Depression: What Every Woman Should Know
Life is full of emotional ups and downs. But when the "down" times are long lasting or interfere with your ability to function, you may be suffering from a common, serious illness-depression. Clinical depression affects mood, mind, body, and behavior. Research has shown that in the United States about 19 million people-one in ten adults-experience depression each year, and nearly two-thirds do not get the help they need.9 Treatment can
alleviate the symptoms in over 80 percent of the cases. Yet, because it often
goes unrecognized, depression continues to cause unnecessary suffering.
Depression is a pervasive and impairing illness that affects both women
and men, but women experience depression at roughly twice the rate of men.1
Researchers continue to explore how special issues unique to
women-biological, life cycle, and psycho-social-may be associated with
women's higher rate of depression.
No two people become depressed in exactly the same way. Many people
have only some of the symptoms, varying in severity and duration. For some,
symptoms occur in time-limited episodes; for others, symptoms can be present
for long periods if no treatment is sought. Having some depressive symptoms
does not mean a person is clinically depressed. For example, it is not
unusual for those who have lost a loved one to feel sad, helpless, and
disinterested in regular activities. Only when these symptoms persist for an
unusually long time is there reason to suspect that grief has become
depressive illness. Similarly, living with the stress of potential layoffs,
heavy workloads, or financial or family problems may cause irritability and
"the blues." Up to a point, such feelings are simply a part of
human experience. But when these feelings increase in duration and intensity
and an individual is unable to function as usual, what seemed a temporary
mood may have become a clinical illness.
THE TYPES OF DEPRESSIVE ILLNESS
- In major depression, sometimes referred
to as unipolar or clinical depression, people have some or all of the
symptoms listed below for at least 2 weeks but frequently for several
months or longer. Episodes of the illness can occur once, twice, or
several times in a lifetime.
- In dysthymia, the same symptoms are
present though milder and last at least 2 years. People with dysthymia
are frequently lacking in zest and enthusiasm for life, living a joyless
and fatigued existence that seems almost a natural outgrowth of their
personalities. They also can experience major depressive episodes.
- Bipolar Disorder, or manic depression, is not
nearly as common as other forms of depressive illness and involves
disruptive cycles of depressive symptoms that alternate with mania. During
manic episodes, people may become overly active, talkative, euphoric, irritable,
spend money irresponsibly, and get involved in sexual misadventures. In
some people, a milder form of mania, called hypomania, alternates with
depressive episodes. Unlike other mood disorders, women and men are
equally vulnerable to bipolar disorder; however, women with bipolar
disorder tend to have more episodes of depression and fewer episodes of
mania or hypomania.
SYMPTOMS OF DEPRESSION AND MANIA
A thorough diagnostic evaluation is needed if three to five or more of the
following symptoms persist for more than 2 weeks (1 week in the case of
mania), or if they interfere with work or family life. An evaluation involves
a complete physical checkup and information gathering on family health
history. Not everyone with depression experiences each of these symptoms. The
severity of the symptoms also varies from person to person.
- Persistent sad, anxious, or "empty" mood
- Loss of interest or pleasure in activities, including
- Restlessness, irritability, or excessive crying
- Feelings of guilt, worthlessness, helplessness,
- Sleeping too much or too little, early-morning
- Appetite and/or weight loss or overeating and weight
- Decreased energy, fatigue, feeling "slowed
- Thoughts of death or suicide, or suicide attempts
- Difficulty concentrating, remembering, or making
- Persistent physical symptoms that do not respond to
treatment, such as headaches, digestive disorders, and chronic pain
- Abnormally elevated mood
- Decreased need for sleep
- Grandiose notions
- Increased talking
- Racing thoughts
- Increased activity, including sexual activity
- Markedly increased energy
- Poor judgment that leads to risk-taking behavior
- Inappropriate social behavior
CAUSES OF DEPRESSION
There is a risk for developing depression when there is a family history
of the illness, indicating that a biological vulnerability may be inherited.
The risk is somewhat higher for those with bipolar disorder. However, not
everybody with a family history develops the illness. In addition, major
depression can occur in people who have had no family members with the
illness. This suggests that additional factors, possibly biochemistry,
environmental stressors, and other psychosocial factors, are involved in the
onset of depression.
Evidence indicates that brain biochemistry is a significant factor in
depressive disorders. It is known, for example, that individuals with major
depressive illness typically have dysregulation of certain brain chemicals,
called neurotransmitters. Additionally, sleep patterns, which are biochemically
influenced, are typically different in people with depressive disorders.
Depression can be induced or alleviated with certain medications, and some
hormones have mood-altering properties. What is not yet known is whether the
"biochemical disturbances" of depression are of genetic origin, or
are secondary to stress, trauma, physical illness, or some other
Environmental and Other Stressors
Significant loss, a difficult relationship, financial problems, or a major
change in life pattern have all been cited as contributors to depressive
illness. Sometimes the onset of depression is associated with acute or
chronic physical illness. In addition, some form of substance abuse disorder
occurs in about one-third of people with any type of depressive disorder.7
Other Psychological and Social Factors
Persons with certain characteristics-pessimistic thinking, low
self-esteem, a sense of having little control over life events, and a
tendency to worry excessively-are more likely to develop depression. These
attributes may heighten the effect of stressful events or interfere with
taking action to cope with them or with getting well. Upbringing or sex role expectations
may contribute to the development of these traits. It appears that negative
thinking patterns typically develop in childhood or adolescence. Some experts
have suggested that the traditional upbringing of girls might foster these
traits and may be a factor in women's higher rate of depression.
WOMEN ARE AT GREATER RISK FOR DEPRESSION THAN MEN
Major depression and dysthymia affect twice as
many women as men. This two-to-one ratio exists regardless of racial and
ethnic background or economic status. The same ratio has been reported in ten
other countries all over the world.12
Men and women have about the same rate of bipolar disorder
(manic-depression), though its course in women typically has more depressive
and fewer manic episodes. Also, a greater number of women have the rapid
cycling form of bipolar disorder, which may be more resistant to standard
A variety of factors unique to women's lives are suspected to play a role
in developing depression. Research is focused on understanding these,
including: reproductive, hormonal, genetic or other biological factors; abuse
and oppression; interpersonal factors; and certain psychological and
personality characteristics. And yet, the specific causes of depression in
women remain unclear; many women exposed to these factors do not develop
depression. What is clear is that regardless of the contributing factors,
depression is a highly treatable illness.
THE MANY DIMENSIONS OF DEPRESSION IN WOMEN
Investigators are focusing on the following areas in their study of
depression in women:
The Issues of Adolescence
Before adolescence, there is little difference in the rate of depression
in boys and girls. But between the ages of 11 and 13 there is a precipitous
rise in depression rates for girls. By the age of 15, females are twice as
likely to have experienced a major depressive episode as males.2
This comes at a time in adolescence when roles and expectations change
dramatically. The stresses of adolescence include forming an identity,
emerging sexuality, separating from parents, and making decisions for the
first time, along with other physical, intellectual, and hormonal changes.
These stresses are generally different for boys and girls, and may be
associated more often with depression in females. Studies show that female
high school students have significantly higher rates of depression, anxiety
disorders, eating disorders, and adjustment disorders than male students, who
have higher rates of disruptive behavior disorders.6
Adulthood: Relationships and Work Roles
Stress in general can contribute to depression in persons biologically
vulnerable to the illness. Some have theorized that higher incidence of
depression in women is not due to greater vulnerability, but to the
particular stresses that many women face. These stresses include major
responsibilities at home and work, single parenthood, and caring for children
and aging parents. How these factors may uniquely affect women is not yet
For both women and men, rates of major depression are highest among the
separated and divorced, and lowest among the married, while remaining always
higher for women than for men. The quality of a marriage, however, may contribute
significantly to depression. Lack of an intimate, confiding relationship, as
well as overt marital disputes, have been shown to be related to depression
in women. In fact, rates of depression were shown to be highest among
unhappily married women.
Women's reproductive events include the menstrual cycle, pregnancy, the
post pregnancy period, infertility, menopause, and sometimes, the decision
not to have children. These events bring fluctuations in mood that for some
women include depression. Researchers have confirmed that hormones have an
effect on the brain chemistry that controls emotions and mood; a specific
biological mechanism explaining hormonal involvement is not known, however.
Many women experience certain behavioral and physical changes associated
with phases of their menstrual cycles. In some women, these changes are
severe, occur regularly, and include depressed feelings, irritability, and
other emotional and physical changes. Called premenstrual syndrome
(PMS) or premenstrual dysphoric disorder (PMDD), the changes
typically begin after ovulation and become gradually worse until menstruation
starts. Scientists are exploring how the cyclical rise and fall of estrogen
and other hormones may affect the brain chemistry that is associated with
Postpartum mood changes can range from transient
"blues" immediately following childbirth to an episode of major
depression to severe, incapacitating, psychotic depression. Studies suggest
that women who experience major depression after childbirth very often have
had prior depressive episodes even though they may not have been diagnosed
Pregnancy (if it is desired) seldom contributes to
depression, and having an abortion does not appear to lead to a higher
incidence of depression. Women with infertility problems may be subject to
extreme anxiety or sadness, though it is unclear if this contributes to a
higher rate of depressive illness. In addition, motherhood may be a time of
heightened risk for depression because of the stress and demands it imposes.
Menopause, in general, is not asssociated with an increased
risk of depression. In fact, while once considered a unique disorder,
research has shown that depressive illness at menopause is no different than
at other ages. The women more vulnerable to change-of-life depression are
those with a history of past depressive episodes.
Specific Cultural Considerations
As for depression in general, the prevalence rate of depression in African
American and Hispanic women remains about twice that of men. There is some
indication, however, that major depression and dysthymia may be diagnosed
less frequently in African American and slightly more frequently in Hispanic
than in Caucasian women. Prevalence information for other racial and ethnic
groups is not definitive.
Possible differences in symptom presentation may affect the way depression
is recognized and diagnosed among minorities. For example, African Americans
are more likely to report somatic symptoms, such as appetite change and body
aches and pains. In addition, people from various cultural backgrounds may
view depressive symptoms in different ways. Such factors should be considered
when working with women from special populations.
Studies show that women molested as children are more likely to have
clinical depression at some time in their lives than those with no such
history. In addition, several studies show a higher incidence of depression
among women who have been raped as adolescents or adults. Since far more
women than men were sexually abused as children, these findings are relevant.
Women who experience other commonly occurring forms of abuse, such as
physical abuse and sexual harassment on the job, also may experience higher
rates of depression. Abuse may lead to depression by fostering low
self-esteem, a sense of helplessness, self-blame, and social isolation. There
may be biological and environmental risk factors for depression resulting
from growing up in a dysfunctional family. At present, more research is
needed to understand whether victimization is connected specifically to
Women and children represent seventy-five percent of the U.S. population
considered poor. Low economic status brings with it many stresses, including
isolation, uncertainty, frequent negative events, and poor access to helpful
resources. Sadness and low morale are more common among persons with low incomes
and those lacking social supports. But research has not yet established
whether depressive illnesses are more prevalent among those facing
environmental stressors such as these.
Depression in Later Adulthood
At one time, it was commonly thought that women were particularly
vulnerable to depression when their children left home and they were
confronted with "empty nest syndrome" and experienced a profound
loss of purpose and identity. However, studies show no increase in depressive
illness among women at this stage of life.
As with younger age groups, more elderly women than men suffer from
depressive illness. Similarly, for all age groups, being unmarried (which
includes widowhood) is also a risk factor for depression. Most important,
depression should not be dismissed as a normal consequence of the physical,
social, and economic problems of later life. In fact, studies show that most
older people feel satisfied with their lives.
About 800,000 persons are widowed each year. Most of them are older, female,
and experience varying degrees of depressive symptomatology. Most do not need
formal treatment, but those who are moderately or severely sad appear to
benefit from self-help groups or various psychosocial treatments. However, a
third of widows/widowers do meet criteria for major depressive episode in the
first month after the death, and half of these remain clinically depressed 1
year later. These depressions respond to standard antidepressant treatments,
although research on when to start treatment or how medications should be
combined with psychosocial treatments is still in its early stages. 4,8
DEPRESSION IS A TREATABLE ILLNESS
Even severe depression can be highly responsive to treatment. Indeed,
believing one's condition is "incurable" is often part of the
hopelessness that accompanies serious depression. Such individuals should be
provided with the information about the effectiveness of modern treatments
for depression in a way that acknowledges their likely skepticism about
whether treatment will work for them. As with many illnesses, the earlier
treatment begins, the more effective and the greater the likelihood of
preventing serious recurrences. Of course, treatment will not eliminate
life's inevitable stresses and ups and downs. But it can greatly enhance the
ability to manage such challenges and lead to greater enjoyment of life.
The first step in treatment for depression should be a thorough
examination to rule out any physical illnesses that may cause depressive
symptoms. Since certain medications can cause the same symptoms as
depression, the examining physician should be made aware of any medications
being used. If a physical cause for the depression is not found, a
psychological evaluation should be conducted by the physician or a referral
made to a mental health professional.
Types of Treatment for Depression
The most commonly used treatments for depression are antidepressant
medication, psychotherapy, or a combination of the two. Which of these is the
right treatment for any one individual depends on the nature and severity of
the depression and, to some extent, on individual preference. In mild or
moderate depression, one or both of these treatments may be useful, while in
severe or incapacitating depression, medication is generally recommended as a
first step in the treatment.3
In combined treatment, medication can relieve physical symptoms quickly,
while psychotherapy allows the opportunity to learn more effective ways of
In mild to moderate cases of depression, psychotherapy is also a treatment
option. Some short-term (10 to 20 week) therapies have been very effective in
several types of depression. "Talking" therapies help patients gain
insight into and resolve their problems through verbal give-and-take with the
therapist. "Behavioral" therapies help patients learn new behaviors
that lead to more satisfaction in life and "unlearn"
counter-productive behaviors. Research has shown that two short-term
psychotherapies, interpersonal and cognitive-behavioral, are helpful for some
forms of depression. Interpersonal therapy works to change interpersonal
relationships that cause or exacerbate depression. Cognitive-behavioral
therapy helps change negative styles of thinking and behaving that may
contribute to the depression.
Treating Recurrent Depression
Even when treatment is successful, depression may recur. Studies indicate
that certain treatment strategies are very useful in this instance.
Continuation of antidepressant medication at the same dose that successfully
treated the acute episode can often prevent recurrence. Monthly interpersonal
psychotherapy can lengthen the time between episodes in patients not taking
THE PATH TO HEALING
Reaping the benefits of treatment begins by recognizing the signs of
depression. The next step is to be evaluated by a qualified professional.
Although depression can be diagnosed and treated by primary care physicians,
often the physician will refer the patient to a psychiatrist, psychologist,
clinical social worker, or other mental health professional. Treatment is a
partnership between the patient and the health care provider. An informed
consumer knows her treatment options and discusses concerns with her provider
as they arise.
If there are no positive results after 2 to 3 months of treatment, or if
symptoms worsen, discuss another treatment approach with the provider.
Getting a second opinion from another health or mental health professional
may also be in order.
Here, again, are the steps to healing:
- Talk to a health or mental health professional.
- Choose a treatment professional and a treatment
approach with which you feel comfortable.
- Consider yourself a partner in treatment and be an
- If you are not comfortable or satisfied after 2 to 3
months, discuss this with your provider. Different or additional
treatment may be recommended.
- If you experience a recurrence, remember what you
know about coping with depression and don't shy away from seeking help
again. In fact, the sooner a recurrence is treated, the shorter its
duration will be.
Depressive illnesses make you feel exhausted, worthless, helpless, and
hopeless. Such feelings make some people want to give up. It is important to
realize that these negative feelings are part of the depression and will fade
as treatment begins to take effect.
Along with professional treatment, there are other things you can do to
help yourself get better. Some people find participating in support groups
very helpful. It may also help to spend some time with other people and to
participate in activities that make you feel better, such as mild exercise or
yoga. Just don't expect too much from yourself right away. Feeling better
WHERE TO GET HELP
If unsure where to go for help, ask your family doctor, OB/GYN physician,
or health clinic for assistance. You can also check the Yellow Pages
under "mental health," "health," "social
services," "suicide prevention," "crisis intervention
services," "hotlines," "hospitals," or
"physicians" for phone numbers and addresses. In times of crisis,
the emergency room doctor at a hospital may be able to provide temporary help
for an emotional problem and will be able to tell you where and how to get
Listed below are the types of people and places that will make a referral
to, or provide, diagnostic and treatment services.
- Family doctors
- Mental health specialists such as psychiatrists,
psychologists, social workers, or mental health counselors
- Health maintenance organizations
- Community mental health centers
- Hospital psychiatry departments and outpatient
- University- or medical school-affiliated programs
- State hospital outpatient clinics
- Family service/social agencies
- Private clinics and facilities
- Employee assistance programs
- Local medical and/or psychiatric societies
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9 Robins LN and Regier DA (Eds). Psychiatric Disorders in America, The Epidemiologic Catchment Area Study. New York: The Free Press, 1990.
10 Rubinow DR, Schmidt PJ, and Roca CA. Estrogen-serotonin interactions: Implications for affective regulation. Biological Psychiatry, 1998;44(9):839-50.
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Source: NIH Publication No. 00-4779, August 2000