ATrain Education

Continuing Education for Health Professionals

Depression: Gender Matters

Gender and Depression

Sex and Gender

The terms sex and gender are often used interchangeably, though they refer to different concepts (Bem, 1993). Sex is the biologic designation as male or female. A person’s sex is the result of human reproductionthe coming together of chromosomes from the father and mother. Gender is a perception that is shaped by society and culture. In terms of gender, maleness and femaleness are defined by a myriad of determinants including what we wear, our jobs, and our household tasks (Small, 1995).

Wood and Eagly (2002) use the term sex to denote the groupings of people into female and male categories; for them, the term gender refers to the meanings that societies and individuals ascribe to female and male categories. Deaux (1985) suggested that in research it is appropriate to use the term sex when participants are selected based on biologic characteristics.

In 2001 the Institute of Medicine published a report entitled “Exploring the Biological Contributions to Human Health: Does Sex Matter?” which addressed and highlighted the role of biologic sex differences in health and disease. It focused particularly on sex differences in nonreproductive areas of the male and female. The institute drew several conclusions:

  1. Sex (being male or female) is an important basic human variable that should be considered when designing and analyzing studies in all areas and at all levels of biomedical and health-related practice.
  2. Differences in health and illness are influenced by individual genetic and physiologic constitutions, as well as by an individual’s interaction with environmental and experiential factors.
  3. The incidence and severity of diseases vary between the sexes and may be related to differences in genetic constitution and individuality, in exposures, the routes of entry, the processing of a foreign agent, and cellular responses.
  4. Basic genetic and physiologic differences in combination with environmental and experimental factors result in behavioral and cognitive differences between males and females. (IOM, 2001)

Epidemiology of Depression and Gender

Beginning in the 1970s and continuing today, gender has been an important variable in understanding depression (Bird and Rieker, 1999; Kuehner, 2003). In 1977 Weissman and Klerman reviewed the evidence for differing rates of depression between the sexes, in the United States and elsewhere, during the previous forty years. They found that studies showed women experienced depression at rates much higher than men, and critically analyzed the various explanations offered. These explanations included the possibility that the higher rates found in women may not be accurate as well as the possibility that the higher rate found in women may be the result of biologic susceptibility, psychosocial factors such as social discrimination, or female-learned helplessness.

The World Health Organization (WHO) has been conducting research on the epidemiology of depression since the 1970s. In a 1979 WHO report, Sartorius estimated that 100 million individuals in the world suffer from depression and these people then affect three times as many other people during their illness. Despite WHO’s long history of research on depression, gender differences in depression have not become part of WHO’s research until recently (Culbertson, 1997).

In 2001 WHO published a report on mental health and illness throughout the world. The research found that the overall prevalence of mental and behavioral disorders does not seem to be different between men and women. Anxiety and depressive disorders are, however, more common among women, while substance use disorders and antisocial personality disorders are more common among men (Gold 1998).

In 1990 Nolen-Hoeksema published Sex Differences in Depression, which reviewed studies of depression and gender conducted outside the United States. She found a mean 2:1 female-male ratio of depression in developed nations. However, in studies of depression in some developing countries, she reported no significant findings of female-male depression differences. Her book explored the reasons for the high sex differences and exceptions to the general trend. For instance, she found that among prepubescent children, boys are more likely to be diagnosed as depressed than girls, but by age 14 girls become more prone to depression. She notes that among college students, the Old Order Amish, the widowed, and people 65 and older, no sex differences were found.

More recently, Nolen-Hoeksema, Larson, and Grayson (1999) examined how social conditions and personality characteristics affect each other and contribute to the gender difference in depressive symptoms. In their study, women reported more chronic strain, a greater tendency to ruminate, and a lower sense of mastery than men. But other researchers, such as Cochran and Rabinowitz (2000) and Pollack (1998), believe that men and women may experience comparable levels of depression but express it in different ways. Pollack notes that when the percentages of alcohol abuse, depression, and antisocial personality disorder in men and the percentages for depression and anxiety disorders for women are combined, the results are comparable.

Though there is disagreement about whether women’s rate of depression is much higher than men’s or whether they are similar but expressed through different symptoms, there is no disagreement about the fact that depression and suicide are closely related and men’s suicide rate is much higher than women’s (Möller-Leimkühler, 2002). Further, the rates of depression and suicide in males have been increasing since the 1980s (Culbertson, 1997), treatment for depression in men is less effective than it is for women (Möller-Leimkühler et al., 2004), and depression is less likely to be diagnosed in men than it is in women (Möller-Leimkühler, 2002).

Suicide, Depression, and Gender

The following data are derived the National Center for Health Statistics, 2009.

General Information on Suicide

  • More than 36,000 people in the United States die by suicide every year.
  • In 2009 (latest available data), there were 36,909 reported suicide deaths.
  • Suicide is the fourth leading cause of death for adults between the ages of 18 and 65 years in the United States.
  • Currently, suicide is the tenth leading cause of death in the United States.
  • A person dies by suicide about every 15 minutes in the United States.
  • Every day, approximately 101 Americans take their own life.
  • Ninety percent of all people who die by suicide have a diagnosable psychiatric disorder at the time of their death.
  • There are an estimated 8 to 25 attempted suicides for every suicide death.

Depression and Suicide

  • More than 60% of all people who die by suicide suffer from major depression. If we include alcoholics who are depressed, this figure rises to over 75%.
  • Depression affects nearly 10% of Americans ages 18 and over in a given year, or more than 24 million people.
  • More Americans suffer from depression than coronary heart disease (17 million), cancer (12 million), and HIV/AIDS (1 million).
  • About 15% of the population will suffer from clinical depression at some time during their lifetime. Thirty percent of all clinically depressed patients attempt suicide; half of them ultimately die by suicide.
  • Depression is among the most treatable of psychiatric illnesses. Between 80% and 90% of people with depression respond positively to treatment, and almost all patients gain some relief from their symptoms. But, first, depression has to be recognized.

Gender and Suicide

  • There are four male suicides for every female suicide, but 3 times as many females as males attempt suicide.
  • Between the mid-1950s and the late 1970s, the suicide rate among U.S. males aged 1524 more than tripled. Among females aged 1524, the rate more than doubled during this period. The youth suicide rate generally leveled off during the 1980s and early 1990s, and since the mid-1990s it has been steadily decreasing.
  • Between 1980 and 1996, the suicide rate for African American males aged 1519 has doubled.
  • The suicide rates for men rise with age, most significantly after age 65.
  • About 60% of older adults who take their own lives see their primary care physician within a few months of their death.

This latter statistic points out the importance of recognizing symptoms of depression.

Warning Signs of Suicide

Suicide can be prevented. While some suicides occur without any outward warning, most people who are suicidal do give warnings. The American Foundation for Suicide Prevention (AFSP) is exclusively dedicated to understanding and preventing suicide through research, education and advocacy, and to reaching out to people with mental disorders and those impacted by suicide. The AFSP offers the following warning signs.

Observable Signs of Serious Depression

  • Unrelenting low mood
  • Pessimism
  • Hopelessness
  • Desperation
  • Anxiety, psychic pain, and inner tension
  • Withdrawal
  • Sleep problems
  • Increased alcohol and/or other drug use
  • Recent impulsiveness and taking unnecessary risks
  • Threatening suicide or expressing a strong wish to die

Making a Plan

  • Giving away prized possessions
  • Sudden or impulsive purchase of a firearm
  • Obtaining other means of killing oneself such as poisons or medications
  • Unexpected rage or anger

The emotional crises that usually precede suicide are often recognizable and treatable. Although most depressed people are not suicidal, most suicidal people are depressed. Serious depression can be manifested in obvious sadness, but often it is expressed as a loss of pleasure or withdrawal from activities that had been enjoyable. In men, it can often manifest in increased irritability, anger, and hostility. Suicide can be prevented through early recognition and treatment of depression and other psychiatric illnesses.

Hopelessness (often present in those with severe depressive illness) and previous suicide attempts are significant and independent prospective risk factors for suicide (Brown et al., 2000). Although previous suicide attempts are an important risk factor, two-thirds of suicides occur on the first attempt (Mann, 2002). Other identified risk factors for completed suicide include being widowed or divorced, living alone, having a recent adverse event (such as job loss or death of loved one), having severe anxiety, having a chronic medical illness (especially a central nervous system disorder), and having a family history of suicide attempts or completions (Gaynes et al., 2004).

The assessment of suicidal thoughts or behavior and decisions about possible interventions are extremely important for all clinicians, not just mental health professionals. Up to two-thirds of patients who commit suicide have seen a physician in the month before their death (Matthews et al., 1994). It is rare for a patient to report thoughts of suicide spontaneously to their physician, and this is particularly true for men (Matthews et al., 1994). Thus it is particularly important that clinicians be sensitive to warning signs and be willing to ask the right questionsin ways that are likely to illicit a response that will lead to an accurate assessment of risk.

Suicide Rates for Males and Females

Suicide rates have increased significantly for both young men and older men over the past 25 years (Cochran and Rabinowitz, 2000). Suicide rates in men increase with advancing age (Anderson et al., 1997; Murphy, 1998).

These findings are corroborated in Will Courtenay’s (2011) Dying to be Men: Psychosocial, Environmental, and Biobehavioral Directions in Promoting the Health of Men and Boys. Courtenay cites the following suicide and death rates from the Centers for Disease Control (CDC).

Source: CDC, 2010.

Suicide and Death Rates for Males and Females
(per 100,000 population)

Age group

Male rate

Female rate

Male/female ratio

1519

10.9

2.7

4.0

2024

21.4

4.0

5.4

2529

19.5

4.7

4.2

3034

18.3

5.2

3.5

3544

23.9

6.8

3.5

4554

25.8

8.8

2.9

5564

21.4

7.0

3.1

6574

21.5

3.4

6.3

7584

27.3

3.9

7.0

85 or older

38.6

2.2

17.5

We see that the suicide rate for males is higher than it is for females at all stages of life; it is always in double digits for males and single digits for females. The lowest rate for males is higher than the highest rate for females. The mid-life years (4564) are difficult for both males and females, but the years after retirement (65+) show suicide rates dropping significantly for females but increasing dramatically for males. As populations age throughout the world, the issue of suicide in male seniors needs to be addressed seriously.

Do Men Act Out and Women Act In?

One of the most interesting and intriguing experiments on gender differences in depression was conducted by J. Douglas Bremner, director of mental health research at the Atlanta Veterans Administration Medical Center and author of the book Does Stress Damage the Brain? (2002). Bremner gathered a group of formerly depressed patients and, with their permission, gave them a beverage that was spiked with an amino acid that blocks the brain’s ability to absorb serotonin, the neurotransmitter that allows us to feel upbeat and happy.

Of great interest were the gender-specific differences in the way men and women reacted to the potion that blocked the effects of the serotonin. Typical of the males was John, a middle-aged businessman who had fully recovered from a bout of depression, thanks to a combination of psychotherapy and Prozac.

Within minutes of drinking the brew, however, “He wanted to escape to a bar across the street,” recalls Bremner. “He didn’t express sadness, he didn’t really express anything. He just wanted to go to Larry’s Lounge.”

Contrast John’s response with that of female subjects like Sue, a mother of two who was in her mid-thirties. After taking the cocktail, “She began to cry and express her sadness over the loss of her father two years ago,” recalls Bremner. “She was overwhelmed by her emotions.”

The implications of this research study can help us better understand how to recognize the different ways men and women experience depression. John didn’t “look depressed” or seem sad. He didn’t want to talk. He wasn’t emotional. He acted out. He just wanted to get a drink. Sue, on the other hand, “looked depressed.” She cried and talked about her sadness over the loss of her father. She “acted in” her sense of loss and depression and expressed her emotions freely.

A number of studies have found that men are less likely than women to seek help for depression (Möller-Leimkühler, 2002). Men don’t feel depressed so they don’t seek help for the problem. Even healthcare professionals fail to see the man as depressed, but as withdrawn, angry, or alcoholic.

Women and Depression

Psychologist Susan Nolen-Hoeksema (1995) interviewed 1,328 people aged 25 to 75. Participants were asked how depressed they felt, and what they found themselves doing when their mood was low. They were given a test to measure their tendency to “ruminate,” or brood, about how bad they felt and what they were doing to deserve to feel this bad. Participants were asked about problems they had experienced as a result of alcohol dependence or abuse, including losing a job or an important relationship. In addition, they were asked about the extent to which they drank to cope with negative feelings, to help themselves feel better, and to deal with stress.

“I have found that women’s tendency to ruminate more than men is tied to their lack of power and the stresses that come with this lack of power in society,” says Nolen-Hoeksema. “In addition, women’s stronger emotional ties to others, compared to men’s, may contribute to their tendency to ruminate.”

Nolen-Hoeksema found that while women tend to over-think when they are depressed, men tend to act out their pain. They often drink to escape their feelings of hopelessness and helplessness. “But some men are ruminators and some women drink to cope,” she adds, “and for both men and women, rumination and drinking to cope are related.” In other words, people who do one are at increased risk of doing the other.

While alcohol may temporarily dampen rumination for men, Nolen-Hoeksema suggests that it seems to fuel rumination in women. Instead of quelling women’s worries, using alcohol to cope with distress just gives them one more thing to worry about, she speculates.

Men and Depression

The National Institute of Mental Health (2001) published a booklet on depression in men. Its introduction declares:

Both men and women get depression. But men can experience it differently than women. Men may be more likely to feel very tired and irritable, and lose interest in their work, family, or hobbies. They may be more likely to have difficulty sleeping than women who have depression. And, although women with depression are more likely to attempt suicide, men are more likely to die by suicide.

NIMH interviewed a number of men, including Will and Patrick, who describe their experiences with depression

“When I was feeling depressed I was very reckless with my life,” says Will, an attorney. “I didn’t care about how I drove, I didn’t take care walking across the street, I didn’t care about dangerous parts of the city. I wasn’t affected by any kinds of travel warnings. I didn’t care. I didn’t care whether I lived or died and so I was going to do whatever I wanted whenever I wanted. And, when you take those kinds of chances, you have a greater likelihood of dying.”

“I’d drink and I’d just get numb,” says Patrick, a retired first sergeant in the U.S. Air Force. “I’d get numb to try to numb my head. I mean, we’re talking many, many beers to get to that state where you could shut your head off, but then you’d wake up the next day and it’s still there. Because you have to deal with it, it doesn’t just go away. It isn’t a two-hour movie and then it goes ‘The End’ and you press Off. I mean it’s a twenty-four hour a day movie and you’re thinking there is no end. It’s horrible.”