Women and Dression
Major depression and dysthymia affect
twice as many women as men. This two-to-one ratio exists regardless
of racial and ethnic background or economic status. The same ratio
has been reported in ten other countries all over the world.12
Men and women have about the same rate of bipolar disorder
(manic-depression), though its course in women typically has more
depressive and fewer manic episodes. Also, a greater number of
women have the rapid cycling form of bipolar disorder, which may
be more resistant to standard treatments.5
A variety of factors unique to women's lives are suspected to
play a role in developing depression. Research is focused on understanding
these, including: reproductive, hormonal, genetic or other biological
factors; abuse and oppression; interpersonal factors; and certain
psychological and personality characteristics. And yet, the specific
causes of depression in women remain unclear; many women exposed
to these factors do not develop depression. What is clear is that
regardless of the contributing factors, depression is a highly
treatable illness.
Investigators are focusing on the following areas in their study
of depression in women:
The Issues of Adolescence
Before adolescence, there is little difference in the rate of
depression in boys and girls. But between the ages of 11 and 13
there is a precipitous rise in depression rates for girls. By
the age of 15, females are twice as likely to have experienced
a major depressive episode as males.2 This comes at
a time in adolescence when roles and expectations change dramatically.
The stresses of adolescence include forming an identity, emerging
sexuality, separating from parents, and making decisions for the
first time, along with other physical, intellectual, and hormonal
changes. These stresses are generally different for boys and girls,
and may be associated more often with depression in females. Studies
show that female high school students have significantly higher
rates of depression, anxiety disorders, eating disorders, and
adjustment disorders than male students, who have higher rates
of disruptive behavior disorders.6
Adulthood: Relationships and Work Roles
Stress in general can contribute to depression in persons biologically
vulnerable to the illness. Some have theorized that higher incidence
of depression in women is not due to greater vulnerability, but
to the particular stresses that many women face. These stresses
include major responsibilities at home and work, single parenthood,
and caring for children and aging parents. How these factors may
uniquely affect women is not yet fully understood.
For both women and men, rates of major depression are highest
among the separated and divorced, and lowest among the married,
while remaining always higher for women than for men. The quality
of a marriage, however, may contribute significantly to depression.
Lack of an intimate, confiding relationship, as well as overt
marital disputes, have been shown to be related to depression
in women. In fact, rates of depression were shown to be highest
among unhappily married women.
Reproductive Events
Women's reproductive events include the menstrual cycle, pregnancy,
the postpregnancy period, infertility, menopause, and sometimes,
the decision not to have children. These events bring fluctuations
in mood that for some women include depression. Researchers have
confirmed that hormones have an effect on the brain chemistry
that controls emotions and mood; a specific biological mechanism
explaining hormonal involvement is not known, however.
Many women experience certain behavioral and physical changes
associated with phases of their menstrual cycles. In some women,
these changes are severe, occur regularly, and include depressed
feelings, irritability, and other emotional and physical changes.
Called premenstrual syndrome (PMS) or premenstrual
dysphoric disorder (PMDD), the changes typically begin
after ovulation and become gradually worse until menstruation
starts. Scientists are exploring how the cyclical rise and fall
of estrogen and other hormones may affect the brain chemistry
that is associated with depressive illness.10
Postpartum mood changes can range from transient
"blues" immediately following childbirth to an episode of major
depression to severe, incapacitating, psychotic depression. Studies
suggest that women who experience major depression after childbirth
very often have had prior depressive episodes even though they
may not have been diagnosed and treated.
Pregnancy (if it is desired) seldom contributes
to depression, and having an abortion does not appear to lead
to a higher incidence of depression. Women with infertility problems
may be subject to extreme anxiety or sadness, though it is unclear
if this contributes to a higher rate of depressive illness. In
addition, motherhood may be a time of heightened risk for depression
because of the stress and demands it imposes.
Menopause, in general, is not asssociated with
an increased risk of depression. In fact, while once considered
a unique disorder, research has shown that depressive illness
at menopause is no different than at other ages. The women more
vulnerable to change-of-life depression are those with a history
of past depressive episodes.
Specific Cultural Considerations
As for depression in general, the prevalence rate of depression
in African American and Hispanic women remains about twice that
of men. There is some indication, however, that major depression
and dysthymia may be diagnosed less frequently in African American
and slightly more frequently in Hispanic than in Caucasian women.
Prevalence information for other racial and ethnic groups is not
definitive.
Possible differences in symptom presentation may affect the
way depression is recognized and diagnosed among minorities. For
example, African Americans are more likely to report somatic symptoms,
such as appetite change and body aches and pains. In addition,
people from various cultural backgrounds may view depressive symptoms
in different ways. Such factors should be considered when working
with women from special populations.
Victimization
Studies show that women molested as children are more likely
to have clinical depression at some time in their lives than those
with no such history. In addition, several studies show a higher
incidence of depression among women who have been raped as adolescents
or adults. Since far more women than men were sexually abused
as children, these findings are relevant. Women who experience
other commonly occurring forms of abuse, such as physical abuse
and sexual harassment on the job, also may experience higher rates
of depression. Abuse may lead to depression by fostering low self-esteem,
a sense of helplessness, self-blame, and social isolation. There
may be biological and environmental risk factors for depression
resulting from growing up in a dysfunctional family. At present,
more research is needed to understand whether victimization is
connected specifically to depression.
Poverty
Women and children represent seventy-five percent of the U.S.
population considered poor. Low economic status brings with it
many stresses, including isolation, uncertainty, frequent negative
events, and poor access to helpful resources. Sadness and low
morale are more common among persons with low incomes and those
lacking social supports. But research has not yet established
whether depressive illnesses are more prevalent among those facing
environmental stressors such as these.
Depression in Later Adulthood
At one time, it was commonly thought that women were particularly
vulnerable to depression when their children left home and they
were confronted with "empty nest syndrome" and experienced a profound
loss of purpose and identity. However, studies show no increase
in depressive illness among women at this stage of life.
As with younger age groups, more elderly women than men suffer
from depressive illness. Similarly, for all age groups, being
unmarried (which includes widowhood) is also a risk factor for
depression. Most important, depression should not be dismissed
as a normal consequence of the physical, social, and economic
problems of later life. In fact, studies show that most older
people feel satisfied with their lives.
About 800,000 persons are widowed each year. Most of them are
older, female, and experience varying degrees of depressive symptomatology.
Most do not need formal treatment, but those who are moderately
or severely sad appear to benefit from self-help groups or various
psychosocial treatments. However, a third of widows/widowers do
meet criteria for major depressive episode in the first
month after the death, and half of these remain clinically depressed
1 year later. These depressions respond to standard
antidepressant treatments, although research on when to start
treatment or how medications should be combined with psychosocial
treatments is still in its early stages. 4,8
REFERENCES
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JM, Frank E, Young E, Shear MK. Adolescent onset of the gender
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LS, Reynolds CF, Alexopoulos GS, Bruce ML, Conwell Y, Katz IR,
Meyers BS, Morrison MF, Mossey J, Niederehe G, and Parmelee P.
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RE, Frank E, Perel JM, Cornes C, Houck PR, Mazumdar S, Dew MA,
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12 Weissman MM, Bland RC, Canino GJ,
Faravelli C, Greenwald S, Hwu HG, Joyce PR, Karam EG, Lee CK,
Lellouch J, Lepine JP, Newman SC, Rubin-Stiper M, Wells JE, Wickramaratne
PJ, Wittchen H, and Yeh EK. Cross-national epidemiology of major
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