Sex, stressful life events, and adult onset depression and alcohol dependence: Are men and women equally vulnerable?
Highlights
▸ Using a large prospective US national sample, we investigate if males and females have sex-specific responses to stress. ▸ The number of stressful events predicted onset of major depression and alcohol dependence in both males and females. ▸ We did not find evidence that sex-specific responses to stressful events lead to sex differences for either disorder. ▸ There is a need for new models that incorporate both physiological and social aspects of vulnerability.
Introduction
Major depression (MD) is approximately twice as common in females compared to males (Kessler, 2003), whereas alcohol dependence (AD) is approximately twice as common in males compared to females (Hasin, Stinson, Ogburn, & Grant, 2007). Both MD and AD present an enormous burden to individuals and society: the World Health Organization estimates that depression is the leading cause of years lost to disability for both females and males, and alcohol use disorders are the second leading cause of years lost to disability for males (World Health Organization, 2008). Researchers have attempted to determine the origin of sex differences in MD (Hyde et al., 2008, Piccinelli and Wilkinson, 2000) and AD (Hensing and Spak, 2009, Wilsnack et al., 2009), yet many questions remain unanswered (Holmila and Raitasalo, 2005, Piccinelli and Wilkinson, 2000).
Stressful life events are associated with an increased risk of both MD (Kessler, 1997) and AD (Dawson, Grant, & Ruan, 2005;Lloyd & Turner, 2008); the current study investigates whether sex-specific responses to stressors explain sex differences in both disorders. It has long been hypothesized that females are more likely to report internalizing symptoms in response to stress (e.g., somatization, affective or anxiety disorders), while males are more likely to report externalizing symptoms in response to stress (e.g., aggression or substance abuse disorders) (Aneshensel et al., 1991, Conger et al., 1993). If such differential vulnerability exists, it would explain the observed sex differences in MD and AD.
Theoretically, sex differences in disorders would be predicted by stress–diathesis models of psychopathology, wherein one sex or the other has a pre-existing vulnerability (i.e., diathesis) to develop the disorder once exposed to a stressor (Ingram & Luxton, 2005). According to stress–diathesis theory, stressful events present a challenge to the adaptive capacity of the individual, and stable characteristic(s) of the individual (i.e., diathesis factors) will influence subsequent vulnerability to disorders (Bleuler, 1963, Meehl, 1962). Observing sex differences in the association between stress and psychopathology, ruling out differential stress exposure, would therefore be consistent with the existence of a sex-specific diathesis. What constitutes the actual diathesis that is responsible for sex differences in psychiatric disorders could include a wide range of factors. For example, genetic or other physiologic (e.g., hormonal) differences between the sexes could contribute to sex differences in the vulnerability to stressors; in addition, cognitive and interpersonal variables could also function as potential vulnerabilities (Monroe & Simons, 1991). Therefore, determining the nature of sex-specific stress responses could provide important insights into the theoretical underpinnings of sex differences in MD and AD, as well as provide insights into sex-specific etiologies of both disorders.
Section snippets
Evidence for and against sex-specific stress responses
There is inconclusive evidence for sex-specific effects of stress in the development of higher rates of MD among females, and higher rates of AD among males (Dawson et al., 2005, Kendler et al., 2001, Maciejewski et al., 2001, Perreira and Sloan, 2001). Maceijewski and colleagues (Maciejewski et al., 2001) found that among males and females who did not experience a stressful life event there was no sex difference in MD; yet, females who had been exposed to a stressful life event had a threefold
Methodological requirements for demonstrating sex-specific stress responses
In order to determine whether sex-specific stress responses can account for sex differences in MD and AD, establishing the causal ordering between stress exposure and psychiatric outcome is essential. This is a challenging feat for cross-sectional studies, including those that use retrospective reports for experiences over the life course, yet many prior studies in this area have collected information about exposures and outcomes in the same interview (Dawson et al., 2005, Nazroo et al., 1997,
Sample
The sample for the current study includes participants in Waves 1 (2001–2002) and 2 (2004–2005) of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a nationwide representative household survey of adults in the United States (B. F. Grant, Kaplan et al., 2003). At both waves, face-to-face interviews were conducted by trained non-clinician United States Census Bureau Field Representatives using the Alcohol Use Disorder and Associated Disabilities Interview Schedule –
Results
The proportion of the sample with first onset MD during the NESARC follow-up period was 4.96% (3.70% among males, 6.09% among females; p < .0001). For first onset of AD, the proportion was 2.85% (3.80% among males, 1.98% among females; p < .0001). Table 1 presents sample characteristics for individuals included in either the MDD or AD analyses, which represents 95.6% of participants who completed Wave 2 (1516 participants were not eligible for both the MDD and AD analyses because they had a
Discussion
The results of this study are not consistent with a stress–diathesis model as a basis for sex differences in adult onset MD and AD. In this study, stressful life events were not more likely to predict incidence of MD among females compared to males, and were not more likely to predict incidence of AD among males compared to females. Contrary to our expectations, number of stressful life events was more strongly associated with odds of MD for males compared to females, after adjustment for
Conclusions
In conclusion, we did not find empirical support for differential responsivity to stressful life events as an explanation of sex differences in MD and AD. We do not interpret the results of this study as evidence against the involvement of social stressors in sex differences in MD and AD, given that (a) simple checklists of stressors as used in the current study might be too crude of an instrument to detect sex-specific vulnerabilities, and (b) sex (i.e., male versus female)—rather than social,
Acknowledgments
This research was supported by a doctoral research award to the first author from the Canadian Institutes of Health Research.
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