Gender Differences in Depression - Reporting Bias Hypothesis - Literature review Example

Gender Differences in Depression: The Reporting Bias Hypothesis Clinically, depression is more than just ‘feeling blue’ occasionally. Depression is, in fact, a debilitating disorder of mood and cognition. It involves a persistent state of feeling sad and worthless that impacts one’s thoughts, behavior and physical health. The World Health Organization (WHO) ranks depression as one of the most burdensome diseases in the world (WHO, 2002). Globally, unipolar depressive disorders account for 4.5% of total disability-adjusted life-years (DALYs) and for 12% of total years lived with disability (YLDs) (WHO, 2002). Furthermore, according to the WHO, depression is the leading cause of disability in the U.S. among those aged 15-44 years (WHO, 2004), affecting approximately 14.8 million American adults, age 18 and older, in a given year (Kessler et al., 2005). The public health significance of depressive disorders is enormous. The exact etiology of depression is still being intensely researched. Several factors including genetic, biological, psychological, and environmental issues could be involved in the development of depression (Lewinsohn et al., 1988). There is evidence to show that depression occurs with considerable frequency in childhood and adolescence (Costello et al., 1996); the gender difference in major depression usually manifests at mid-puberty that is, around 13 years of age (Goodwin et al., 2004) and persists through adult life (Piccinelli & Wilkinson, 2001). Studies have indicated consistent gender differences in depressive disorder. For instance, the prevalence of depressive disorders has been shown to be 1.5 to 2 times higher in women than in men, beginning in early adolescence (Weismann & Klerman, 1985; Kessler et al., 1993; Ayuso-Mateos et al., 2001; Vicente et al., 2004; Modabernia et al., 2008). Contrary to the above, Stordal et al. (2001) reported minimal gender differences. Many explanations have been put forth for the observed gender difference involving artifactual, psychosocial, genetic and endocrine causes. According to Piccinelli and Wilkinson (2001), while artifactual determinants may enhance female predominance somewhat, for the most part gender differences in depressive disorders are genuine. The authors did not find any genetic and biological factors to influence the manifestation of gender differences. Silverstein (2002) observed the prevalence of somatic depression (e.g., appetite and sleep disturbances, and fatigue) but not pure depression (that is, all the depression criteria minus the somatic criteria) to be much higher among women than men. Women especially of childbearing and child rearing age have been found to have the most significant mental health risk from depression (Glied & Kofman, 1995). Determinants of gender differences in depressive disorders are still unclear. Piccinelli and Wilkinson (2001) are of the view that “adverse experiences in childhood, depression and anxiety disorders in childhood and adolescence, sociocultural roles with related adverse experiences, and psychological attributes related to vulnerability to life events and coping skills” are likely to play a role in the emergence of gender differences. Causes of depression in women (a) Hormonal fluctuations Heading the list is the bioactivity of women's hormones that regulate mood through their effect on certain brain chemicals. Hormonal fluctuations during the menstrual cycle leading to premenstrual dysphoric disorder (PMDD) is well established. So also the hormonal changes that occur during pregnancy can cause depression in women already at high risk. Postpartum depression could also result from hormonal fluctuations. In women with past histories of depression, rapid fluctuations in reproductive hormones occurring during perimenopause and menopause could produce an increased risk of depression. (b) Stress Severe stress, like the death of or divorce from a spouse or loss of job affects women differently than men. Stress causes depression in both genders but women are affected three times more than men under the same circumstances (Maciejewski et al., 2001). Furthermore, how an individual reacts to stress is also determined by the person’s genetic make-up (Caspi et al., 2003). (c) Social and cultural causes The dual roles of a career and home-making are frought with stress for those women predisposed to depression. The often conflicting and overwhelming responsibilities in their life make such women vulnerable to depressive disorders. Single mothers have been found to be particularly at risk. (d) Socioeconomic causes Low socioeconomic status is generally associated with high psychiatric morbidity as poverty is a severe, chronic stressor than can lead to depression. Lower socioeconomic status has been found to increase the chronicity of depression (Lorant et al., 2003) while financial crisis and unemployment can have a causal influence on depression and suicide (Gunnell et al., 2009). Women, in general, experience a higher prevalence of depression as well as a lower socioeconomic status (Lorant et al., 2003). (e) Psychological causes Women who are depressed generally seem to be lacking in coping mechanisms. Low self-esteem resulting from body image dissatisfaction has been described as an increasing risk factor for depression in women in Western societies (Veale et al., 2003). (f) Presence of comorbid conditions To confound matters, depression is strongly linked with other illnesses, for example, heart disease and osteoporosis, which women have a high propensity to develop. Cardiovascular disease is the leading cause of mortality in women accounting for more than 500,000 deaths each year in the United States. Cardiovascular mortality is doubled in the presence of major depression in both men and women (Naqvi et al., 2005). Matching the higher incidence of depression in women in the general population, depression is far more prevalent in women post-acute myocardial infarction (Frasure-Smith et al., 1999), and, interestingly, the gender differences in depressive symptoms are significantly higher among younger female patients (Carney et al., 1987). Women with acute myocardial infarction were observed to be more severely depressed compared to men, and, also, the depressive symptoms seemed to persist longer (Drory et al., 2003). Men and depression Both men and women develop the standard symptoms of depression, but they experience depression differently. Besides, the mechanism of coping with the symptoms could be gender-based (www.nimh.nih.gov). However, while generally men seem to more readily acknowledge symptoms of depression such as fatigue, irritability, loss of interest in work and hobbies, and sleep disturbance, they do not express feelings of sadness, worthlessness, and excessive guilt. Men are also more likely than women to report substance abuse. Besides, the number of suicide deaths is 4 times higher in men than in women (Kochanek et al., 2004). The high suicide rates among men would indicate that men do not avail of proper diagnosis and treatment for depression. This could be worrisome from the public health perspective especially when the gender gap in depression seems to be closing. Earlier, studies had found women to be 2-3 times more likely to experience depression than men; recent survey shows they are just 1.7 times more likely (Kessler et al, 2003). Reporting Bias vis a vis gender There is a gender bias in the perception of depression by women as compared to men. Also, self or family-rated as well as physician-diagnosed depression seem to be generally prompted by a gender bias. Self-reported morbidity seems to be higher in women compared to men; self-image, gender-role orientation and body shape are some explanations offered for the above (Sweeting, 2007). However, Bogner and Gallo (2004) found no evidence of a differential presentation of depressive symptoms by gender. A possible explanation for the higher rates of depression prevalent in women compared to men seems to be the fact that family members readily acknowledge symptoms of depression in their female relatives but not in their male relatives. Brommelhoff et al. (2004) conducted a study to understand whether the higher rates of depression reported in women than in men could be explained by a gender bias existing within the family reporting depression. The study examined 205 adult patients in order to determine whether family members more readily recognized/reported depression in female but not male relatives. Results indicated that women were more likely to be reported as depressed by a family member as compared to men, while the women themselves did not acknowledge being depressed. Furthermore, women who acknowledged being depressed also attributed their depression to internal causes that is, held themselves responsible for their depressed mood. In contrast to this, earlier studies have shown men to blame external factors such as unemployment or divorce, as causing their depression (Calhoun et al., 1974). It is possible that the family members, with their display of a gender bias while attributing the causes of depression in female relatives to internal factors, could actually be holding the women more responsible for their mental illness than men. Due to gender bias, women are, therefore, more likely to get a false positive diagnosis for depression compared to men (Brommelhoff et al., 2004). Family physicians have also shown a tendency to be more aware of depression in female patients than in male patients (Borowsky et al., 2000). Studies by Williams et al. (1995) and Bertakis et al. (2001) found evidence for gender bias among primary care physicians and conclusively showed that being female increases the likelihood of being diagnosed as depressive by the clinicians. In conclusion, gender differences, socioeconomic factors as well as the reporting bias encountered in family members, self and physicians can impede proper diagnosis of depressive disorders. References Ayuso-Mateos JL, Vazquez-Barquero JL, Dowrick C, Lehtinen V. et al., 2001. Depressive disorders in Europe: Prevalence figures from The ODIN study. British Journal of Psychiatry, 179:308–316. doi: 10.1192/bjp.179.4.308. Bertakis KD, Helms LJ, Callahan EJ, Azari R. et al., 2001. Patient gender differences in the diagnosis of depression in primary care. J Wom Health Gender- Based Med. 10:689. Borowsky SJ, Rubenstein LV, Meredith LS, Camp P. et al., 2000. Who is at risk of nondetection of mental health problems in primary care? J Gen Intern Med., 15:381. Calhoun LG, Cheney T. & Dawes AS. 1974. Locus of control, self-reported depression, and perceived causes of depression. J Consult Clin Psychol., 42:736 Carney RM, Rich MW, Tevelde A, Saini J. et al., 1987. Major depressive disorder in coronary artery disease. Am J Cardiol., 60:1273–1275. Caspi A, Sugden K, Moffitt TE, et al. 2003. Influence of life stress on depression: moderation by a polymorphism in the 5-HTT gene. Science, 301(5631):386-389. Costello, E. J., Angold, A., Burns, B. J., et al (1996) The Great Smoky Mountains Study of Youth. Goals, design, methods, and the prevalence of DSM-III-R disorders. Archives of General Psychiatry, 53, 1129 -1136. Drory Y, Kravetz S, Hirschberger G. 2003. Israel Study Group on First Acute Myocardial Infarction. Long-term mental health of women after a first acute myocardial infarction. Arch Phys Med Rehabil., 84:1492–1498. Frasure-Smith N, Lespérance F, Juneau M, Talajic M. et al., 1999. Gender, depression, and one-year prognosis after myocardial infarction. Psychosom Med., 61:26–37 Glied, S., & Kofman, S. 1995. Women and mental health: Issues for health reform [background paper]. The Commonweath Fund, Commission on Women's Health, New York, p. 25. Goodwin R.D., Fergusson D.M. & Horwood L.J. 2004. Panic attacks and the risk of depression among young adults in the community. Psychotherapy & Psychosomatics, 73:158-165. Gunnell, D., Platt, S., & Hawton, K. 2009. The economic crisis and suicide. BMJ, 338: b1891. Kessler RC, Chiu WT, Demler O, Walters EE. 2005. Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry, 62(6):617-27. Kessler RC, McGonagle KA, Swartz M, Blazere DG et al., 1993. Sex and depression in the National Comorbidity Survey, 1: life time prevalence, chronicity and recurrence. J Affect Disord., 29:85–96. Kochanek KD, Murphy SL, Anderson, RN, & Scott, C. 2004. Deaths: final data for 2002. National Vital Statistics Reports; 53(5). Hyattsville, MD: National Center for Health Statistics, 2004. Lewinsohn PM, Hoberman HH & Rosenbaum M. 1988. A prospective study of risk factors for unipolar depression. Journal of Abnormal Psychology, 97(3): 251- 264. Lorant, V., Deliège, D., Eaton, W., Robert, A., et al., 2003. Socioeconomic Inequalities in Depression: A Meta-Analysis. Am J Epidemiol., 157: 98-112. Maciejewski PK, Prigerson HG & Mazure CM. 2001. Sex differences in event related risk for major depression. Psychol Med. 31:593-604. Modabernia, M.J., Tehrani, H.S., Fallahi, M. Shirazi, M. et al. 2008. Prevalence of depressive disorders in Rasht, Iran: A community based study. Clin Pract Epidemol Mental Health. 4: 20. Naqvi TZ, Naqvi S. Bairey-Merz CN. 2005. Gender differences in the link between depression and cardiovascular disease. Psychosom Med., 67(Suppl 1):S15–18. Silverstein, B. 2002. Gender differences in the prevalence of somatic versus pure depression: a replication. American Journal of Psychiatry, 159:1051-1052. Stordal E, Bjartveit Kruger M, Dahl NH, Kruger Q. et al., 2001. Depression in relation to age and gender in the general population: the Nord-Trondelag Health Study (HUNT). Acta Psychiatr Scand. 104:210–216. Sweeting, HN., West, PB & Der, GJ. 2007. Explanations for female excess psychosomatic symptoms in adolescence: evidence from a school-based cohort in the West of Scotland. BMC Public Health, 7:298. Veale D, Kinderman P, Riley S, Lambrou C. 2003. Self-discrepancy in body dysmorphic disorder. Br J Clin Psychol.,42:157–169. doi: 10.1348/014466503321903571. Vicente B, Kohn R, Rioseco P, Saldivia S, Baker C. et al., 2004. Population prevalence of psychiatric disorders in Chile: 6-month and 1-month rates. British Journal of Psychiatry, 184:299–306. doi: 10.1192/bjp.184.4.299. Weisseman, M.M. & Klerman, G.L., 1985. Gender and Depression. Trends in Neurosciences, 8:416–420. Williams JBW, Spitzer RL, Linzer M, et al. 1995. Gender differences in depression in primary care. Am J Obstet Gynecol. 173:654. WHO, World Health Organization, 2002. The World Health Report 2002: Reducing Risks, Promoting Healthy Life. Geneva, Switzerland. WHO, 2004. The World Health Report 2004: Changing History, Annex Table 3: Burden of disease in DALYs by cause, sex, and mortality stratum in WHO regions, estimates for 2002. Geneva, Switzerland. Read More