Depression and Gender
An International Review
Frances M. Culbertson
University of Wisconsin - Whitewater and Mental Health Associates
American Psychologist, vol. 52, no. 1. 25-31.
This article reviews and updates major research findings on depressive disorders and gender relationships in the United States and abroad. It also considers some of the World Health Organisation’s assessment instruments that may clarify the relationship between depression and gender and its cross-cultural ramifications. With psychology converging across national boundaries and with gender being a variable in psychological research both nationally and internationally, gender and its relationship to depressive states is emerging as a focal point of interest and concern.
Beginning in the 1970s and continuing to the present two important and stimulating developments in the area of depression have occurred cross-culturally. One development was represented by the beginning studies of Weissman and Klerman (1977) on sex differences and the epidemiology of depression. The other development was marked by the World Health Organisation’s (WHO's) initiations into the areas of standardisation of psychiatric diagnosis, classification, and statistics (Sartorius, 1972; WHO, 1973) and its concomitant development of assessment instruments that have proved to be reliable and valid across nations (Janca, Ustun. & Sartorius, 1994).
Gender and Depression
For the past 30 years or so, in the United States and internationally, women have experienced depression about twice as frequently as men. Some researchers even quote a female-male ratio of 3:1 for depression (Klerman & Weissman, 1989; Wetzel, 1994). For major depression which is a more impairing than a number of other medical conditions, the ratio has been reported as four women for every man, although rates vary with ethnicity and culture (Sileo, 1990). For bipolar disorder (manic depression), the rates are equal between the sexes (Weissman, 1987).
Given these ratios for depression in women and men, gender is an important variable in cross-culturally conceptualising, assessing, and treating depression. Cross-cultural research on depression and gender should help answer some questions associated with the differences between women and men in the occurrence of depression observed in some countries.
Review of Literature on Gender and Depression
Although there has been much research on gender in the United States, gender as a research variable has not been widely used in studies conducted outside the United States. Despite WHO's long history of research on depression, those efforts did not include psychology until recently, and the inclusion of gender differences in depression has not become part of WHO's research.
This article reviews seven significant publications that together form an important part of the foundation for a cross-cultural understanding of depression and gender differences. These studies, listed chronologically, are as follows: (a) WHO's publications from 1973 to 1995; (b) studies by the National Institute of Mental Health (NIMH; Depression Awareness, Recognition, and Treatment [D/ART] Program, 1987); (c) psychiatric studies of Weissman and Klerman (1977; Klerman & Weissman, 1989); (d) an American Psychological Association (APA) task force report (McGrath, Keita, Strickland, & Russo, 1990); (e) Nolen-Hoeksema's (1990) study on sex differences in depression; (f) 1993 publications by the Depression Guideline Panel and the Agency for Health Care Policy and Research (AHCPR); and (g) the National Co-morbidity Study by Kessler, McGonagle, and Zhao (1994).
World Health Organisation’s Studies
Research in the field of clinical depression has been an ongoing task for WHO from the 1970s to the mid-1990s and undoubtedly will continue for some time. In a WHO report, Sartorius (1979) estimated that more than 100 million individuals in the world suffer from depression and these 100 million people then affect three times as many other people during their illness. Also, Sartorius reported that the recognition of culture as an important variable in depression studies led to studying depressive disorders in five different cultures: Basel, Switzerland; Montreal, Canada; Nagasaki and Tokyo, Japan; and Tehran, Iran. Three goals in Sartorius et al.'s (1983) study were to develop simple, reliable instruments to measure depression in different cultures; to of the depressive states that may occur in these different cultures, and to establish a network of field centres for further research. This 10-year study led to the findings that cross-cultural studies were feasible and appropriate for long-term, follow-up investigations and that the simple assessment instruments used in this study were reliable (Sartorius et al., 1983).
In 1989, Sartorius reported that WHO was engaged in a 10-year follow-up study of depression involving a number of different countries to examine whether the positive findings of symptom similarity would be more generally confirmed. In addition, he reported that WHO had produced new cross-cultural instruments for assessing mental health status that were proving to be reliable and valid for cross-cultural studies.
Sartorius (1993) noted that WHO's program in epidemiological psychiatry had three achievements: The first was its contribution of knowledge to the field of mental illness in different sociocultural settings; the second was its contribution to reliable and valid methods (e.g., assessment procedures), which allow for meaningful national and cross-cultural studies; and the third was the development of a network of participating individuals and centres. The WHO reports on the assessment instruments relevant for cross-cultural studies of depression, research beginning in the 1980s and continuing into the 19905, are discussed later in this article.
WHO has been a major contributor to cross-cultural studies of depression, but these research programs mainly have been in primary medical care or hospital settings where there are few, if any, psychologists. But this is now a changing condition, and engagement of psychologists in medical settings may provide avenues for psychologists to also become involved in WHO research. It should be noted that with the influx of psychologists in this field of study, gender studies may be more likely to become part of WHO's research programs. As noted above, at present, WHO studies do not involve gender comparisons, although they do include equal numbers of men and women in their samples.
Depression Awareness, Recognition, and Treatment Program
In 1987, NIMH published a review of the epidemiological studies of depression conducted in the United States and other Western nations (NIMH, D/ART Program, 1987). The results of this major study reported the lifetime prevalence of affective disorders, which included depression, anxiety disorders, and substance abuse, and the co-morbidity of these disorders. This review also investigated the relationship between gender and depression. It found that women had higher rates of depression than men, with a ratio of 2:1 being very common. Only bipolar depression occurred with equal frequency in women and men. The D/ART Program review suggested that there were three possible explanations for this difference: (a) Women were more willing than men to seek help and thus were recorded in the data base of depression in higher numbers; (b) biological differences in women and men may have been a causal factor; and (c) psychosocial factors such as different rearing environments, different social roles, and less favourable economic and social opportunities and positions in their world, may have had a relevant influence. It was theorised that depression in men may be concealed by their use of alcohol.
With regard to treatment strategies, the NIMH, D/ART Program (1987) report indicated that antidepressive drugs and short-term psychotherapies were effective. The D/ART Program also stressed the need to research gender in relation to treatment. .
In addition, the NIMH, D/ART Program's (1987) review of studies of depression reported that although women were more susceptible to depression than men in later life, prior to adolescence there was no such gender difference. Also in this report, the D/ART Program noted the progress that was occurring internationally in assessment and diagnosis of psychiatric disorders by WHO, especially in developing consistent diagnostic criteria for depression, as much work continues to be needed in this area. The hope was expressed that better cross-cultural research studies would assist in determining the biological and psychosocial determinants related to gender differences and depression in all national and international studies, The D/ART Program emphasized the importance of longitudinal studies to support an understanding of the relationship between early development and childhood depression and between childhood depression and adult depression.
In 1989, Klerman and Weissman reported findings of several large epidemiologic studies that suggested a persistent gender effect. The studies were conducted in the United States, Sweden, Germany, Canada, New Zealand, Puerto Rico, and Korea. The review of these studies by Klerman and Weissman reported temporal changes in depression for cohorts born after World War II as follows: (a) Onset periods or depression were decreased, and increases occurred in late adolescence or early adulthood; (b) rates of depression increased for all participants from 1960 to 1975; (c) women were persistently reported to be two-three times more likely to be depressed than men across all adult ages; (d) a persistent family effect occurred; and (e) there was a suggestion of a narrowing of differential risk to men and women due to a rise in the risk of depression in young men. These findings occurred in samples from the United States. Sweden. Germany, Canada, and New Zealand but not in samples from Korea and Puerto Rico nor in the sample of Mexican Americans living in the United States.
American Psychological Association's Task Force on Depression
In 1990, APA published its taskforce findings on depression among women in the United States (McGrath et al. 1990). The findings regarding gender and depression were as follows: In the United States, women were at higher risk for depression than were men because of socioeconomic, biological, and emotional variables; women's personalities and cognitive styles and lack of problem solving strategies were associated with depressive states; post-traumatic stress, as in sexual or physical abuse, was noted as one of the major contributing factors to depression; married women were more likely to be depressed, and the more children there were in the family, the greater was the frequency of reported depression; and lastly, for women, economic status was highly related to reported depressive symptoms, and poverty was found to be a "pathway to depression” (McGrath et al., 1990, p. xii). Given these findings, McGrath et al. suggested that treatment involve a careful diagnosis and that cognitive-behavioural, interpersonal, and sociocultural feminist therapy as treatment modalities, as well as medications, be closely monitored for treatment efficacy.
Work by Nolen-Hoeksema
In 1990, Nolen-Hoeksema published her book Sex Differences in Depression, which reviewed studies of depression and gender conducted outside the United States. Nolen-Hoeksema reported on gender differences in depression in individuals from high-income countries (developed countries) and low-income countries (developing countries). In her review of studies of treated cases of depression outside the United States, Nolen-Hoeksema reported that there was a mean 2:1 female-male ratio of depression in developed nations. However, in studies of depression outside the developed nations, she reported no significant findings of female-male depression differences, especially in developing countries. These findings led her to suggest that the culture of a country is a significant determinant of female-male differences in depression.
Nolen-Hoeksema (1990) also reported that high-income countries, for example, Sweden, Denmark, and Australia, had significant gender differences in depression whereas low-income countries, for example, Nigeria and Uganda, did not. However, these findings cannot be generalised to all high-low-income countries. As Nolen-Hoeksema noted, her review of studies from 1956 to 1981 included only those investigations that were considered adequate in methodology and design; therefore, many other studies and countries were excluded from her analyses. Of the studies she included in her analyses, women were diagnosed as having depressive disorders significantly more frequently than men, at a 2: 1 ratio. She also found that women reported a greater number of depressive symptoms than did men.
Agency for Health Care Policy and Research
In 1993, AHCPR published two volumes on depression in primary care. These volumes provide guidelines for patients and primary care physicians regarding detection and treatment of depression in primary care settings. They also report gender differences related to depression. In its epidemiologic report on depression in primary care, AHCPR noted that in Western industrialised nations, for major depression, the incidence was 2% for men and 5-9% for women. The lifetime risk factor was 7-12% for men and 20-25% for women. AHCPR also found that risk factors for gender differences occurred in community samples and therefore were not due to female-seeking behaviours, a factor reported to be associated with depression in women. These findings were also reported as being unrelated to race, education, income, and civil status.
The National Co-morbidity Study
Finally, in 1994, Kessler et al., in their National Co-morbidity Study, conducted the first national mental health survey in the United States using a modified WHO diagnostic instrument developed for cross-cultural work. The results of this study revealed that women, as compared with men, had a lifetime and 12-month prevalence of depression of almost 2:1, confirming the findings previously reported. Other findings of interest were that female adolescents had a higher ratio of depression than male adolescents. Hispanics in the sample were the highest reporters of depression and African Americans were the lowest reporters of depression. Kessler et al. noted that despite the complexities of assessing and diagnosing depression, a 2:1 ratio for depression in women compared to men cross-culturally, especially in the developed countries, has been fairly reliable.
Current Status of Gender Differences in Depression
Some recent studies, however, have reported different findings - findings showing a higher rate of depression among men, which may lead to changes in the currently accepted ratio of 2: 1 between women and men. In 1992, Weissman, Bruce, Leaf, Florio, and Holzer found the ratio of depression in women to men to be 2.41: 1. But, the more recent National Comorbidity Study by Kessler et al. in 1994 showed a ratio of 1.7:1 of women compared to men, indicating a higher relative rate of depressive disorders for men than previously reported. Furthermore, in both studies, the rates of depression in men between the ages of 20 and 30 were higher than in women, similar to the NIMH, D/ART Program (1987) findings. Kessler et al.' s findings of higher ratios of depression for female adolescents as compared with male adolescents support the 1991 data of Reinherz, Frost, and Bilge that higher ratios of depression were occurring in younger people than in older people and: at younger age levels, female adolescents were reported to be experiencing higher levels of depression than male adolescents.
It must be noted that not all of the research findings across cultures are the same with respect to rates of depression and gender differences. In developing countries, the depression and gender ratios are not the same as those reported above. Kisekka (1990) noted the 1972 study of Orley in which gender differences, in psychiatric institutions of Africa were compared. Orley found higher rates for men than for women in contrast to the findings or no gender differences by Nolen-Hoeksema (1990). To account for this difference, Kisekka speculated that, the gender differences may have been due to men in the work situation being more readily referred for mental health assistance; that men were more aggressive, and this aggression was more likely to be noted by the police; and that most referrals to institutions came from the police. To account for the women's findings, Kisekka noted that women, more often than men, might seek out alternative facilities for help, such as churches and “indigenous, traditional healers”.
Another study of psychiatric disorders in two African villages in Uganda by Orley, Blitt, and Wing (1979) found no differences in depressive states between men and women. An interesting side note to their study is that they found depression to be the highest reported disorder for all Ugandans and that Ugandan village women, as compared with women living in the inner suburbs of London, were more likely to report depression; the reported depression was more severe; and twice as many of the Ugandan women as compared with the British women were reported to be depressed.
Studies of depression in developed nations provide some fairly consistent findings regarding gender differences in depression. The findings from low-income nations, such as Africa, yield mixed gender-depression ratios. Further cross-cultural research, including that done on high-income and low-income nations' differences, and developed and developing countries' differences, in gender-depression relationships is needed to allow researchers to understand the underlying factors of gender-depression ratio differences. Cross-cultural research will prevent researchers from making erroneous assumptions and inferences about depression as well as illuminate cultural variables that contribute to or mitigate against depression, particularly gender differences.
Although continued cross-cultural research is needed to gain a better understanding of depression and gender (see discussion in the Conceptualisation of Depression section below), there is another important issue that needs to be addressed as research data are gathered. That issue is the conceptualisation and assessment of depression in research studies and its importance to the understanding of these differences.
Conceptualisation of Depression
There appear to be consistent findings, no matter what diagnostic instruments are used or where people are assessed (e.g., in a community, a hospital, a primary care facility, educational settings), that women experience depressive states more frequently than men, with the ratio of 2: I appearing to be robust. However, it is not known if the depressive states are similar or different. Who is more likely to show depressive-anxiety disorders? Who is more likely to experience major depressive disorders? Is the depressive experience similar in men and women? Are the symptoms of depression similar or different across cultures? Do male and female assessors in different nations evaluate depression and patient problems similarly? To answer these questions, reliable and valid instruments are needed that will generate accurate and meaningful data.
The Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) is an attempt to provide a common diagnostic plan with an agreed-upon conceptualisation and language for mental disorders in the United States. This manual, as well as the International Classification of Diseases (WHO, 1992), provides a system for classification of disordered behaviours and diagnoses of mental disorders, such as depression, that can be used in most countries around the world. However, although these diagnostic systems are presently used, a universally acceptable conceptualisation, assessment, and diagnosis of depression continues to be problematic (Kleinman & Good, 1985).
World Health Organisation’s Assessment Instruments
In an endeavour to provide instruments of' “common language,” WHO, over three decades, developed and researched a group of instruments for assessing mental disorders, labelled the Composite International Diagnostic Interview (CIDI), the Schedules for Clinical Assessment in Neuropsychiatry (SCAN), and the International Personality Disorder Examination (IPDE; Loranger et al., 1994). To date, these instruments have been field- tested in 30 centres around the world. Data are now emerging that indicate the instruments are deemed to be generally acceptable, appropriate, and reliable across cultures (Janca et al., 1994; Sartorius, 1994; Wing, Babor, Jablensky, Regier, & Sartorius, 1990; Wittchen, Robins, & Cottler, 1992).
The CIDI instrument has a core version (CIDI Core Version 1:1) that is a highly structured instrument intended for use by trained lay interviewers. The SCAN instrument is primarily designed for experienced clinical psychologists or psychiatrists to apply in clinical settings. It is a semi-structured assessment instrument for adults and consists of an interview schedule, a present-state examination, a glossary of differential definitions, an item-group checklist, and a clinical-history schedule. It is a much more comprehensive instrument than the CIDI. The IPDE assesses characteristics of mental health problems relevant to a diagnosis of personality disorder. This instrument is also intended to be used by experienced clinical psychologists or psychiatrists.
The University of Michigan Survey Research Centre used a modified CIDI instrument in Kessler et al.’s (1994) study of lifetime and 12-month prevalence of Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev.; American Psychiatric Association, 1987) psychiatric disorders in the United States. This was the first study to administer a structured psychiatric interview (modified CIDI) to a national probability sample. Recently, Wittchen et al. (1992) conducted a study on the cross-cultural feasibility and reliability of the CIDI. WHO and other researchers are continuing to collect data using these assessment instruments across a number of countries.
Training and reference centres throughout the world are now open to assist mental health clinicians, psychologists, psychiatrists, and other researchers in the use of these instruments. Training in the administration and interpretation of the CIDI in the United States is available at the Department of Psychiatry of the Washington University School of Medicine. Training in the administration and interpretation of the SCAN instrument is available at the University of Connecticut Health Centre, Farmington; the Washington University School of Medicine; and the Johns Hopkins University School of Hygiene and Public Health. IPDE training centres are located at the Cornell Medical Centre. These instruments should be a significant resource for psychologists interested in cross-cultural research in mental disorders, especially depression, by providing common assessment tools for cross-cultural comparisons. It is important for researchers to remember that except for Kessler et al.'s (1994) study, gender in WHO work has not been a variable, and yet the importance of understanding the role of gender in mental health assessment and treatment is crucial, nationally and internationally.
How Cross-Cultural Research Informs Work on Women and Depression
The additional issues regarding depression in women that need to be considered for cross-cultural comparisons are (a) continued work on symptom similarities of depression in men and women; (b) risk factors for depression, such as educational, economic, social, political, and cultural factors and their interactions; and (c) developmental stages and their relationships with depressive disorders.
Generally, depression is defined as a disorder of the mind that affects the physical, psychological, and social functioning of an individual. Most investigators consider reports of sadness, helplessness, eating disturbances, social withdrawal, loss of ability to concentrate, ideas of inadequacy or worthlessness, tension, lack of energy, and anxiety to be signs or symptoms of depression (Beck, Ward, Mendelsohn, Mack, & Erbaugh, 1961; McGrath et al., 1990). Are these symptoms universal and cross culturally similar? This question is presently being pursued by WHO (Sartorius, 1989). Hopefully, gender comparisons will also be explored.
Risk factors that lead to depressive states in a culture are also being studied by WHO. McGrath et al. (1990) reported that in the United States, women's risk factors for depression include reproductive issues, personality styles, sexual and physical abuse, marriage and children, minority status, and genetic factors. Are these risk factors for depression common to women around the world?
Developmental stages and their relationships to depressive disorders, particularly in the aging population, have become an important research area in understanding depressive states. Are there psychological differences and stresses at different age levels (developmental periods of life) that give rise to depressive disorders? Do these different developmental inputs and depressive disorders require different treatment approaches?
The significance of developmental levels to the understanding and treatment of aging persons and depression has been pinpointed in the work of Newman, Engel, and Jensen (1991). They investigated characteristics of early and later aging in women, particularly their depressive symptom differences. Their findings indicated that there were two different depressive symptom patterns in the aging sample. The pattern in the younger age cohorts was labelled depressive syndrome. The pattern in the older age cohorts was labelled depletion syndrome.
The elderly depletion syndrome had the features of self-worthlessness, a feeling of no interest in things, loss of appetite, a general sense of hopelessness, and thoughts of death or dying. Symptoms of dysphoric mood and self-blame were not significant variables, as is usually found in the classic depressive symptom model. Thus, it was suggested that older persons may be at decreased risk for the classic depression syndrome but at increased risk for a quieter, more unconventional form that is not recognised in the mental health setting. Newman et al. (1991) stated that two very different pictures of the mental health of the aging population, especially regarding depression, may be emerging. These findings need further study in order to test their cross-cultural validity and reflect the importance of including developmental stages in cross-cultural research on depression.
From the review of the studies reported in this article, the ratio of women to men for depression is about 2:1 in developed countries, but for developing countries, the ratios vary, with most reporting no differences in ratios. For major depression, the ratio is more often reported as 3:1 or 4:1, and for bipolar disorder, it is more likely to be reported as 1:1. According to the literature reported above, these ratio differences appear to be fairly reliable and stable. Symptom similarities for depression across nations also appear to be fairly reliable. Findings from current, ongoing WHO studies (Sartorius, 1993; Thornicroft & Sartorius, 1993), with many more nations participating in these studies, will more firmly establish the findings reported here.
Progress toward commonality in the conceptualisation of depression and the development of a common language across nations is occurring, Assessment instruments that will hopefully prove to be reliable and valid across cultures are continuing to be tested, and the findings for reliability and validity, to date, are encouraging.
The number of national and international studies of depression that involve gender comparisons has in- creased for both developed and developing countries. The cultural dimension of depression in analysis of data is being recognised as significant, in addition to the biopsychosocial aspects of depressive disorders. However, more research is needed.
The relationship of developmental ages and depression needs much research, especially as the early developmental ages in which depression occurs appear to have a significant relationship with adult depression. In these research areas, internationally and cross-culturally, psychologists have been only minimally involved, but they have much to contribute. With the growth of health psychology, as well as clinical, developmental, and school psychology, international involvement of psychologists into questions in this area and into cross-cultural research programs could be most productive.
Recently, Desjarlais, Eisenberg, Good, and Kleinman (1995) stressed the importance of multidisciplinary involvement and advanced training and education across the professions as essential elements for cross-cultural work in low-income countries.
WHO and its training centres in the United States - the World Federation of Mental Health, the International Council of Psychologists, the International Association of Applied Psychology, the International Association of Cross-Cultural Psychology, the Inter-American Society of Psychology - and APA's Committee on International Relations foster and promote individual, group, and interdisciplinary interactions and research opportunities.
International studies are important for understanding normal and abnormal behaviours, particularly depression in women, depression across the life cycle, and the multiple factors that contribute to the varied disorders of depression.
In the world today, to understand depression, findings from reliable and valid assessments across cultures, cross-cultural commonalties and differences, treatment strategies, as well as gender differences across nations are sorely needed. The international agencies noted above foster individual, group, and interdisciplinary research opportunities as well as networking, communicating, and meeting with colleagues with similar interests. They also encourage research collaboration in cross-cultural work and reporting and publishing of results at their conventions and in their journals. These are inviting opportunities for psychologists who wish to engage in studies on gender, culture, and other factors. These fields of study can be exciting and rewarding ones for the psychologists involved and should lead to significant contributions to human welfare.
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Editors note. A version of this article was originally presented as part of an Award for Distinguished Contributions to the International Advancement of Psychology address at the 103rd Annual Convention of the American Psychological Association, New York, August 1995.
Author's note. Frances M. Culbertson, Department of Psychology, University of Wisconsin - Whitewater, and Mental Health Associates, Madison, WI.
I would like to express my appreciation and thanks to Robert Koehler and Alice Cunningham for their assistance in library searches. Correspondence concerning this article should be addressed to Frances M. Culbertson, Mental Health Associates, 20 South Park Street, Suite 403, Madison, WI 53716. ,