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might be responsible for the higher EXPLANATORY FACTORS Farmer, 1996; Harrington, 1996; Silberg
prevalence rates among females. Findings et al,
al, 1999).
are controversial: some studies report Several risk factors have been investigated. Much attention has been devoted to
higher rates of first-onset depression in They are listed in Table 1. parental separation/divorce (with resulting
females rather than a greater number, or lack of child care in early years) and to
longer duration, of episodes (Kessler et al,al, the effects of physical and sexual abuse in
1993; Wilhelm et al,al, 1997); others show a Familial environment and adverse childhood as possible risk factors for
female preponderance in recurrent and experiences in childhood depression in adult life. Adverse experi-
chronic depression (Stefa
(Stefansson
Á nsson et al,
al, 1994; Genetic studies have shown that environ- ences in childhood have been shown to
Bracke, 1998). In any case, the course of ill- mental factors shared in families do not increase the risk of later depression through
ness loses its relevance in computing substantially influence liability to major several pathways, including: biological
lifetime prevalence rates, which are con- depression and do not contribute to mechanisms (that is, long-term dysregula-
sistently higher in females than in males. observed gender differences (Kendler et al,al, tion of the hypothalamic±pituitary±adrenal
Differential mortality in males and 1995; McGuffin et al,
al, 1996). None the less, axis); personal vulnerability (namely low
females with depression has been also the role of familial environment cannot be self-esteem, helplessness, external locus of
considered but can hardly account for totally dismissed, because events occurring control, poor coping strategies); adverse
gender differences in depression, since these within families and not shared by family environmental factors (such as lack of
appear at puberty through adult life and members remain candidates. Familial social support, low social status, ongoing
decrease in older cohorts, when the differ- factors may contribute to vulnerability to difficulties like single parenthood or
ential effect of mortality is expected to be depression in terms of personal attributes unplanned pregnancy); and a depression
more pronounced. modulating the response to life events, with episode in teenage years (Kendler et al, al,
no increased risk of illness in the absence of 1993; Bifulco et al, al, 1998; Weiss et al,
al,
such crises. Age and strictness of diagnostic 1999). However, gender differences in the
criteria may be critical variables, since association between adverse experiences in
Help-seeking and illness depressive illness in children, as well as childhood and adult depression have been
behaviour milder forms of depression, seems to be poorly investigated. The available evidence
Females are more likely to report physical largely related to unique or shared suggests that early traumatic experiences
and psychological symptoms and to seek environmental factors (Brown, 1996; may be partly responsible for a female
medical help, although few gender differ-
ences have been detected in illness behav-
iour, sick role or defence style (Spinhoven
& Kooiman, 1997; Gijsbers van Wijk et
al,
al, 1999). Females do not appear to report Table 1 Risk factors explaining gender differences in depression
milder symptoms than males on mental
health scales (Tousignant et al,
al, 1987) and
Childhood familial environment and Females are at greater risk of sexual abuse and seem to be
gender does not seem to predict under-
adverse experiences more sensitive to the effect of adverse experiences in
reporting of psychological symptoms
childhood
(Lyness et al,
al, 1995; Cantwell et al,
al, 1997).
Prior depression and anxiety disorders Females are at increased risk of depression and anxiety
disorders at earlier ages
Social roles and cultural norms Role limitation with associated lack of choice, role overload
Depression spectrum and competing social roles contribute to females'
Developmental pathways towards depres- increased risk of depressive illness
sion may differ by gender, with females Adverse life events Females do not experience higher rates of adverse life
suffering from pre-existing anxiety dis- events but may differ in the quality of experience
orders and males experiencing more ex- associated with them, possibly due to their distinctive
ternalising disorders, such as alcoholism, social circumstances
antisocial personality and drug misuse. In
Vulnerability and coping style No consistent gender differences in personality attributes
this regard, the concept of `depression
and coping styles compatible with a depressive image
spectrum disease' has been suggested to
Social support No contribution to females' increased risk of depressive
identify a specific gene±environment inter-
action leading to depression in females illness
and alcoholism in males. At present, the Genetic factors No direct contribution to females' increased risk of
evidence suggests that the above-mentioned depressive illness
disorders may share genetic and environ- Gonadal hormones Partial effect, although smaller than that of environmental
mental factors with depression but cannot variables
be considered simply as indirect mani- Adrenal axis and thyroid axis Contrasting findings for adrenal axis. Limited role for
festations of depression (Cadoret et al, al, thyroid axis
1996; Kendler et al,al, 1997; Stallings et al,
al, Neurotransmitter systems Uncertainty about their effects
1997; Dawson & Grant, 1998).
4 87
P I C C IIN
NEE L L I & W I L K IN
I N S ON
preponderance in depression rates, since demands posed by marriage and the differential role of life events in males and
females are at greater risk of certain events resulting limited number of roles available females, but the quality of experience
(such as sexual abuse) and seem to be more to females. Similar reasons may explain associated with life events may contribute
sensitive to their depressogenic effects why looking after small children is to gender differences in depression.
(Rodgers, 1994; Veijola et al,
al, 1998). associated with greater risk of depression The assumption that females might be
in females. Both home-making and child at higher risk of depression owing to higher
care reduce the likelihood of females being rates of adverse life events has received
Prior depression and anxiety
in paid employment or put additional inconsistent support, with some studies
disorders
responsibilities on those who are employed. showing gender differences in the expected
Females are at greater risk of depression Married females with no paid employment direction and others finding similar levels
and anxiety disorders at earlier ages than have to rely for identity and self-esteem of life events in males and females. In any
males, and this may partly account for their on the role of housewife, a role that carries case, the excess of life events in females
preponderance in rates of adult depression. many frustrating elements and has been has not been found to account entirely for
Among possible reasons accounting for the increasingly devalued in modern societies. their higher frequency of affective disorders
greater risk to females and at earlier ages, On the other hand, females entering the (Bebbington, 1996).
psychological attributes such as neuro- job market face economic discrimination Older studies simply recorded the level
ticism may be key determinants, acting as and job inequality along with role overload of life events and did not assess whether
vulnerability factors in response to life and role conflict caused by concurrent males and females differ in the meaning
events (Wilhelm et al,
al, 1997). primary responsibility for household chores they attach to them. Craig (1996) reported
Depressive episodes in childhood and and child care. Although employment tends that experiences of defeat, humiliation and
adolescence, rather than those at older to have beneficial effects on psychological entrapment were at the heart of depressive
ages, predict more episodes and longer well-being, these effects may be reduced episodes in males and females, although
duration of depression in adult life and or reversed where there is role conflict females were far more likely to report such
provide a strong link between adverse and overload. experiences, possibly because of their
experiences in childhood and adult depres- Indirect evidence for the strong effect distinctive social circumstances. Similarly,
sion (Kendler et al,al, 1993; Parker et al,
al, exerted by social and cultural factors is Wilhelm et al (1998) found no gender
1997; Bifulco et al,al, 1998). Considerable provided by those studies showing no, or differences in frequency of life events or
attention has been devoted to the role of limited, gender differences in depression in anticipated impact of pleasant and
anxiety. Using discrete-time survival rates: in samples where males and females unpleasant events, whereas the actual
models, Kessler et al (1996) showed that are matched for the putative social deter- impact of unpleasant events was rated
the associations between major depression minants of depression (Jenkins, 1985; higher by females.
and first onsets of other mental disorders Wilhelm et al,
al, 1997); and in cultural groups An increased risk of the onset of depres-
in the same year as depression were where high value is attached to the female sion may reasonably be expected when
generally strong and persistent over many role, such as in Mediterranean countries severe events occur in life domains to which
years, and especially so for generalised (Mavreas et al, al, 1986; Va
Vazquez-Barquero
 zquez-Barquero individuals attach a strong sense of value
anxiety. More recently, Parker et al et al,
al, 1987), among the Old Order Amish and commitment. Individuals with few
(1997) assessed risk factors differentiating (Egeland & Hostetter, 1983) or among overvalued goals and/or lacking an intimate
early-onset (that is, at an age younger than orthodox Jews in the London area sense of perceived choice are at high risk
26 years) from late-onset depression and (Loewenthal et al,al, 1995). since they are left with few alternatives
found that anxiety disorders were more The `role strain' hypothesis is unlikely for self-definition and self-evaluation when
likely to precede early-onset than late-onset to account entirely for gender differences their main goals are threatened. Both of
depression. Finally, Breslau et al (1995) in depression. For example, despite sig- these situations are more likely for females.
showed that controlling for prior anxiety nificant associations between emotional Consistent with a role hypothesis, a study
disorders reduced by more than 50% the distress and role underload (in both of couples reported that the excess of
size of the estimated association between genders) or role overload (in females), in a depression onset among females following
gender and depression. representative sample of private households adverse life events was entirely restricted
in England, Wales and Scotland, gender to crises involving children, housing or
differences in emotional distress persisted reproductive problems. This occurred
Social roles and cultural norms after controlling for socio-economic status, among those couples with a clear gender
The identification of individuals at high number of social roles and occupancy of difference in the associated roles, resulting
risk for developing depression, based on traditional female caring and domestic roles in increased responsibility of females in
socio-demographic variables and data (Weich et al,
al, 1998). these areas (Nazroo et al, al, 1997). These
collected across different countries and findings suggest that biological sex
cultural groups, indicates that social roles represents a useful starting approach in
and cultural influences contribute to a research on gender differences in depres-
female preponderance in depression rates. Life events sion, provided that the observed differences
Detailed reviews of epidemiological Stressful life events retain a substantial are then related to sociocultural roles and
findings (Bebbington, 1996, 1998) suggest causal relationship with the onset of de- norms by considering an individual's
that marriage may have detrimental effects pressive episodes (Kendler et al,
al, 1999). multiple social identities within his or her
in females, possibly due to gender-specific No clear evidence is available on the current and biographical contexts.
488
G E N D E R D I F F E R E N C E S IIN
N D E P R E S S I ON
Vulnerability and coping style activity stimulates the right posterior other hand, genetic factors might indirectly
hemisphere. The tendency to activate the increase vulnerability to depression in one
The role of adverse life events in producing left hemisphere as opposed to the right gender through temperamental
temperamental features
depression is mostly mediated through hemisphere under a variety of circum- associated with low self-esteem
self-esteem and
interaction with individual vulnerability, stances has been related to vulnerability to reduced social support or social integration
as expressed by personality characteristics, depression. To the extent that the right (Kessler et al,
al, 1992; McGuffin et al,
al, 1996;
attributional style and cognitive coping hemisphere influences the hypothalamic± Kendler et al,
al, 1998).
(Brewin, 1996; Ha Hanninen
È nninen & Aro, 1996). pituitary±adrenal axis, physical activity In the search for genetic factors impli-
Familial aggregation of depressive episodes, may be able to provide a normative cated in gender differences in depression,
temperamental features such as low restructuring of the axis, whose function attention has been paid both to genes
self-esteem,
self-esteem, and life events suggest that is affected in depression (Heller, 1993). contributing to sexual dimorphism and to
genetic factors may influence stable per- genes resulting in family resemblance. No
sonal characteristics involved both in Social support empirical evidence has supported a link
vulnerability to depression and in exposure Poor social support is related to onset and between the preponderance of females in
to high-risk environments (McGuffin et al, al, relapse of depression either through a direct depression and dominant genes located on
1988; Kendler et al,al, 1993, 1998). effect unrelated to levels of concurrent the X-chromosome (Faraone et al, al, 1987).
Bebbington (1996) has reviewed the adversities or through a buffering action The assumption that females have lower
evidence on the effects produced by which adds to the effect of adversities illness thresholds than males (threshold
expectations and attributional style in (Brugha, 1990). However, levels of social liability model) has received no support,
depression. Expectations of negative out- support do not seem to contribute to gender since the risk of recurrence of depressive
comes and of helplessness lead to hopeless- differences in depression. illness seems to be independent of the
ness, which may progress into depression. It has been claimed that females have a proband's gender (Merikangas et al, al,
The experience is moderated by causal stronger affiliative style than males, since 1985). An alternative explanation may be
attributions to events, by evaluation of their they require greater social support for their that females have greater liability to depres-
consequences and by the related inferences psychological health. As a consequence, sion owing to systematic non-familial bio-
about the self. Individuals at risk of females may be more vulnerable to events logical and/or environmental differences,
depression have been described as charac- affecting their close emotional ties and with familial transmission contributing to
terised by globality (that is, failure is related more likely to develop depression in variation around the means (Rice et al, al,
to factors applying across a variety of response to them (`cost of caring' hypo- 1984).
situations); stability (namely, factors thesis). Contrary to expectation, there is
responsible for failure are unlikely to no evidence for the excess of depression
change over time); and internality (where Gonadal hormones
among females being caused by reduced
the individual regards himself or herself as social support.
support. Research on the association Gonadal hormones influence neurotrans-
relatively incompetent). At present, there between social support and depression in mitter functioning and circadian rhythms
is insufficient support for the notion that males and females has provided contro- through both genomic and non-genomic
the cognitive characteristics of females are versial findings, with some studies reporting effects and contribute to personality
more consistent with a depressive attri- that social support is equally important in features and coping responses to stress
butional style than those of males. males and females as a predictor of recovery (Parry, 1995), but other biological factors
According to Nolen-Hoeksema (1987), from depression, and others showing greater and environmental variables seem to be
the increased vulnerability of females to beneficial effects or even a detrimental more prominent in depression (Seeman,
depression is mainly related to gender action in either of the two genders (Bebbing- 1997).
differences in coping with an initial lower- ton, 1996). A sharp increase in depression rates in
ing of mood, rather than in personality females occurs usually around mid-puberty.
characteristics of assertiveness and A direct relationship between levels of
passivity, which may predispose to depres- Genetic factors gonadal hormones and negative affect has
sion. Specifically, males tend to distract Although genetic factors retain a strong been reported, although the social impact
themselves from their mood by engaging influence on liability to depression, they of puberty, the resulting cognitive changes
in physical or instrumental activities, do not seem to contribute to the increased and the rising levels of life stress also can
whereas females are less active and risk to females by a direct mechanism. A be involved. A pathogenetic role of early
ruminate over the possible causes and recent population-based twin study of life- pubertal timing has not been confirmed by
implications of their depression, thus help- time major depression showed that the recent studies, which showed that pubertal
ing to prolong the depressed mood. Indeed, degree of genetic liability to depression is status was a better predictor of the emer-
less-effective coping responses involving similar in males and females who share gence of depression than the timing of
verbal and self-consolatory strategies have most of the genetic risk factors (Kendler pubertal transition (Bebbington, 1996;
been shown to occur more frequently in & Prescott, 1999). Another study Angold et al,
al, 1998; Silberg et al,
al, 1999).
females (Ha
(Hanninen
È nninen & Aro, 1996). confirmed these findings for major depres- Genetic factors influencing the risk of de-
Neurocognitive studies have suggested sion defined according to DSM±IV (Ameri- pression and negative life events have been
that verbal strategies like rumination may can Psychiatric Association, 1994) criteria, reported to interact with pubertal status
produce increased activity of the left but not for other definitions of major and gender to produce higher depression
posterior hemisphere, whereas physical depression (Bierut et al,
al, 1999). On the rates in adolescent girls, suggesting that
489
P I C C IIN
NEE L L I & W I L K IN
I N S ON
the genetic predisposition to depression and range according to age, most males with Bracke, P. (1998) Sex differences in the course of
depression: evidence from a longitudinal study of a
to stressful events may be `switched on' at depression lie within reference ranges. By
representative sample of the Belgian population. Social
puberty in females (Silberg et al,
al, 1999). inference, an age-related gender difference Psychiatry and Psychiatric Epidemiology,
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Breslau, N., Schultz, L. & Peterson, E. (1995) Sex
Other hormonal factors noradrenalin system has been suggested differences in depression: a role for preexisting anxiety.
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Activation of the hypothalamic±pituitary±
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