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Life is full of emotional ups and downs and everyone experiences the “blues” from time to time. But when the “down” times are long lasting or interfere with an individual’s ability to function at home and at work, 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 17 million people –one in ten adults –experience depression each year, and nearly two-thirds do not get the help they need. Treatment can alleviate the symptoms in over 80 percent of 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 and to identify new areas that hold promise of deepening our understanding. 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.
To grasp the specifics of depression in women, it is essential to have a broad understanding of the illness itself. To this end, this chapter 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 psychosocial – that are unique to women and may be associated with depression.
Jane slowly walked into the house, as though her body ached in every muscle. Jeff had already tucked the kids in bed. When he asked why she was late, Jane told him she was trying to catch up at work. She was too tired to say more, and too scared to admit that she could hardly concentrate or remember what she was supposed to be doing. Jeff had cooked dinner – again – but Jane had no appetite. She felt guilty as she pushed away her plate, apologized, and went to bed.Sitting in silence was familiar to Jeff. He was reluctant to speak because Jane often flew off the handle these days, so unlike the good-humored woman she used to be. Jeff and her coworkers had noticed the change in Jane – the way she kept to herself, her forced smile, her pessimism and loss of interest in things. As she struggled through her days, neither Jane nor Jeff understood what was happening to her. She felt alone and empty, often plagued by negative thoughts and bad feelings about herself. One day she said she couldn’t see the point in living anymore. That was when Jeff became alarmed and encouraged Jane to seek professional help. They found out that she had clinical depression.
Jane, our fictional patient, experienced many of the symptoms that characterize depressive illness. Her story depicts how depression alters not just mood but one’s entire existence, and how it impacts not just the affected individual but family and coworkers. Most importantly, it illustrates the importance of awareness of the illness, so that early recognition and appropriate treatment can keep depressive symptoms and their impact to a minimum.
No two people become depressed in exactly the same way. Many have only some of the symptoms, varying in severity and duration. For some, symptoms occur in time-limited episodes; for others, symptoms can be present for long periods if no treatment is sought. The age at which depression first appears also varies. There is evidence that in individuals born after 1945, it occurs at a younger age than in previous generations. Common to all age groups, affecting rich and poor alike, depressive illness occurs most frequently in adults between the ages of 25 and 44.
Having some depressive symptoms does not mean a person is clinically depressed. For example, it is not unusual for those who have lost a loved one to feel sad, helpless, and disinterested in regular activities. Only when these symptoms persist for an unusually long time is there a reason to suspect that grief has become depressive illness. Similarly, living with the stress of potential layoffs, heavy workloads, or financial or family problems may cause irritability and “the blues”. Up to a point, such feelings are simply a part of human experience. But when the symptoms increase in number, duration and intensity, so that an individual is unable to function as usual, a temporary mood has very likely become a clinical illness.
Major depression, Jane’s illness, emerges in episodes. Some people have one episode in a lifetime; others have recurrent episodes. While initial symptoms may not always seem significant, eventually the individual will experience emotional pain and misery and impairment in productivity at work and home and in relationships with family and friends.
Sometimes the episodes appear seasonally – typically with depression occurring in fall and winter and diminishing in the spring. Women seem to be especially prone to this kind of depression, known as Seasonal Affective Disorder (SAD).
Manic-depressive illness, also called bipolar disorder, involves cycles similar to major depression alternating with inappraopriate "highs," Unlike other depressions, women and men are equally vulnerable. During manic episodes, people become overly active, euphoric, irritable, talkative and may spend more money irresponsibly and get involved in sexual adventures.
Depression
Mania
A thorough diagnostic evaluation is needed if five or more of these symptoms persist for more that 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. |
Dysthymia involves symptom similiar to those of major depression. They are milder but longer lasting, with a minimum duration of two years. People with dysthmia are frequently lacking in zest and enthusiasm for life, living joyless and fatigued existences that seem almost natural growths of their personalities. If, in addition, they have a major depression episode, as often happens, they are sometimes referred to as having "double depression."
There is a risk for developing depression when there is a family history
of the illness, indicating that abiological vulnerbility may be inherited.
The risk is somewhat higher for those woth bipolor disorder. However, not
everbody with a family history develops the illness. In addition, major depressio
can occur in people who have had no family members with the illness. This
suggests that additional factors, possibly biochemistry, environmental stressors,
and other psychosocial factors, are involved in the onset of depression.
Evidence indicates that brain biochemistry is a significant factor i in depressive disorders. It is klnown, for example, that individuals with major depressive illness typically have too little ot too much of certain brain chemicals, called neurotransmitters. Additionally, sleep patterns, which are biochemically influenced, are typically different in people with mood disorders. Depression can be induced or alleviated with certain medications, and some hormones have mood-altering properties. What is not yet known is whether the “biochemical disturbances” of depression are of genetic origin, or are secondary to stress, trauma, physical illness, or some other environmental condition.
Significant loss, a difficult relationship, financial problems, or a major change in life pattern have all been cited as contributors to depressive illness. Sometimes the onset of depression is associated with acute or chronic physical illness. In addition, some form of substance abuse disorders occurs in about one third of people with any type of depressive disorder.
Persons 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 or with getting well. Upbringing or sex role expectations may contribute
to the development of these traits. It appears that negative thinking patterns
typically develop ing childhood or adolescence.
Many factors that appear to contribute to depression are common to both women and men, while the specific causes of depression in women remain unclear. However, varied factors unique to women’s lives are suspected to contribute to depression – developmental, reproductive, hormonal, genetic, and other biological factors; abuse and oppression; interpersonal factors; and certain psychological and personality characteristics.
Regardless of contributing factors, depression is a highly treatable illness and the types of treatment discussed later in this chapter are effective for a majority of women.
The issues of adolescence The higher incidence of depression in females begins in adolescence, when there are dramatic changes in roles and expectations along with other physical, intellectual and hormonal changes. The added stresses of adolescence include forming an identity, confronting sexuality, separating from parents, and making decisions for the first time. These significant issues are generally different for boys and girls. Studies show that female high school students have significantly higher rates of depression, anxiety disorders, eating disorders, and adjustment disorders than male students, who have higher rates of disruptive behavior disorders.
Adulthood : relationship and work roles Stress in general can contribute to depression in persons biologically vulnerable to the illness. Some have theorized that the higher incidence of depression in women is not due to greater vulnerability, but to the multidimensional stresses that many women face, such as major responsibilities at home and work, single parenthood, and caring for children and aging parents. How these factors uniquely affect women is not yet fully understood.
For both women and men, rates of major depression are highest among the separated and divorced, and lowest among the married, while remaining always higher for women than for men. The quality of a marriage, however, may contribute significantly to depression. Lack of an intimate, confiding relationship, as well as marital disputes, have been shown to be related to depression in women. In fact, rates of depression were shown to be highest among unhappily married women.
Significant events in women’s reproductive life cycle include menstruation,
pregnancy, the post pregnancy period, and menopause. These events bring fluctuations
in mood that for some women include depression. Further, infertility and the
decision not to have children can also bring about changes in mood. Researchers
have confirmed that hormones have an effect on the brain chemistry that controls
emotions and mood; a specific biological mechanism explaining hormonal involvements
is not known, however.
Menstruation and premenstrual syndrome Many women experience certain normal behavioral and physical changes associated with phases of their menstrual cycles. Some women, however, regularly experience a significant number of extreme changes, including depressed feelings, irritability, and other emotional and physical manifestations. Though not considered a disorder in the most recent diagnostic manual for psychiatry, these extreme changes are generally called premenstrual syndrome (PMS) or premenstrual dysphoric disorder (PMDD). The changes typically begin after ovulation and become gradually worse until menstruation starts. Scientists are exploring how the cyclical rise and fall of estrogen and other hormones may affect the brain chemistry that is associated with depressive illness.
Pregnancy 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.
Postpartum depression Following childbirth, women may experience sadness that ranges from transient “blues” to an episode of major depression to severe, incapacitating, psychotic depression. Studies suggest that women who experience depressive illness after childbirth very often have had prior depressive episodes, though they may not have been diagnosed and treated. For most women, postpartum depressions are transient with no adverse consequences.
Maternal depression Because women typically carry the primary responsibility for child care, the impact of their depressive illness on their parenting ability is of particular concern. Evidence suggests that maternal depression may have a negative effect on a child’s behavior, and psychological and social development. Those findings give additional emphasis to the importance of women recognizing the need for and seeking treatment for depression.
Menopause A definitive study has shown that, in general, menopause is not associated with an increased risk of depression. In fact, while once considered a unique disorder, research has shown that depressive illness at menopause is no different than at other ages. The women more vulnerable to change-of-life depression are those with a history of past depressive episodes.
As in depression in general, the prevalence rate of depression in African American and Hispanic women remains about twice that of men. There is some indication, however, that major depression and dysthmia may be diagnosed less frequently in African American and slightly more frequently in Hispanic than in Caucasian women. Prevalence information for other racial and ethnic groups is not definitive.
Possible differences in symptom presentation may affect the way depression is recognized and diagnosed among minorities. For example, African Americans are more likely to report somatic symptoms, such as appetite change. In addition, people from various cultural backgrounds may view depressive symptoms in different ways. Such factors should be considered when working with women from special populations.
As mentioned earlier, persons with certain characteristics appear to be more likely to develop or have difficulty overcoming depression. 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, 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. There is currently insufficient scientific data to verify this theory.
It is known that far more women than men are sexually abused as children. 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, there appears to be a higher incidence of depression among women who were raped as adults. 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. It has been suggested that abuse may lead to depression by fostering low self-esteem, a sense of helplessness, self-blame, and social isolation. Research is needed to understand the connection between victimization and depression.
Low economic status brings with it many stresses, including isolation, uncertainty, frequent negative events, and poor access to helpful resources. It is known that depressive feelings and demoralization are common among the poor, the deprived, and those lacking social supports, and yet is not clear whether depressive illnesses are more prevalent among victims of such environmental stressors. In fact, one very large study has shown that these illnesses tend to equally affect the poor and the rich.
Close examination of the facts casts doubt on “the empty nest syndrome” as an explanation for depression in older women. The lack of increased rates of depression among women at this stage of life suggests that most women do not get depressed when children leave home.
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 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 the rate of clinical depression in older people is lower than that of the general population, and 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 many 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 of a spouse, but only half of these remain clinically depressed one year later. These depressions respond to standard antidepressant medications, although the optimal timing of the intervention is a matter of clinical judgment.
Even severe depressions 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 treatments for depression. As with may illnesses, the earlier the treatment begins, the more effective it is 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.
The most commonly used treatments for depression are antidepressant medications, psychotherapy, or a combination of the two. Which of these is the right treatment for an individual case 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 medication is generally recommended as a first step in treatment. In combined treatment, medication can relieve physical symptoms quickly, while psychotherapy allows the opportunity to learn more effective ways of handling problems.
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 brain related to moods. Antidepressant medications are not habit-forming. To be effective, medications must be taken for at least 4-6 months (in first episodes), 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 medications being used should be reviewed because some can interact negatively with antidepressant medications. There may be restrictions during pregnancy.
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 and resolve 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.
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 at high risk for suicide or with 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.
People who experience Seasonal Affective Disorder (SAD) can also be helped by a new form of therapy using lights, called phototherapy.
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 dosage that successfully treated the acute episode can often prevent recurrence. Monthly interpersonal psychotherapy can lengthen the time between episodes in patients not taking medication.
Reaping the benefits of treatment begins by recognizing the signs of depression. The list of symptoms listed earlier can be used for this purpose.
The next step is to be evaluated by a qualified professional. Depression can be diagnosed and treated by psychiatrist, psychologists, clinical social workers, and other mental health professionals, as well as by primary care physicians.
Treatment is 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 you don’t feel some improvement after several weeks of treatment, or if symptoms worsen, discuss this with your treatment provider. Trying another treatment approach, or getting a second opinion from another health or mental health professional, may be in order.
Depressive illnesses make you feel exhausted, worthless, helpless and hopeless. Such feelings make some people want to give up. It is important to realize the these negative views are part of the depression and will fade as treatment begins to take effect.
Along with professional treatment, there are other things you can do to help yourself get better. Some people find participating in support groups very helpful. It may also help to spend some time with other people and to participate in activities that make you feel better, such as mild exercise. Just don’t overdo it or expect too much from yourself right away. Feeling better takes time. Your treating professional can also suggest other self-help strategies.
The most important thing anyone can do for the depressed person is to help him or her get appropriate diagnosis and treatment. This may involve encouraging the person to seek professional help or to stay in treatment once it is instituted.
The second most important thing is to offer emotional support. This involves understanding, patience, affection, and encouragement. Engage the depressed person in conversation or activities and be gently insistent if you meet resistance. Remind that person that with time and help, he or she will feel better.
For further information on depression, call:
1-800-421-4211
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