Elsevier

The Lancet Psychiatry

Volume 4, Issue 2, February 2017, Pages 146-158
The Lancet Psychiatry

Series
Why is depression more common among women than among men?

https://doi.org/10.1016/S2215-0366(16)30263-2Get rights and content

Summary

Women are about twice as likely as are men to develop depression during their lifetime. This Series paper summarises evidence regarding the epidemiology on gender differences in prevalence, incidence, and course of depression, and factors possibly explaining the gender gap. Gender-related subtypes of depression are suggested to exist, of which the developmental subtype has the strongest potential to contribute to the gender gap. Limited evidence exists for risk factors to be specifically linked to depression. Future research could profit from a transdiagnostic perspective, permitting the differentiation of specific susceptibilities from those predicting general psychopathologies within and across the internalising and externalising spectra. An integration of the Research Domain Criteria framework will allow examination of gender differences in core psychological functions, within the context of developmental transitions and environmental settings. Monitoring of changing socioeconomic and cultural trends in factors contributing to the gender gap will be important, as well as the influence of these trends on changes in symptom expression across psychopathologies in men and women.

Introduction

Epidemiological research shows substantial gender-related differences in prevalences for specific mental disorders. Women's preponderance has been consistently identified within the internalising spectrum, which includes depressive, anxiety, eating, and somatoform disorders, whereas men predominate in externalising disorders such as substance use, impulse control, and antisocial personality disorders.1 This Series paper will focus on gender differences (panel 1)2, 3, 4, 5, 6, 7, 8 in depression as part of the internalising spectrum, and on possible factors that might explain the gender gap.

Section snippets

Prevalence

A 2003 review9 listed evidence from studies up to the early 2000s yielding sex ratios of about 2·1 for lifetime and 1·7 for point prevalence (women:men) of major depressive disorder and dysthymia in adults, and similar ratios for studies in adolescents. Findings from subsequent national and international studies sub-stantiate these previous findings across multiple sociocultural settings (table).10, 11, 12, 13, 14, 15, 16 The gender gap appears to be similar for high-income countries versus

Possible explanations for the gender gap in depression

Depression is heterogeneous regarding risk factors and phenotypes, and the importance of specific risk factors to explain the gender gap could plausibly vary across these different conditions. Furthermore, transdiagnostic research shows that both distal and proximal risks can be related to multiple outcomes within and across the internalising and externalising spectra.46, 47 Considering an isolated inspection of such factors in relation to a specific disorder would therefore be misleading,

Artefact hypotheses

Artefact hypotheses postulate that depression is equally common in both genders, but lower treatment use and lower depression recognition in men than in women, or the existence of gender-specific depressive symptoms, would result in arbitrarily increased depression prevalence among women. However, the evidence for this view is limited. Prevalence estimates are generally derived from representative general population studies and should therefore not be biased by gender differences in treatment.

Genetic factors

The heritability of major depressive disorder is estimated at 30–40%,53 with mixed evidence for a stronger genetic risk for women than for men.53, 54 To date, genome-wide association studies have not been very successful in identifying genetic markers of major depressive disorder,55 probably because of heterogeneity in risk factors. A genome-wide association study for neuroticism56 identified high genetic correlation with major depressive disorder and a similar single-nucleotide polymorphism

Temperament, personality, and coping styles

Consistent gender differences in early childhood emerge in effortful control, indicating a better ability of girls than of boys to regulate attention and inhibit impulses, in line with boys' greater incidence of externalising problems.96 Boys also score higher on surgency than do girls, linked to the Big Five personality trait of extraversion, indicating that boys are slightly more active and impulsive, and derive more pleasure from high-intensity stimuli.96 Findings from prospective studies

Common stress exposure and stress susceptibility

Adolescent girls have a greater number of interpersonal stressors and are more susceptible to these stressors than boys.19, 104, 115 Moreover, gender differences in stress generation have been identified: depression associated with subsequent dependent stress is more common in girls than in boys.116, 120 Stress generation is rather specific to depression, is especially pronounced in adolescent girls, and predicts subsequent depressive symptoms.116 In a large longitudinal study,120 adolescent

Environmental factors: macro level

Gender is associated with various mental health determinants such as economic position, access to resources, and social status. Relatedly, the degree of structural gender equality, measured at the macro or state level in terms of political participation, economic autonomy, and reproductive rights, affects the gender ratio in depression. Women in US states with lower gender equality report more depressive symptoms than those from states with higher gender equality.143 In a representative

Summary

The assessment of possible factors contributing to the gender gap in depression in this Series paper suggests several gender-related depressive subtypes, which might deserve specific assessment in future research (panel 3). These subtypes of depression—early onset, developmental, reproductive, and pathophysiological—are not exhaustive and might overlap in risk factors and clinical phenotypes.

Whereas the early-onset subtype has no potential to explain the gender gap, and might mainly include

Conclusion

Generally, only limited evidence exists for gendered risk factors to be specific for depression. Future research can clearly profit from incorporating a transdiagnostic perspective that includes dimensional assessment of multiple areas of psychopathology. Application of hierarchical models might help to differentiate depression-specific susceptibilities from those predicting general psychopathology, within and across the internalising and externalising spectra.46, 51, 149 Particularly, gender

Search strategy and selection criteria

I searched PubMed and PsycINFO for large national and multinational studies and reviews published in the last decade, until June 5, 2016, for the epidemiological part of the Series paper. I included individual studies if they used population-based samples, covered large sample sizes (>5000), used structured or standardised assessments to assess depressive disorders, and allowed the calculation of sex-related odds ratios. For the analytical part of the paper, I primarily searched PubMed and

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