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 an individual's ability to function, that person 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 more than 19 million people- almost one in ten adults- will experience depression this year, yet nearly two thirds will not get the help they need. Treatment can alleviate the symptoms in over 80 percent of the cases. Yet, because it often goes unrecognized, depression continues to cause unnecessary suffering.

Women are disproportionately affected by depression, experiencing it at roughly twice the rate of men. Research continues to explore how the illness affects women. At the same time, it is important to increase women's awareness of what is already known about depression, so that they seek early and appropriate treatment. That is the purpose of this material.

To grasp the specifics of depression in women, it is essential to have a broad understanding of the illness itself. To this end, this material presents an overview of depression as a pervasive and impairing illness that affects women and men in similar fashion. It then focuses on special issues-- biological, life cycle, and psychsocial--that are unique to women and may be associated with depression.

What is Depression?

There are three types of depression:

1. major depression, also known as unipolar or clinical depression, people have some or all of the symptoms (listed on the next page) for at least 2 weeks or as long as several months or even longer. Episodes of the illness can occur once, twice, or several times in a lifetime.
2. In dysthymia, the same symptoms are present though milder, but lasting at least two years. People with dysthymia also can experience major depressive episodes, which is sometimes called a "double depression."
3. Manic-depression, or bipolar illness, which is not nearly as common as other forms of depressive illness each year, and involves disruptive cycles of depressive symptoms that alternate with euphoria, irritable excitement or mania

Symtpoms of Depression and Mania

A thorough diagnostic evaluation is needed if five or more of the following symptoms persist for more than two weeks, 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.

Depression

• 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

Mania

• Abnormally elevated mood
• Irritability
• Severe insomnia
• Grandiose notions
• Increased talking
• Racing thoughts
• Increased activity, including sexual activity
• Markedly increased energy
• Poor judgement that leads to risk-taking behavior
• Inappropriate social behavior

Some people mistakenly try to "reduce their" depressive symptoms through alcohol or other mood-altering drugs, while such drugs may provide temporary relief, they will eventually complicate the depressive disorder and its treatment, and can lead to dependence and the life problems that come with it.

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 eleven other countries all over the world. 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.

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 and that the types of treatment discussed later in this brochure are effective for a majority of women.

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

Studies show that the higher incidence of depression in females begins in adolescence, when roles and expectations change dramatically. The stresses of adolescence include forming an identity, confronting 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.

Adulthood: relationships and work roles

It is known that 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, and are areas currently under study. How these factors may uniquely effect women is not yet fully understood.

Reproductive events

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, its relation to depressive disorders is not yet understood. Some have questioned whether it is, in fact, a disorder. Further research will no doubt add to our understanding of this long-ignored condition.

Postpartum depressions

can range from transient "blues" following childbirth to severe, incapacitating, psychotic depressions. Studies suggest that women who experience depression after childbirth very often have had prior depressive episodes. However, for most women, postpartum depressions are transient, with no adverse consequences.

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, young motherhood may be a time of heightened risk for depression, due to the stress and demands it imposes.

Personality and psychology

Studies indicate that individuals with certain characteristics-- pessimistic thinking, low self-esteem, a sense of having little control over life events, and proneness to excessive worrying-- are more likely to develop depression. These attributes may heighten the effect of stressful events or interfere with taking action to cope with them. Some experts have suggested that the traditional upbringing of girls might foster these traits and that may be a factor in the higher rate of depression.

Others have suggested that women are not more vulnerable to depression than men, but simply express or label their symptoms differently. Women may be more likely to admit feelings of depression, brood about their feelings, or seek professional assistance. Men, on the other hand, may be socially conditioned to deny such feelings or to bury them in alcohol, as reflected in the higher rates of alcoholism in men. Current research may provide some answers about which of these theories is correct.

Victimization

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 were raped as 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. At present, more research is needed to understand whether victimization is connected specifically to depression.

Poverty

Women and children represent seventy-five percent of the U.S. population considered poor. Some researchers are therefore exploring the possibility that poverty is one of the "pathways to depression." 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. One very large study has shown that these illnesses tend to equally effect the poor and the rich.

Depression in later adulthood

Once, depression at menopause was considered a unique illness known as "involutional melancholia." Research has shown, however, that depressive illnesses are no different, and no more likely to occur, at menopause than at other ages. In fact, the women most vulnerable to change-of-life depression are those with a history of past depressive episodes. An old theory, the "empty nest syndrome", stated that when children leave home, women may experience a profound loss of purpose and identity that leads to depression. 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. Despite this, 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. Remarkably, a third of widows/widowers 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 medications, although there is relatively little research on when to start medications or how medications should be combined with psychosocial treatments.

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 patients should be provided with the information about the effectiveness of modern treatments for depression. 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.

As a first step, a thorough physical examination may be recommended to rule out any physical illnesses that may cause depressive symptoms.

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 an individual case and 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. In combined treatment, medication can relieve physical symptoms quickly, while psychotherapy allows the opportunity to learn more effective ways of handling problems.

Medications

The medications used to treat depression include tricyclic antidepressants, monoamine oxidase inhibitors (MAOIs), serotonin reuptake inhibitors (SRIs), and bupropion. Each acts on different chemical pathways of the human brain related to moods. Antidepressant medications are not habit-forming. To be effective, medications must be taken for about 4-6 months (in a first episode), carefully following the doctor's instructions. Medications must be monitored to ensure the most effective dosage and to minimize side effects.

The prescribing doctor will provide information about possible side-effects and dietary restrictions.

In addition, other medically prescribed medications being used should be reviewed because some can interact negatively with antidepressant medication. There may be restrictions during pregnancy.

Psychotherapy

In mild to moderate cases, psychotherapy is also a treatment option. Some short-term (10-20 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.

Other treatments

Despite the unfavorable publicity electroconvulsive therapy (ECT) has received, research has shown that there are circumstances in which its use is medically justified and can even save lives. This is particularly true for those with extreme suicide risk, psychotic agitation, severe weight loss or physical debilitation due to other physical illness. ECT may also be recommended for persons who cannot take or do not respond to medication.

Some people experience depressive illness during the winter (seasonal depression), and are helped by a new form of therapy using lights, called phototherapy.

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. Depression can be diagnosed and treated by primary care physicians as well as psychiatrists, psychologists, clinical social workers, and other mental health professionals.

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 2-3 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.
• Talk to a health or mental health professional.
• Choose a treatment professional and a treatment approach.
• Consider yourself a partner in treatment, and be an informed consumer.
• If you are not comfortable or satisfied after about 2-3 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.

Source: National Institute of Mental Health, National Institutes of Health, March 2000