Women And Depression
What is Depression?
Major depression is a mood disorder characterized by one or more major depressive episodes (i.e., at least two weeks of depressed mood or loss of interest or pleasure in nearly all activities) accompanied by at least four additional symptoms such as changes in sleep, appetite, or weight, and psychomotor activity; decreased energy; feelings of worthlessness or guilt; difficulty thinking, concentrating, or making decisions; or recurrent thoughts of death or suicidal ideation, plans, or attempts. Dysthymia or dysthymic disorder "is characterized by at least two years of depressed mood for more days than not, accompanied by additional depressive symptoms that do not meet criteria for a major depressive episode (American Psychiatric Association, 1994, p. 317).
Depression is a common and highly treatable disorder affecting over 17 million American adults annually. Once identified, depression can almost always be successfully treated either by psychotherapy, medication, or a combination of both. Unfortunately, according to the Agency for Health Care Policy and Research, depression is underdiagnosed and undertreated by primary care and other non-mental health practitioners.
Major depression can cause severe impairment in social and physical functioning and is often a major precipitating factor in suicide. It has been associated with higher medical costs, greater disability, poor self-care and adherence to medical regimens, and increased morbidity and mortality from medical illness (Katon & Sullivan, 1990).
Women are approximately two times more likely than men to suffer from major depression and dysthymia (Research Agenda for Psychosocial and Behavioral Factors in Women's Health, 1996). Depression has been called the most significant mental health risk for women, especially younger women of childbearing and childrearing age (Glied & Kofman, 1995).
Depression in women is misdiagnosed approximately 30 percent to 50 percent of the time. Approximately 70 percent of the prescriptions for antidepressants are given to women, often with improper diagnosis and monitoring. Prescription drug misuse is a very real danger for women (McGrath et al., 1990).
Risk Factors for Depression
High levels of depressive symptoms are particularly common among individuals with economic problems and those of lower socioeconomic status. Individuals who are less educated and unemployed are at higher risk for depression. These risk factors are overrepresented among women (McGrath et al., 1990).
Women of color are more likely than Caucasian women to share a number of socioeconomic risk factors for depression, including racial/ethnic discrimination, lower educational and income levels, segregation into low status and high-stress jobs, unemployment, poor health, larger family sizes, marital dissolution, and single parenthood (McGrath et al., 1990).
Women confronting the impact of immigration and acculturation reported a higher level of depression than those women without such conflicts. For example, the National Center for Health Statistics (1994) indicated that Asian American women over the age of 65 have the highest female suicide rate among all ethnic and racial groups. In addition, Asian American adolescent girls have the highest rates of depressive symptoms of all racial groups and have the highest suicide rate among all women between 15 and 24 years of age.
The rate of sexual and physical abuse is much higher than previously suspected and is a major factor in women's depression. Depressive symptoms may be long-standing effects of post-traumatic stress disorder for many women (McGrath et al., 1990).
Married women have higher rates of depression than unmarried women, but the reverse is true for men. Marriage seems to confer a greater protective advantage on men than on women. In unhappy marriages, women are three times as likely as men to be depressed. Women's risk of depressive symptoms and demoralization is higher among mothers of young children and increases with the number of children in the house (McGrath et al., 1990).
What is Needed?
Expand research on differential response patterns to treatment for major depression in women and men, including established and new psychopharmacological and psychosocial treatments. Outcome assessments should include various measures of cognitive and psychosocial functioning, as well as symptom assessments (Kessler et al., 1994).
Fund research to develop methods to prevent depression. Depression recurs in more than 50 percent of patients who recover from an initial episode (Frank et al., 1990). We must focus on prevention in addition to treatment.
Expand insurance coverage for mental health problems to equal that provided for physical health problems. Affordable and accessible treatment for mental health and related health care are key factors in their use. Yet most insurance coverage is inadequate for all but very short-term care.
Conduct research on barriers to treatment and on ways to facilitate treatment entry, compliance, and retention. Although effective interventions often are available, the majority of people with psychological disorders do not obtain professional treatment. Even among people with a history of three or more comorbid disorders, less than 50 percent ever obtain specialty sector mental health treatment (Kessler et al., 1994).
Expand research on risk factors for depression among different populations of women. Data are limited on risk factors for various subgroups of women including adolescent girls, lesbians, women of color, rural women, and older women.
Expand research and therapeutic attention to women with depressive symptoms who do not meet criteria for major depression. High utilization of medical services and social impairment are associated with the presence of depressive symptoms, as well as with diagnosed depression. Individuals with depressive symptoms have comparable, or higher, rates of emergency department use, use of medications, medical consultations for emotional problems, attempted suicide, and days lost from work as individuals with diagnosable depression (Glied & Kofman, 1995; Johnson et al., 1992).
Expand research examining the effects of treating depression to enhance the rates of recovery and survival for women with medical conditions. Major depression is a source of increased morbidity and an independent risk factor for mortality in patients with medical conditions (Frasure-Smith, et al., 1993). Identification and treatment of depression in women with medical disorders, and in aging women who tend to have higher rates of medical illness, should be a focus of research.
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.
Frank, E., Kupfer, D. J., Perel, J. M., Cornes, C., Jarrett, D. B., Mallinger, A. G., Thase, M. E., McEachran, A. B., & Grochocinski, V. J. (1990). Three-year outcomes for maintenance therapies in recurrent depression. Archives of General Psychiatry, 47, 1093-1099.
Frasure-Smith, N., Lesperance, F., & Talajic, M. (1993). Depression following myocardial infarction: Impact on 6-month survival. Journal of the American Medical Association, 270, 1819-1825.
Glied, S., & Kofman, S. (1995, March). Women and mental health: Issues for health reform background paper]. New York: The Commonwealth Fund, Commission on Women's Health.
Johnson, J., Weissman, M. M., & Klerman, G. L. (1992). Service utilization and social morbidity associated with depressive symptoms in the community. Journal of the American Medical Association, 267, 1478-1483.
Katon, W., & Sullivan, M. D. (1990). Depression and chronic mental illness. Journal of Clinical Psychiatry, 51, 3-14.
Kessler, R. C., McGonagle, K. A., Zhao, S., Nelson, C. B., Hughes, M., Eshleman, S., Wittchen, H-U., & Kendler, K. S. (1994). Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: Results from the National Comorbidity Survey. Archives of General Psychiatry, 51, 8-19.
McGrath, E., Keita, G. P., Stickland, B. R., & Russo, N. F. (1990). Women and depression: Risk factors and treatment issues. Washington, DC: American Psychological Association.
National Center for Health Statistics, Centers for Disease Control and Prevention. (1994). Health, United States 1995. Hyattsville, MD: U.S. Public Health Service.
Research agenda for psychosocial and behavioral factors in women's health. (1996, February). Washington, DC: Women's Programs Office, American Psychological Association.
For further information please contact Lori Valencia Greene of the APA Public Policy Office at 202-336-5931.