Depression: What Every Women Should Know Depression: What Every Women Should Know
National Institute of Mental Health
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.2 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.5
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 sex
Restlessness, irritability, or excessive crying
Feelings of guilt, worthlessness, helplessness, hopelessness, pessimism
Sleeping too much or too little, early-morning awakening
Appetite and/or weight loss or overeating and weight gain
Decreased energy, fatigue, feeling “slowed down”
Thoughts of death or suicide, or suicide attempts
Difficulty concentrating, remembering, or making decisions
Persistent physical symptoms that do not respond to treatment, such as headaches, digestive disorders, and chronic pain
Abnormally elevated mood
Decreased need for sleep
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 condition.
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.
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.5 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 treatments.3
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.6 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.7
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 fully understood.
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 postpregnancy 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 depressive illness.8
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 and treated.
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 associated 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 depression.
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.9,10
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.11 In combined treatment, medication can relieve physical symptoms quickly, while psychotherapy allows the opportunity to learn more effective ways of handling problems.
There are several types of antidepressant medications used to treat depressive disorders. These include newer medications—chiefly the selective serotonin reuptake inhibitors (SSRIs)—and the tricyclics and monoamine oxidase inhibitors (MAOIs). The SSRIs—and other newer medications that affect neurotransmitters such as dopamine or norepinephrine—generally have fewer side effects than tricyclics. Each acts on different chemical pathways of the human brain related to moods. Antidepressant medications are not habit-forming. Although some individuals notice improvement in the first couple of weeks, usually antidepressant medications must be taken regularly for at least 4 weeks and, in some cases, as many as 8 weeks, before the full therapeutic effect occurs. To be effective and to prevent a relapse of the depression, medications must be taken for about 6 to 12 months, carefully following the doctor’s instructions. Medications must be monitored to ensure the most effective dosage and to minimize side effects. For those who have had several bouts of depression, long-term treatment with medication is the most effective means of preventing recurring episodes.
The prescribing doctor will provide information about possible side effects and, in the case of MAOIs, dietary and medication restrictions. In addition, other prescribed and over-the-counter medications or dietary supplements being used should be reviewed because some can interact negatively with antidepressant medication. There may be restrictions during pregnancy.
For bipolar disorder, the treatment of choice for many years has been lithium, as it can be effective in smoothing out the mood swings common to this disorder. Its use must be carefully monitored, as the range between an effective dose and a toxic one can be relatively small. However, lithium may not be recommended if a person has pre-existing thyroid, kidney, or heart disorders or epilepsy. Fortunately, other medications have been found helpful in controlling mood swings. Among these are two mood-stabilizing anticonvulsants, carbamazepine (Tegretol®) and valproate (Depakote®). Both of these medications have gained wide acceptance in clinical practice, and valproate has been approved by the Food and Drug Administration for first-line treatment of acute mania. Studies conducted in Finland in patients with epilepsy indicate that valproate may increase testosterone levels in teenage girls and produce polycystic ovary syndrome in women who began taking the medication before age 20.12 Therefore, young female patients should be monitored carefully by a physician. Other anticonvulsants that are being used now include lamotrigine (Lamictal®) and gabapentin (Neurontin®); their role in the treatment hierarchy of bipolar disorder remains under study.
Most people who have bipolar disorder take more than one medication. Along with lithium and/or an anticonvulsant, they often take a medication for accompanying agitation, anxiety, insomnia, or depression. Some research indicates that an antidepressant, when taken without a mood stabilizing medication, can increase the risk of switching into mania or hypomania, or of developing rapid cycling, in people with bipolar disorder. Finding the best possible combination of these medications is of utmost importance to the patient and requires close monitoring by the physician.
In the past few years, much interest has risen in the use of herbs in the treatment of both depression and anxiety. St. John’s wort (Hypericum perforatum), an herb used extensively in the treatment of mild to moderate depression in Europe, has recently aroused interest in the United States. St. John’s wort, an attractive bushy, low-growing plant covered with yellow flowers in summer, has been used for centuries in many folk and herbal remedies. Today in Germany, Hypericum is used in the treatment of depression more than any other antidepressant. However, the scientific studies that have been conducted on its use have been short-term and have used several different doses.
Because of the widespread interest in St. John’s wort, the National Institutes of Health (NIH) is conducting a 3-year study, sponsored by three NIH components—the National Institute of Mental Health, the National Institute for Complementary and Alternative Medicine, and the Office of Dietary Supplements. The study found that St. John’s wort was no more effective in treating major depression than placebo (inactive sugar pill). Another NIH study in underway looking at St. John’s wort for the treatment of minor depression.
The Food and Drug Administration issued a Public Health Advisory on February 10, 2000. It stated that St. John’s wort appears to affect an important metabolic pathway that is used by many drugs prescribed to treat conditions such as heart disease, depression, seizures, certain cancers, and rejection of transplants. Therefore, health care providers should alert their patients about these potential drug interactions. Any herbal supplement should be taken only after consultation with the doctor or other health care provider.
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.
For individuals whose depression is severe or life threatening or for those who cannot take antidepressant medication, electroconvulsive therapy (ECT) is useful.11 This is particularly true for those with extreme suicide risk, severe agitation, psychotic thinking, severe weight loss or physical debilitation as a result of physical illness. Over the years, ECT has been much improved. A muscle relaxant is given before treatment, which is done under brief anesthesia. Electrodes are placed at precise locations on the head to deliver electrical impulses. The stimulation causes a brief (about 30 seconds) seizure within the brain. The person receiving ECT does not consciously experience the electrical stimulus. At least several sessions of ECT, usually given at the rate of three per week, are required for full therapeutic benefit.
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 medication.
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:
Check your symptoms against the list on page 3.
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 informed consumer.
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 takes time.
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 further help.
Listed below are the types of people and places that will make a referral to, or provide, diagnostic and treatment services.
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 clinics
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