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
SeriesWhy is depression more common among women than among men?
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
References (158)
- et al.
Sex differences in anxiety and depression clinical perspectives
Front Neuroendocrinol
(2014) - et al.
On sex/gender related similarities and differences in fMRI language research
Brain Res Rev
(2009) - et al.
Beyond a catalogue of differences: a theoretical frame and good practice guidelines for researching sex/gender in human health
Soc Sci Med
(2012) - et al.
The size and burden of mental disorders and other disorders of the brain in Europe 2010
Eur Neuropsychopharmacol
(2011) - et al.
Predicting female depression across puberty: a two-nation longitudinal study
J Am Acad Child Adolesc Psychiatry
(2008) - et al.
Age- and gender-specific prevalence of depression in latest-life—systematic review and meta-analysis
J Affect Disord
(2012) - et al.
First-incidence of DSM-IV mood, anxiety and substance use disorders and its determinants: results from the Netherlands Mental Health Survey and Incidence Study-2
J Affect Disord
(2013) - et al.
What are the causes of late-life depression?
Psychiatr Clin North Am
(2013) - et al.
Risk for recurrence in depression
Clin Psychol Rev
(2007) - et al.
Prevalence and predictors of persistent versus remitting mood, anxiety, and substance disorders in a national sample of older adults
Am J Geriatr Psychiatry
(2014)
Two-year course of depressive and anxiety disorders: results from the Netherlands Study of Depression and Anxiety (NESDA)
J Affect Disord
Determinants of persistence of major depressive episodes in the general population. Results from the Netherlands Mental Health Survey and Incidence Study (NEMESIS)
J Affect Disord
Is excess mortality higher in depressed men than in depressed women? A meta-analytic comparison
J Affect Disord
Mortality and life expectancy in persons with severe unipolar depression
J Affect Disord
Sex differences in depression symptoms in treatment-seeking adults: confirmatory analyses from the Sequenced Treatment Alternatives to Relieve Depression study
Compr Psychiatry
Non-psychotic mental disorders in the perinatal period
Lancet
The genetics of major depression
Neuron
Genetic and epigenetic underpinnings of sex differences in the brain and in neurological and psychiatric disease susceptibility
Prog Brain Res
An update on the interaction between the serotonin transporter promoter variant (5-HTTLPR), stress and depression, plus an exploration of non-confirming findings
Behav Brain Res
5-HTTLPR and gender differences in affective disorders: a systematic review
J Affect Disord
FKBP5 moderation of depressive symptoms in peer victimized, post-institutionalized children
Psychoneuroendocrinology
Pubertal timing and the development of psychopathology in adolescence and beyond
Horm Behav
Allopregnanolone levels and reactivity to mental stress in premenstrual dysphoric disorder
Biol Psychiatry
Depression and midlife: are we overpathologising the menopause?
J Affect Disord
Menopause and depression: is there a link?
Maturitas
Sensitivity to the depressogenic effect of stress and HPA-axis reactivity in adolescence: a review of gender differences
Neurosci Biobehav Rev
The effects of sex and hormonal status on the physiological response to acute psychosocial stress
Psychoneuroendocrinology
Sex differences in stress responses: social rejection versus achievement stress
Biol Psychiatry
The potential role of hypocortisolism in the pathophysiology of stress-related bodily disorders
Psychoneuroendocrinology
An invariant dimensional liability model of gender differences in mental disorder prevalence: evidence from a national sample
J Abnorm Psychol
Distinguishing between sex and gender: history, current conceptualizations, and implications
Sex Roles
Recommendations for sex/gender neuroimaging research: key principles and implications for research design, analysis, and interpretation
Front Hum Neurosci
Institute of Medicine Committee on Understanding the Biology of Sex and Gender Differences
Gender medicine. Sex- and gender-specific aspects of clinical medicine
Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz
Gender differences in unipolar depression: an update of epidemiological findings and possible explanations
Acta Psychiatr Scand
Cross-national associations between gender and mental disorders in the World Health Organization World Mental Health Surveys
Arch Gen Psychiatry
Cross-national epidemiology of DSM-IV major depressive episode
BMC Med
Epidemiology of major depressive disorder: results from the National Epidemiologic Survey on Alcoholism and Related Conditions
Arch Gen Psychiatry
The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R)
JAMA
Prevalence of mental disorders and trends from 1996 to 2009. Results from the Netherlands Mental Health Survey and Incidence Study-2
Soc Psychiatry Psychiatr Epidemiol
Twelve-month prevalence, comorbidity and correlates of mental disorders in Germany: the mental health module of the German Health Interview and Examination Survey for Adults (DEGS1-MH)
Int J Methods Psychiatr Res
A systematic review of gender-specific rates of unipolar and bipolar disorders in community studies of pre-pubertal children
Bipolar Disord
Major depression in the national comorbidity survey-adolescent supplement: prevalence, correlates, and treatment
J Am Acad Child Adolesc Psychiatry
Depression from childhood into late adolescence: Influence of gender, development, genetic susceptibility, and peer stress
J Abnorm Psychol
The epidemiological modelling of major depressive disorder: application for the Global Burden of Disease Study 2010
PLoS One
High occurrence of mood and anxiety disorders among older adults: the National Comorbidity Survey Replication
Arch Gen Psychiatry
Population-based study of first onset and chronicity in major depressive disorder
Arch Gen Psychiatry
Sociodemographic and psychopathologic predictors of first incidence of DSM-IV substance use, mood and anxiety disorders: results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions
Mol Psychiatry
Prevalence and predictors of recurrence of major depressive disorder in the adult population
Acta Psychiatr Scand
Preventing suicide: a global imperative
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