Why do women have more depressive disorders than men?
Since the beginning of the 21st century, according to the World Health Organization (WHO), the detection of depression has increased by almost 20% worldwide. Women under 29 and over 55 are the main affected. It is estimated that more than 25% will present an episode of major depression throughout their lives, compared to 12% of men.
Epidemiological studies consistently show that, from puberty onwards, depressive disorders and anxiety disorders are two to three times more common in women than in men. According to the National Institute of Statistics, in Spain, in July 2020, the prevalence of depression in women was 7.15%, compared to 3.5% in men. In severe depressive episodes, the difference is even greater: for every severe case in men, there are 3.5 in women.
Dr. Juan Ángel Bellón Saameño
Although these data are replicated in all studies, when studying population subgroups that are socially homogeneous in terms of education, culture, parity, and other aspects, gender differences are not always found. This finding allows us to make some considerations. While depression in general is more common in women, the female predominance is not always consistent across all depressive subtypes. Another consideration is that gender differences are more evident in heterogeneous community samples and may be absent in samples from socially homogeneous groups. Therefore, there is evidence to support the idea that it is not that women are more prone to developing depression, but rather that women experience more precipitating social factors and are more vulnerable to certain social factors.
Risk factors for depression and how to prevent it
Several hypotheses have been proposed to explain gender differences in depression. These explanatory hypotheses are not mutually exclusive and probably complement each other. We are talking about biological hypotheses, sociocultural hypotheses, and hypotheses that artificially amplify gender differences .
Biological factors that contribute to depression
Biological factors that may contribute to vulnerability to depression are genetic and hormonal , with sex steroids being the main contributors. This hormonal hypothesis is supported by the increase in depressive disorders at puberty and the decrease in incidence after menopause. It has also been suggested that genetic factors may contribute to these differences between men and women, but no consistent empirical support has been found to date.
The sudden drop in estrogen in the blood, experienced before menstruation, after childbirth and during menopause, is related to moments of greater vulnerability to depression, anxiety and other major psychiatric disorders or, even, to aggravating existing pathologies in women. It is very important for the treatment of mental disorders in women to understand how sex hormones, mainly estradiol but also progesterone, influence neurotransmission, neuromodulation, synaptic plasticity and neurodegeneration. Practically, all neurotransmitter systems (serotonergic, dopaminergic, cholinergic, gabaergic, etc.) respond to estrogen.
Sociocultural factors in women's depression
Other factors that may explain the differences in the prevalence of depression between men and women are sociocultural factors, which include structural gender inequalities and cultural factors.
Structural gender inequality refers to the differences in access to power and resources between men and women. Among many others, it includes the wage gap, the lack of education for girls in some parts of the world, the underrepresentation of women in decision-making positions, and sexist violence. The influence of structural inequality on the gender gap in depression can act through different pathways. For example, the structural power of men has enabled sexual harassment of women at work, and the wage gap means that women who experience violence from their partners cannot afford to leave the home. And there is evidence that both sexual harassment and intimate partner violence increase the risk of depression, anxiety, and post-traumatic stress disorder in the person who is the victim.
It is not that women are more likely to develop depression, but rather that women experience more precipitating social factors and are more vulnerable to certain social factors.
On the other hand, cultural factors are the set of values, aptitudes, theories, ideologies, norms and material goods created by human beings. Gender itself is a cultural construction that differentiates and shapes the roles, perceptions and status of women and men in a society. The feminist revolution that began during the second half of the 20th century has made some necessary steps regarding the rights and role of women within society. But it is a fact that, in the social and cultural sphere, there are still many questions to be resolved; we are talking about gender stereotypes, the social roles attributed to women for the very fact of being one. As soon as a girl is born, messages arrive to her in a more or less explicit form that present the ideal image of how a woman should be and act. This high demand is sometimes impossible to achieve and at others it comes into conflict with her desires. Then, she runs the risk of falling into feelings of low self-esteem, guilt, incapacity, shame or even isolation and personal abandonment, a precursor to depression. This high demand and the feminine ideal is responsible for many mental health problems and disorders such as anorexia and bulimia are up to six times more common in women than in men.
In addition, women are socially attributed the role of family and home caregiver , a role that they often assume by ignoring their own desires, needs or aspirations. It has been proven that the incorporation of women into the world of work has meant that they work about 15 hours more per week than men. Working outside the home does not reduce domestic and family involvement, which leads to an overload of stress and less space for the satisfaction of their personal leisure and self-care needs (diet, physical activity, hours of sleep, social relationships), which are protective against depression.
Gender bias in the diagnosis of depression
Other factors that must be taken into account when explaining the differences in the prevalence of depression in men and women are all those that artificially overestimate gender differences. The hypothesis of methodological errors in data collection indicates that gender differences are not real. They are not because women overreport, and men report fewer somatic and psychological complaints to their doctors. The tendency of women to voluntarily report more symptoms of depression than men, to score higher on scales to measure symptoms, and to seek more medical help makes it easier for them to end up with these diagnoses and that doctors tend to think more about the diagnosis of depression when they are faced with a woman.
One aspect that may challenge the gender difference in depression is gender-biased responding , that is, men are less likely to report certain symptoms that are considered unmasculine. Some evidence supports these biases. For example, in a community sample of people who meet criteria for major depressive disorder, women will be more likely to report more symptoms, such as crying. The male role penalizes crying, while the female role not only does not penalize it but allows or even encourages it. Stereotypes mark femininity and masculinity and, as masculinity is constructed, it promotes inequalities, with the man dominant, aggressive and insensitive, and the woman weak, sensitive, obedient and delicate.
One aspect that may question the gender difference in depression is the gender-biased response, that is, men are less likely to report certain symptoms that are considered unmasculine.
Another gender bias is the differential presentation of diseases and disorders that causes the symptoms and manifestations of the same medical condition to be different in men and women. In the case of depression, this difference leads to underdiagnosis in men. Men who are depressed may be irritable or aggressive, rather than sad, and tend to spend more time away from home and consume more substances such as alcohol. These symptoms do not match those expected in a person with depression and, for this reason, they receive other diagnoses such as substance use disorder or personality disorder.
I'm very sad. Do I have depression?
Some hypotheses for assessing gender differences are based on the assumption that each gender category is homogeneous, when in reality it is heterogeneous. This heterogeneity is given to us by intersectionality, which postulates that each person belongs to multiple social categories based on gender, race, social class, sexual orientation, country of origin, immigration status, profession, academic level, physical appearance, skin color and fertility. And that the intersection of these factors can explain some differences that do not only depend on gender. For example, most epidemiological studies analyze data on gender differences, educational level or age, but not all of them together. Therefore, the analysis is not truly intersectional. It is different to be a woman, university student and young than to be a woman, uneducated and middle-aged.
In conclusion, epidemiological data show that there are more women than men diagnosed with depression, but these gender differences in depression are contributed to by sociocultural factors and methodological errors that overestimate depression in women and underestimate it in men, without forgetting that a biological basis also contributes to it, about which very little is still known.
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