Written by Kartiki Churi, MD, Chief Medical Officer, Axis Integrated Mental Health
If you refer patients for mental health care, you already sense the pattern. Some patients get labeled fast. Some get missed for years. And more often than we want to admit, the split tracks with the patient’s gender.
This is a short, evidence-based primer for referring providers across Colorado. It is drawn from the workshop our clinical team teaches through TPN.health. If you finish reading and want the full case examples and Q&A, you can earn a free continuing education credit hour here.
What is gender bias in mental health care?
Gender bias in mental health care means a patient’s gender changes how their symptoms get labeled, treated, or missed. It is rarely intentional. It shows up in intake language, screening tools, training cases, and the “typical patient” picture we learned in school.
The bias runs in two directions at once. Women get diagnosed with depression and anxiety even when something else could explain their symptoms. Men get missed altogether because their depression does not look like the textbook. Both directions cause harm.
A note on scope. This article uses “men” and “women” throughout because the research we cite, including the CDC, Colorado Health Institute, and CDPHE data sets, still reports outcomes in binary categories. Gender is not binary, and the same bias patterns we describe here also affect nonbinary, transgender, and gender-diverse patients, often more severely. The clinical picture for LGBTQIA+ patients deserves its own dedicated piece rather than a paragraph inside this one. We have started that conversation in our earlier article, The State of LGBTQ Mental Health in Colorado, and a follow-up piece for referring providers is on our editorial calendar.
What do Colorado’s numbers tell us we’re missing?
The state pattern is stark. In 2024, the age-adjusted suicide rate in Colorado was 20.83 per 100,000, and roughly 78% of suicide fatalities were male. The Colorado Health Institute has reported that the state’s male suicide rate is more than three times the female rate.
At the same time, 1 in 5 Colorado adults live with depression, and about 266,000 Coloradans report serious thoughts of suicide, ranking the state 47th nationally on that metric (Mental Health America).
Read those numbers together and a clinical signal appears: silence is not the absence of symptoms. Silence is a symptom. The men in the highest-risk column are often the ones who never make it onto our schedule.
Why does depression wear different masks in men and women?
The same PHQ-9 score can travel two very different paths depending on who is filling it out.
A meta-analysis of 144 US studies from 1982 to 2017 found that women have consistently higher rates of depression diagnoses than men, and that gap has not moved in over 35 years (Platt et al., 2021, American Journal of Epidemiology). Some of that gap is real. Some is bias.
Most tools were built around “internalizing” signs: sadness, guilt, tears, sleep and appetite changes. Women often show these. Men more often show “externalizing” signs: irritability, anger, withdrawal, risk-taking, substance use, workaholism, and a fast “I’m fine.” A screening tool built around tearfulness misses the man whose depression looks like rage, distance, or relentless work. That is where the pattern in Colorado’s suicide data begins.
What about anxiety and pain?
Anxiety is not always panic. In women it often looks like persistent worry, insomnia, avoidance, and somatic complaints. In men it often looks like agitation, a need for control, overworking, a short temper, or shutting down with a drink. The internal alarm is the same. The behavior on the outside is not.
Pain complicates the story further. Research from the International Association for the Study of Pain and the AAMC shows women generally report more pain, greater pain sensitivity, and higher vulnerability to many chronic pain conditions. Yet in one recent review, fewer than 20 percent of pain studies presented sex-disaggregated data. Pain is not weakness. Pain is data. When we treat a woman’s pain as emotion rather than evidence, we delay the workup and erode the trust that makes future care possible.
How does bias enter the exam room?
Bias rarely announces itself. It arrives quietly, dressed as common sense.
“She’s overwhelmed” ends the workup at stress or hormones. “He’s just stressed” normalizes the irritability and withdrawal of a treatable depression. Both sentences sound reasonable. That is exactly what makes them dangerous. When the story we assume is wrong, the care plan that follows is wrong too. Four patterns repeat: depression missed in men, symptoms over-attributed to hormones in women, somatic complaints dismissed instead of investigated, and referrals for advanced care that arrive months or years too late.
Where are the highest-risk patients being missed?
Two clinical populations deserve special attention because they usually surface first outside of psychiatry.
Perinatal patients. Perinatal depression affects up to 1 in 5 pregnant and postpartum women and often shows up first in OBGYN or primary care visits. Many patients and providers hesitate to start an antidepressant because of fetal exposure concerns. A randomized controlled trial summarized by the MGH Center for Women’s Mental Health showed Deep TMS delivered at 1 Hz to the right dorsolateral prefrontal cortex produced higher response and remission rates than sham, with estrogen and progesterone levels remaining stable and no major side effects for mother or baby.
Adolescents. In 2023, 40 percent of US high school students reported persistent feelings of sadness or hopelessness, according to the CDC’s Youth Risk Behavior Survey. Teen distress is not “teen drama.” It is a clinical signal. In teens, depression often looks like anger read as defiance, withdrawal read as moodiness, fatigue chalked up to phones, or school refusal labeled as attitude. As of November 2025, BrainsWay Deep TMS is FDA-cleared as an adjunctive treatment for major depressive disorder in adolescents ages 15 to 21, meaning teens no longer need to cycle through years of failed medications before advanced care is on the table.
The 60-Second Bias Check: a self-audit for your next five patients
Here is a quick exercise, not a validated tool, that our workshop attendees say changes how their week runs.
For each patient with a positive depression or anxiety screen, ask yourself:
- If this patient were the opposite gender, would I have ordered the same labs, screens, and referrals?
- Have I asked about anger, risk-taking, overworking, or substance use, not just sadness and sleep?
- Have I asked about menstrual cycle, perimenopause, thyroid, iron, and postpartum status?
- Have I taken the reported pain and functional impairment as data worth investigating?
If any answer is “no,” you have found a place where bias may be shaping care. That is your moment to add one screen, one lab, one referral, or one honest question.
Why aren’t breakthrough treatments reaching these patients?
For patients with treatment-resistant depression, the field has moved far beyond a single class of pills. Deep TMS is a noninvasive magnetic stimulation therapy that targets the brain networks involved in depression, with 82 percent response and 65 percent remission rates in real-world data (Tendler et al., Psychiatry Research). Spravato is an FDA-approved esketamine nasal spray for treatment-resistant depression and depression with acute suicidal ideation, covered by Colorado Medicaid and most commercial plans.
The problem is not the science. The problem is the pipeline. If patients and providers do not know these options exist, they cannot choose them.
Which patients should I refer now?
Consider a warm hand-off to Axis when any of the following patterns emerge:
- an inadequate response after two antidepressant trials at adequate dose and duration
- partial response with persistent functional impairment; multiple medication intolerances
- a PHQ-9 that stays moderate to severe despite active treatment
- persistent suicidal ideation without imminent risk
- a patient who wants to minimize medication burden
- or perinatal or adolescent patients who fit the profiles above.
Patients do not need to “fail everything” before Deep TMS or Spravato is discussed. A referral can simply be a consultation. To refer, call or text 720-400-7025, email referral@axismh.com, or use our provider referral page. New patients are seen within seven days.
How do I earn a free CE credit hour on gender bias in mental health?
Our clinical team, led by Dr. Kartiki Churi, teaches this content as a live one-hour workshop through TPN.health for referring providers across Colorado. Attendees earn one continuing education credit hour, get real de-identified case examples, and can bring questions to the Q&A. The workshop fits primary care, OBGYN, neurology, therapy, psychology, and psychiatric providers, and is offered virtually and in person across our Denver/Aurora, Denver Tech Center, Boulder/Louisville, and Westminster locations.
Reserve your seat for the free CE workshop.
Frequently Asked Questions
What are common examples of gender bias in mental health diagnosis?
The most common examples are women getting a depression or anxiety label when the real driver is ADHD, thyroid disease, perimenopause, or a chronic pain condition, and men getting missed because their depression presents as anger, workaholism, or substance use instead of sadness. Both patterns delay real care. Read more on our women’s depression treatment page.
How does depression look different in men versus women?
Women more often report sadness, crying, guilt, and sleep or appetite changes, which match the internalizing symptoms most screening tools were built for. Men more often report irritability, anger, withdrawal, risk-taking, workaholism, or a change in alcohol use. If a male patient screens negative on the PHQ-9 but a partner or family member is worried, treat that as a signal, not a clearance. See our full depression treatment page.
Can I refer a patient to Axis before they have failed two antidepressants?
Yes. A patient does not need to “fail everything” first. Our psychiatric team will do a full evaluation and match your patient to the right level of care, from medication management and therapy to Deep TMS or Spravato. Refer through our provider referral page or call 720-400-7025.
What questions should I add to spot gender bias in my own screening?
Add four quick prompts to your intake or follow-up. Have you felt more irritable, angry, or quick to snap in the last two weeks? Have you had unexplained fatigue, brain fog, or cycle changes? Have you increased alcohol, cannabis, or nicotine use to cope? How is your pain affecting your day? These catch presentations that a standard PHQ-9 and GAD-7 miss. Our team walks through this in detail at the free CE workshop.
How do I sign up for the free CE credit workshop on gender bias?
Register through the TPN.health link at hubs.ly/Q04r8QrJ0. The workshop is one hour, offered live and virtually, and grants one continuing education credit hour on completion. Seats are limited to keep the Q&A intimate, so early registration is recommended.
