Research reportEpidemiology of women and depression
Introduction
The World Health Organization’s Global Burden of Disease (GBD) Study estimated that nonbipolar major depression is the leading cause of disease-related disability among women in the world today (Murray and Lopez, 1996). This paper reviews recent epidemiological research on women and depression. The discussion begins with a review of basic descriptive epidemiological patterns and then turns to theories and epidemiological evidence about the causes of the higher prevalence of depression among women than men. The paper closes with a discussion of needed future research.
Section snippets
Prevalence
The higher prevalence of depression among women than men is one of the most widely documented findings in psychiatric epidemiology. This difference has been found throughout the world using a variety of diagnostic schemes and interview methods (reviewed by Nolen-Hoeksema, 1987). The prevalence of major depression among women in these studies has typically been between one and a half and three times that of men. Despite this consistency, there is enormous variation in the estimated total
Issues related to ascertainment
Before accepting the above results at face value, it is important to note that concerns have been raised that gender differences in the estimated prevalences of depression might be due, at least in part, to self-report bias. The argument here is that women may be more willing than men to admit their depression to an interviewer (Young et al., 1990). However, the available evidence is inconsistent with this hypothesis in three ways. First, a higher prevalence of current depression among women
Historical trends
Epidemiological surveys suggest that the prevalence of major depression has increased dramatically over the past few decades among both women and men (Cross-National Collaborative Group, 1992). Neither the population distribution of sex hormones nor the gene pool change this quickly, which means that the influence of changing environmental conditions must account for these dramatic increases. Before considering what such environmental conditions might be, it is important to recognize that
Influences of women’s social roles
It has been known for over two decades (Gove, 1972) that women report higher levels of depressed mood than men in community surveys and that this gender difference is stronger for married people than for the unmarried. More recent data have shown that the same specification exists for major depression. This specification is the main empirical basis for the sex-role theory of female depression (e.g. Barnett et al., 1987). The basic claim of this theory is that women are more depressed than men
Risk factors
Most research on risk factors for depression has focused on the predictors of episode onset of major depression. A number of consistently significant risk factors have been found, including family history, childhood adversity, various aspects of personality, social isolation, and exposure to stressful life experiences (see Kessler, 1997 for a review). It is important to note that the family history results have generally shown little specificity; that is, family histories of anxiety or
Comorbidity
Breslau (1995) proposed the existence of an interesting specification: that the gender difference in depression is partly due to a difference in prior anxiety. She supported this claim by showing that the odds-ratio (OR) of gender predicting major depression substantially attenuates when controls are introduced for the prior existence of anxiety. A similar result was recently reported by Wilhelm et al. (1997). This finding is indirectly consistent with the result, reported above, that the
Biological markers of susceptibility and exposure
The emergence of the gender difference in depression during puberty has recently been analyzed in a prospective epidemiological study by Angold et al. (1999) that followed cohorts of prepubescent boys and girls through puberty using direct measures of sex hormones from blood samples. An early report from this study found that the increase in depression among girls relative to boys occurs sharply at mid-puberty (Tanner stage III) and that change in body morphology is more important than increase
Conclusions and future directions
The available evidence makes it clear that depression is a problem of enormous importance among women. Given that depression often begins early in life and that the gender difference emerges with puberty, the focus of prevention has so far been on children and adolescents (Dryfoos, 1990, Hamburg, 1992). Although a great deal of risk factor research has been carried out in an effort to inform these interventions, the confounding of information about prior history with information about first
Acknowledgments
Preparation of this paper was partially supported by grants R01 MH41135, R01 MH46376, R01 MH49098, R37 MH42714 and K05 MH00507 from the US National Institute of Mental Health with supplemental support from the National Institute of Drug Abuse (through a supplement to MH46376) and the WT Grant Foundations (Grant 90135190). Portions of this paper previously appeared in Frank, E. (Editor) Gender and its Effect on Psychopathology, American Psychiatric Press, Washington, DC, 2000, pp. 61–84, and are
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