Gender differences in major depressive disorder: Results from the Netherlands study of depression and anxiety

Abstract

Background

Although an overall gender difference in prevalence of major depressive disorder (MDD) has been well established, several questions concerning gender differences in the clinical manifestation of depression remain. This study aims to identify gender differences in psychopathology, treatment, and public health consequences in patients with MDD.

Methods

Baseline data from the Netherlands Study of Depression and Anxiety (NESDA) were used, including 1115 participants (364 men, 751 women, mean age 41 years) with a DSM-IV diagnosis of current MDD. Characteristics studied included symptom profiles, comorbidity, treatment, and public health consequences.

Results

Women reported a younger age of onset of single (27.8 years vs. 31.6 years; p=0.001) and recurrent MDD (24.8 years vs. 27.6 years; p=0.014), a higher comorbidity of panic disorder with agoraphobia (24.9% vs. 17.3%; p=0.006) and life-time overall anxiety disorder (77.6% vs. 71.4%; p=0.029) than men. More men than women suffered from comorbid alcohol dependence or abuse (48.1% vs. 24.5%; p<0.001). An increased prevalence of atypical depression in women (24.6% vs. 17.3%; p=0.009) was found. Women were treated more frequently by an alternative caretaker (20.6% vs. 14.8%; p=0.025), men more often in mental health care organizations (61.0% vs. 53.7%; p=0.025). No gender differences in frequency of medication use or counseling were found.

Limitations

Cross sectional design.

Conclusions

Main gender differences in the clinical presentation of MDD concerned a younger age of onset, higher anxiety and lower alcohol use comorbidity and higher prevalence of atypical depression in women. These differences were accompanied by differences in health care use.

Introduction

Gender affects many aspects of psychopathology, such as prevalence of specific disorders, the expression of symptoms, the course of illness, help-seeking behavior, and response to treatment (Afifi, 2007). A gender difference in prevalence of Major Depressive Disorder (MDD) with twice as much women as men having a life time diagnosis of MDD, is well established in both community and clinical samples (Kessler et al., 1993, Kuehner, 2003). This difference has led to questions concerning gender effects on the clinical manifestation of depression. Previous reports using clinical and epidemiologic samples showed inconsistent findings. A few studies reported female preponderance in prevalence of atypical (Angst et al., 2002b, Lamers et al., 2010), anxiety (Clayton et al., 1991) and somatic (Silverstein, 2002) symptoms. However, in other studies no major differences between men and women in presentation of symptoms of MDD were found (Vedel Kessing, 2005, Carter et al., 2000). It thus remains unclear whether depressive symptoms differ systematically between men and women.

Regarding comorbidity, there are also some indications for gender differences. The STAR⁎D study reported that women with MDD showed significantly higher rates of comorbid generalized anxiety disorder, bulimia and somatization disorder, while men were more often afflicted with comorbid substance use disorder (Marcus et al., 2005, Marcus et al., 2008). In the Netherlands Mental Health Survey and Incidence Study, significantly more women than men showed a 12-month prevalence of comorbid mood and anxiety disorder (de Graaf et al., 2002). Gender differences in the pattern of depressive symptoms and comorbidity may be relevant because these patterns have been associated with differences in severity, course and health consequences of MDD. For example, atypical symptoms (increased appetite, increased weight, hypersomnia, leaden paralysis, mood reactivity and interpersonal sensitivity) which appear to be more prevalent in women, have been associated with lower age of depression onset, longer episode duration, increased axis I comorbidity, higher suicide risk, and greater functional impairment (Agosti and Stewart, 2001, Matza et al., 2003, Posternak and Zimmerman, 2002). Furthermore, MDD patients diagnosed with comorbid anxiety have poorer outcomes as compared to those with either an anxiety or depressive disorder alone (Kessler et al., 1999, Wittchen and Essau, 1993).

Unfortunately, most clinical studies concerning gender differences in the clinical manifestation of MDD often used relatively small, single-site samples. The Netherlands Study of Depression and Anxiety (NESDA) offers the opportunity to examine gender differences in clinical presentation of depression in a large sample of subjects diagnosed with MDD. Some gender differences in the NESDA sample have been reported previously in the context of specific research questions (Boschloo et al., 2011, Lamers et al., 2010, Lamers et al., 2011). In the present study, a broader array of gender differences is systematically described and analyzed. The aim of this study was to identify gender differences in psychopathology (symptom profile, severity and comorbidity), treatment (received form, medication use), and public health consequences (work productivity, health care use) in subjects diagnosed with MDD.