mental disorder. Gender-specific prevention and treatments targeted to specific events 

across the life span are more effective. 

y Interventions may have different effects on men and women with selected mental health conditions. 

Women should be aware that a variety of treatments are available and should be encouraged to pursue 

the ones that best meet their needs. 

Products 

Fact sheets on sex and gender differences, lists of organizations, summary of scholarly articles, Web 

sites, TV messages, age-specific videos, and pamphlets 

Workgroup 1: Biological and Development Factors 

The Biological and Developmental Factors Breakout Group was given the list of issues to 

prioritize indicated in the following box.

Issues to Prioritize 

1. Understanding basic neurological sex 

differences 

2. The need for increased effort to relate 

biological and genetic mental health 

research to sex and gender differences in 

the prevalence and course of mental 

disorders 

3. Sex and gender differences in treatment 

response (both efficacy and side effects) 

4. Factors contributing to the emergence of 

sex and gender differences in mental 

disorders in adolescents 

5. Sex and gender differences and the 

effects of psychotherapeutic medications 

6. The neurobiology and psychology of sex 

and gender differences in social behavior 

and attachment 

7. Understanding the biological bases of 

normative sex and gender differences 

8. How the developmental phases of young 

females affect their mental health status 

as women 

18
Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

Defining sex and gender 

The group began with a discussion of the 

distinctions between sex and gender, leading 

to the following definitions: Sex is a 

biological construct defined by the organs 

with which a person is born. It changes little 

over time or across different cultures. In 

contrast, gender is a societal construct that 

reflects a person’s sex as it figures in a 

context of culture, family, and social 

environment. 

It was noted that these definitions are further 

complicated by the need to incorporate 

lesbian, gay, bisexual, and transgender 

(LGBT) concerns. 

The role of biology versus environment 

A major point of discussion for the group 

was the role of biology and the question of 

whether biology should be viewed 

separately or within a social context. The 

point was made that biological factors often 

unfold in a way that is influenced by the 

environment. However, as one researcher 

noted, some mental illnesses are responsive 

to medical treatment, so that the role of 

biology cannot be ruled out – especially 

since much information has been gained 

through studies and clinical trials on the role 

of biology. This raises the issue, which 

constitutes an ongoing debate between 

scientists and advocates, regarding who 

should be the source of expertise. 

Taking a life span approach 

It was noted that while the morning 

workshop presentations had focused on 

adults there also is a need to understand and 

transmit the message that women and girls 

are not the same. The importance of looking 

across the continuum of women’s lives and 

taking a life span approach to mental health 

issues was highlighted. Workgroup 

members also commented on the importance 

of acknowledging that there are critical 

high-risk periods during a woman’s life 

when mental disorders are more likely to 

occur. This concept of a life span approach 

was threaded throughout the workgroup’s 

discussions and ultimately was identified as 

a priority issue. 

Following this discussion, the group was 

able to synthesize and redefine three 

priorities from the eight under consideration. 

Their resulting key priorities are listed 

below. 

Key Priorities: Workgroup 1 

Biological and Developmental Factors 

1. Understanding the biobehavioral bases for 

sex and gender differences as related to 

mental health 

2. Taking a life span approach to mental health 

– understanding sex and gender differences 

in etiology, course, and high-risk periods 

3. Understanding male and female differences 

in biobehavioral response to 

psychotherapeutic and behavioral mental 

health treatment (including side effects, 

efficacy, and compliance) 

Key Priority #1: Understanding 

the biobehavioral bases of sex 

and gender differences as related 

to mental health 

Discussion 

It was suggested that there is a dearth of 

research regarding sex and gender 

differences in the brain and that the brain 

must be understood before addressing 

environmental factors. The group discussed 

the need for a clear understanding of 

cognitive processes, emotions, and 

interpersonal functioning. 

19
Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

Audiences 

Participants discussed the need to address 

several different audiences, including the 

medical research community, the general 

public, and policymakers. One suggestion 

was that messages targeting 

policymakers also could be 

put into language for the 

general public. There also 

was discussion about 

targeting specific audiences 

within the general 

population, such as 

families, teachers, and 

researchers. In the end, the 

group agreed to target two 

primary groups comprised 

of: 

y The general public 

y A combination of 

policymakers, research 

funders, providers, and 

trainers 

Messages 

The group crafted several messages, adapted 

to different target audiences. These include 

the following: 

Message to the general public 

Biobehavioral factors underlie sex and 

gender differences in the way people think 

and feel. 

The point was made that the sex and gender 

differences referred to in the above message 

would have to be further specified and 

demonstrated. 

Message to policymakers 

Biobehavioral differences between men 

and women are known through a small but 

growing body of research. Greater 

knowledge will enhance our capacity to 

understand the etiology, treatment, and 

prevention of mental health issues and to 

inform sex and gender based prevention 

and treatment efforts. 

Message for all audiences 

Greater knowledge will enhance our 

capacity to understand the etiology, 

prevention, and treatment 

of mental health disorders 

and to inform sex and 

gender based prevention 

and treatment strategies. 

 “Clinical experience is an 

essential part of evidence-based 

practices. What is lacking now is 

an understanding of the full scope 

of the existing evidence base. 

There is a tension between 

clinical and empirical data. The 

clinical data on biological 

differences may be stronger than 

most suspect, even if there is a 

shortage of empirical data.” 

– Breakout group member 

Formats 

The group’s recommended 

formats included: 

y A report including facts 

and implications of sex and 

gender differences that also 

would include a list of 

organizations supporting 

sex and gender specific 

treatment and awareness 

y A pamphlet, which would 

accompany the report and include empirical 

data on selected mental health conditions for 

ethnic minorities and underserved 

populations 

Cultural Concerns 

Participants noted the importance of having 

providers, the general public, and trainers 

understand that mental health symptoms 

manifest differently for ethnic minorities. 

Gaps in care for minorities need to be 

addressed as well, it was argued, though 

there is concern that the existing data are 

uneven. One participant shared the 

information that several fact sheets already 

exist on the topic and can be obtained 

through the Society for Women’s Health 

Research. 

20
Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

Key Priority #2: Taking a life span 

approach to understanding sex and 

gender differences in the etiology, 

course, and high-risk periods of 

mental health conditions 

Discussion 

One participant emphasized the importance 

of examining the ways in which different 

periods in a woman’s life affect her mental 

health; another added that mental health 

problems carry different economic, social, 

and personal costs at various points of the 

life span. The point was also made that there 

are sex and gender differences in the 

etiology, course, and high-risk periods of 

mental health conditions over a life span. 

It also was noted that taking a sex and 

gender based approach to mental health can 

be beneficial to both men and women, 

including understanding more about what 

causes mental health problems at different 

times in a person’s life. 

Audiences 

The group worked to identify key periods of 

the life span, which deserve special attention 

regarding mental health concerns. Members 

agreed that in tailoring the message across 

the life span, the following audiences should 

be targeted: 

y Adolescents 

y Postpartum mothers 

y Parents 

y Caregivers 

y Researchers 

y Policymakers 

y Providers 

Messages 

The group crafted several messages, adapted 

to different target audiences. These include 

the following: 

Message to the adolescent audience 

Early puberty is a high-risk period for 

specific mental disorders.

Message for all audiences 

Research shows that important events and 

times of a woman’s or girl’s life increase 

the likelihood of developing a mental 

disorder. Sex and gender specific 

prevention and treatments targeted to 

specific events across the life span are 

more effective. 

Formats 

The group brainstormed about ways to reach 

the various age-group audiences. One 

participant emphasized the importance of 

bringing the message to the audience, rather 

than expecting the audience to request a 

Surgeon General publication. Suggested 

potential venues for reaching different 

audiences included: 

y Web sites 

y MTV and informational programming 

concerning emotional crises 

y Public service announcements that could 

be delivered through community centers and 

churches, especially targeting adult women 

y 1-800 phone numbers 

Cultural Concerns 

Participants noted that any materials 

produced should be translated into multiple 

languages. Furthermore, they recommended 

that the message should consider and 

incorporate cultural concerns and mores and 

be disseminated in age and culturally 

appropriate settings. 

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Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

Key Priority #3: Understanding male 

and female differences in 

biobehavioral response to 

psychotherapeutic and behavioral 

mental health treatment (including 

efficacy, side effects, and 

compliance) 

Discussion 

Participants noted that there are new 

treatment models that are person centered 

and others based on a social model of 

disability. It is important, they commented, 

for the general public to know that treatment 

models are transitioning; women have the 

right to multiple options and should assert 

themselves when it comes to their own 

treatment. 

Further points that were raised on this topic 

included the following: 

y There are multiple treatment options, and 

it is important to understand that what works 

best for women might differ from what 

works best for men. 

y There are limited data suggesting that the 

response to a given treatment may differ 

among men and women. More research is 

needed that is not merely secondary 

analysis. 

y There are choices for treatment that allow 

consumers to pursue different options if a 

particular treatment is not working. Having 

options is empowering to the consumer. 

y An important takeaway is that there are a 

variety of treatments available that may or 

may not be influenced by sex and gender. 

The group worked to identify health issues 

germane to women that should be 

considered when receiving mental health 

treatment. Their list included: 

y The menstrual cycle 

y Menopause 

y Medications 

y Pregnancy 

y Age-related hormonal fluctuations 

Audiences 

For issues related to sex and gender 

differences, the group identified the 

following audiences: 

y Educators 

y Researchers 

y Members of the general public 

y Providers – with special emphasis being 

placed on mental health providers 

Messages 

The group crafted one message for all 

audiences: 

There is evidence that interventions may 

have different effects on men and women 

with selected mental health conditions. 

Women should be aware that a variety of 

treatments are available and should be 

encouraged to pursue the ones that best 

meet their needs. 

Formats 

The workgroup identified the following 

channels for disseminating the message: 

y Following the BodyWise Model 

(developed by OWH) – producing and 

adjusting a two-page fact sheet to target 

specific audiences 

y Using the 4-Women Web site (developed 

and maintained by OWH) 

y Listservs 

y Information Clearinghouse – developing a 

high-level, government-supported 

22
Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

clearinghouse of information that the public 

could access. Workgroup 1 Participants 

Facilitators Cross-cutting cultural concerns Cora Wetherington, Ph.D., National Institute on 

Drug Abuse In formatting the message, the group 

discussed how to incorporate culturally 

sensitive and accurate material. They 

recognized that cultural attitudes may cause 

shame and associate stigma with mental 

illness. There was agreement that the 

message should include information 

regarding different ethnicities’ responses to 

treatment and incorporate and validate the 

use of alternative healing methods. 

Kimberly Yonkers, M.D., Yale University 

School of Medicine 

Participants 

Cheryl Bowers-Stephens, M.D., M.B.A.,

Louisiana Department of Health and Hospitals 

Sylvia Caras, People Who 

Nereida Correa, M.D., Albert Einstein College 

of Medicine 

Mary Gee, B.A., Eating Disorders Coalition for 

Research Policy and Action 

Melva Green, M.D., American Psychiatric 

Association 

Phyllis Greenberger, M.S.W., Society for 

Women’s Health Research 

Gail Hutchings, M.P.A., SAMHSA 

Nadine Kaslow, Ph.D., Emory University 

School of Medicine 

Ruby Martinez, R.N., National Latino 

Behavioral Health Association 

Caroline Mazure, Ph.D., Yale University School 

of Medicine 

Richard Nakamura, Ph.D., National Institute of 

Mental Health 

Eileen Ouellette, M.D., J.D., FAAP, American 

Academy of Pediatrics

23
Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

Workgroup 2: Specific Mental Disorders At-A-Glance 

Key Priorities 

1. Developing communiqués and toolkits focused on children and adolescent girls 

2. Developing communiqués and toolkits focused on adult women 

3. Developing communiqués and toolkits focused on older women 

Messages 

y Mental health is essential to health (for children and adolescents). 

y Mental health is essential to health. Recovery is the goal (for adult women). 

y Mental health is essential to health. Good mental health is possible even in the absence of good 

physical health (for older women). 

Products 

Educational kits for parents and educators, toolkits for group facilitation, Web-based tools, iPod 

messages, visual non-literacy materials, multi-lingual and low literacy print materials, audio materials, 

videos, story-telling formats, PSAs. 

Workgroup 2: Specific Mental Disorders 

The Specific Mental Disorders Workgroup was given a long list of issues to consider. They were 

asked to prioritize 3 from the 20 presented in the box below. 

Issues to Prioritize 

1. Substance use and abuse (alcohol, illicit 

prescription use, tobacco, other drugs) 

2. Loss, depression, and anxiety across the 

life span 

3. Perinatal depression and anxiety and its 

effects on the family 

4. Adolescent depression, anxiety, and 

suicide 

5. The impact of race, ethnicity, culture, 

class, sexual orientation, and age on the 

expression of symptoms 

6. The relationship between depression, 

anxiety, and other negative mood states 

and substance abuse, especially smoking 

7. Recognition of enduring effects of 

depression and anxiety 

8. Comorbidity of mental disorders 

(depression, anxiety, mood disorders, 

substance abuse, including smoking, 

eating disorders, harming oneself, 

suicide) 

9. The impact on children of parental 

institutionalization (psychiatric, 

correctional, and military deployment) 

10. Understanding why women are more 

prone to suicide attempts than men 

11. The interaction of mental disorders with 

other illnesses, as both cause and 

consequence (e.g., cardiovascular 

disease, diabetes) 

12. Eating disorders 

13. Obesity and body image issues 

14. Research on serious mental illness in 

women 

15. Sex and gender differences in course, 

pathophysiology, and treatment response 

in mental disorders 

16. Posttraumatic stress disorder 

17. Bipolar disorder 

18. Schizophrenia 

19. Personality disorders 

20. Dissociative disorders 

24
Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

“There is a need for alternative 

tools besides labels and 

diagnoses to reach targeted 

audiences who may already be 

underserved. Otherwise, if all you 

have is a hammer, everything is 

going to look like a nail.” 

– Breakout group participant 

Language and stigma 

The group began by 

discussing the 

consequences, both positive 

and negative, of diagnosing 

and assigning a title to an 

individual’s symptoms. 

Some voiced concerns that 

certain diagnoses carried a 

stigma that might prevent 

women from seeking 

treatment – especially in some ethnic 

communities. The question was raised 

regarding whether consumers were being 

pathologized by terms such as “disorders”. 

There was a push by some participants to be 

less label-oriented in favor of being more 

distress-oriented or reframing issues in a 

more positive way; for example using terms 

such as “seeking peace”. 

Others were in favor of embracing a 

diagnosis. One participant suggested the 

creation of a crosswalk that could expand 

the understanding to incorporate physical 

symptoms and subsequently a more holistic 

view of a given disorder. 

Another comment was that more 

consideration should be given to thinking 

outside the box. The concern was voiced 

that consumers would not pick up a 

pamphlet titled “Mood Disorders” 

voluntarily – underscoring the need for tools 

besides labels and diagnoses to reach the 

targeted audiences that may already be 

underserved. 

Ultimately, it was noted that the two 

approaches were not incompatible in terms 

of disseminating the message. Emphasizing 

the importance of targeting particular 

audiences, the suggestion was made that 

educational materials could be tailored for 

primary care providers; an overall piece 

could be crafted to address mental health in 

relation to overall well-being; and a third 

educational piece could target communities 

with high prevalence. It 

was pointed out that there 

needs to be a balance 

between the two 

approaches and emphasis 

placed on disseminating 

specific information. 

Prioritizing the issues 

After much discussion 

about cross-cutting issues, 

audiences, and what types of tools might be 

most effective coming from the Surgeon 

General, this workgroup ultimately 

identified three major areas of concern: 

1. Mood and anxiety disorders, including 

cross-cutting themes such as culture, faith, 

family, resiliency, and available treatment 

options 

2. Trauma, including such cross-cutting 

themes as culture, recovery, and resilience 

3. Co-occurrence of mental disorders with 

medical issues 

Overall audiences and messages 

The workgroup identified several crosscutting themes: 

y Culture is an essential consideration. 

y Promotion of resilience is an important 

goal. 

y Critical life events can challenge coping. 

y Mental health is essential to overall health. 

Although the workgroup identified three 

major age groups as their primary focus for 

the development of communiqués and 

toolkits, they also noted the need to address 

multiple audiences with messages regarding 

each of these age groups. Those audiences 

included not only consumers and members 

of the public but also providers and 

policymakers. 

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Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

There was considerable discussion about the 

types of messages to be conveyed to 

different audiences – particularly for the 

general public and underserved audiences. 

The concern was expressed that messages 

should be crafted in a language that people 

use and can understand, and that is culturally 

appropriate. For example, one person noted 

that most people do not use many of the 

terms used in the list of priority issues; they 

refer more to terms such as “illness”. 

Another participant commented that patients 

do not care about their Beck Depression 

Inventory score but rather about whether or 

not they can get up in the morning. This led 

to the suggestion that messages be reviewed 

from the bottom up to ask people themselves 

in venues such as peer-to-peer interviewing 

questions such as “How do they understand 

the message?” and “Do we need to develop 

different tools?” 

Building greater communication between 

providers and consumers 

Another point raised was the need to design 

tools that could help build bridges between 

providers and consumers. This was seen as 

important in helping to move the clinical 

community to be more responsive and 

communicative with consumers. It was 

suggested that this would mean not only 

incorporating consumer terms into provider 

materials, but also including clinical terms 

in materials for consumers. One person 

added, however, that in order to get 

providers to pay attention to messages, “you 

have to come with a hammer” with 

substantive information and with strategies 

such as incorporating messages or changes 

through credentialing bodies or CME 

credits. 

Translating research and best practices into 

practice 

The issue of how information is translated 

from research into practice was discussed. 

The point was made that there is a dearth of 

hard information on knowledge transfer and 

that anecdotal evidence would suggest that 

the translation is not occurring. This led to 

the suggestion that more information is 

needed on what it takes for people to 

become comfortable with a tool, what 

works, what does not, what should be 

replicated, what type of training is needed, 

and where information is distributed. 

The hope was shared that the bully pulpit of 

the Surgeon General would offer a greater 

opportunity to be heard and discuss mental 

health in terms of whole health. The 

suggestion was made that messages with the 

backing of the Surgeon General then could 

be distributed through the pipelines and 

networks of existing organizations – 

including those represented at this meeting. 

Looking across the life span 

As a result of the discussion of specific 

mental disorders, cross-cutting themes, and 

target audiences, members of the workgroup 

began to move toward a developmental and 

life course approach. Thus, rather than 

prioritizing specific disorders from the given 

list, participants felt it was important to give 

priority to different age ranges and life 

transitions, emphasizing how those relate to 

the risks, course, prevention, and treatment 

of these disorders. 

As a result, the group agreed to prioritize 

their message, audience, and suggested 

communiqués or toolkits according to three 

age ranges, including childhood and 

adolescence, adult women, and older 

women. These age groups became the 

framework for the discussion of specific 

products and the focus of the group’s 

identified priority areas, as indicated below. 

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Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

Workgroup 2: Specific Mental Disorders 

Framework for Developing Toolkits 

and Communiqués 

1. Developing communiqués and toolkits 

focused on children and adolescent girls 

2. Developing communiqués and toolkits 

focused on adult women 

3. Developing communiqués and toolkits 

focused on older women 

The group discussed issues related to 

particular age groups, such as the 

importance of focusing on prevention with 

children and youth. They also looked at 

issues that cut across different age groups, 

such as the importance of mental health to 

overall health. The point was made that this 

workshop presented an opportunity to get 

away from the usual silos, defined by 

funding streams, to make a more integrated, 

holistic-oriented product. 

Key Priority #1: Communiqués and 

toolkits focused on children and 

adolescents 

Several participants viewed the period of 

childhood and adolescence as an important 

one for promoting resilience and prevention. 

They noted that effective toolkits for girls 

exist – including tools for at-risk girls – that 

are designed to help build self-esteem and 

self reliance. It was noted that these types of 

toolkits would be given more force if the 

Surgeon General was behind them. 

Another topic that generated discussion had 

to do with girls and young women who are 

at risk or already living with mental or cooccurring disorders, including those who 

may not make it always onto the radar 

screen (e.g., runaways, the growing 

population of young women in junior 

college). Several life events and challenges 

were identified as being particularly 

associated with this age group, including the 

effects of trauma, illness, and family 

breakup or loss. The positive and negative 

coping mechanisms that girls employ in the 

face of the challenges were discussed, 

including behavioral problems, substance 

abuse, mood symptoms, and resilience. 

Message 

The key message for materials focusing on 

this age group was: 

Mental health is essential to health. 

Audiences 

The identified audiences for this message 

include: 

y Consumers 

y Family members 

y Health care providers 

y Policymakers 

y Educators 

Dissemination strategies to reach these 

audiences were mentioned, such as working 

through schools, teacher associations, and 

parent-teacher associations. 

Formats 

The suggested formats include: 

y For girls 

y Information downloadable to an iPod 

y Web-based tools 

y Toolkits for group facilitation 

y For parents 

y Educational kits 

y For teachers and parole officers 

y Toolkits 

y For providers 

y Continuing education units (CEUs) 

y Board exams 

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Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

Cross-cutting cultural concerns 

The priority cross-cutting cultural concerns 

highlighted by this group included: 

y The need to improve the pipeline of 

minority providers 

y The need to increase the understanding of 

cultural and age-specific modes of 

expression among providers, teachers, and 

others who interact with children and 

adolescents 

Key Priority #2: Communiqués and 

toolkits focused on adult women 

Message 

The key message for materials focusing on 

this age group was: 

Mental health is essential to overall health. 

Recovery is the goal. 

Audiences 

A wide audience was identified for this 

message, including: 

Consumers, families, faith-based 

organizations, providers, policymakers, 

employers, community organizations, 

women’s groups, child care providers, 

criminal justice system, educational 

institutions, welfare-to-work programs, 

peer educators and lay home visitors, 

public housing, vocational rehab 

programs, AARP, and caregivers 

Formats 

The suggested formats to reach the 

identified audiences with the identified 

message include: 

y Visual, nonliteracy materials (e.g., film, 

video, sound) 

y Facilitator’s guides (e.g., tool associated 

with a video) designed with something to 

deal with emotional reactions that may be 

triggered through use of this tool 

y Self-assessment tools 

y Print materials, including multi-language 

and low-literacy products 

Cross-cutting cultural concerns 

One focus of discussion on this topic was 

the need to understand points of intervention 

for particular groups of women. For 

example, it was noted that selfdetermination and self-reliance are key 

within the African-American community 

and lack of these can be seen as a real 

failure. Thus, to break down stigma, it is 

important that mental health tools be 

adapted to different cultural groups in ways 

that address how they view mental health 

and illness. 

The group stressed the importance of 

ensuring that tools are reviewed and 

developed by members of specific 

communities and cultures – and that these 

reflect knowledge of how individuals can be 

reached within their cultural context. 

Examples were shared of materials that 

successfully bridge different cultures, such 

as the book Woman Who Glows in the 

Dark, which was written by Elena Avila, a 

nurse who practiced both Western medicine 

and indigenous folk healing. 

Key Priority #3: Communiqués 

and toolkits focused on older 

adult women 

Message 

The key message for materials focusing on 

this age group was: 

Mental health is essential to overall health. 

Good mental health is possible even in the 

absence of good physical health. 

Audiences 

Numerous audiences were identified for this 

message and this age group. They included: 

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Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

AARP; employers; nonclinical retirement 

communities; faith-based organizations; 

beauty parlors; bingo parlors; adult day 

care centers; community services for the 

elderly; areawide Agency on Aging; 

nursing centers and assisted living centers; 

and public health services, such as 

Medicare, SSI, and Medicaid 

Formats 

The recommendations regarding formats 

included: 

y Large-print materials 

y Audio and low-vision materials 

y Information that is short and sweet 

y Videos 

y PSAs (celebrity voices may resonate more 

with harder to reach populations) 

y No acronyms 

y Color contrast 

y Storytelling and oral histories 

Cross-cutting cultural concerns 

A number of issues were identified as 

relating particularly to this group. One set of 

issues had to do with generational 

differences, respect for elders, caring for 

other family members, or being cared for by 

family members, and end-of-life concerns. 

Others included issues of poverty and 

restricted income, privacy, indirect 

communications, and the use of multiple 

medications. 

Opportunities for collaboration 

This topic generated considerable discussion 

and development of partnering 

opportunities. Suggestions regarding 

potential funders and partners included: 

y Private foundations (e.g., Kaiser, the 

Robert Wood Johnson Foundation, the 

Commonwealth Fund, Pew, Ford) 

y National Foundation for Mental Health 

y American Psychological Association 

y National Association of Mental Health 

y Business partners such as Estee Lauder, 

Ford, The Body Shop, Avon, Amway, and 

Tupperware 

y Interdisciplinary partners, such as the 

National Hispanic Medical Association, 

National Hispanic Nurses Association, and 

faith-based groups, women’s organizations 

y Accreditation organizations 

y Women’s athletics organizations 

y International groups that have shown an 

interest in mental health and women (e.g., 

World Bank, WHO, the United Nations) 

y Educational organizations 

y Migrant centers 

y National Association of Commissioners 

for Mental Health 

y National spokespersons, such as Oprah 

Winfrey or the head of women’s health for 

Aetna 

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Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

Workgroup 2 Participants 

Facilitators 

Catherine Roca, M.D., National Institute of 

Mental Health 

Ellen Frank, Ph.D., University of Pittsburgh 

Medical Center 

Participants 

Andrea Blanch, Ph.D., Center for Women, 

Violence and Trauma 

Silvia Canetto, Ph.D., Colorado State 

University 

Linda Chaudron, M.D., M.S., University of 

Rochester 

Judith Cook, Ph.D., University of Illinois at 

Chicago 

Helen Coons, Ph.D., Women’s Mental Health 

Association 

Charlene Doria-Ortiz, Center for Health Policy 

Development, Inc. 

Linda Frisman, Ph.D., University of Connecticut 

Susan Gorin, C.A.E., National Association of 

School Psychologists 

Barbara Hylard, Depression and Bipolar 

Support Alliance 

Frances Murphy, M.D., M.P.H., Veterans 

Health Administration and President’s Mental 

Health Initiative 

Linda Prescott, Sister Witness International 

Barbara Yee, Ph.D., University of Hawaii 

30
Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

Workgroup 3: Trauma, Violence, and Abuse At-A-Glance 

Priorities 

1. Developmental and mental health effects of trauma 

2. Integration of health and mental health 

3. Effects of emotional abuse 

Messages 

y What is trauma and how common is it? 

y (Convey the human face of trauma, use everyday language, promote individual and community action 

to address trauma, violence, and abuse) 

y Recovery is possible. 

y Mental health is an essential part of physical health. 

y There is no separation between mind, body, brain, and behavior. 

y There is a need to develop psychological literacy around the mind-body connection. 

y Emotional abuse is “soul murder”. 

y Emotional abuse includes neglect, which is the “violence of silence”. 

y Emotional abuse negates your existence. 

Products 

Letter from the Surgeon General; PSAs; toolkits; Institute of Medicine report on trauma; fact sheets on 

myths and misconceptions about trauma; fact sheets on how trauma and abuse affect the brain; animated 

version of how the brain works for children; Surgeon General’s speeches highlighting this topic; teaching 

CD-ROM with discussion guide; fact sheet defining trauma, violence, and abuse and their prevalence. 

Workgroup 3: Trauma, Violence, and Abuse 

The workgroup was presented with a list of seven topics from which to identify key priorities. 

They are listed in the box below. 

Issues to Prioritize 

1. Effects of early trauma (abuse, neglect, 

loss of a parent) on the development of 

depression and anxiety in women, 

especially on African-American women. 

[The group agreed to change this point to 

read: Mental health and developmental 

effects of trauma, abuse, neglect, and 

loss.] 

2. Sexual violence against girls and women 

3. Childhood abuse, whether physical or 

sexual, and its long-term effects 

4. Domestic violence in heterosexual and 

same-sex relationships 

5. Emotional abuse at any age 

6. Effects of bullying, teasing, and sexual 

harassment in school 

7. Sex and gender discrimination, sexual 

harassment, and violence in the 

workplace 

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Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

Defining trauma 

There was considerable 

discussion based on this list 

regarding the need to 

broaden the definition of 

trauma, violence, and abuse 

to include things such as 

impersonal trauma (e.g., 

effects of war, natural 

disasters) and the impact of 

trauma, violence, and abuse 

on productivity, business, 

and the workforce. 

Similarly, several 

participants commented on the need to look 

at trauma, violence, and abuse within the 

cultural, historical, and political context of 

how and where they occur – not just as 

isolated incidents. They also considered the 

role of poverty as a context – though the 

group agreed that poverty was a mediating, 

not a causal, factor associated with these 

events. 

Provider concerns 

Another topic that generated a great deal of 

conversation centered on developing tools 

for providers to enable them to appropriately 

assess trauma, violence, and abuse. 

Participants noted that providers, 

particularly general practitioners, need a 

better understanding of how to ask questions 

about trauma, violence, and abuse and what 

to do with the answers – especially since 

they may be the only providers that 

consumers encounter. Several participants 

explained that there are many myths and 

misconceptions about how to deal with 

individuals who have suffered these events, 

and providers worry about such concerns as 

whether consumers will fall apart, how to 

develop a trusting atmosphere, and whether 

a provider should show emotional reactions. 

Participants expressed the need to develop 

tools and protocols that providers can use to 

deal with the fallout of a 

revelation of past trauma, 

violence, or abuse. 

One participant noted that 

in her experience, it is 

easier to inform criminal 

justice workers about 

trauma, violence, and abuse 

than it is mental health 

professionals. Another 

participant added that it is 

not possible to train all 

providers to become trauma 

professionals. There are 

three levels of awareness regarding trauma: 

trauma aware, trauma sensitive, and trauma 

competent. 

“Providers don’t want to open that 

can of worms [assessing trauma, 

violence, and abuse], because 

they do not know how to deal with 

it and don’t have the referral 

services necessary. They need 

protocols to know how to ask the 

questions and deal with the 

fallout.” 

—Breakout group participant 

The group further reviewed the issues to 

prioritize to see if some could be eliminated 

or condensed. They discussed the need to 

add elder abuse and emotional abuse to the 

list of issues under the top priorities. 

Ultimately, the workgroup agreed to 

highlight the following three priority areas. 

Key Priorities: Workgroup 3 

Trauma, Violence, and Abuse 

1. Developmental and mental health effects 

of trauma 

2. Integration of health and mental health 

3. Effects of emotional abuse 

Key Priority #1: Developmental and 

mental health effects of trauma 

Message 

There was a great deal of discussion about 

defining a message for this priority area, 

starting with the need to define trauma. 

Other points that participants wanted to 

convey in the message touched on the idea 

that trauma harms us all, that recovery is 

32
Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

possible and widespread, and that people 

who have experienced trauma should not 

feel ashamed or at fault. 

Several participants commented on the fact 

that there is a lot of shame associated with 

being abused (or being an abuser) and that 

the message of this key priority would need 

to be reassuring, empathy building, and 

presented in a way that victims of abuse will 

not immediately reject. 

The suggestion was made that the goal of 

the message should be to help change 

behavior, including for individuals at the 

precontemplative stage of change (i.e., those 

who have no intention of changing their 

behavior in the near future). One individual 

noted that the message needs to be brought 

to peoples’ doorsteps and shaped to resonate 

with the target audience. Thus, one angle 

that was suggested was to talk about safety 

and how violence, abuse, and trauma affect 

all aspects of our lives (e.g., how we work, 

how we learn, how we raise our children). In 

the end, the group agreed that the message 

should do the following: 

y Define trauma 

y Recognize the prevalence of trauma 

y Convey the message that recovery is 

possible 

y Use a common language that is directed to 

the individual and community level to take 

action 

y Put a human face on trauma 

Audiences 

There was much discussion of potential 

audiences for a Surgeon General’s 

communiqué on violence, trauma, and 

abuse. Some of the suggestions included 

State mental health commissioners or 

governors, social workers, churches/faithbased organizations, individuals and 

communities, other sectors (e.g., business), 

and the general public. Eventually, the group 

decided to focus on two priority audiences: 

y The general public (at the individual and 

community levels) 

y Providers (from multiple sectors) 

Format 

The workgroup participants proposed that 

the format of this communiqué take the form 

of a two-step process: 

Step 1: A letter from the Surgeon General 

to the general public addressing the 

centrality of trauma, violence, and abuse 

in women’s lives. It was suggested that 

this letter could go out to every household, 

similar to the Surgeon General’s letter on 

HIV/AIDS that was disseminated in the 

1980s. 

Step 2: A series of follow-up activities that 

could include PSAs targeted to specific 

audiences, toolkits, an Institute of 

Medicine (IOM) report on trauma, fact 

sheets on the myths and misconceptions 

about trauma, an emphasis on in-service 

training, and State trauma plans (as 

integrated into State mental health plans). 

Many potential resources and models were 

cited by workshop participants to help guide 

the development of communiqués, 

including: 

y The 1986 Surgeon General’s letter on 

HIV/AIDS 

y Lessons from breast cancer campaign 

models 

y A domestic violence campaign through 

hairdressers 

33
Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

y Real Men and Real 

Depression Campaign 

y Trauma certificate 

program at the University 

of Maryland 

y The Ohio business case 

on mental health report, 

soon to be released 

Key Priority #2: Integration of mental 

health and overall health 

The group discussed the question of how to 

address what some participants referred to as 

“a mind/body breakdown” – or the 

prevailing tendency to separate mental 

health and overall health in language, 

financing, service delivery, and common 

perceptions. The point was made that this 

separation increases stigma. The group 

grappled with developing suggestions on 

how the Surgeon General could address the 

issue of needing to integrate mental health 

more fully with overall health and stress the 

interoperability between the two. 

Message 

Numerous issues were raised during the 

discussion of how to frame a message, or 

several messages, related to the mind/body 

connection and importance of mental health 

to overall health. The first had to do with 

making the case for the connection and 

integrating the two as part of overall health. 

There was much discussion on the topic of 

the stigma associated with mental health. 

One participant noted the need to explain to 

people that there is a “range of normal or 

healthy behavior.” 

Another suggestion was to look at the use of 

stigmatizing language associated with 

mental health issues; for example, one 

person commented, we never hear of 

“serious cancer,” so why refer to a “serious 

mental disorder?” Similarly, the point was 

made that the terms mental and substance 

use conditions carried less 

of a stigma than terms such 

as mental disorder and 

substance abuse. 

Ultimately, the group 

crafted the following 

messages related to 

addressing the mind/body 

dichotomy: 

“We never hear of a serious 

cancer, so why refer to a serious 

mental disorder?” 

—Breakout group participant

y Mental health is an essential part of 

overall physical health. 

y There is no separation among the mind, 

body, brain, and behavior. 

y There is a need to develop psychological 

literacy around the mind-body connection. 

Audiences 

Participants felt that communiqués should 

be developed for the general public as well 

as for providers from multiple sectors. In 

addition, workgroup members highlighted 

the importance of reaching out to particular 

age groups that may be traditionally 

underserved or left out. Specifically, the 

group proposed to focus on: 

y Younger audiences (e.g., through Boys 

and Girls Clubs, 4H, etc.) 

y Older adults, who may be particularly 

affected by issues of stigma and could 

benefit from more understanding about the 

mind-body connection 

Format 

Several ideas regarding formats were 

proposed, including: 

y Fact sheets on how the brain works – on 

how psychosocial factors affect the brain 

and how that affects behavior 

y An animated version of how the brain 

works for children and youth (e.g., the blue 

part of the brain reacts like this when this 

happens) 

y An interactive video 

34
Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

Resources 

The workgroup raised the question of how 

to leverage other groups that are addressing 

some of these mind-body issues (e.g., anger 

management). 

Key Priority #3: Effects of emotional 

abuse 

Message 

There was considerable discussion regarding 

how to convey messages about the 

importance and severity of the consequences 

of emotional abuse, which some participants 

also referred to as “soul murder”. 

Participants shared thoughts and concerns 

regarding the effects of emotional abuse – 

how it negates one’s existence, damages 

self-esteem, and can be as damaging as or 

worse than physical or sexual abuse. They 

also noted the difficulties of getting people 

to recognize the importance of emotional 

abuse; for example, one workgroup member 

commented that Child Protective Services 

will respond to cases of physical or sexual 

abuse but, when it comes to emotional 

abuse, will say that it “is not really going to 

stand up.” One person cited the work of 

Maxine Harris (e.g., Trauma Recovery and 

Empowerment: A Clinician’s Guide for 

Working with Women in Groups) as a good 

resource on the damaging effects of 

emotional abuse. 

Workgroup members also talked about the 

role of emotional abuse in the context of 

sports. They discussed the need to train 

athletes to talk to kids and teach about rules 

and understandable lines that need to be 

respected. Participants noted the importance 

of teaching children and youth that you can 

act both aggressively on the field and 

respectfully off the field. 

Although they found it difficult to define 

emotional abuse and craft succinct 

messages, the workgroup did come up with 

three key messages regarding emotional 

abuse, including: 

y Emotional abuse is “soul murder.” 

y Emotional abuse includes neglect, which 

is the “violence of silence.” 

y Emotional abuse negates your existence. 

Audiences 

The following audiences were identified for 

messages relating to emotional abuse: 

y Students 

y Parents 

y Older adults 

y Coaches 

y Teachers 

Cross-cutting cultural concerns 

Several workgroup members grappled with 

the question of how the definition and 

concept of emotional abuse may differ 

across diverse cultures (e.g., effect of 

spanking) and through the process of 

acculturation. They noted that there was a 

tension between what may be accepted in a 

particular culture and what may be 

personally damaging. As one participant 

commented, “Simply because something is 

accepted by a cultural group does not mean 

that it is right.” 

The group discussed the importance of 

education, helping to identify what is abuse, 

and giving parents – including those who 

honestly believe that they are doing what is 

best for their child – an alternative that 

might be better. Participants also 

acknowledged the flip side of this type of 

awareness and education. For example, one 

workgroup member explained the risk of 

having a woman who suddenly learns that 

what she has been experiencing in her 

family is abuse but who is then disowned by 

35
Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

her family, because they do not believe that 

their behavior toward her is inappropriate. 

Dissemination 

The group came up with numerous 

suggestions regarding strategies for 

disseminating messages about emotional 

abuse. These included: 

y Having the Surgeon General include in his 

speeches that emotional abuse is a serious 

issue that needs to be addressed 

y Developing a fact sheet including a 

definition of emotional abuse, prevalence, 

and examples 

y Developing a film about emotional abuse 

y Developing a CD-ROM teaching tool with 

a discussion guide 

y Developing illustrative vignettes 

y Getting these messages into pop culture 

(e.g., reality shows, Superman, etc.) 

y Developing a list of how to identify 

emotional abuse for different age groups 

Workgroup members also cited numerous 

opportunities that they saw for building on 

existing vehicles or venues to further 

disseminate messages about emotional 

abuse. These included: 

y Building on the clearinghouse capacity of 

the newly formed Center on Women, 

Violence, and Trauma 

y Increasing knowledge about what is 

already out there, such as existing 

clearinghouses and resources 

y Developing an article (brief summary) 

about this Surgeon General’s Workshop on 

Women’s Mental Health that can be used for 

developing activities around women’s health 

month 

y Developing a cadre of responders for the 

aftermath of crisis – possibly taking the 

form of a National Guard of Responders 

composed of individuals interested in 

helping to address trauma 

y Supporting current leaders and 

developing emerging ones (e.g., on 

college campuses, in research 

positions at the NIH or the CDC) to 

carry the trauma message forward 

Workgroup 3 Participants 

Facilitators 

A. Kathryn Power, M. Ed., Center for Mental 

Health Services, Substance Abuse and Mental 

Health Services Administration 

Rene Andersen, M.Ed., Center on Women, 

Violence, and Trauma 

Participants 

Elizabeth Clark, Ph.D., M.P.H., ACSW, 

National Association of Social Workers 

Susan Cochran, Ph.D., University of California, 

Los Angeles 

Rachele Donnell, R.N., Red Lake 

Comprehensive Health Services 

Rachel Fleissner, M.D., American Academy of 

Child and Adolescent Psychiatry and University 

of North Dakota 

Joan Gillece, Ph.D., National Technical 

Assistance Center, National Association of State 

Mental Health Program Directors 

G. Grijalva-Gonzales, Substance Abuse 

Services, San Joaquin County Health Care 

Services 

Maxine Harris, Ph.D., Community Connections 

Ruta Mazelis, Cutting Edge Newsletter, Sidran 

Institute 

Pamela Mulder, Ph.D., Marshall University 

Susan Nolen-Hoeksema, Ph.D., Yale 

University 

Karen Peterson, M.D., Uniformed Services 

University of the Health Sciences 

Rick Peterson, Ph.D., Texas A&M University, 

National Association of Rural Mental Health 

Carole Warshaw, M.D., National Training and 

Technical Assistance Center on Domestic 

Violence, Trauma, and Mental Health 

36
Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

Workgroup 4: Social Stress Factors and Stigma At-A-Glance 

Priorities 

1. Discrimination and stigma of women and girls who live with mental health issues 

2. Depression and anxiety disorders among women and girls across the life span 

3. The need to integrate mental health issues in settings where women and girls naturally congregate 

Messages 

y Discrimination is stigma. Stigma is compounded by factors such as sex and gender, culture, race, 

ethnicity, poverty, age, and locality. 

y Stigma leads to lost opportunities. 

y Women and girls have an increased level of suffering from mental health issues, associated with issues 

of family responsibility, poverty, employment, and access to mental health services. 

y Having a mental disorder is not your fault and not something of which to be ashamed. 

y It takes strength to reach out for help. 

y Treatment works. 

y Women and girls face unique risks at specific developmental stages (adolescence, pregnancy, postpartum, menopause, elderly years, etc.). 

y Early intervention and identification promote greater success. 

y It is important to distinguish between depression and normal sadness. 

y Building knowledge helps to enhance access to identification and intervention. 

y There is no health without mental health. 

Products 

Legislative breakfast, briefs with recommendations, PR materials, messages on commonly used products 

(e.g., diapers), bookmarks, cards, screening for moms when they bring children to the pediatrician, public 

transportation venues, school health curricula, first-aid approach, community networks, Web sites, 

workforce development, identifying champions, expanding State and national health weeks 

Workgroup 4: Social Stress Factors and Stigma 

The group was asked to consider and prioritize the list of six issues pertaining to social stress 

factors and stigma indicated in the box below. 

Issues to Prioritize 

1. Increased risk of victimization for all 

women 

2. The extent to which lower socioeconomic 

status and/or immigrant status relates to 

mental health 

3. The discrimination and lack of social 

acceptance that those with mental 

disorders face 

4. Internal barriers to seeking and receiving 

mental health care such as shame and 

guilt 

5. Negative images of girls and women, 

particularly among minority women, in 

television, magazines, and film-related 

media 

6. The need for additional research on the 

economic impact of maternal mental 

illness on family health outcomes 

37
Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

As the group reviewed the identified issues 

and addressed the task of trying to prioritize 

them, the discussion touched on several key 

themes, including stigma, cultural issues, 

and social stressors. 

Stigma 

Much concern was voiced among members 

of the workgroup regarding aspects of our 

current mental health system that serve to 

reinforce issues of stigma surrounding 

mental health. For example, participants 

noted that the fragmentation of services, 

limitations on mental health coverage, and 

the lack of affordability of drugs to treat 

mental disorders contribute to stigma. The 

state of mental health treatment was 

characterized by one participant as “separate 

and unequal.” Discrimination was referred 

to as the “big elephant in the room,” and the 

argument was made that discrimination not 

only occurs in public mental health care but 

is in fact legally sanctioned in mental health. 

The resulting stigma and discrimination, it 

was noted, result in greater stress on 

individuals seeking help. 

Several participants discussed strategies for 

getting messages out to the public to address 

and help reduce stigma. One concern 

specifically was in reaching families, who 

often expect to confront the challenge of 

mental illness alone and not discuss it with 

outsiders. It was suggested that there was a 

need to explain that mental illness is not just 

a family affair. One person noted, for 

example, that the literature on anxiety 

disorders suggests that these are biologically 

based illnesses. Explaining this to families 

helps them to understand that this is a 

medical diagnosis, just like heart disease, 

and should be seen as an illness that can be 

treated. 

However, it was noted that describing 

mental illness as a function of genetics 

might prove offensive to an older 

population. The message “You have a real 

illness” seems to be more effective at 

addressing issues of shame, guilt, and 

stigma. Another participant suggested that 

there might be helpful “people first” 

language to be gleaned from the Institute for 

Mental Disease. 

Participants also shared examples and ideas 

of ways to integrate mental health screening 

with other assessments to destigmatize the 

issue further. The example was raised of a 

screening assessment that included two 

trigger questions for mental illness listed 

with a series of other health screening 

questions, which reduces stigma. However, 

the point was made that once you screen a 

person for a mental disorder, you need to be 

able to refer them to appropriate information 

or treatments. 

One participant explained that in Australia, 

information packets that include a suicide 

screening are given to every middle school 

student. Similarly, high school students 

receive a lunch kit with information on 

mental health agencies, birth control 

resources, drug issues, and other information 

– the point being that the widespread 

dissemination of this information helps 

reduce stigma and increase awareness. 

Culture 

Language barriers coupled with a lack of 

cultural sensitivity by providers were cited 

as a significant challenge to overcoming 

stigma in some communities. Participants 

noted that it would be important to have 

some background information on different 

issues regarding social stress factors and 

stigma within different cultures. Another 

related comment was that consideration 

needs to be given to individuals who are 

minorities but foreign born – a population 

which is often overlooked. This may require 

developing targeted materials for specific 

communities, as several group members 

noted, that are not simply a translation or 

adaptation of materials developed for the 

38
Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

“mainstream” population. It was 

recommended that materials be developed 

from the ground up to reflect specific 

cultures and cultural issues. 

Other participants cautioned that diversity 

should not be focused solely on race or 

ethnicity, but also on issues such as sexual 

orientation, geography (e.g., underserved 

rural or urban environments), and age 

groups (e.g., children). Several people 

commented that one consumer may belong 

to many groups and that emphasis should be 

placed on starting with one core message 

that resonates across many sociocultural 

strata. 

Social stressors 

The workgroup spent time identifying social 

stressors that might affect women’s mental 

health, their resilience, their ability or 

willingness to seek help, and their outcomes. 

The list of issues they compiled included: 

y Poverty 

y Homelessness 

y Being uninsured or underinsured 

y Lack of knowledge regarding mental 

illness or substance abuse 

y Living in a rural environment 

y Living in the inner city 

y Isolation 

y Incarceration 

y Living in the projects 

y Aging 

y Immigration (e.g., guilt, trauma history, 

acculturation) 

y Racism 

y Lack of long-term coverage for treatment 

After creating this broad list of social 

stressors, the group turned its focus toward 

identifying those factors that are of 

particular concern to women. This list 

included: 

y Women acting as primary caregivers for 

family members 

y Stigma for women associated with 

substance abuse 

y Stigma for women associated with loss of 

child custody due to mental health issues 

y Girls with a mentally ill parent tend to take 

on caregiver roles 

y In the caregiver role women have little 

time for self-assessment 

y Peer pressure for girls (e.g., smoking, the 

“mean girl” phenomenon) 

y High rates of victimization for both 

women and girls 

y Negative images, especially of minority 

girls and women 

y Women and girls having different mental 

health issues 

The power of public health education, it was 

noted, should not be underestimated. 

Workgroup members shared examples of 

positive campaigns or changes that could 

serve as models. One example given was of 

a generation of children who have been 

taught to cough into their arms instead of 

their hands. Another example that was 

highlighted was of the effectiveness of the 

seat belt safety message – largely because it 

has been translated into law. 

Several issues were discussed but ultimately 

placed in a “parking lot” for future 

consideration. These included: 

y Trafficking of women 

y Single-payer systems 

y The state of mental health care in the 

United States 

y Parity 

y Housing 

39
Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

Based on their long discussion and 

consideration of priorities, the workgroup 

identified three priority issues, presented in 

the following box. 

Key Priorities: Workgroup 4 

Social Stress Factors and Stigma 

1. Discrimination and stigma of women and girls 

who live with mental health issues 

2. Depression and anxiety disorders among 

women and girls across the life span 

3. The need to integrate mental health issues in 

settings where women and girls naturally 

congregate 

Key Priority #1: Discrimination and 

stigma of women and girls who live 

with mental health issues 

Message 

Following their lengthy discussion on 

discrimination and stigma, the workgroup 

members agreed to highlight the following 

messages: 

y Stigma is discrimination. It is exacerbated 

by factors such as sex and gender, race and 

ethnicity, poverty, age, and locality (e.g., 

rural, inner city). 

y Stigma leads to lost opportunities. 

y Women and girls have an increased level 

of suffering from mental health issues, 

associated with issues of family 

responsibility, poverty, employment, and 

access to mental health services. 

y Having a mental disorder is not your fault 

and not something of which to be ashamed. 

y It takes strength to reach out for help. 

y Treatment works. 

Audiences 

The group members identified the following 

audiences for this priority issue: 

y Policymakers 

y General public – including schools, faithbased organizations, etc. 

y Primary care providers 

y Families 

y Service utilization sites 

Format 

The group noted that the Health Resources 

and Services Administration (HRSA) is 

already in the process of developing a 

toolkit related to women’s mental health for 

primary care settings. The suggestion was 

made that if resources are limited, it would 

be important to focus on areas of high risk 

or service-based programs, such as the 

Supplemental Food Program for Women, 

Infants, and Children (WIC). 

Some of the recommendations for formats 

focused on reaching a general public 

audience. Suggested formats included: 

y Age-appropriate pamphlets 

y Messages in school planners 

y Word of mouth 

y Ways to get into the media 

y Web-based formats for younger audiences 

y Radio-based formats for older audiences 

Another suggestion with regard to targeting 

policymakers was to try to come up with 

formats and materials that could show the 

economic benefits or cost-benefit analysis of 

addressing stigma and discrimination to 

promote greater understanding, prevention, 

and treatment of mental health issues. 

40
Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

A final suggestion was to look at existing 

resources and ways to help disseminate or 

integrate those further. 

Cross-cutting cultural concerns 

Participants identified cultural barriers 

related to discussing “problems” with 

someone of another culture, race, or 

ethnicity. They also noted the importance of 

addressing cultural barriers within a 

community that contribute to 

misunderstanding, stigma, and 

discrimination. 

Key Priority #2: Depression and 

anxiety disorders among women and 

girls across the life span 

Message 

The group developed several messages 

related to this priority area: 

y Women and girls have unique behavioral 

health risks at specific developmental stages. 

Examples include adolescence, pregnancy, 

postpartum, menopause, and elderly years. 

y Early intervention and identification 

promote greater success. 

y It is important to distinguish between 

depression and normal sadness. 

y Building knowledge helps to enhance 

access to identification and intervention. 

Audiences 

The workgroup members focused on several 

specific audiences for this topic and set of 

messages, including: 

y Primary care family practices 

y OB/GYNs 

y Pediatricians 

y Schools 

y Sororities and other college-based 

organizations 

Formats 

The workgroup members suggested the 

following formats for conveying the 

messages, including: 

y Putting messages on commonly used 

products, such as diapers, formula, etc. 

y Bookmarks, cards (high school, college) 

y Screening for moms when they bring their 

child to the pediatrician 

y Putting messages on public transportation 

venues (e.g., bus shelters) 

Cross-cutting cultural concerns 

Participants identified several cultural 

concerns. One had to do with addressing the 

culture of silence surrounding depression 

and mental disorders generally, particularly 

within diverse racial, ethnic, or cultural 

groups. A related issue was the role of 

traditional practices and values with regard 

to depression and anxiety disorders. Another 

concern was the fact that depression and 

mental disorders are seen as a family issue 

in some cultures, one that needs to be kept 

within the family sphere – thus discouraging 

individuals from seeking treatment. 

Key Priority #3: Failure to integrate 

mental health issues in settings 

where women and girls are 

Message 

The workgroup crafted a very simple 

message to address this priority issue: 

There is no health without mental health. 

Audiences 

They identified numerous audiences: 

y Schools 

41
Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

y Primary care physicians Workgroup 4 Participants y People in all health-related disciplines 

y Facilitators Faith-based organizations 

Teresa Chapa, Ph.D., M.P.A., Office of Minority 

Health, Office of Public Health and Science, 

DHHS 

y Community-based organizations, such as 

scout groups, the Rotary Club, and the 

League of Women Voters Kinike Bermudez-Walker, National Asian 

American Pacific Islander Mental Health 

Association y Public education students (pre-K through 

grade 12) 

y Stores, barber shops/beauty parlors, 

clinics, and local hangouts 

Participants 

Alan Allery, Ph.D., M.H.A., M.Ed., University of 

North Dakota School of Medicine and Health 

Science Formats 

Belinda Biscoe, Ph.D., University of Oklahoma, 

College of Continuing Education The suggested formats included: 

y A first-aid approach (psychological firstaid for children already exists) Jerilyn Cohen-Ross, M.A., LLCSW, Anxiety 

Disorders Association of America 

y A school health curriculum Larke Huang, Ph.D., American Institutes for 

Research y A community-based campaign within 

social networks Jean Lau Chin, Ed.D., Alliant International 

University Carmen Lee, Stamp Out Stigma 

y A Web site Richard M. Lerro, M.L.A., Eating Disorders 

y Coalition Workforce development 

Jacki McKinney, M.S.W., Center on Women, 

Violence, and Trauma y Toolkits 

y Champions within the community Dennis Mohatt, Western Interstate Commission 

on Higher Education y Mentors 

Lisa Najavits, Ph.D., Veterans Affairs, Boston 

Healthcare System y Health advocates 

y Identified health weeks or health days Jon Perez, Ph.D., Indian Health Service 

Lincoln Stanley, M.A., American Association Cross-cutting cultural concerns for Marriage and Family Therapy 

The group discussed issues of language: 

how the message is framed, by whom, and 

whether or not it is in a person’s mother 

tongue. The suggestion was made that 

diverse consumers should be involved in the 

development and implementation of 

communiqués to ensure greater cultural 

competence. They also pointed out the need 

to address issues related to persons with 

physical disabilities. 

42
Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

Workgroup 5: Identification and Intervention Issues At-A-Glance 

Priorities 

1. Preventive interventions for the most common and disabling disorders, such as major depression and 

anxiety 

2. The need for screening for depression, anxiety, and other common mental disorders in primary care, 

schools, and other settings 

3. The importance of consumer and provider empowerment, self-determination, and choice in mental 

health treatment 

Messages 

y The concept of mental health must be broadened to include other systems (e.g., primary care, 

education, employment, housing). It also should use a strengths-based approach, highlight prevention 

as the beginning of the continuum of care, and expand the scope of services across generations and 

from individuals to families. 

y Identify and develop holistic screening tools to assess mental disorders. 

y Community involvement is needed to establish a process of empowerment and self-determination. 

y Barriers (language, culture, costs) must be removed to empower consumers and providers. Federal 

agencies (e.g., Health, Education, Justice, Labor) can help remove these barriers. 

y A collaborative care strategy is needed to overcome financial and administrative silos. 

Products 

Community partnerships with health care, employers, schools, managed care organizations, insurers, and 

peer support groups; community toolkits with examples of effective tools, reviews of the latest science; 

education protocol on how to use assessment tools; identify champions to promote use of assessment 

tools; consumer education communiqué; toolkit for advocacy and community mobilization; 

intergenerational worksheet to manage mental health issues; local mental health care decision making 

flow sheets (like those of Cancer Regional Centers); storytelling approaches; address issues for 

immigrant women and families 

Workgroup 5: Identification and Intervention Issues 

The key priority issues assigned to this workgroup are listed in the box below. 

Issues to Prioritize 

1. The importance of consumer and 

provider empowerment, selfdetermination, and choice in mental 

health treatment 

2. Models for transitioning women from 

institutions to re-entry into family and 

community living 

3. Preventive interventions for the most 

common and disabling disorders, such as 

major depression and anxiety 

4. Depression and anxiety that go 

undiagnosed and therefore untreated 

5. The need for screening for depression, 

anxiety, and other common mental 

disorders in primary care, schools, and 

other settings 

6. The need to implement the comprehensive nationwide program for suicide 

prevention previously described in the 

National Strategy for Suicide Prevention 

7. The lack of support and care options for 

older women 

8. Complementary and alternative medicine 

in relation to self-treatment of mental 

disorders 

43
Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

As members of the workgroup considered 

how to identify the top three priority issues 

they also identified a number of related 

issues that affect the diagnosis and treatment 

of women’s mental disorders. Those issues 

are grouped here according to common 

themes: 

Target populations 

y Older populations, especially their 

growing demographics and rising rates of 

responsibility in raising grandchildren 

y An increasing number of women who are 

foreign born and the lack of a support 

system for them, especially the elders 

Access to and funding for mental health 

services 

y The role of insurance companies in 

empowering or disempowering providers in 

their ability to provide care 

y Health economics and the waste of health 

care dollars when alternative practices are 

not validated 

y Access to care – mental health being seen 

as an additional burden rather than as a 

critical part of care 

y The need for education, interagency 

coordination, and less fragmentation that 

contributes to underdiagnosis and 

mistreatment of mental disorders 

y Bringing care into the home (helps address 

barriers) 

Treatment issues 

y Choosing one’s own path to health, 

reducing isolation, and increasing 

networking opportunities 

y Treating individuals versus working with 

the family unit 

y The sense that believing in treatment can 

help to make it more effective 

y The need to promote community-driven 

supports 

y Faith-based activities 

Prevention 

y Preventive efforts are critical to improving 

health status but are not well funded. 

Provider education and training 

y Training and education – the need to shift 

how and whom we train 

y The lack of minority health providers 

Of the issues presented to the group, the 

following three were chosen as the top 

priority issues. 

Key Priorities: Workgroup 5 

1. Identification and Intervention Issues 

2. Preventive interventions for the most 

common and disabling disorders, such as 

major depression and anxiety 

3. The need for screening for depression, 

anxiety, and other common mental disorders 

in primary care, schools, and other settings 

4. The importance of consumer and provider 

empowerment, self-determination, and 

choice in mental health treatment 

Key Priority #1: Preventive 

interventions for the most common 

and disabling disorders, such as 

major depression and anxiety 

Message 

Members of the workgroup argued that the 

concept of mental health needed to be 

broadened to take into consideration other 

systems, such as primary health care, 

education, employment, and housing. They 

emphasized the fact that mental health 

affects and is affected by these systems. 

44
Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

The group also identified the following 

attributes of a message for this topic: 

y Uses a strengths-based approach 

y Highlights prevention as the beginning of 

the continuum of care 

y Expands the scope of services across 

generations and from individuals to families 

Audiences 

The identified audiences included: 

y The entire health care system, especially 

the primary health care system 

y Schools 

y Employers 

y Insurers, especially managed care 

y Community-level organizations 

y Self-help groups 

Formats 

The group suggested the need to create 

community partnerships with health care, 

employers, schools, managed care, insurers, 

and peer support groups. Participants noted 

that it would be important to establish a 

knowledge base within the community to 

help recognize prevention and resilience 

issues. Two other suggestions were that 

treatment must connect women in care to 

other systems options and that community 

involvement in the intervention process 

should be developed and enhanced. 

Cross-cutting cultural concerns 

The following cross-cutting cultural 

concerns were raised: 

y Recommendations must be community 

driven and developed by stakeholder 

partners. 

y Consideration of self-directed 

complementary and alternative treatments 

should be integrated into the development of 

communiqués and toolkits. 

Priority Issue #2: The need for 

screening for depression and other 

common mental disorders in primary 

care, schools, and other settings 

Message 

For this topic, the group came up with the 

following message: 

Identify and develop holistic screening 

tools for the assessment of mental 

disorders. 

In discussing the message, the suggestion 

was made that there was a need to create 

tools that measure the “whole woman.” The 

example was offered of the Medical 

Outcomes Study Short-Form 36 (SF-36), 

which has been extensively tested and 

validated and is a functional health selfassessment measure with physical and 

mental health scales. It measures mentalcomponent-improved-scores by 

(1) antidepressants and (2) self-described 

behavior changes (spiritual growth, dealing 

with relationships, doing work they are good 

at what matters, taking care of themselves). 

It was explained that the process of using a 

simple tool to identify mental health issues 

helps patients feel listened to and holds 

providers accountable to dealing with these 

issues and suggesting interventions. 

Other participants discussed the need to 

establish functional health measurements 

that ask the right measurement questions. 

Also noted was the need to create a structure 

for mental health measurement and response 

that can be integrated and standardized into 

current practices, especially in primary care 

practice. Group members noted the 

importance of interpreting the numbers and 

being able to “translate the numbers back 

into people.” The suggestion was made that 

45
Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

tools be adapted to the unique needs of 

diverse populations or providers through 

methods such as demonstration programs, 

which also would test their functionality in a 

“living laboratory” or real world setting. 

One participant raised the issue of 

developing broadly based, holistic screening 

tools that could empower consumers (e.g., 

self-assessment tools) and promote access to 

services. These types of tools would need to 

focus on functionality and quality of life, it 

was explained, rather than simply on 

symptom reduction. They also would need 

to be culturally and developmentally 

appropriate. 

Another key point of discussion was the 

need for identified referral systems and 

services to follow up on screenings and 

assessments. Participants pointed to the 

importance of education and training to 

properly use assessment tools – and to avoid 

bias and discrimination based on healthrelated stereotypes. As one person noted, 

“the tool is only as useful as the training on 

how to use it properly.” One suggestion was 

the possibility of developing a training 

manual to describe the process of using an 

assessment tool. As a final comment, one 

workgroup member noted that assessment 

tools can be important for securing funding. 

Audiences 

The suggested audiences for this message 

were: 

y Federal agencies 

y Funders 

y Schools 

y Providers 

y Consumers 

Formats 

The following suggestions were made 

regarding potential formats: 

y Community-based and tested toolkit. 

Workgroup members discussed the need to 

gather information to develop or find 

existing assessment and screening tools. As 

part of this process, they proposed the 

development of a toolkit that identifies such 

things as examples of effective tools and 

reviews of recent scientific research on this 

topic. 

y Educational protocol. The group identified 

the need to train providers on how to use 

assessment tools tailored to the specific 

needs of women, especially those of color. 

The training and curricula would need to be 

culturally and linguistically appropriate, 

relevant, and sensitive, and it would need to 

include training in self-assessment 

techniques. The training should be fieldbased and able to highlight how these tools 

work in real-life settings. 

y Something that gathers information on the 

importance of using these tools and how it 

can improve women’s mental health 

outcomes. This would be designed to inform 

stakeholders. 

y Champions. Identifying individuals to 

champion the use and integration of tools 

within communities. It was noted that 

champions can be found often in times of 

tragedy. 

Cross-cutting cultural concerns 

The group underscored the importance of 

community-driven involvement in the 

development of materials. This was defined 

as including the active involvement of 

community-based organizations and 

individuals from both within and outside of 

mental health. It was noted that stakeholder 

partnerships should be established and 

include a reciprocal communication of ideas. 

The need for culturally and linguistically 

appropriate training on the use of 

assessments was also re-emphasized as part 

of this discussion. 

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Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

Challenges 

Along with their recommendations, 

workgroup members identified a series of 

challenges, including: 

y How to respond to the mental health issues 

that are identified by 

assessment tools 

y How to identify which 

types of activities and 

treatments have worked and 

will work for patients 

y How to establish an 

adequate supply of 

providers to whom you can refer patients 

Key Priority #3: The importance of 

consumer and provider 

empowerment, self-determination, 

and choice in mental health treatment 

There was some disagreement regarding the 

phrasing of this priority issue. Several 

participants expressed the concern that the 

concept of mental health needed to be 

broadened to include the wider context in 

which women’s mental health plays out. 

There was also interest in including the 

concept of self-directed care. One other 

suggestion was to include this sentence: 

“Mental health care strategies include 

alternative and complementary treatment 

options.” 

Ultimately, the priority was left as indicated. 

Messages 

The following messages were recommended 

by the group: 

y Community involvement is necessary to 

establish a process for empowerment and 

self-determination. As one participant noted, 

“We don’t just want to be at the table; we 

want to eat at the table.” 

y Health systems and Federal agencies (e.g., 

the Departments of Health and Human 

Services, Education, Labor, and Justice) 

should help remove barriers (e.g., language, 

cultural, financial) to consumer choices and 

empowerment. 

y A collaborative care 

strategy (e.g., substance 

abuse and mental health) is 

necessary to overcome 

financial and administrative 

silos. 

“We don’t just want to be at the 

table; we want to eat at the table.” 

– Workgroup member 

and consumer representative 

Audiences 

Workgroup members identified a broad 

array of audiences for this topic, including: 

y The entire health care system 

y Schools 

y Employers 

y Insurers 

y The community 

y Self-help groups 

Formats 

The following formats were suggested: 

y Consumer education communiqué for 

consumers, providers, and advocates 

y A toolkit on advocacy and community 

mobilization for empowering women 

y Intergenerational worksheets and plans of 

management for mental health issues, with 

separate worksheets for different population 

groups, providers, consumers, and 

policymakers 

y Toolkits for immigrants and refugees 

about their rights and explaining the basics 

about the mental health treatment system, 

making legal provisions accessible to 

vulnerable populations 

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Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

y A local mental health 

care decisionmaking flow 

sheet, perhaps similar to 

one developed by the 

Cancer Regional Centers 

y A Surgeon General’s Call 

to Action, to pull in 

representation from all 

stakeholders to make 

recommendations happen 

Several comments regarding formats 

touched on the idea of using nontraditional 

communication methods, such as a 

storytelling approach. 

Challenges and strategies 

to overcome them 

The workgroup cautioned that communiqué 

development would need to anticipate 

challenges and resistance to holistic 

concepts and the use of terms such as “living 

laboratories” that are unfamiliar to more 

mainstream communities, such as 

policymakers and planners, training 

institutions, mental health centers or 

authorities, school districts, and such. 

To address these challenges, members of the 

workgroup proposed the following: 

y Invite stakeholders who may be potential 

sources of resistance to participate in the 

decisionmaking process. 

y Develop clinical Centers of Excellence for 

Women’s Mental Health. These could be 

national, State based, county based, Tribe 

based, university based, or special 

populations based. 

y Develop structures to organize 

community-based groups, including faithbased groups, around women’s mental 

health that operate outside of clinical 

Centers of Excellence. There may be 

opportunities to create pilot 

projects at this level as 

well. 

y Create “living 

laboratories”, pilot projects, 

or “transitional research” to 

initiate this process. Start 

small to see how they work, 

and expand them if they do 

well. The ultimate goal is to 

make new initiatives 

standard in current practice. An example of 

a “living laboratory” could be a recovery 

group. 

“Mental health is not an individual 

issue. It affects whole 

communities and is partly caused 

by the broader community. 

Women are complex, and they 

require a complex strategy to 

address all of their nuances.” 

—Breakout group participant 

y Develop a sex and gender focused national 

effort focused at the State level to address 

mental health issues (e.g., trauma) by 

developing State-level leadership (e.g., 

governors and their spouses, State mental 

health directors, State Medicaid directors). 

y Identify women’s mental health 

champions. 

Further priority issues from the group 

As a wrap-up to their workgroup discussion, 

participants went around the table and 

identified their own priority issues: 

Focus on specific women’s mental health 

issues, such as older women’s issues, 

perinatal depression, and substance abuse 

issues. 

y Focus on agencies and organizations (e.g., 

medical, social worker) that can think about 

and mobilize on these issues. 

y Develop practical tools in a way that 

makes practitioners, consumers, and others 

want to grab hold of them and use them. 

y Mobilize serious resources to improve 

training and workforce development as a 

way to improve quality of services for 

women. 

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Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

y Think more fully about how to reach 

nonmedical providers and providers of 

alternative or complementary medicine. 

Workgroup 5 Participants 

Facilitators 

y Focus more energy on prevention at early 

ages with ways to strengthen girls and 

young women. Remove stigma and begin 

empowerment regarding mental health early 

in life. Blend these efforts across 

generations within communities. 

Susan E. Salasin, Center for Mental Health 

Services, SAMHSA 

R. Dale Walker, M.D., Ph.D., Oregon Health 

and Science University 

Participants 

Evelyn Becker, Ph.D., Indian Health Service 

y Use existing leadership and develop future 

leaders, recognizing the capacity of 

underutilized advocates. 

Dwana Bush, M.D., Center for Integrative Health 

Vickey Coffey, M.S.A., Chicago Metropolitan 

Battered Women’s Network 

Deborah Donaldson, Sedgwick County 

NACBHD y Increase the level of communication and 

build bridges between communities. 

Yoon Han, M.Ed., M.S.W., Asian Counseling 

and Referral Service y Address mental health issues through a life 

span approach, and recognize that providers 

have their own mental health issues. 

Pablo Hernandez, M.D., American Institutes for 

Research 

D.J. Ida, Ph.D., National Asian American Pacific 

y Take a serious look at sources from which Islander Mental Health Association 

future funding will come. Luella Klein, M.D., American College of 

Obstetricians and Gynecologists y Consider women’s mental health within 

the complex context of their lives. Denise Laine, Ph.D., National Jewish Medicinal 

and Research Center and American Academy of 

Nurse Practitioners 

Joanne Nicholson, Ph.D., University of 

Massachusetts Medical School 

Paulette Running Wolf, Ph.D., First Nations 

Behavioral Health Association 

David Takeuchi, Ph.D., University of 

Washington 

Katherine Wisner, M.D., M.S., Western 

Psychiatric Institute and Clinic, University of 

Pittsburgh Medical Center 

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Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

Workgroup 6: Treatment Access and Insurance At-A-Glance 

Priorities 

1. Effects of racial, ethnic, and linguistic disparities in health service access, data, evaluation, and delivery 

on mental health status 

2. Access to appropriate and effective care through primary care providers, mental health specialists, and 

nonclinical settings 

3. Financial and structural barriers – including insurance coverage, reimbursement policies, and mental 

health parity 

Messages 

y Include and know your community. 

y Disparities come at a high cost to society. 

y Everyone can do something to eliminate racial and ethnic disparities. 

y Health care providers and lay workers are key to eliminating disparities, but they need specific tools 

and support. 

y We need 100% access and must build capacity for “no wrong door”. 

y Integrate mind, body, and soul. We should use a holistic approach, based on the biopsychosocial 

model. 

y What every woman should know about mental health care... 

y Access to appropriate care is a woman’s right. 

y Women’s health is funda-MENTAL. 

y Lack of parity for mental health coverage affects our future human and economic resources and costs 

society. 

y Society gains when effective and accessible mental health care is available. 

Products 

Toolkits for health care and lay providers; assessment tools; consumer-based DVDs in pediatric offices, 

nail salons, consumer groups; PSA, profiles of best employers and insurers that promote and address 

mental health; State Report Cards on mental health; communiqués for employers that make the business 

case for mental health; Web-based CEUs. 

Workgroup 6: Treatment Access and Insurance 

The key priority issues assigned to this workgroup are listed in the box below. 

Issues to Prioritize 

1. Access to appropriate care through 

primary care providers and mental health 

specialists 

2. The effects of racial and ethnic disparities 

in health service access and delivery on 

mental health status 

3. Lack of parity for mental health care 

coverage 

4. Insurance coverage 

5. Competing demands for women that limit 

their ability to access care (e.g., taking 

care of children and other relatives) 

6. Better access to treatments for 

adolescent depression, anxiety disorders, 

and eating disorders 

7. Access to sex and gender appropriate 

diagnostic and treatment services 

8. The lack of culturally and linguistically 

competent providers and treatment 

materials 

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Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

The group considered and commented on 

each of these issues in order. 

1. Access to appropriate care through 

primary care providers and mental health 

specialists 

Here the point was raised that most people 

go to doctors, not mental health specialists. 

Thus, there is a need to learn how to 

integrate mental health concepts into 

primary care – creating a seamless system 

between the primary care physician and 

mental health services. It was noted that 

even if physicians know how to help deal 

with mental health issues, they lack the time 

in a typical office visit. In addition, 

appropriate care is not always there – 

particularly to address sex and gender, 

culture, and age specific issues, and it is 

important that care be not only appropriate 

but also effective. 

The need to look at best practices was 

raised, with the comment that although 

primary care doctors have the reputation for 

being uncomfortable with mental health 

issues, there are models out there for doctors 

to cover it better. The problem is that these 

models are not well-disseminated or widely 

used. 

It was noted that consumers do not always 

have a choice regarding the type of provider 

they can see. The suggestion was made that 

we need to look at the full continuum of 

care, including personal, family, and 

community roles and resources. Following 

the continuum to the end, noted a workgroup 

member, also means caring for the provider, 

who is vulnerable to stresses and mental 

health issues as well. 

2. The effects of racial and ethnic 

disparities in health service access and 

delivery on mental health status 

The workgroup members agreed that 

disparities should be considered as an 

overarching issue that reaches across 

multiple topics listed among the priority 

issues. 

3. Lack of parity for mental health coverage 

The discussion of this topic began with the 

question of how to define parity. One 

comment was that the issue of lack of 

affordable and effective insurance coverage 

combines lack of parity for mental health 

coverage with issues of insurance coverage. 

There was some discussion about whether 

these are different issues or should be 

combined. An additional topic that was 

raised regarding parity concerned the 

question of medical codes driving what 

types of things doctors do during visits. 

4. Insurance coverage 

One point raised related to this topic was 

that there is sometimes a lack of 

understanding regarding insurance coverage 

– that some people may have coverage but 

not understand what is covered. This was 

seen as an issue that needed to be more fully 

understood at a community level – 

understanding coverage and how to get 

treatment. Participants commented on the 

fact that there are differences in coverage 

across the country and that within a given 

State, there are varying levels of access to 

care among groups such as undocumented 

immigrants or members of particular racial 

and ethnic groups. 

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Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

5. Structural barriers were noted, as were 

provider incentives from insurance 

companies or accreditation bodies to use 

particular screening tools. 

Competing demands for women that limit 

their ability to access care (e.g., caretaking 

of children and older relatives) 

Participants recognized the need for 

actionable and practical solutions to address 

the issue of competing demands and sex and 

gender roles. One suggestion was to focus 

on nonclinical settings, such as self-care, 

that may be easier to fit into women’s lives. 

Other ideas included involving schools, 

churches, Head Start, and similar programs 

or organizations to fit into women’s multiple 

constraints and 

responsibilities. One 

commenter noted that the 

group should not focus only 

on mothers. 

A further suggestion was to 

encourage more girls and 

women to go into health 

professions to increase the 

supply of providers who are 

potentially more culturally 

competent and sensitive to sex and gender 

differences. 

6. Better access to treatments for 

adolescent depression, anxiety disorders, 

and eating disorders 

and 

7. Access to gender-appropriate diagnostic 

and treatment services 

These two topics generated little discussion 

other than to consider where these types of 

services are delivered. 

8. The lack of culturally and linguistically 

competent providers and treatment 

materials 

Suggestions for addressing this topic 

included looking at how to train providers to 

deal with cultural stigma, addressing 

provider-patient communications, and 

exploring examples of culturally appropriate 

best practices. 

Other topics 

Several other topics were considered during 

this discussion. These included the 

following: 

y Developing tools to address how 

consumers should talk with providers and 

what was the best use of 

time during an office visit. 

“Mental illness does not 

discriminate, so why does the 

health care system? As a result, 

women are disproportionately 

affected.” 

—Breakout group participant 

y The need for more 

information on what 

resilience is and how to 

support good mental health 

during the primary care 

visit. The need for wellness 

and prevention models for 

mental health was 

highlighted. 

y Further exploration of nonclinical models, 

such as self-care. For example, patient care 

management through the Internet has been 

shown to be effective. 

y The need for toolkits to address financial 

issues (getting health care, including mental 

health services), integrated care issues (what 

to expect from a primary care provider on an 

annual visit), and health disparities/cultural 

competence. 

To reflect the richness of the discussion, the 

group proposed to highlight several 

overarching issues as a preamble to their list 

of top priorities. Those overarching issues 

include: 

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Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

y The incorporation and involvement of 

women, following the theme: for the 

community and by the community. 

y Culture must be considered very broadly, 

including not only race and ethnicity but 

also sexual orientation, disabilities, life span, 

socioeconomic position, geography, and 

religious context. 

y We must make the business case for the 

high cost of disparities for each priority area. 

y We must recognize the importance of 

public discourse and the media for fostering 

a national dialogue and use these to create 

new expectations for women’s mental 

health. 

The workgroup members voted to identify 

the top priority issues and easily identified 

three as the most important and overarching, 

with several others seen as fitting under 

them. Some of the wording was revised to 

expand or define the issues more clearly, 

resulting in the three highlighted in the box 

below. 

Key Priorities: Workgroup 6 

Treatment Access and Insurance 

1. Effects of racial, ethnic, and linguistic 

disparities in health service access, data, 

evaluation, and delivery on mental health 

status 

2. Access to appropriate and effective care 

through primary care providers, mental 

health specialists, and nonclinical settings 

3. Financial and structural barriers – including 

insurance coverage, reimbursement policies, 

and mental health parity 

Key Priority #1: Effects of racial, 

ethnic, and linguistic disparities in 

health service access, data, 

evaluation, and delivery on mental 

health status 

Messages 

The following messages were articulated by 

the group: 

y Include and know your community. 

Participants emphasized the importance of 

including experts from the community and 

of being trained by people from the relevant 

culture, racial group, ethnic group, or gender 

orientation. In addition, they argued that 

there was a need to include the appropriate 

data and evaluation tools – developed with 

the input of the appropriate cultural 

perspective. 

y Disparities come at a high cost to society. 

Emphasize and demonstrate the high cost of 

disparities to society (e.g., DALY metric). 

y Everyone can do something to eliminate 

racial/ethnic disparities. 

y Health care and lay providers are crucial 

to eliminating racial/ethnic disparities, but 

they need support and specific tools to do 

so. Tools exist, as do referral sources and 

community resources, but they must be 

more effectively identified and used. 

One person noted that mental illness does 

not discriminate, but the health care system 

does. As a result, she added, women are 

disproportionately affected. 

Audiences 

The group identified the following 

audiences, noting that these would vary 

depending on the particular message: 

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Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

y Providers, including lay providers 

(messages such as “Know your patients, and 

know what to tell them”) 

y Elementary through high school youth 

y Policymakers (messages on such topics as 

costs of health disparities) 

y General public (messages such as 

“Disparities do not discriminate; why does 

the health system?”) 

y Consumers (messages that help empower 

them) 

Formats 

Workgroup members felt that messages for 

the consumer should be empowering and 

help them to talk with their provider. 

However, the concern was raised regarding 

how to get people to listen to these 

messages. This was recognized as the 

challenge with recommending formats. One 

participant suggested looking for good 

models and pointed to the example of the 

Primary Prevention toolkit that came out 

about 10 years ago (possibly from the Office 

of the Surgeon General), which included 

stickers, folders, and other freebies. 

Their suggested formats included: 

y Toolkits for providers (supports to 

eliminate disparities) to be used for provider 

certificates and training 

y Communiqués aimed at businesses, 

insurance companies, and policymakers 

highlighting the high costs of disparities 

Cross-cutting cultural concerns 

Members of the workgroup suggested that 

culture should be considered very broadly – 

not just race and ethnicity, but also life span, 

sexual orientation, disabilities, 

socioeconomic status, living in rural areas, 

and religious context (as mentioned in 

Healthy People 2010). 

Key Priority #2: Access to 

appropriate and effective care 

through primary care providers, 

mental health specialists, and 

nonclinical settings 

Messages 

The group articulated the following 

messages: 

y 100 percent access. The group’s primary 

message was that access must be universal, 

which in turn would lead to zero disparities. 

y Integrating mind, body, and soul. A 

holistic approach was advanced, using the 

biopsychosocial model and integrating the 

delivery of care to address the whole person. 

y What every woman should know about 

mental health. This includes a “navigator” 

theme, which has been used successfully in 

the cancer community to help consumers 

navigate the health care system to obtain the 

services, information, and treatment they 

need. This message also includes the idea 

that every woman should have some basic 

wellness/prevention tools. 

y Access to appropriate care is a woman’s 

right. Everyone should have access to at 

least one effective intervention for his or her 

particular diagnosis, issue, problem, or 

health care concern. 

y Women’s health is funda-MENTAL. Access 

barriers to services and care may vary by 

individual, community, or context, so you 

need community participation and 

partnership to identify, prioritize, and rectify 

barriers. We need an integrated system that 

connects primary care providers and mental 

health providers that can offer culturally, 

54
Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

racially, and ethnically appropriate best care 

practices. 

Audiences 

Two key audiences were identified for these 

messages: providers and consumers. 

Formats 

The group’s suggested formats included the 

following: 

For consumers 

y An educational DVD offered in pediatric 

offices, food stamp programs, churches, 

beauty shops, gyms, and other venues 

where women can be reached. It would 

address the life span, contemplate different 

groups of women, and provide role 

models. It also would address navigation 

issues such as how to access treatment, 

which treatments are available, and so 

forth. 

y PSAs for radio and TV stations 

For providers 

y CEUs and conferences to build capacity 

through integrated treatment. Emphasize 

access to care in clinical and nonclinical 

(peer support groups, etc.) settings that 

focus on prevention, wellness, and care 

using the biopsychosocial model. 

Dissemination must recognize the 

challenge of getting providers to read 

materials, which can be addressed through 

strategies such as CE courses or Webbased information. 

Key Priority #3: Financial and 

structural barriers – including 

insurance coverage, reimbursement 

policies, and mental health parity 

Messages 

These were the messages articulated by the 

workgroup regarding the issue of financial 

and structural barriers: 

y Lack of parity for mental health 

coverage affects our future human and 

economic resources and costs society. 

y Society gains when effective and 

accessible mental health care is available 

(e.g., low employee turnover, increased 

productivity, less need to hire and train 

new employees). 

The point was made that it was important to 

show data demonstrating the cost benefits of 

mental health coverage to employers, 

insurers, and policymakers. 

Another issue raised during this discussion 

was the importance of ensuring that 

coverage takes into account the caregiver 

role, primarily played by women, and gives 

assistance in navigating the system. 

Audiences 

The identified audiences for these messages 

included employers, payers (insurers), and 

policymakers. 

Formats 

Suggested formats included: 

y A toolkit or communiqué for businesses 

showing the business case for offering 

mental health coverage 

y Media partnerships 

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Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

y Profiles of employers offering the best 

mental health coverage and services (e.g., 

report card, best companies to work for, 

incentives) 

y A report card of State coverage and 

services for mental health 

Workgroup 6 Participants 

Facilitators 

Jane Wilson, M.S., Office of Public Health and 

Science, DHHS 

Vickie Mays, Ph.D., M.S.P.H., University of 

California-Los Angeles 

Participants 

Margarita Alegria, Ph.D., Cambridge Health 

Alliance, Harvard Medical School 

Thelma Baskin, Kansas City 

Angeline Bushy, Ph.D., R.N., University of 

Central Florida 

Lorraine Cole, Ph.D., National Black Women’s 

Health Imperative 

Kathleen DeBold, B.S., The Mautner Project 

Rani Desai, Ph.D., M.P.H., American Public 

Health Association, VA Connecticut Healthcare 

System 

Carmen Inoa-Vazquez, Ph.D., Bellevue 

Hospital Center 

Oscar Morgan, M.A., National Mental Health 

Association 

Shirley Repta, Ph.D., M.B.S., APRN, B.C., 

American Psychiatric Nurses Association 

Catherine Shisslak, Ph.D., University of 

Arizona College of Medicine 

Nancy C. Speck, Houston, TX 

Sharon Sweede, M.D., American Academy of 

Family Physicians 

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Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

Workgroup 7: Health System Issues At-A-Glance 

Priorities 

1. Medication issues for women 

2. Inadequate emphasis on women’s mental health issues in education and training for health care 

providers 

3. Family planning and women with major mental illness 

Messages 

y Additional evidence-based information is urgently needed concerning the safety and effectiveness of 

psychotherapeutic medications, including sex and gender and reproductive cycle factors and 

consideration of nonpharmacological interventions. 

y Women’s mental health needs should be incorporated into all levels of health care curricula, including 

in the knowledge, skills, and attitudes regarding sex and gender differences and issues of race, 

ethnicity, and culture. 

y Discussions about reproductive health and family planning should be incorporated into the care of all 

women with major mental illness. 

Products 

PSA, booklets, proclamation, posters, RFPs, Web-based CEUs, advocacy toolkit, letters to governing 

bodies of educators, press releases 

Workgroup 7: Health System Issues 

The list of priority issues to be considered by the health system issues breakout group is 

identified in the box below. 

There was considerable general discussion 

on the topic of health systems issues prior to 

consideration of how to prioritize the ones 

presented to the group. 

Budget constraints 

Budgetary concerns at the State and provider 

system level were identified as one problem 

plaguing the health care delivery system. As 

one provider put it, “Money and budget 

undercut all of the issues in this group.” 

Similarly, fragmentation in the system itself 

Issues to Prioritize 

1. Lack of information on safety, dosing, 

and effectiveness of medications during 

pregnancy and lactation 

2. Inclusion of women in clinical trials and 

pharmacokinetics/pharmacodynamics of 

drugs 

3. Inadequate emphasis on women’s mental 

health issues in academic curricula for 

 physicians and other health care 

professionals 

4. Side effects of medication 

5. The role of hormone therapy in 

symptomatic perimenopausal women 

6. Family planning and women with major 

mental illness 

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Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

was identified as an important barrier along 

with the lack of agreement on how to deliver 

mental health care; for example, whether it 

should be focused more on pharmacology or 

nonpharmacological issues. 

Technology transfer 

However, the primary concern for many 

group participants, which was not listed as a 

priority, was the issue of technology transfer 

– or how to transfer knowledge from 

research and the evidence base into language 

and tools that would be beneficial to 

consumers – especially those, like homeless 

women, who are most at risk. The group 

suggested several solutions for improving 

the transfer of technology. One suggestion 

was to use partnerships to help determine 

what is working and what is not, based on 

evidence-based practice. Other suggestions 

for improving the translation of research into 

practice included increased advocacy, 

research, education, and training. 

Redefining the issues 

Many members of the workgroup felt that 

the issues listed were not really health 

system issues and that important issues that 

belonged under this topic were missing. 

It was noted by several in the group that 

there was heavy emphasis placed on 

pharmacological concerns within the six 

priority issues. The emphasis on 

pharmacology seemed almost in direct 

contrast to how many participants defined a 

health system. They were reminded that the 

topics had been chosen according to both 

their importance and their action potential. 

Many other issues identified in the concept 

mapping might have fit more closely with 

the group’s definition of health system 

issues but may not have been considered 

very high in action potential. 

By consensus, the group identified three 

overarching themes that they felt needed to 

be integrated throughout the discussion of 

health system issues. Those themes 

included: 

y Safety 

y Quality 

y Disparities 

After much discussion, the workgroup 

members decided to condense several issues 

and define the three priority issues as listed 

below. 

Key Priorities: Workgroup 7 

Health System Issues 

1. Medication issues for women 

2. Inadequate emphasis on women’s mental 

health issues in education and training for 

health care providers 

3. Family planning and women with major 

mental illness 

Key Priority #1: Medication issues for 

women 

Messages 

Workgroup members noted that the research 

shows greater rates of unwanted pregnancies 

among women with major mental disorders, 

indicating that their family planning needs 

are not well-met. The group formulated the 

following message to address this issue: 

Additional evidence-based information is 

urgently needed concerning the safety and 

effectiveness of psychotherapeutic 

medications, including sex and gender and 

reproductive cycle factors and consideration 

of nonpharmacological interventions. 

This message reflected concerns raised by 

participants regarding the following issues: 

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Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

y The lack of information on safety, dosing, 

and effectiveness of medications during 

pregnancy and lactation 

y The need to include women in clinical 

trials and understand the 

pharmacokinetics/pharmacodynamics of 

drugs 

y The need to gain further understanding of 

the side effects of medication 

y The role of hormone therapy in 

symptomatic perimenopausal women 

y The need to define sex and gender broadly 

– across age, race, ethnicity, and transgender 

issues 

Audiences 

The primary audience defined by this group 

for this issue was the research community, 

including pharmaceutical companies and 

Federal organizations such as the NIH, the 

Food and Drug Administration, and the 

Agency for Healthcare Research and 

Quality. 

Formats 

The group identified several means and 

venues for disseminating the message: 

y Proclamation 

y Request for proposals 

y Web-based continuing education for 

providers 

y Advocacy toolkits 

y Congress 

y Health care providers 

y Advocacy groups 

y Consumers 

y National Health Policy Forum (for 

Congressional staffers) 

Cross-cutting cultural concerns 

The following issues were identified as 

cross-cutting cultural concerns: 

y Race and ethnic disparities 

y Class 

y Stigma 

y Language barriers 

y Belief systems 

y Trust 

y Stereotypes about legal and immigration 

status 

Resources and challenges 

The group identified several resources to 

address this issue, including additional 

funding, policy changes, and public/private 

partnerships or collaborations. 

In terms of challenges, there were two major 

areas of concern, including ethical issues 

and the institutionalization of reporting 

requirements around race and gender. 

Key Priority #2: Inadequate emphasis 

on women’s mental health issues in 

education and training for health care 

providers 

Messages 

The group formulated the following 

message: 

Women’s mental health should be 

incorporated into all levels of health care 

curricula, including in the knowledge, 

skills, and attitudes regarding sex and 

gender differences and issues of race, 

ethnicity, and culture. 

Other issues that participants felt should be 

included in health care training included: 

y Standards of care and best practices 

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Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

y Knowledge of sex and gender differences 

in disease manifestations in response to 

therapy 

Audiences 

The group thought that this message should 

target the following audiences: 

y Health care educators 

y Administrators 

y Students 

y Policymakers 

y Health care providers 

y Professional organizations 

y Case managers 

Formats 

The group identified several means for 

disseminating the message: 

y Communiqués 

y Letters to governing bodies of educators 

y Press releases for the general public 

Cross-cutting cultural concerns 

Several overarching concerns were raised: 

y Racial and ethnic disparities 

y Limited English proficiency 

y Cultural competence of providers 

Resources 

One resource that this group recommended 

was the development of a multidisciplinary 

expert consensus group. The suggestion was 

made that one of the projects it could 

undertake would be a multidisciplinary 

needs assessment. 

Key Priority #3: Family planning and 

women with major illness 

Message 

There was consensus among the participants 

that the term “family planning” was too 

narrow. It was agreed that “reproductive 

health” should be added instead for a more 

comprehensive message. As a result, the 

following message was proposed by the 

workgroup: 

Discussions about reproductive health and 

family planning should be incorporated into 

the care of all women with major mental 

illness. 

Audiences 

The group proposed several audiences for 

this message: 

y Health care providers 

y Students and trainees 

y Consumers 

y Administrators 

y Professional associations 

Formats 

The group identified several formats and 

venues for disseminating the message: 

y Booklets or pamphlets 

y PSAs 

y Proclamations 

y Posters 

y Mental health centers 

y Drop-in centers 

y Correctional facilities 

y Professional association meetings 

y Advocacy organizations 

y Conferences 

y Churches 

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Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

Cross-cutting cultural concerns 

Workgroup 7: Health Systems Issues The following list was identified as 

incorporating key cultural considerations for 

effectively disseminating the message: Facilitators 

Duiona Baker, M.P.H., Substance Abuse and 

y Language barriers Mental Health Services Administration 

y Belief systems regarding reproductive 

health 

Laura Miller, M.D., University of Illinois-Chicago 

Participants y Treatment disparity Ellen Bassuk, M.D., National Center on Family 

Homelessness y Stigma 

Karen Bower, Esq., Bazelon Center for Mental 

Health y Stereotypes 

y Sexual orientation Rosaly Correa-de-Araujo, M.D., Albert Einstein 

College of Medicine 

Resources Candace Fleming, Ph.D., University of 

Workgroup members also proposed several Colorado Health Sciences Center 

resources to inform and develop this topic: Howard Goldman M.D., Ph.D., M.P.H., 

University of Maryland y Funding sources 

Mary Harper, Ph.D., R.N., D.Sc., FAAN, LLD,

Rosalyn Carter Institute of Family Caregiving, 

Johnson and Johnson 

y Marketing specialists 

y Needs assessments 

Catherine Judd, M.S., P.A., University of Texas 

Medical Branch y Focus groups 

Susan Kornstein, M.D., Virginia 

Commonwealth University 

Theanvy Kuoch, M.A., Khmer Health 

Advocates 

Ginger Lerner-Wren, New Freedom Commission 

Jaquelyn Resnick, Ph.D., Association for 

University and College Counseling Centers 

Alina Salganicoff, Ph.D., Henry J. Kaiser 

Family Foundation 

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Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

Workgroup 8: Protective and Resilience Factors At-A-Glance 

Priorities 

1. Relationships and social and community supports 

2. Knowledge and education 

3. Culture, spirituality, traditions, faith, and making meanings 

Messages 

y Every girl needs at least one supportive, safe, trusting, loving relationship to develop resiliency and 

positive mental health and wellness. 

y Protecting and nurturing your daughter means protecting and nurturing yourself. 

y The development of more programs in the arts, sports, music, and such can build self-efficacy and selfesteem as prevention and as a form of healing and recovery. 

y Communicate the prevalence, impact, and appropriate response to sexual and physical abuse. 

y Sexual and physical abuse traumas exist. Here is the damage they can cause, and here are ways 

people can protect themselves or recover and heal. 

y Create a safe environment by recognizing culture, spirituality and traditions. Respect and validate 

women’s voices and the meaning that they make out of their life experiences. 

Products 

PSAs, pamphlets, Web site, radio TV, awareness campaign, research on resilience with resulting 

materials in plain language, soap opera and talk shows, curriculum development, certification and 

licensure, criteria for professional competencies, handbooks, literature for adolescents, training 

curriculum, peer training, ways to acknowledge negative cultural issues (e.g., trauma assessment tool). 

Workgroup 8: Protective and Resilience Factors 

The workgroup was asked to pick three priority issues from the list indicated in the following 

box. 

There was considerable discussion 

surrounding this list, which ultimately the 

workout group members redefined 

significantly in order to identify three key 

priorities for protective and resilience 

factors. 

Issues to Prioritize 

 1. Coping skills for stress and emotional 

issues 

2. Enhancing resilience factors, such as 

active coping and assertiveness in girls, 

to prevent emotional problems 

3. Lack of knowledge about mental health 

well-being versus signs and symptoms of 

mental health problems 

4. The relation of physical activity to 

depression or anxiety treatment 

5. Mentoring and positive role modeling 

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Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

Numerous overarching issues were raised 

during the course of this discussion, and 

they are summarized below: 

Starting young 

Much of the general discussion around the 

question of prioritizing the issues began with 

an emphasis on the importance of starting 

young. Participants noted that issues of 

protective factors and resilience, as well as 

the risk factors that may undermine them, 

begin in childhood. 

Relational perspective 

Several group members commented on the 

importance of thinking about resiliency from 

a relational perspective – for example, the 

fact that young girls are still socialized to 

take care of everyone else and not 

themselves. It was noted that the early 

literature on resiliency did not take into 

account the relational approach. More 

recently there has been a change to adopt 

this approach and look at results from a 

contextual perspective to see why some 

children will do well in one situation while 

another will not, or why a child will do well 

in one situation and fail in another. 

It also was pointed out that some literature 

defines resilience differently, following the 

varied pathways people take to deal with 

difficulties. Thus, for example, researchers 

might look at how different people deal with 

grief, with some finding a way to use it as a 

growth experience. 

Societal pressures on girls and women 

An issue raised by several group members 

had to do with strong societal pressures on 

girls and women from the media industry 

and other social arenas. These pressures 

change with time, it was noted, and 

currently reflect the greater sexualization of 

society, idealized body images, and 

increased violence. 

Violence, abuse, and trauma 

The theme of violence was picked up by 

several workgroup members, who spoke of 

personal experiences with the issue of 

unaddressed childhood trauma resulting 

from physical and sexual assaults – and the 

resulting mental health and health risk issues 

that they lead to later in life. Group 

members shared stories of family members 

and others they had known who struggled 

with the effects of the childhood trauma and 

had not found the type of treatment or 

support they needed. For example, one 

person told of the experience of trying to 

find help for her daughter, a victim of sexual 

assault at age 4, in a system that was not 

equipped to meet her needs – and ultimately 

failed her. She noted that doctors and 

teachers were caring but did not have the 

knowledge or training to help. She 

expressed her frustration at the way money 

is spent for conferences and physicians but 

misses the people who are affected and need 

help. 

Suggestions were made regarding the need 

to inform providers and others who interact 

with children better to identify signs of 

trauma or abuse and to know how to refer 

victims to appropriate services. The concern 

was raised that these individuals face the 

temptation to take the path of least 

resistance or just to treat the immediate 

symptoms they see without trying to identify 

a deeper cause, such as child abuse. One 

person noted that providers need to be 

taught to “ask the questions”. 

Similarly, several people raised the issue of 

needing to offer greater supports to parents, 

including the grown victims of abuse. As 

one participant pointed out, the average age 

for posttraumatic stress disorder among girls 

is 16 years. These girls grow up to have their 

own children – raising the question of how 

to build in supports and stop the cycle of 

victimization. 

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Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

Models to build protective factors and 

resilience 

Group members then discussed the 

importance of protective factors and of 

creating safe and supportive environments. 

They spoke of the need for building in 

supports, such as support groups where 

people can talk freely, and noted that just 

one significant relationship can be a 

protective factor. 

There was a call for more models of 

evidence-based practice and promising 

practices in all aspects of the mental health 

system. One person specified that there was 

a need to change the paradigm from a 

disease focus to an evidence-based focus. 

Participants added that it was important to 

look at strengths instead of just problems – 

looking at strengths such as competencies, 

skills, and abilities. They also noted the 

protective, strengths-building, self-efficacy 

developing roles of factors such as sports, 

physical activity, and good nutrition – 

though one participant commented that for 

some children these are not attainable. 

Several overarching themes emerged from 

the group’s discussion: 

y To talk about resilience, you must talk 

about risk. 

y The goal is to decrease risk and increase 

protective factors. Resilience surrounds 

both. 

y Regarding trauma, it is critically important 

to increase knowledge and education on 

every level. 

Reframing the priority issues 

Group members agreed that the five priority 

issues that they had been given presented a 

mismatching combination of formats, with 

some representing activities and others 

representing subcategories of broader issues. 

As a result, participants discussed ways to 

reframe and repackage the priority issues. 

Within this discussion, the concern was 

raised that other workgroups had been 

assigned tasks related to risk factors and 

issues such as trauma and abuse. Thus, the 

suggestion was made to focus on how to 

build resiliency with protective factors, with 

the understanding that this must be done in 

coordination with the mitigation of risks 

(which overlaps with other workgroups). 

Identifying protective factors 

Participants brainstormed to create an 

extensive list of protective factors. That list 

includes safe environment; one or more 

significant relationships; honoring women’s 

experiences; nutrition; trust; social supports; 

community connections; supportive 

relationships; strength-based competencies, 

self-efficacy; empowerment; knowledge and 

education; healthy lifestyles; adequate health 

care access and quality; ownership and 

informed choices regarding a woman’s own 

body; spirituality; cultural values and 

traditions; respect for diversity, including 

sexual orientation and women who are not 

mothers; awareness and acceptance of 

trauma histories; and integration of mind, 

body, and spirit. 

Four general categories were identified for 

classifying these different protective factors: 

y Relationships and social and community 

supports 

y Strength-based competencies and selfefficacy 

y Knowledge, education, and recognition 

y Culture, spirituality, and traditions 

There was recognition that more research is 

needed on what factors affect people of 

different cultures and races. 

Following this lengthy discussion, the 

workgroup defined its own three priority 

issues, based to some extent on the original 

list provided, but refined and condensed to 

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Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

reflect the knowledge and concerns of the 

workgroup participants. Their key priorities 

are listed in the box below. 

Key Priorities: Workgroup 8 

Protective Factors and Resilience 

1. Relationships and social and community 

supports 

2. Knowledge and education 

3. Culture, spirituality, traditions, faith, and 

making meanings 

Key Priority #1: Relationships and 

social and community supports 

Message 

Members of the group commented on the 

essential importance for girls of having a 

relationship or bond with someone and that 

parents often underestimate its importance. 

They noted that authentic relationships with 

transparent communication need to start 

early and continue throughout life. One 

person added that to start healing, you just 

need to have some significant relationship 

with another person. It was noted that this 

significant relationship does not necessarily 

have to be with a parent but can be with a 

person who has their best interests in mind. 

Another issue that was raised was how to 

help parents, particularly mothers, create 

resilience in their child even if they do not 

have it themselves. 

Based on their discussion, the group 

members recommended the following 

messages: 

y Every girl needs at least one supportive, 

safe, trusting, loving, healthy relationship 

(may or may not be with a biological parent) 

to develop resiliency and positive mental 

health and wellness. 

y Protecting and nurturing your daughter 

means protecting and nurturing yourself. 

Another area, which came up later in the 

discussion but was identified as belonging 

here, focused on looking at or asking what 

girls are good at and what makes them 

strong, instead of focusing on pathology. 

This led to the development of an additional 

message: 

y The development of more programs in the 

arts, sports, music, and such can build selfefficacy and self-esteem as prevention and 

as a form of healing and recovery. 

Audiences 

Although the group members recognized 

that there are numerous potential audiences 

and could be numerous products for this 

priority, they tried to narrow the focus. 

Ultimately, the group decided to focus on 

two audiences: 

y Parents (broadly defined to include 

caretakers and other parent-like figures) 

y Girls 

Formats 

Their proposed formats included: 

y PSAs for girls and parents 

y Pamphlets 

y Research on resilience in girls, including 

more studies on both what the protective 

factors are and what builds and destroys 

resiliency 

y Literature for adolescents that reflects 

lessons from research in plain language 

Cross-cutting cultural concerns 

The group noted that when preparing 

products for non-English-language 

audiences, there needs to be not just a 

linguistic translation but an adaptation that 

incorporates cultural translation and 

considerations as well. 

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Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

Another issue which came 

up during the discussion 

was the cultural tradition – 

for example, among Latinas 

– to put others before 

themselves always. 

Dissemination and 

resources 

The following dissemination venues were 

recommended: 

y Schools 

y The Internet 

y Radio and TV 

y Providers’ offices 

In terms of resources, the suggestion was 

made that we need to get youth together 

(who have not been silenced) to craft the 

language for girls. Participants noted that 

attention would have to be paid to ensuring a 

cross-representation of communities, 

cultures, and kids who have gone through 

the good and the bad. The same was 

recommended for messages targeted to 

parents. 

Key Priority #2: Knowledge and 

education 

Messages 

Although they considered more tailored 

messages, ultimately members of the 

workgroup agreed that messages for this 

topic should be aimed at a broad public 

audience to try to reduce the stigma 

surrounding mental health issues. 

Two similar suggested messages were 

proposed, though only the first was included 

in the PowerPoint presentation for the 

plenary session. While they overlap, both 

are presented here to capture the full range 

of discussion and nuances: 

Talk about the prevalence, 

impact, and appropriate 

response to sexual and 

physical abuse across the 

life span. 

Sexual and physical abuse 

traumas exist. Here is the 

damage they can cause, and here are the 

ways people can protect themselves or 

recover and heal. 

Culture speaks to everyone, 

gives a message of hope, and 

helps to make meaning out of life 

experiences. 

Audiences 

The primary audience identified for this 

topic was the general public. The secondary 

ones include providers, educators, and 

others who interact with girls. 

Formats 

The following formats were proposed: 

For the general public: 

y PSAs 

y Soap operas 

y Talk shows 

y Peer training (especially for targeted 

populations) 

For professionals: 

y Integration of messages into degree 

training (interdisciplinary), CEUs, 

licensure by professional associations 

y Legislation on training for providers in 

this area 

y Handbooks 

y Use of real-life experiences and 

perspectives from people who have been 

there and experienced trauma or abuse to 

help educate providers 

Cross-cutting cultural concerns 

Though it was referred to as a taboo subject, 

someone noted that in some cultures, incest 

and domestic violence are acceptable. To 

address this issue, it is important to use 

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Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

women from within those cultures who want 

change. 

Another issue that was raised under this 

category was age-appropriate concerns. 

Key Priority #3: Culture, spirituality, 

traditions, faith, and making meaning 

Messages 

The group noted that many cultural and 

spiritual issues were encompassed under the 

two previous key priority issues. 

Nonetheless they considered how culture 

speaks to everyone, gives a message of 

hope, and helps to make meaning out of life 

experiences. Similarly, the comment was 

made that faith helps women and girls to 

overcome. 

Another point was made regarding the need 

to address the viability of different lifestyles 

(e.g., gay, lesbian, transgender, bisexual, 

questioning) without treating them as 

diagnoses. 

A final topic of discussion was the 

detrimental cultural values in women’s lives. 

As one person explained, when treating 

trauma, you always believe the woman; in 

substance abuse, you never believe the 

woman because of ingrained ideas that 

substance users are necessarily liars. 

Ultimately, the group proposed the 

following message: 

“Create a safe environment by recognizing 

culture, spirituality, and traditions. Respect 

and validate women’s voices and the 

meaning that they make out of their life 

experiences.” 

Audiences 

The following audiences were identified for 

this topic: 

y Providers 

y Families 

y General public 

Formats 

The suggested formats included: 

y Criteria for professional development 

y Handbooks 

y Training curricula 

y Ways to acknowledge negative cultural 

issues (e.g., a newly developed trauma 

assessment for women to be used as a State 

standard that addresses these issues) 

Cross-cutting cultural concerns 

Several people commented that it was 

important to remember that there is a 

women’s culture that has no cultural/racial 

boundaries: women have many of the same 

problems and feel the same way about them. 

Nonetheless, there was recognition that 

providers must be made aware and expected 

to respect the diverse cultural aspects of 

people’s lives and what is important to the 

individual (e.g., many African-American 

women feel that they must endure and can 

carry everything on their backs). 

Another concern was related to the conflict 

between professional values and cultural 

values (e.g., if a girl does not make eye 

contact, it may be for cultural reasons). 

It was also pointed out that the word 

“resilience” does not exist in Spanish, but 

there are other cultural values that can 

promote resilience. 

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Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

Finally, participants discussed the negative 

influences of cultural beliefs and norms that 

may prevent women from seeking help for 

mental disorders or may pressure them to 

stay in situations of There was a reminder, 

too, about the negative aspects of culture 

and the need to support women who are 

trying to escape those negative aspects. 

Workgroup 8: Protective Factors and 

Resilience 

Facilitators 

Sabrina Matoff-Stepp, M.A., HRSA Office of 

Women’s Health 

Sheryl Schrepf, M.S.W., Federation of Families 

for Children’s Mental Health 

Participants 

Rene Anderson, Western Massachusetts 

Training Consortium 

Mary Behrens, R.N., M.S.N., FNPC, American 

Nurses Association 

Caroline Clauss-Ehlers, Ph.D., Rutgers 

University 

Norma Finkelstein, Ph.D., Institute for Health 

and Recovery 

Ludy Green, Ph.D., Second Chance 

Employment Services 

Ann Jennings, Ph.D., SAMHSA Center on 

Women, Violence, and Trauma 

Gwendolyn Puryear Keita, PhD, American 

Psychological Association 

Ana Lazu, Latinas Unidos Siempre 

Jody Ruskamp-Hatz, M.S.W., National 

Conference of State Legislatures 

Ashley Thornton, Border Children’s Mental 

Health Collaborative 

Antonette Zeiss, Ph.D., Veterans Health 

Administration 

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Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

Day 2 – Final Session 

Overview of Themes and 

Recommendations from the Breakout 

Workgroup Presentations 

Rear Admiral Kenneth Moritsugu, M.D., 

M.P.H., Deputy Surgeon General, greeted the 

workshop participants and thanked them for 

their hard work and generosity in sharing 

their perspectives and personal experiences 

for this effort. Dr. Moritsugu also thanked 

the American Psychiatric Association, the 

American Psychological Association, the 

National Association of Social Workers, and 

the Society for Women’s Health Research 

for sponsoring the workshop reception. 

Dr. Moritsugu expressed Dr. Carmona’s 

regrets regarding not being able to stay for 

both days of the workshop due to a mission 

assignment from the White House in 

celebration of World AIDS Day. The 

Surgeon General reported that he was very 

excited and energized by this workshop. He 

reiterated his commitment to the issue of 

women’s and girls’ mental health and to the 

goals of the workshop. 

In his role as Deputy Surgeon General, Dr. 

Moritsugu explained that he provides 

oversight and direction for the development 

of Surgeon General’s documents. Dr. 

Moritsugu assured the workshop participants 

that he would be recording and considering 

the outcomes of their discussions carefully – 

and bringing these back to the Surgeon 

General. 

In honor of the fact that it was World AIDS 

Day, the Deputy Surgeon General took a 

few minutes to acknowledge the heavy toll 

that HIV/AIDS takes on women and girls 

and how it relates to issues of women’s 

mental health. 

He reminded the audience that an estimated 

39.4 million people worldwide were living 

with HIV at the end of 2004 and more than 

20 million had died of AIDS since 1981. 

December 1, noted Dr. Moritsugu, serves as 

a reminder that action makes a difference in 

the fight against HIV/AIDS. He added that 

across our own Nation, African-American 

and Latina women are at particular risk for 

HIV/AIDS, and no one is immune to HIV. 

He noted that the percentage of women 

being infected with HIV has increased 

sharply to 27 percent of new cases. 

As was discussed within some of the 

workgroups, Dr. Moritsugu commented that 

mental health issues can put women at risk 

for engaging in health risk behaviors – such 

as injection drug use or sexual contact – that 

can put them at risk for acquiring HIV. 

Thus, he said, it is very timely that we have 

come together to develop messages and 

communication strategies to better address 

the mental health issues of women and girls, 

which also may help protect them from 

developing other health problems, including 

HIV/AIDS. 

Dr. Moritsugu reminded the workshop 

participants that the President’s Emergency 

Plan for HIV/AIDS Relief is a $15 billion 

global initiative to provide HIV/AIDS 

prevention and treatment services in 15 

countries. He added that domestically, the 

President is working with Congress to 

reauthorize the Ryan White Comprehensive 

AIDS Resources Emergency Act, which 

funds primary health care and support 

services for individuals living with 

HIV/AIDS. 

However, the battle against HIV/AIDS 

cannot be won by political leadership alone, 

warned Dr. Moritsugu. Individuals hold the 

most important keys to eradicating HIV – 

prevention and early diagnosis are vitally 

important. 

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Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

Similarly, individuals hold 

the key, both alone and in 

united forums, for 

addressing and promoting 

the mental health of women 

and girls. 

Dr. Moritsugu concluded 

by saying that he looked 

forward to hearing the 

recommendations of the 

workgroups and working 

together to set the direction 

of how to proceed with 

Surgeon General’s 

communiqués to address 

the important issues of women’s and girls’ 

mental health. 

Wanda K. Jones, Dr.P.H., Deputy Assistant 

Secretary for Health, OWH, invited the 

facilitators from the eight working groups to 

present their groups’ recommendations. 

These were offered in the form of 

PowerPoint slides, which highlighted the 

three priority issues identified by each 

workgroup as well as the corresponding 

major messages, audiences, suggested 

formats, dissemination strategies, challenges 

and resources, and cross-cutting cultural 

concerns described in the previous chapter 

of this report. 

Comments from the Workshop 

Participants 

Following the workgroup presentations, Dr. 

Jones invited the workshop participants to 

share questions and comments with the 

larger group. The following highlights major 

themes and issues raised in those comments: 

Prevention 

y If we want to build prevention and 

resilience, it is important to identify what 

good mental health looks like (e.g., positive 

relationships, autonomy). There are plenty 

of images in the media about bad mental 

health, but we do not have 

the picture of good mental 

health. We need more data 

on this. It also would be 

helpful to explore how 

better to harness innovative 

technologies that can help 

boost resiliency. 

y We need to pay more 

attention to the theme of 

prevention. The mental 

health challenges of trauma 

and violence are 

preventable. We must 

prevent the 

intergenerational cycle of abuse. Los 

Angeles has billboards and other public 

campaigns designed to address this topic. 

We also need to educate State legislators 

about prevention and mental health. 

“The work you have been doing 

at this workshop and the ideas 

and recommendations you have 

generated will be very helpful in 

setting the direction for how we 

will proceed with the development 

of Surgeon General 

communiqués to address the 

mental health of our Nation’s 

women and girls.” 

– Kenneth Moritsugu

Deputy Surgeon General

y We need to focus on self-care for the 

caregivers and nurture the deficit disorder 

that women face who care for others. 

y Prevention needs to include issues such as 

eating disorders. We see disorders such as 

anorexia, which affects 2.5 million people in 

the United States, in children as young as 9 

years. Binge eating disorders are not even on 

the table. 

Families 

y Families are critical, and they are the first 

place we learn to heal. 

y We need to acknowledge and support the 

role women play in holding families 

together in the face of immigration to this 

country and the traumas that may precipitate 

or follow that change. Many carry the 

burden of trauma silently, face language and 

other barriers, and do not know that they 

have a right to access services. 

70
Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

Integrating mental health and overall health 

y We will never address the issue of parity 

between mental health and other health 

unless we have a workgroup specifically 

designed to address this issue. 

y We need to integrate mental health with 

primary care, but the payment systems do 

not match. We need to advocate for greater 

parity and integration with legislators and 

health care business representatives. 

Target populations 

y Although aging was mentioned in some 

discussions and presentations, we need more 

dialogue on this issue, including with 

women themselves. We need to talk about 

conveying the message to older women that 

they should not give up taking care of 

themselves. We need to address issues of 

isolation. The Administration on Aging is in 

the process of developing a toolkit 

addressing depression in women over 

age 65. 

y The issues of trafficking and prostitution, 

which affect an estimated 30,000 to 50,000 

women and girls in the United States, need 

to be addressed. 

y Incarcerated women and women with HIV 

face undue mental health needs. 

y Rural women and girls often have no place 

or no one to whom they can turn. In the past 

40 years, there has been no progress in 

increasing the supply of providers. 

Moreover, 61 percent of people in rural 

areas are underserved for mental health. In 

Nebraska, there is only one provider for 

cognitive behaviors in the whole State. 

y Women in the military now constitute 15 

percent of our overseas troops. Some are 

given only 4–6 weeks’ notice before being 

deployed. Some are four months 

postpartum. They face issues of trauma, 

abuse, and secrecy – the “don’t ask, don’t 

tell” policy affects these areas, too. 

y It is important to look at both sex and 

gender differences and similarities. Men can 

be our allies, too. 

Developing products and sharing existing 

resources 

The 1980s letter from the Surgeon General 

on HIV/AIDS is something that people still 

remember. It can be a very effective tool. 

y A document highlighting exemplary 

practices would be very useful for 

presenting to legislators; such as a 

compendium of consumer networks, State 

standards, and other such resources for 

mental health issues, such as trauma or 

eating disorders. 

y We need information for parents written at 

a sixth-grade level and readily available to 

families. Educate parents and children on 

why mental health is important and that 

there are resources out there to help with 

healing. 

y We need to train front-line staff to be 

mental health savvy and responsive. They 

well may determine whether a person speaks 

up or returns to a provider. 

y There is a new evidence-based report on 

eating disorders due to be released in the 

spring of 2006. Another report is focusing 

on feedback from focus group participants 

regarding the use and effectiveness of 

domestic violence hotlines. 

y California passed a tax for mental health 

services. The next phase will be on 

identifying innovations so that California 

counties can incorporate some into their 

mental health plans. 

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Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

Closing Remarks 

Rear Admiral Kenneth Moritsugu, M.D., 

M.P.H., Deputy Surgeon General, closed the 

meeting by reiterating the Surgeon 

General’s personal commitment to bringing 

hope to those suffering 

from mental disorders – 

directly or indirectly 

through individuals they 

love – and to a strategy of 

prevention so that fewer 

women and girls will suffer 

in the future. 

The Deputy Surgeon 

General reviewed some of 

the major themes heard at 

this workshop that can help 

serve as a guide in the 

development of Surgeon 

General’s communiqués 

and toolkits. Those themes included the 

following: 

y Mental health is integrally important to 

overall health, or as one group put it, there is 

no health without mental health. 

y To address stigma, mental health needs to 

evolve, as cancer has, to be seen and 

accepted as another chronic condition. 

y We must recognize that many families 

have their “day stories” and their “night 

stories” hiding secrets of abuse, trauma, and 

pain. 

y Mental disorders touch all of us directly 

and through the people we love. 

y When it comes to mental health, sex 

matters – and so do gender differences in the 

causes, course, treatments, and prevention of 

mental disorders. 

y The importance of trauma, violence, and 

abuse needs to resonate more clearly with 

the general public, providers, researchers, 

and policymakers. 

y We must continue to spread the word that 

recovery is possible, and we must transform 

the mental health services system beyond 

treatment of acute 

symptoms to one that is 

focused on recovery. 

y We must look at mental 

health issues such as 

specific conditions, risk, 

resilience, and protective 

factors across the life spans 

of women, from childhood 

through the later years. 

Products should be 

designed to target different 

age groups and life stages. 

y Culture is clearly a 

priority that cuts across all of the areas of 

discussion related to the mental health of 

women and girls. Tools must be culturally 

competent and developed with the 

participation of diverse consumers and 

communities. 

“The Surgeon General 

communiqués and toolkits we 

develop will be a platform upon 

which we will build the awareness 

to move all of the stakeholders – 

consumers, providers, 

policymakers, researchers, and 

the media – to action.” 

– Kenneth Moritsugu

Deputy Surgeon General

y Culture also must be considered from a 

strengths-based perspective and as a source 

of protective factors and resilience. 

Dr. Moritsugu noted that the different 

breakout workgroups had generated some 

excellent and creative ideas for concrete 

products and toolkits, ranging from a letter 

from the Surgeon General to the American 

people, to iPod messages for teens, audio 

and low-vision materials, storytelling 

formats, PSAs, messages on commonly used 

products, assessment tools, profiles of model 

practices or best companies for mental 

health, and many more. 

Everything we do will affect the lives of 

individuals, commented Dr. Moritsugu. He 

added that he would not forget the human 

aspect of the issue of women and girls’ 

72
Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

73

mental health – as expressed by Rene 

Andersen, Dr. Carmona, and many others 

during the course of this workshop. Dr. 

Moritsugu also reminded workshop 

participants of lessons learned from 

Hurricane Katrina shared by Dr. BowersStephens regarding the disproportionate 

effects of natural disaster on women and 

children. These must be taken into 

consideration, he noted, as we continue to 

develop our Nation’s disaster planning and 

emergency preparedness. 

The Deputy Surgeon General concluded by 

assuring the workshop participants that the 

goal was not to produce just another Federal 

report that would collect dust on a shelf. He 

reminded the audience that Surgeon 

General’s publications through the years 

have been catalysts for action to improve the 

health of Americans. Dr. Carmona, he 

added, is passionate about the need for 

action, not just talk, and committed to seeing 

that the communiqués have a true impact on 

the lives of individuals. Dr. Moritsugu 

finished by thanking participants for their 

contributions and dedication, saying that 

everyone has a role to play in this endeavor 

and that the Office of the Surgeon General 

will rely on the continued input and work of 

the people gathered at this meeting. 
Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

Health Systems Issues• Lack of information on safety, dosing, and effectiveness of

medications during pregnancy and lactation.

• Inclusion of women in clinical trials and

pharmacokinetics/pharmacodynamics of drugs.

• Inadequate emphasis on women’s mental health issues in

academic curricula for physicians and other health careprofessionals.

• Side effects of medication.• The role of hormone therapy in symptomatic perimenopausal

women.

• Family planning and women with major mental illness.

Identification and Intervention Issues• The importance of consumer and provider empowerment,

self-determination, and choice in mental healthtreatment.

• Models for transitioning women from institutions to

re-entry into family community living.

• Preventive interventions for the most common and

disabling disorders, such as major depression andanxiety.

• Depression and anxiety that go undiagnosed and

therefore untreated.

• The need for screening for depression, anxiety, and other

common mental disorders in primary care, schools, andother settings.

• The need to implement the comprehensive nationwide

program for suicide prevention previously described inthe National Strategy for Suicide Prevention.

• The lack of support and care options for female older

adults.

• Complementary and alternative medicine in relation to

self-treatment of mental disorders.

Treatment Access and Insurance• Access to appropriate care through primary care

providers and mental health specialists.

• The effects ofracial and ethnic disparities in health

service access and delivery on mental health status.

• Lack of parity for mental health care coverage.• Insurance coverage.• Better access to treatments for adolescent

depression, anxiety disorders, and eating disorders.

• Access to gender appropriate diagnostic and

treatment services.

• The lack of culturally and linguistically competent

providers and treatment materials.

• Competing demands for women that limit their abili ty

to access care (e.g., caretaking of children and olderrelatives).

Protective and Resilience Factors• Coping skills for stress and emotional issues.• Enhancing resiliency factors such as active coping and assertiveness in girls to prevent emotional problems.• Lack of knowledge about mental health well-beingversus signs and symptoms of mental health problems.• The relation of physical activity to depression or anxiety treatment.• Mentoring and positive role modeling.

Social Stress Factors and Stigma• Increased risk of victimization for all women.• The extent to which lower socioeconomic status and/or immigrant status relates to men

• The discrimination and lack of social acceptance that those with mental disorde• Internal barriers to mental health care such as shame and guilt.• Negative images of girls and women, particularly among minority women, in television, 

• The need for additional research on the economic impact of maternal mental illn

Biological and Developmental Factors• Understanding basic neurological sex differences.• The need for increased effort to relate biological and genetic mental health research to epidemiological gender

differences in prevalence and course of mental disorders.

• Sex differences in treatment response (both efficacy and side effects).• Factors contributing to the emergence of gender differences in mental disorders in adolescents.• Gender differences and the effects of psychotropic medications.• The neurobiology and psychology of sex differences in social behavior and attachment.• Understanding the biological bases of normative sex and gender differences.• How the developmental phases ofyoung females affect their mental health status as women.

Specific Mental D• Substance use a

prescription use 

• Loss, depression• Perinatal depres

the family.

• Adolescent depr• The impact ofrace

orientation and 

• The relationship 

and other negat

ve 

abuse, especiall

• Recognition of e

anxiety.

• Comorbidity of m

anxiety, mood dismoking, eating suicide).

• The impact on c

tion (psychiatric, deployment).

• Understanding wh

suicide attempts 

• The interaction o

illnesses, both acardiovascular di

• Eating disorders• Obesity and body • Research on ser• Gender differen

treatment respo

• Post traumatic st• Bipolar disorder.• Schizophrenia.• Personality disord• Dissociative disor

Trauma, Violence, and A• The effects of early trauma 

on the development of deespecially African Ameri

• Sexual violence against • Childhood abuse, wheth

long term effects.

• Domestic violence in he

ships.

• Emotional abuse at any ag• The effects of bullying, 

school.

• Gender discrimination, s

the workplace.

Health

Systems Issues

Treatment,

Access

and Insurance

Trauma,Violence

and Abuse

Specific Mental

Disorders

Biological

and Developmental

Factors

Identification

and Intervention

Issues

Social Stress

Factors and Stigma

Appendix A: Conceptual Framework 
Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

Appendix B: Communiqués and 

Toolkits: Ideas from Leadership 

Interviews and Facilitated 

Discussions 

Toolkits for Consumers and Families 

y Information about specific mental 

disorders (e.g., prevention, symptoms, 

treatment options) 

Breakout group participants will develop 

recommendations for Surgeon General’s 

communiqués and toolkits on issues 

affecting the mental health of women and 

girls. These products might include some of 

the following ideas suggested in the 

leadership interviews and facilitated 

discussions held earlier this year: 

y Information about breaking down the 

barriers for constant re-enrollment for 

Medicaid (e.g., every 6 months for some 

States) that includes guidelines about what 

must be done to access publicly funded 

services, when, and by whom 

y A community-based resource directory 

y Information about self-advocacy (e.g., 

how to ask questions, what questions to 

ask), patients’ rights, confidentiality, and 

HIPAA 

y A People’s Piece booklet for consumers 

on women’s mental health, similar to 

companion booklets for recent Surgeon 

General’s reports on smoking and bone 

health y Information on issues that affect only 

women or primarily women (e.g., eating 

disorders, domestic violence, trauma, abuse, 

depression and anxiety) 

y A TEN TIPS series for consumers and 

providers on issues of concern for the 

mental health of women or girls 

y y A self-screening tool or checklist Booklets on what we know about sex and 

gender differences in major mental 

disorders, risk factors, violence, stigma, 

trauma, etc. 

Toolkits for Professionals 

y Culturally competent screening y Booklets on best practices and promising 

models for professionals and policymakers 

(e.g., “Current Issues in Women’s Mental 

Health”) 

y Community-based resource directory to 

distribute to consumers 

y Community-based resource directory for 

providers (e.g., who to go to for questions 

and advice) y Interactive Web-based toolkits for 

consumers and professionals with links to 

resources (e.g., OWH’s BodyWise toolkit on 

nutrition, physical activity, and eating 

disorders), OWH’s BodyWorks toolkit on a 

range of health issues and questions for 

girls, AoA’s new depression selfmanagement toolkit, HRSA’s nutrition and 

physical activity toolkit for Bright Futures, 

HRSA’s new toolkit promoting emotional 

and spiritual wellness, model programs, and 

white papers 

y Issues that affect only women or primarily 

women (e.g., eating disorders, domestic 

violence, trauma, violence and abuse, 

depression and anxiety) 

y Appropriate waiting room environments 

(e.g., showing a stress management video 

instead of Jerry Springer) 

y Confidentiality and HIPAA 

y Provider empowerment 

y Provider support and self-care (e.g., how 

to deal with one’s own stigma, how to seek 

support for one’s own response to people’s 

distress and one’s own wellness) 

Other ideas include suggestions for toolkits 

targeted specifically to consumers and 

families and to professionals: 

75
Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

Appendix C: Participant List 

The Surgeon General’s Workshop 

on Women’s Mental Health 

Participants List 

Hyatt Regency Tech Center 

Denver, CO 

November 30–December 1, 2005

Participants 

Margarita Alegria, Ph.D. 

Director/Professor of Harvard Medical 

School Psychiatry 

Center for Multicultural Mental Health 

Research 

Cambridge Health Alliance, Harvard 

Medical School 

120 Beacon Street, Fourth Floor 

Somerville, MA 02143 

Phone: (617) 503-8447 

Fax: (617) 503-8430 

Email: malegria@charesearch.org 

Alan Allery, B.S., M.H.A., M.Ed., 

M.H.A., Ph.D. 

Director, National Resource Center on 

Native American Aging 

North Dakota Student Health Center for 

Rural Health 

University of North Dakota School of 

Medicine and Health Science 

P.O. Box 9038 

Grand Forks, ND 58202 

Phone: (701) 777-3859 

Fax: (701) 777-4835 

Email: alan.allery@und.nodak.edu 

Rene Anderson, M.Ed. 

Statewide Parent Advocate Coordinator 

Child & Family Studies 

Florida Mental Health Institute 

13301 Bruce B. Downs Boulevard 

Tampa, Fl 33612-3899 

Phone: (813) 974-2199 

Fax: (813) 974-7376 

Email: randerso@fmhi.usf.edu 

Thelma Baskin 

627 West 87th Terrace 

Kansas City, MO 64114 

Phone: (816) 668-3038 

Fax: (816) 349-3344 

Ellen Bassuk, M.D. 

President, National Center on Family 

Homelessness 

Associate Professor of Psychiatry, Harvard 

Medical School 

National Center on Family Homelessness 

181 Wells Avenue 

Newton, MA 02459 

Phone: (617) 964-3834 Ext. 14 

Fax: (617) 244-1758 

Email: 

ellen.bassuk@familyhomelessness.org 

76
Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

Evelyn Becker, Ph.D. 

Clinical Psychologist 

Mental Health Clinic 

Behavioral Health Department 

Indian Health Service 

P.O. Box 649 

Fort Defiance, AZ 

Phone: (928) 729-8503 

Fax: (928) 729-8502 

Email: evelyn.becker@ihs.gov 

Mary Behrens, R.N., M.S.N., F.N.P.-C 

First Vice President 

American Nurses Association 

5504 East 22nd Street 

Casper, WY 82609 

Phone: (307) 577-5023 

Fax: (307) 234-3283 

Email: mary.behrens@bresnan.net 

Belinda Biscoe, Ph.D. 

Assistant Vice President for University 

Outreach 

Public and Community Services 

Administrations 

University of Oklahoma, College of 

Continuing Education 

555 East Constitution Avenue, Suite 128 

Norman, OK 73072 

Phone: (405) 325-1711 

Fax: (405) 325-7676 

Email: bpbiscoe@ou.edu 

Andrea Blanch, Ph.D. 

Director 

Center for Women, Violence and Trauma 

520 Ralph Street 

Sarasota, FL 34242 

Phone: (941) 349-8213 

Fax: (941) 349-8215 

Email: akblanc@aol.com 

Karen A. Bower, Esq. 

Senior Staff Attorney 

Bazelon Center for Mental Health Law 

1101 15th Street, N.W., Suite 1212 

Washington, DC 20005 

Phone: (202) 467-5730 Ext. 132 

Fax: (202) 223-0409 

Email: karenb@bazelon.org 

Dwana Bush, M.D. 

Family Physician 

The Center for Integrative Health 

171 Mt. Paran Road, N.E. 

Atlanta, GA 30342 

Phone: (404) 255-5774 

Fax: (404) 255-5994 

Email: dbush@integrativehealth.com 

Angeline Bushy, Ph.D., R.N. 

Professor and Bert Fish Chair 

School of Nursing 

University of Central Florida 

1200 Speedway Boulevard 

Daytona Beach, FL 32114 

Phone: (386) 258-6573 

Fax: (386) 506-3998 

Email: abushy@mail.ucf.edu 

Silvia Canetto, Ph.D. 

Professor 

Department of Psychology 

Colorado State University 

Fort Collins, CO 80523 

Phone: (970) 491-5415 

Fax: (970) 491-1032 

Email: scanetto@lamar.colostate.edu 

Sylvia Caras 

146 Crystal Terrace 5 

Santa Cruz, CA 95060 

Phone: (831) 426-5335 

Fax: (831) 426-5335 

Email: sylvia@peoplewho.org 

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Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

Linda Chaudron, M.D., M.S. 

Assistant Professor 

Department of Psychiatry 

University of Rochester School of Medicine 

300 Crittenden Boulevard, Box Psych 

Rochester, NY 14642 

Phone: (585) 273-2113 

Fax: (585) 276-0307 

Email: linda.chaudron@urmc.rochester.edu 

Elizabeth Clark, Ph.D., A.C.S.W., M.P.H. 

Executive Director 

National Association of Social Workers 

750 First Street, N.E., Suite 700 

Washington, DC 20002 

Phone: (202) 336-8200 

Fax: (202) 336-8313 

Email: bclark@naswdc.org 

Caroline Clauss-Ehlers, Ph.D. 

Assistant Professor of Counseling 

Psychology 

Educational Psychology 

Graduate School of Education 

Rutgers University 

10 Seminary Place 

New Brunswick, NJ 08901 

Phone: (732) 932-7496 

Fax: (732) 932-6829 

Email: csce@rcirutgers.edu 

Susan Cochran, Ph.D., M.S. 

Professor of Epidemiology 

Department of Epidemiology 

UCLA School of Public Health 

University of California, Los Angeles 

Box 951772 

Los Angeles, CA 90095 

Phone: (310) 206-9310 

Fax: (310) 206-6039 

Email: cochran@ucla.edu 

Vickie Coffey, M.S.A. 

Executive Director 

Chicago Metropolitan Battered Women's 

Network 

203 North Wabash Avenue, Suite 2323 

Chicago, IL 60601 

Phone: (312) 750-0730 

Fax: (312) 750-0733 

Email: 

vcoffey@batteredwomensnetwork.org 

Jerilyn Cohen-Ross, M.A., L.I.C.S.W. 

President and Chief Executive Officer 

Anxiety Disorders Association of America 

5225 Wisconsin Avenue, N.W., Suite 400 

Washington, DC 20015 

Phone: (202) 363-1010 

Fax: (202) 363-2383 

Email: jerilyn@rosscenter.com 

Lorraine Cole, Ph.D. 

President and Chief Executive Officer 

National Black Women's Health Imperative 

600 Pennsylvania Avenue, S.E., Suite 310 

Washington, DC 20003 

Phone: (202) 548-4000 

Fax: (202) 543-9743 

Email: nbwhp@nbwhp.org 

Judith Cook, Ph.D. 

Director, Mental Health Service Research 

Program Professor of Sociology in 

Psychiatry 

University of Illinois, Chicago 

104 South Michigan Avenue, Suite 900 

Chicago, IL 60603 

Phone: (312) 422-8180 Ext. 19 

Fax: (312) 422-0740 

Email: cook@ripco.com 

Helen Coons, Ph.D. 

President and Clinical Director 

Women's Mental Health Association 

225 South 17th Street, Suite 2701 

Philadelphia, PA 19103 

Phone: (215) 306-2963 

Fax: (610) 667-1985 

Email: hcoons@voicenet.com 

78
Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

Nereida Correa, M.D. 

Education Core Director 

Bronx Center for Reducing and Eliminating 

Disparities in Health 

Obstetrics, Gynecology and Women's 

Health 

Institute of Community and Collaborative 

Health 

Albert Einstein College of Medicine 

1300 Morris Park Avenue, Mazur Room 100 

Bronx, NY 10461 

Phone: (718) 430-2753 

Fax: (718) 430-3729 

Email: ncorrea@montefiore.org 

Rosaly Correa-de-Araujo, M.D., M.Sc., 

Ph.D. 

Director of Women's Health and Gender 

Based Research 

Agency for Healthcare and Research and 

Quality 

U.S. Department of Health and Human 

Services 

540 Gaither Road 

Rockville, MD 20850 

Phone: (301) 427-1550 

Fax: (301) 427-1562 

Email: ncorrea@ahrq.gov 

Kathleen DeBold, B.S. 

Executive Director 

The Mautner Project 

1707 L Street, N.W., Suite 230 

Washington, DC 20036 

Phone: (202) 332-5536 

Fax: (202) 332-0662 

Email: kdebold@mautnerproject.org 

Rani Desai, Ph.D., M.P.H. 

Section Chair 

Mental Health Section 

American Public Health Association 

NEPEC/182, VA CT Health Care System 

950 Campbell Avenue 

West Haven, CT 06546 

Phone: (203) 937-3850 

Fax: (203) 937-3463 

Email: rani.desai@yale.edu 

Deborah Donaldson 

Director, Human Services Chair 

Sedgwick County NACBHD 

635 North Main 

Wichita, KS 67203 

Phone: (316) 660-7670 

Fax: (316) 383-7925 

Email: ddonalds@sedgwick.gov 

Charlene Doria-Ortiz 

Executive Director 

Center for Health Policy Development, Inc. 

6989 Alamo Downs Parkway 

San Antonio, TX 78238 

Phone: (210) 520-8020 

Fax: (210) 520-9522 

Email: chpd@chpdonline.org 

Norma Finkelstein, Ph.D. 

Executive Director 

Institute for Health and Recovery 

349 Broadway 

Cambridge, MA 02139 

Phone: (617) 661-3991 

Fax: (617) 661-7277 

Email: 

normafinkelstein@healthrecovery.org 

Rachel Fleissner, M.D. 

Child Psychiatrist, Medical Director 

Associate Professor 

American Academy Child and Adolescent 

Psychiatry 

Prairie St. Johns 

University of North Fargo 

510 Fourth Street South 

Fargo, ND 58103 

Phone: (701) 476-7860 

Fax: (701) 280-5795 

Email: rfleissner@prairie-stjohns.com 

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Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

Candace Fleming, Ph.D. 

Associate Professor 

Psychiatry, F800 

American Indian and Alaska Native 

Programs 

University of Colorado Health Sciences 

Center 

P.O. Box 6508 

Aurora, CO 80045-0508 

Phone: (303) 724-1471 

Fax: (303) 724-1474 

Email: candace.fleming@uchsc.edu 

Linda Frisman, Ph.D. 

Director of Research 

Department of Mental Health and Addiction 

Services Research 

University of Connecticut 

410 Capitol Avenue, MS #14 RSD 

Hartford, CT 06106 

Phone: (860) 418-6788 

Fax: (860) 418-6692 

Email: linda.frisman@uconn.edu 

Patricio Garcia 

Lieutenant 

Office of the Surgeon General 

5600 Fishers Lane, Room 18-66 

Rockville, MD 20857 

Mary Gee, B.A. 

Evaluator/FAC Liaison 

Eating Disorders Coalition for Research, 

Policy and Action 

Davis Y. Ja and Associates, Inc. 

362 Victoria Street 

San Francisco, CA 94132 

Phone: (415) 585-2773 

Fax: (415) 239-4511 

Email: mgee@isomers.com 

Joan Gillece, Ph.D. 

Program Manager of Seclusion and 

Restraint 

Division of Specific Populations, Mental 

Hygiene Administration 

National Technical Assistance Center 

National Association of State Mental Health 

Program Directors 

66 Canal Plaza, Suite 302 

Alexandria, VA 22314 

Phone: (703) 739-9333 

Fax: (703) 548-9517 

Email: joan.gillece@nasmhpd.org 

Howard Goldman, M.D., M.P.H., Ph.D. 

Professor 

Department of Psychiatry 

University of Maryland 

10600 Trotters Trail 

Potomac, MD 20854 

Phone: (301) 983-1671 

Email: hh.goldman@verizon.net 

Susan Gorin, C.A.E. 

Executive Director 

National Association of School 

Psychologists 

4340 East West Highway, Suite 402 

Bethesda, MD 20814 

Phone: (301) 347-1640 

Fax: (301) 657-4323 

Email: sgorin@naspweb.org 

Ludy Green, Ph.D. 

President and Founder 

Second Chance Employment Services 

818 18th Street, N.W., Suite 420 

Washington, DC 20006 

Phone: (202) 486-7428 

Fax: (202) 331-7428 

Email: ludygreen@aol.com 

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Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

Melva Green, M.D. 

American Psychiatric Association 

1000 Wilson Boulevard, Suite 1825 

Arlington, VA 22209-3901 

Phyllis Greenberger, M.S.W. 

President and Chief Executive Officer 

Society for Women's Health Research 

1025 Connecticut Avenue, N.W., Suite 701 

Washington, DC 20036 

Phone: (202) 223-8224 

Fax: (202) 833-3472 

Gloria Grijalva-Gonzales 

Certified Substance Abuse Counselor 

Behavioral Health Services 

Substance Abuse Services 

San Joaquin County Health Care Services 

P.O. Box 690491 

Stockton, CA 95269 

Phone: (209) 518-0670 

Fax: (209) 468-7032 

Email: gloria6587@sbcglobal.com 

Yoon Han, M.Ed., M.S.W. 

Project Director 

Behavioral Health 

Asian Counseling and Referral Service 

720 Eighth Avenue, South, Suite 200 

Seattle, WA 98104 

Phone: (206) 695-7591 

Fax: (206) 965-7606 

Email: yoonjooh@acrs.org 

Maxine Harris, Ph.D. 

Chief Executive Officer for Clinical Affairs 

and Co-Founder 

Community Connections 

801 Pennsylvania Avenue, S.E., Suite 201 

Washington, DC 20003 

Phone: (202) 546-1512 

Fax: (202) 544-5365 

Email: mharris@ncemi.org 

Pablo Hernandez, M.D. 

Superintendent 

Wyoming Department of Health 

Wyoming State Hospital 

P.O. Box 177, 831 Highway 150 South 

Evanston, WY 82931-0177 

Phone: (307) 789-3464 

Fax: (307) 789-5277 

Email: pherna@state.wy.us 

Larke Huang, Ph.D. 

Managing Research Scientist 

American Institutes for Research 

1000 Thomas Jefferson Street, N.W. 

Washington, DC 20007 

Phone: (202) 403-5180 

Fax: (202) 403-5007 

Email: lhuang@air.org 

Gail Hutchings, M.P.A. 

Chief of Staff 

Behavioral Health Policy Collaborative, 

LLC 

Substance Abuse and Mental Health 

Services Administration 

U.S. Department of Health and Human 

Services 

4923 Waple Lane 

Alexandria, VA 22304 

Phone: (240) 276-2000 

Fax: (240) 276-2010 

Email: gailhutch@aol.com 

Barbara Hylard 

Director of Constituency Relations 

Depression and Bipolar Support Alliance 

730 North Franklin Street, Suite 501 

Chicago, IL 60610 

Phone: (800) 826-3632 

Fax: (312) 642-7243 

Email: bhylard@dbsalliance.org 

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Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

D. J. Ida, Ph.D. 

Executive Director 

National Asian American Pacific Islander 

Mental Health Association 

1215 19th Street, Suite A 

Denver, CO 80202 

Phone: (303) 298-7910 

Fax: (303) 298-8081 

Email: djida@naapimha.org 

Carmen Inoa-Vazquez, Ph.D. 

Director, Institute for Multicultural Health 

Department of Psychiatry 

Bellevue Hospital Center 

104 East 40th Street, Suite 607 

New York, NY 10016 

Phone: (212) 689-2528 

Fax: (413) 375-4393 

Email: drvazquez@drcarmenvazquez.com 

Ann Jennings, Ph.D. 

Trauma Systems Consultant 

Center on Women, Violence and Trauma 

Substance Abuse and Mental Health 

Services Administration 

21 Ocean Street 

Rockland, ME 04841 

Phone: (207) 712-3516 

Email: afj@gwi.net 

Catherine Judd, M.S., P.A. 

Clinical Assistant Professor 

Physician Assistant Program 

South Western Allied Health Sciences 

University of Texas Medical Branch 

120 Shadybrook Drive 

DeSoto, TX 75115 

Phone: (972) 223-7321 

Email: cjudd1@hotmail.com 

Nadine Kaslow, Ph.D. 

Professor and Chief Psychologist 

Department of Psychiatry and Behavioral 

Sciences 

Grady Health System 

Emory University School of Medicine 

80 Jesse Hill Jr. Drive, S.E. 

Atlanta, GA 30303 

Phone: (404) 616-4757 

Fax: (404) 616-2898 

Email: nkaslow@emory.edu 

Luella Klein, M.D. 

Vice President 

Division of Women's Health Issues 

American College of Obstetricians and 

Gynecologists 

409 12th Street, S.W. 

Washington, DC 20024 

Phone: (202) 863-2434 

Fax: (202) 484-3917 

Email: lklein@acog.org 

Susan Kornstein, M.D. 

Professor of Psychiatry and 

Obstetrics/Gynecology 

Department of Psychiatry 

Virginia Commonwealth University 

3805 Cutshaw Avenue, Suite 504 

Richmond, VA 23230 

Phone: (804) 828-5647 

Fax: (804) 828-5644 

Email: skornste@mail2.vcu.edu 

Theanvy Kuoch, M.A. 

Executive Director 

Kmer Health Advocates 

29 Shadow Lane 

West Hartford, CT 06110 

Phone: (860) 561-3345 

Email: MFS47@aol.com 

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Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

Denise Laine, Ph.D. 

Manager, Past President of American 

Academy of Nurse Practitioners 

Employee Health and Infectious Control 

National Jewish Medical and Research 

Center 

American Academy of Nurse Practitioners 

1400 Jackson Street, Southside G-119 

Denver, CO 80206-2761 

Phone: (303) 348-1604 

Fax: (303) 270-2232 

Email: lained@ojc.org 

Jean Lau Chin, Ed.D., A.B.P.P. 

Dean 

California School of Professional 

Psychology 

Alliant International University 

One Beach Street 

San Francisco, CA 94133 

Phone: (415) 955-2048 

Fax: (415) 955-2063 

Email: jchin@alliant.edu 

Ana Lazu 

Executive Director 

Latinas Unidos Siempre 

59 Broadway 

Norwich, CT 06360 

Phone: (860) 887-4844 

Email: analazu@aol.com 

Carmen Lee 

Executive Director 

Stamp Out Stigma 

1572 Winding Way, Suite A 

Belmont, CA 94002 

Phone: (650) 592-2345 

Email: carmensos@aol.com 

Ginger Lerner-Wren 

New Freedom Commission 

17th Judicial Circuit, Broward County 

Florida 

201 S.E. Sixth Street 

Ft. Lauderdale, FL 33301 

Phone: (954) 831-7240 

Fax: (954) 765-4848 

Email: carriola@17th.flcourts.org 

Richard M. Lerro, M.L.A. 

Executive Director 

Eating Disorders Coalition 

611 Pennsylvania Avenue, S.E. #423 

Washington, DC 20003 

Phone: (202) 542-9570 

Fax: (202) 542-9570 

Email: mlerro@eatingdisorderscoalition.org 

Ruta Mazelis 

Editor, Cutting Edge Newsletter 

Sidran Institute 

6196 Vo Ash Drive, S.W. 

Carrollton, OH 44615 

Phone: (330) 627-5411 

Email: rutamaze@eohio.net 

Carolyn Mazure, Ph.D. 

Director, Women's Health Research at Yale 

Associate Dean for Faculty Affairs 

Professor of Psychology 

Yale University School of Medicine 

P.O. Box 208091 

New Haven, CT 06520 

Phone: (203) 764-6600 

Fax: (203) 764-6609 

Email: carolyn.mazure@yale.edu 

Jacki McKinney, M.S.W. 

Director 

Trauma Knowledge Utilization Project 

Center on Women, Violence and Trauma 

5124 New Hall Street 

Philadelphia, PA 19144 

Phone: (215) 844-2540 

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Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

Dennis Mohatt 

Senior Program Director 

Western Interstate Commission on Higher 

Education 

3035 Center Green Drive 

Boulder, CO 80301 

Phone: (303) 541-0256 

Fax: (303) 541-0291 

Email: dmohatt@wiche.edu 

Oscar Morgan, M.A. 

Senior Vice President 

Policy and Services 

National Mental Health Association 

2001 North Beauregard Street, 12th Floor 

Alexandria, VA 22311 

Phone: (703) 838-7523 

Fax: (703) 684-5968 

Email: omorgan@nmha.org 

Pamela Mulder, Ph.D. 

Associate Professor 

Department of Psychology 

Marshall University 

One John Marshall Drive 

Huntington, WV 25755 

Phone: (304) 696-2770 

Fax: (304) 696-2784 

Email: mulder@marshall.edu 

Frances Murphy, M.D., M.P.H. 

Director 

Deputy Under Secretary for Health Policy 

Coordination 

Veterans Health Administration 

U.S. Department of Veterans Affairs 

810 Vermont Avenue, N.W., Suite 10-H 

Washington, DC 20420 

Phone: (202) 565-6363 

Fax: (202) 565-4207 

Email: frances.murphy@hq.med.va.gov 

Lisa Najavits, Ph.D. 

Associate Professor of Psychology 

Department of Psychiatry 

Women's Health Sciences Division 

Veterans Affairs Boston Healthcare System 

150 South Huntington Avenue 

Jamaica Plains, MA 02130 

Phone: (617) 364-2780 

Email: lisa.najavits@med.va.gov 

Joanne Nicholson, Ph.D. 

Associate Professor of Psychiatry and 

Family Medicine 

Department of Psychiatry 

Center for Mental Health Services Research 

University of Massachusetts Medical School 

55 Lake Avenue North 

Worcester, MA 01655 

Phone: (508) 856-8712 

Fax: (508) 856-8700 

Email: joanne.nicholson@umassmed.edu 

Susan Nolen-Hoeksema, Ph.D. 

Professor 

Psychology Department 

Yale University 

P.O. Box 208205, Two Hillhouse Avenue 

New Haven, CT 06520 

Phone: (203) 432-0699 

Fax: (203) 432-7172 

Email: susan.nolen-hoeksemia@yale.edu 

Eileen Ouellette, M.D., J.D., F.A.A.P. 

American Academy of Pediatrics 

141 Northwest Point Boulevard 

Elk Grove, IL 60007 

Phone: (508) 228-0035 

Email: eouellette@aap.org 

Jon Perez, Ph.D. 

Director 

Division of Behavioral Health 

Indian Health Service 

12300 Twinbrook Parkway 

Rockville, MD 20852 

Phone: (240) 506-7492 

Email: jperez@hqe.ihs.gov 

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Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

Karen Peterson, M.D. 

Psychiatrist 

Psychiatry Department 

Center for the Study of Traumatic Stress 

Uniformed Services University of the Health 

Sciences 

10220 Grant Avenue 

Silver Spring, MD 20910 

Phone: (301) 588-0954 

Fax: (301) 295-2470 

Email: kpeterson@usuhs.mil 

Rick Peterson, Ph.D. 

President 

Texas A&M University 

National Association of Rural Mental Health 

2251 TAMU 

College Station, TX 77843 

Phone: (979) 845-1877 

Fax: (979) 845-6496 

Email: rlpeterson@ag.tamu.edu 

Laura Prescott, B.A. 

President and Founder 

Sister Witness International, Inc. 

315 Vermont Street 

West Roxbury, MA 02132 

Phone: (617) 469-3233 

Fax: (309) 414-9467 

Email: lpleiades@aol.com 

Gwendolyn Puryear Keita, Ph.D. 

Associate Executive Director 

Women's Programs Office 

Public Interest Doctorate 

American Psychological Association 

750 First Street, N.E. 

Washington, DC 20002 

Phone: (202) 336-6044 

Fax: (202) 336-6117 

Email: gkeita@apa.org 

Shirley Repta, Ph.D., M.B.A., 

A.P.R.N., B.C. 

Executive Director 

American Psychiatric Nurses Association 

1555 Wilson Boulevard, Suite 602 

Arlington, VA 22209 

Phone: (703) 243-2442 

Fax: (703) 243-3390 

Email: srepta@apna.org 

Jaquelyn Resnick, Ph.D. 

President 

Association for University and College 

Counseling Center Directors 

P.O. Box 114100 

Gainesville, FL 32611 

Phone: (352) 392-1575 

Fax: (352) 392-8453 

Email: resnick@counsel.ufl.edu 

Paulette Running Wolf, Ph.D. 

Executive Director 

First Nations Behavioral Health Association 

Box 345 

Babb, MT 59411 

Phone: (406) 732-4240 

Fax: (406) 732-9960 

Email: pauletterunningwolf@hotmail.com 

Jody Ruskamp-Hatz, M.S.W. 

Policy Specialist 

Health Program 

National Conference of State Legislatures 

7700 East First Place 

Denver, CO 80230 

Phone: (303) 856-1521 

Fax: (303) 364-7800 

Email: jody.hatz@ncsl.org 

Alina Salganicoff, Ph.D. 

Vice President 

Women's Health Policy 

Henry J. Kaiser Family Foundation 

2400 Sand Hill Road 

Menlo Park, CA 94702 

Phone: (650) 854-9400 

Fax: (650) 854-4800 

Email: alinas@kff.org 

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Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

Maria Sanchez 

National Latino Behavioral Health 

Association 

P.O. Box 387 

Berthoud, CO 80513 

Phone: (303) 932-1007 

Fax: (720) 981-1384 

Email: maria.sanchez@nlbha.org 

Catherine Shisslak, Ph.D. 

Professor 

Family and Community Medicine 

University of Arizona, College of Medicine 

1533 East Mabel Street 

Tucson, AZ 85718 

Phone: (520) 904-4252 

Fax: (520) 792-3756 

Email: cms@u.arizona.edu 

Adrienne Smith, Ph.D. 

Public Health Advisor 

Office on Women's Health 

U.S. Department of Health and Human 

Services 

200 Independence Avenue, S.W., Room 

733E 

Washington, DC 20201 

Phone: (202) 690-5884 

Fax: (202) 690-7172 

Email: asmith@osophs.dhhs.gov 

Nancy C. Speck, Ph.D. 

Mental Health Consultant 

P.O. Box 62247 

Houston, TX 77205 

Phone: (936) 554-0562 

Email: nspeck@earthlink.net 

Lincoln Stanley, M.A. 

Government Affairs Manager 

Legal and Governmental Affairs 

American Association for Marriage and 

Family Therapy 

112 South Alfred Street 

Alexandria, VA 22314 

Phone: (703) 253-0469 

Fax: (703) 253-0506 

Email: lstanley@aamft.org 

Sharon Sweede, M.D. 

Past Chair, Commission on Public Health 

American Academy of Family Physicians 

20 Hanby Drive 

Asheville, NC 28803 

Phone: (828) 298-7911 Ext. 14188 

Fax: (828) 299-2550 

Email: sharon.sweede@med.va.gov 

David Takeuchi, Ph.D. 

Professor 

School of Social Work 

University of Washington 

4101 15th Avenue, N.E. 

Seattle, WA 98105 

Phone: (206) 543-5133 

Fax: (206) 221-3910 

Email: dt5@u.washington.edu 

Ashley Thornton 

Youth Coordinator 

Border Children’s Mental Health 

Collaborative 

7104 Luz de Espejo 

El Paso, TX 79912 

Phone: (915) 833-2890 

Email: angelashley04@hotmail.com 

Carole Warshaw, M.D. 

Executive Director 

Domestic Violence and Mental Health 

Policy Initiative 

National Training and Technical Assistance 

Center on Domestic Violence, Trauma and 

Mental Health 

75 East Wacker Drive, Suite 520 

Chicago, IL 60601 

Phone: (312) 726-7020 

Fax: (312) 726-7022 

Email: clwarshaw@aol.com 

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Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

Katherine Wisner, M.D., M.S. 

Professor of Psychiatry 

Department of Psychiatry 

Western Psychiatric Institute and Clinic 

University of Pittsburgh Medical Center 

3811 O'Hara Street 

Pittsburg, PA 15213 

Phone: (412) 246-6564 

Fax: (412) 246-6960 

Email: wisnerk1@upmc.edu 

Barbara Yee, Ph.D. 

Professor and Chair 

Family and Consumer Sciences 

College of Tropical Agriculture and Human 

Resources 

University of Hawaii, Manoa 

2515 Campus Road, Miller Hall 110 

Honolulu, HI 96822 

Phone: (808) 956-8105 

Fax: (808) 956-2419 

Email: yeebarba@hawaii.edu 

Antonette Zeiss, Ph.D. 

Deputy Chief Consultant 

Office of Mental Health Services 

Veterans Health Administration 

U.S. Department of Veterans Affairs 

810 Vermont Avenue, N.W., Suite 116 

Washington, DC 20420 

Phone: (202) 273-7322 

Fax: (202) 273-9069 

Email: antonette.zeiss2@va.gov 

Presenters 

Rene Andersen, M.Ed. 

Center on Women, Violence, and Trauma 

Public and Community Services Division 

Western Massachusetts Training 

Consortium 

187 High Street, Suite 204 

Holyoke, MA 01040 

Phone: (413) 536-2401 Ext. 3006 

Email: randersen@wmtcinfo.org 

Cheryl Bowers-Stephens, M.D., M.B.A. 

Assistant Secretary 

Office of Mental Health 

Louisiana Department of Health and 

Hospitals 

1201 Capital Access Road, Bin# 12 

Baton Rouge, LA 70821 

Phone: (225) 342-2540 

Fax: (225) 342-1984 

Email: cstephen@dhh.la.gov 

Richard H. Carmona, M.D., M.P.H., 

FACS 

U.S. Surgeon General 

Office of the Surgeon General 

5600 Fishers Lane, Room 18-66 

Rockville, MD 20857 

Wanda K. Jones, Dr.P.H. 

Deputy Assistant Secretary for Health 

Office on Women's Health 

U.S. Department of Health and Human 

Services 

200 Independence Avenue, S.W., 

Room 712E 

Washington, DC 20201 

Phone: (202) 260-4432 

Fax: (202) 401-4005 

Email: wjones@osophs.dhhs.gov 

Kenneth P. Moritsugu, M.D., M.P.H. 

Rear Admiral 

Deputy Surgeon General 

Office of the Surgeon General 

5600 Fishers Lane, Room 18-66 

Rockville, MD 20857 

Richard K. Nakamura, Ph.D. 

Deputy Director 

National Institute of Mental Health 

National Institutes of Health 

6001 Executive Boulevard, Room 

8235/MSC 9669 

Rockville, MD 20852-9669 

Phone: (301) 443-3675 

Fax: (301) 443-2578 

Email: r.nakamura@nih.gov 

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Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

A. Kathryn Power, M.Ed. 

Director, Center for Mental Health Services 

Substance Abuse and Mental Health 

Services Administration 

U.S. Department of Health and Human 

Services 

One Choke Cherry Road, Room 6-1055 

Rockville, MD 20852 

Phone: (240) 276-1310 

Fax: (240) 276-1320 

Email: kathryn.power@samhsa.hhs.gov 

Facilitators 

Rene Andersen, M.Ed. 

Center on Women, Violence, and Trauma 

Public and Community Services Division 

Western Massachusetts Training 

Consortium 

187 High Street, Suite 204 

Holyoke, MA 01040 

Phone: (413) 536-2401 Ext. 3006 

Email: randersen@wmtcinfo.org 

Duiona Baker, M.P.H. 

Associate Administrator 

Substance Abuse and Mental Health 

Services Administration 

U.S. Department of Health and Human 

Services 

One Choke Cherry Road, Room 8-1009 

Rockville, MD 20857 

Phone: (240) 276-2244 

Fax: (240) 276-1076 

Email: duiona.baker@samhsa.hhs.gov 

Kinike Bermudez-Walker 

Consumer Program Director 

National Asian American Pacific Islander 

Mental Health Association 

2365 West Buckingham Road, #1094 

Garland, TX 75042 

Phone: (214) 597-8755 

Fax: (214) 954-0611 

Email: kinikebermudez@yahoo.com 

Teresa Chapa, Ph.D., M.P.A. 

Director 

Division of Policy and Data 

Office of Minority Health 

U.S. Department of Health and Human 

Services 

1101 Wootton Parkway, Suite 600 

Rockville, MD 20852 

Phone: (240) 453-6168 

Email: tchapa@osophs.dhhs.gov 

Ellen Frank, Ph.D. 

Professor of Psychiatry and Psychology 

Department of Psychiatry 

Western Psychiatric Institute and Clinic 

University of Pittsburgh Medical Center 

3811 O'Hara Street 

Pittsburgh, PA 15213 

Phone: (412) 246-5550 

Fax: (412) 246-5530 

Email: franke@upmc.edu 

Sabrina Matoff-Stepp, M.A. 

Director 

Office of Women’s Health 

Health Resources and Services 

Administration 

U.S. Department of Health and Human 

Services 

5600 Fishers Lane, Room 18A-44 

Rockville, MD 20857 

Phone: (301) 443-8695 

Fax: (301) 443-8587 

Email: smatoff-stepp@hrsa.gov 

Vickie Mays, Ph.D., M.S.P.H. 

Professor of Psychology and Health 

Services 

Institute for Social Science Research 

University of California, Los Angeles 

Box 951484, 4250 PPB 

Los Angeles, CA 90095-484 

Phone: (310) 206-5159 

Fax: (310) 206-5895 

Email: mays@ucla.edu 

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Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

Laura Miller, M.D. 

Director 

Department of Psychiatry 

Women's Mental Health 

University of Illinois, Chicago 

912 South Wood Street, M/C 913 

Chicago, IL 60612 

Phone: (312) 996-5090 

Fax: (312) 413-4265 

Email: ljm@psych.uic.edu 

A. Kathryn Power, M.Ed. 

Director, Center for Mental Health Services 

Substance Abuse and Mental Health 

Services Administration 

U.S. Department of Health and Human 

Services 

One Choke Cherry Road, Room 6-1055 

Rockville, MD 20852 

Phone: (240) 276-1310 

Fax: (240) 276-1320 

Email: kathryn.power@samhsa.hhs.gov 

Catherine Roca, M.D. 

Chief, Women's Program 

Office for Special Populations 

National Institute of Mental Health 

U.S. Department of Health and Human 

Services 

6001 Executive Boulevard, Suite 8125 

Rockville, MD 20852 

Phone: (301) 443-3488 

Fax: (301) 443-8552 

Email: croca@mail.nih.gov 

Susan E. Salasin 

Director, Women and Violence Program 

Director, Mental Health and Criminal 

Justice Program 

Center for Mental Health Services 

Substance Abuse and Mental Health 

Services Administration 

U.S. Department of Health and Human 

Services 

One Choke Cherry Road, Room 6-1021 

Rockville, MD 20850 

Phone: (240) 276-1908 

Fax: (240) 276-1960 

Email: susan.salasin@samhsa.hhs.gov 

Sheryl Schrepf, M.S.W. 

Regional Technical Assistance Coordinator 

Federation of Families for Children's Mental 

Health 

2708 West Bluff Road 

Lincoln, NE 68524 

Phone: (402) 470-3785 

Email: sschrepf@ffcmh.org 

R. Dale Walker, M.D., Ph.D. 

Psychiatrist 

Oregon Health and Science University 

3181 S.W. Sam Jackson Park Road 

Mail Code: GH 151 

Portland, OR 97239 

Phone: (503) 494-3703 

Fax: (503) 494-2907 

Email: onesky@ohsu.edu 

Cora Wetherington, Ph.D. 

Women and Gender Research Coordinator 

Sex and Gender Programs 

National Institute on Drug Abuse 

6001 Executive Boulevard 

Room 4282, MSC 9555 

Rockville, MD 20882 

Phone: (301) 443-1263 

Fax: (301) 594-6043 

Email: wetherington@nih.gov 

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Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

Jane Wilson, M.S. 

Acting Regional Health Administrator 

Office of Public Health and Sciences 

U.S. Department of Health and Human 

Services 

1961 Stout Street, Room 498 

Denver, CO 80294-3538 

Phone: (303) 844-7859 

Fax: (303) 844-2019 

Email: jwilson@osophs.dhhs.gov 

Kimberly Yonkers, M.D. 

Associate Professor 

Psychiatry and Epidemiology and Public 

Health 

Yale University School of Medicine 

142 Temple Street, Suite 301 

New Haven, CT 06510 

Phone: (203) 764-6621 

Fax: (203) 764-6766 

Email: kimberly.yonkers@yale.edu 

Writers 

Amy Brown 

Policy Associate 

Evaluation and Research Methods 

Health Systems Research, Inc. 

1200 18th Street, N.W., Suite 700 

Washington, DC 20036 

Phone: (202) 828-5100 

Fax: (202) 828-9469 

Email: abrown@hsrnet.com 

Jason Fizell 

Manager, Proposal Development 

Communications Department 

Health Systems Research, Inc. 

1200 18th Street, N.W., Suite 700 

Washington, DC 20036 

Phone: (202) 828-5100 

Fax: (202) 728-9469 

Email: jfizell@hsrnet.com 

Stacy Gleason, M.P.H. 

Policy Associate 

Evaluation and Research Methods 

Health Systems Research, Inc. 

1200 18th Street, N.W., Suite 700, 

Washington, DC 20036 

Phone: (202) 828-5100 

Fax: (202) 728-9469 

Email: sgleason@hsrnet.com 

Stephanie Hauser 

Research Analyst 

Behavioral Health Promotion. Treatment 

and Recovery 

Health Systems Research, Inc. 

1200 18th Street, N.W., Suite 700 

Washington, DC 20036 

Phone: (202) 828-5100 

Fax: (202) 728-9469 

Email: shauser@hsrnet.com 

Kathryn Hudson, M.P.A. 

Senior Policy Associate 

Behavioral Health Promotion. Treatment 

and Recovery 

Health Systems Research, Inc. 

1200 18th Street, N.W., Suite 700 

Washington, DC 20036 

Phone: (202) 828-5100 

Fax: (202) 728-9469 

Email: khudson@hsrnet.com 

Matthew McCoy 

Research Analyst 

Evaluation and Research Methods 

Health Systems Research, Inc. 

1200 18th Street, N.W., Suite 700 

Washington, DC 20036 

Phone: (202) 828-5100 

Fax: (202) 728-9469 

Email: mmcoy@hsrnet.com 

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Surgeon General’s Workshop on Women’s Mental Health – Workshop Report 

Gretchen Noonan, M.S. 

Policy Associate 

Health Policy 

Health Systems Research, Inc. 

1200 18th Street, N.W., Suite 700 

Washington, DC 20036 

Phone: (202) 828-5100 

Fax: (202) 728-9469 

Email: gnoonan@hsrnet.com 

Laura Sternesky, M.P.A. 

Policy Associate 

Evaluation and Research Methods 

Health Systems Research, Inc. 

1200 18th Street, N.W., Suite 700 

Washington, DC 20036 

Phone: (202) 828-5100 

Fax: (202) 728-9469 

Email: lsternesky@hsrnet.com 

HSR Staff 

Ann Elderkin, P.A. 

Project Director 

Health Policy 

Health Systems Research, Inc. 

1200 18th Street, N.W., Suite 700 

Washington, DC 20036 

Phone: (202) 828-5100 

Fax: (202) 728-9469 

Email: aelderkin@hsrnet.com 

Valerie Gwinner, M.P.P., M.A. 

Director 

Communications Department 

Health Systems Research, Inc. 

1200 18th Street, N.W., Suite 700 

Washington, DC 20036 

Phone: (202) 828-5100 

Fax: (202) 728-9469 

Email: vgwinner@hsrnet.com 

Jamie Hart, Ph.D., M.P.H. 

Director 

Intercultural Health 

Health Systems Research, Inc. 

1200 18th Street, N.W., Suite 700 

Washington, DC 20036 

Phone: (202) 828-5100 

Fax: (202) 728-9469 

Email: jhart@hsrnet.com 

Joy King 

Senior Meetings Manager 

Conference and Project Management 

Health Systems Research, Inc. 

1200 18th Street, N.W., Suite 700 

Washington, DC 20036 

Phone: (202) 828-5100 

Fax: (202) 728-9469 

Email: jking@hsrnet.com 

Tamar Shealy 

Meetings Manager 

Conference and Project Management 

Health Systems Research, Inc. 

1200 18th Street, N.W., Suite 700 

Washington, DC 20036 

Phone: (202) 828-5100 

Fax: (202) 728-9469 

Email: tshealy@hsrnet.com 

91