Research report
Epidemiology of women and depression

https://doi.org/10.1016/S0165-0327(02)00426-3Get rights and content

Abstract

Background: Depression is the leading cause of disease-related disability among women in the world today. Depression is much more common among women than men, with female/male risk ratios roughly 2:1. Aims: Recent epidemiological research is reviewed. Implications are suggested for needed future research. Results: The higher prevalence of depression among women than men is due to higher risk of first onset, not to differential persistence or recurrence. Although the gender difference first emerges in puberty, other experiences related to changes in sex hormones (pregnancy, menopause, use of oral contraceptives, and use of hormone replacement therapy) do not significantly influence major depression. These observations suggest that the key to understanding the higher rates of depression among women than men lies in an investigation of the joint effects of biological vulnerabilities and environmental provoking experiences. Conclusions: Advancing understanding of female depression will require future epidemiologic research to focus on first onsets and to follow incident cohorts of young people through the pubertal transition into young adulthood with fine-grained measures of both sex hormones and gender-related environmental experiences. Experimental interventions aimed at primary prevention by jointly manipulating putative biological and environmental risk factors will likely be needed to adjudicate between contending causal hypotheses regarding the separate and joint effects of interrelated risk factors.

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

References (53)

  • A. Angold et al.

    Pubertal changes in hormone levels and depression in girls

    Psychol. Med.

    (1999)
  • A. Angold et al.

    Puberty and depression: The roles of age, pubertal status, and pubertal timing

    Psychol. Med.

    (1998)
  • J. Angst et al.

    The depressive spectrum: Diagnostic classification and course

    J. Affect. Disord.

    (1997)
  • R.C. Barnett et al.

    Gender and Stress

    (1987)
  • D.G. Blazer et al.

    The prevalence and distribution of major depression in a national community sample: The National Comorbidity Survey

    Am. J. Psychiatry

    (1994)
  • G.W. Brown et al.

    Aetiology of anxiety and depressive disorders in an inner-city population: 2. Comorbidity and adversity

    Psychol. Med.

    (1993)
  • The changing rate of major depression: Cross-national comparisons

    J. Am. Med. Assoc

    (1992)
  • J. Cullberg

    Mood changes and menstrual symptoms with different gestagen/estrogen combinations. A double blind comparison with placebo

    Acta Psychiatr. Scand. Suppl.

    (1972)
  • J.G. Dryfoos

    Adolescents at Risk: Prevalence and Prevention

    (1990)
  • L.J. Eaves et al.

    Genetics and developmental psychopathology: II. The main effects of genes and environment on behavioral problems in the Virginias Twin Study of Adolescent Behavioral Development

    J. Child Psychol. Psychiatry

    (1997)
  • C. Ernst et al.

    The Zurich study XII. Sex difference in depression. Evidence from longitudinal epidemiological data

    Eur. Arch. Psychiatry Clin. Neurosci.

    (1992)
  • X. Ge et al.

    Coming to age too early: Pubertal influences on girls’ vulnerability to psychological distress

    Child Dev.

    (1996)
  • L.A. Giuffra et al.

    Diminished recall and the cohort effect of major depression: A simulation study

    Psychol. Med.

    (1994)
  • F.K. Goodwin et al.

    Manic-Depressive Illness

    (1990)
  • I.H. Gotlib et al.

    Prevalence rates and demographic characteristics associated with depression in pregnancy and the postpartum

    J. Consult. Clin. Psychol.

    (1989)
  • W.R. Gove

    The relationship between sex roles, marital status, and mental illness

    Social Forces

    (1972)
  • Cited by (1481)

    • Retirement as a Leverage Point to Support Geriatric Mental Health

      2024, American Journal of Geriatric Psychiatry
    View all citing articles on Scopus
    View full text