Populations
Depression in Women
Are women more vulnerable than men, or is something different going on?
Depression affects one in five women over the course of a lifetime, double the number in males. Of those, at least half will suffer a second episode. In addition to classical depression, women are also subject to specific types related to their ability to bear children, such as postpartum depression and depression brought on by PMS.
With the onset of puberty, women begin suffering far more than boys, which carries over into adulthood and peaks at perimenopause, the transition into menopause. Thereafter, the numbers gradually recede back to the levels of men.
In October 2000, the American Psychological Association convened a summit of more than 35 experts on women and depression, chaired by Carolyn Mazure PhD of Yale University. In April 2002, the APA released a 59 page report based on that summit, Summit on Women and Depression, which provides a useful indication of what we know and what we don’t know.
Hormonal influence, in particular disturbances in the interaction between the hypothalamic-pituitary-gonadal (HPG) axis, the hypothalamic-pituitary-adrenal (HPA) axis, and neurotransmitters such as serotonin have attracted the attention of researchers. According to the Summit Report: "Depressive symptoms and syndromes are associated with periods when gonadal hormones are undergoing considerable change, mainly during the premenstrual period, the postpartum period, and at the initiation of menopause." As many as 75 percent of women experience some premenstrual emotional and behavioral problems, the Report notes. Meanwhile, pregnancy and delivery produce dramatic changes in estrogen and progesterone levels, as well as major changes in the HPA axis, while perimenopause results in critical fluctuations in estrogen and other hormones.
The Summit Report is quick to point out that these changes have not yet been definitively linked to mood disorders, though the onset of puberty when girls start experiencing depression in greater numbers than boys may be the nearest thing to a smoking gun. "Biology clearly affects the risk of depression and biology is changed by depression," this part of the Report concludes, but what we don’t know is as revealing as what we do know. The Report, for example, failed to cite any genetic studies that might shed some light on gender and depression.
The Summit Report had far more research to go on concerning the topic of life stress and trauma, resulting in decidedly less ambiguous language: "Serious adverse life events are clearly implicated in the onset of depression," says the Report. Eighty percent of depression cases are proceeded by a serious life event, a number of studies suggest, with women three times more likely than men to experience depression in response to stressful events. Childhood sexual abuse, adult sexual assault and male partner violence have been "consistently linked" to higher rates of depression in women. Significantly, 85 percent of the victims of nonfatal intimate assault are women, 15 percent of adult women in the US have been raped. and another three percent have been victims of attempted rape.
Other stressors include poverty, inequality, and discrimination. Women are more likely than men, the Report observes, to have incomes below the poverty line. "Poverty is a pathway to depression in women," says the Report, "in part because poor women have more frequent and uncontrollable adverse life events than the general population."
Making matters worse is the fact that women engage in "ruminative thinking", that is "a mental focus on symptoms of distress and their possible causes and consequences, repetitively and passively." Ruminative behavior, explains the Report, is associated with longer and more severe episodes of depression. "Unmitigated communication", a tendency in women to base their self-worth on relationships and their external environment and take on other people’s problems as their own is also linked to depression.
To add insult to injury, depressed women appear to nongenetically transmit their depression to their offspring. Women with histories of depression, the Report notes, tend to be more critical toward their adolescent children. Depressed women also experience more marital discord and divorce. Even women in remission are vulnerable. Thus, depressed mothers raised in dysfunctional families risk raising future mothers of dysfunctional families.
None of these factors operates in isolation. Instead, biology, psychology, and social factors work together in "complex and reciprocal interactions."
More Findings
Antidepressants: The Summit Report notes that women respond preferentially to SSRIs and men to tricyclics. Women in postmenopause, however, respond less well to SSRIs, but there is evidence that hormone replacement therapy restores this preferential response.
Hormonal Treatments: The Summit Report cites recent studies that suggest the use of estrogen as a mood modulator, either as monotherapy or as an adjunct to other treatments, especially in perimenopausal and postpartum depression. Other hormones with promise include progesterone, the adrenal steroid DHEA, and its sulfate counterpart, DHEA-S (as women age, their DHEA-S levels drop to about 50 to 70 percent of those in men).
Premenstrual Dysphoric Disorder: Premenstrual dysphoric disorder (PMDD) is diagnosed in approximately five percent of menstruating women, with functional disability similar to those found in dysthymia (mild to moderate depression) and major depression. Controlled studies show SSRIs are beneficial in treating symptoms. As opposed to treating depression, which involves daily administration of SSRIs for several months or more, SSRIs for PMDD are efficacious when limited to the luteal phase of the menstrual cycle. The Summit Report observes that women often neglect to bring premenstrual symptoms to the attention of their physician, and that physicians in turn frequently fail to ask their patients the right questions. Also, the Report notes, clinicians may recommend unproven over-the-counter medications or hormonal remedies.
Women with an ongoing mood disorder may also experience exacerbation of symptoms from PMDD, which may heighten the risk of relapse those who have remitted.
Perimenopause: According to the Report, the belief that most women suffer severe mood disturbances or depression with the onset of menopause is not supported by scientific data. Treating depressed women during perimenopause should "vary little" from those with other forms of depression, says the Report.
Aging Women: Studies suggest that older adults have lower rates of depression than other age groups, and there may be a narrowing of the gender gap in old age. Nevertheless, an estimated 10 to 20 percent of older women experience "clinically significant depressive symptoms." The most important risk factor for depression in older women, the Report notes, appears to be physical health problems, including pain, functional limitations, and side effects of medications. Structural brain changes, vascular risk factors, and cognitive impairment are sometimes referred to as vascular depression, which may be more resistant to antidepressant treatment or ECT and may have a more chronic course than other forms of depression. Late onset depression may also be a precursor to dementia.
Offspring: According to the Report: "Offspring of depressed, compared with nondepressed, parents have a significantly increased risk for major depressive disorder, anxiety disorders, and markedly poorer overall functioning." Opportunities for intervention and prevention, the Report notes, are numerous, but "more research on effective treatments ... is urgently needed."
The Workplace: Women in low-skill, high demand jobs are more likely to be depressed, the Report points out, with job discrimination, sex discrimination, and sexual harassment possible causes. Work-family conflicts also correlate with higher levels of depression.
Co-ocurring Substance Dependence: According to the Summit Report, for most depressed women with a substance dependence problem, depression is the primary disorder, with evidence that they are using substances to modulate negative mood. Accordingly, it is critical that depression be treated in drug treatment programs, though this rarely happens, with predictably disappointing results.
Personality Disorders: Women score more highly on neuroticism than men, which is a risk factor for depression. The Summit Report recommends cognitive-behavioral therapy to "modify the negative affect that underlies certain personality disorders."
Lesbians: According to the Summit Report, studies sugges that lesbians are at greater risk for depression than other women, possibly due to the harmful effects of anti-homosexual bias. Affirmative therapies have been developed to meet the needs of individuals with minority sexual orientation, with promising case reports, though there have been no controlled trials to date.
Published 2002, reviewed Feb 15, 2008
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