Gender, parity and the prevalence of minor affective disorder

Are We Medicalizing Women’s Misery? A Critical Review of Women’s Higher Rates of Reported Depression

Epidemiological research consistently reports that women experience higher rates of depression than men. Competing biomedical, psychological and sociocultural models adopt a realist epistemology and a discourse of medical naturalism to position depression as a naturally occurring pathology within the woman, caused by biology, cognitions or life stress. Feminist critics argue that this medicalizes women’s misery, legitimizes expert intervention, and negates the political, economic and discursive aspects of experience. However, the alternative model of social constructionism may appear to dismiss the ‘real’ of women’s distress, and deny its material and intrapsychic concomitants, as well as negate relevant research findings. A critical review of sociocultural and psychological research on women’s depression is conducted. It is argued that a critical-realist epistemology allows us to acknowledge the material-discursive-intrapsychic concomitants of experiences constructed as depression, without privileging one level of analysis above the other, in order to understand women’s higher rates of reported depression.

The impact of altruistic behaviors for children and grandchildren on major depression among parents and grandparents in the United States: a prospective study

BACKGROUND

Although previous studies have suggested that altruistic behaviors are beneficial for mental health, few studies have examined the impact of altruistic behaviors for children and grandchildren (ABC) on the mental health of parents and grandparents using a longitudinal study design. It is needed to test whether paternal and maternal ABC prevent the development of mental health problems in later life.

METHOD

The association between three types of ABC (informal assistance, emotional support, financial support) in 1995-1996 and major depression (MD) in 1998 were examined using a nationally representative longitudinal study in the US (the National Survey of Midlife Development in the United States (MIDUS) in 1995-1996 and the MIDUS Psychological Experience Follow-Up study in 1998, N=724).

RESULTS

Moderate amounts of informal assistance and financial support by fathers/grandfathers, but not by mothers/grandmothers, showed a protective effect on MD 2-3 years later, holding parents/grandparents and children covariates. Emotional support was not associated with MD for both sexes after adjusting for covariates.

LIMITATION

The sample size in this study was relatively small and not all possible covariates were adjusted. The effect of children's/grandchildren's responses for ABC on the development of parental MD was not examined.

CONCLUSION

The impact of ABC on MD in 2-3 years varies depending on the types of ABC and the sex of parents/grandparents. Moderate amounts of informal assistance and financial support had a protective effect on MD in later life among fathers/grandfathers, but not among mothers/grandmothers.

Postnatal depression: a review of current literature

The print and other forms of media offer significant amounts of information to women about pregnancy, parenthood and the birth process, but much less information exists about postnatal depression and how to cope with the frequently painful realities involved in childbirth and parenting--especially when debilitated by postnatal depression (PND). Even less information exists about such women's reactions to interventions by health professionals, which is the subject of my Ph.D study in progress. This article reviews current literature about the clinical presentation of postnatal depression, the three major types of mood disorders following childbirth, the risk factors for postnatal depression, detection and treatment of postnatal depression and the need for further research on treatment outcomes for women with PND.

Prescribed daily doses and 'risk factors' associated with the use of benzodiazepines in primary care

OBJECTIVE

To assess the extent, characteristics and determinants of benzodiazepine prescription in outpatient Primary Health Care.

METHODS

A clinical audit of a stratified random sample of Primary Health Care Centres in the seven islands and 1.6 million inhabitants region of 'Canarias' in Spain was carried out. From those centres, a random sample of 1045 clinical records was reviewed and information on diagnosis, prescription and prescribed dosages was collected in a structured questionnaire. A multivariate logistic regression analysis was performed in order to determine the 'risk factors' for the use of benzodiazepines.

RESULTS

Benzodiazepine prescription was recorded in 23.4% of all clinical records; 87.7% of these were for benzodiazepines classified as anxiolytics (N05B) and 12.3% for hypnotics (N05C2). Benzodiazepine prescription was more common for women, elderly, widowed, divorced, low educational background, housewives and retired people. Using multivariate logistic regression, the probability of benzodiazepine prescription was found to be closely related to age, gender and employment status, but not with educational level. Prescribed Daily Doses were lower than Defined Daily Doses (DDD) in 77.1% of all anxiolytic prescriptions, but were in agreement with DDD in 90% of hypnotic prescriptions. The duration of treatment recorded in the clinical records was 25+/-21 months, with a range of 1 and 144 months. General Practitioners were responsible for 67% of all benzodiazepine prescription. Anxiolytics were prescribed as a single daily dose in 57% of the cases, and only 'at supper' in 48.6%.

CONCLUSION

In the general population attending Primary Health Care Centres of the Canary Islands Health System the prescription of benzodiazepines is higher for women and the elderly, and the most common use is chronic, with a duration of over 2 years in most cases. Anxiolytics are prescribed in doses which are much lower than those used as DDD and were used only 'at night' in almost half of the cases. This could represent an overlapping of the indications with hypnotics, and explain part of the huge difference in the use of anxiolytics in Spain compared with other figures in Europe. This fact must also be taken into account when making inferences of benzodiazepine use from sales statistics, which are very imprecise measures of drug use.

Early life menstrual characteristics and pregnancy experiences among women with and without major depression: the Harvard study of moods and cycles

BACKGROUND

Other than premenstrual dysphoria, few studies have examined the extent to which basic characteristics of the menstrual cycle and the occurrence of other reproductive landmarks impact on the risk of major depression.

METHODS

From a population-based sample of 4161 premenopausal women 36-45 years of age, we identified 332 women who met DSM criteria for past or current major depression and a sample of 644 women with no such history. In person interviews included a detailed assessment of menstrual cycle characteristics from age at menarche through study enrollment as well as other reproductive landmarks.

RESULTS

Risk of depression increased significantly with decreasing age at menarche (P<0.001). The risk of depression was also higher in women with heavier menstrual flow and cycle irregularity during the first 5 years of menstruation. Women with a history of multiple abortions were 2-3-times more likely to develop major depression (95% CI 1.6-4.1). Increasing months of breastfeeding was associated with a decreased risk of depression after adjustment for education, marital status, and number of livebirths (P-value, test of trend=0.012). This association was largely confined to depression during the postpartum period.

LIMITATIONS

Menstrual and pregnancy history exposures were self-reported and retrospectively assessed. However, women with and without a HISTORY of depression were subject to similar recall requirements that likely resulted in an underestimate of most risk estimates.

CONCLUSIONS

Clinicians involved in routine obstetrical and gynecological care of women need to recognize that menstrual and pregnancy history events may serve as potential markers for subsequent psychiatric sequelae.

[Association of depressive symptoms and social functioning in primary care service, Brazil]

OBJECTIVE

Depressive disorders represent a major public health problem due to their high prevalence and psychosocial impact. Depressed patients are assiduous users of primary care services, although their depression is very often misdiagnosed. The objective of the study is to evaluate the association between depressive symptoms and social functioning in individuals that seek primary care services in a Brazilian capital.

METHODS

The study included 2,201 primary care users in the city of Porto Alegre, Brazil. The participants' physical and emotional health was assessed through an interview using a questionnaire including 2 general questions from the World Health Organization's Quality of Life instrument (WHOQOL-brief); other questions from the Medical Outcomes Study Short-Form 12 (SF-12), MHI 5 (MHI-5), Centers for Epidemiologic Studies-Depression (CES-D), and additional questions about work loss days and health care utilization.

RESULTS

Of all individuals, 79.5% were women aged on average 40 years. The intensity of depressive symptoms (measured by CES-D) was 20.2 for women and 16.2 for men. All parameters studied had an inverse relationship with the intensity of depressive symptoms.

CONCLUSIONS

This study reinforce the findings that depressive symptoms have a strong association with poor social functioning and quality of life and a higher utilization of health resources in primary care patients.

Patient gender differences in the diagnosis of depression in primary care

Our purpose was to explore why women are more likely than men to be diagnosed as depressed by their primary care physician. Women were found to have more depressive symptoms as self-reported on the Beck Depression Inventory (BDI). Women having high BDI scores (reflecting significant depression) were more likely than men with high BDI scores to be diagnosed by their primary care physician (p = 0.0295). Female patients made significantly more visits to the clinic than men. For both sexes, patients with greater numbers of primary care clinic visits were more likely to be diagnosed as depressed. Logistic regression revealed that gender has both a direct and indirect (through increased use) effect on the likelihood of being diagnosed as depressed. Patient BDI score, clinic use, educational level, and marital status were all significantly related to the diagnosis of depression. Controlling all other independent variables, women were 72% more likely than men to be identified as depressed, but this effect did not achieve statistical significance (p = 0.0981). In gender-specific analyses, BDI and clinic use were again significantly related to the diagnosis of depression for both sexes. However, educational and marital status predicted depression diagnosis only for women. Separated, divorced, or widowed women were almost five times as likely to be diagnosed as depressed as those who were never married, all other factors being equal. Clinic use and BDI scores were found to be important correlates of the diagnosis of depression. There was some evidence of possible gender bias in the diagnosis of depression.

The course of postpartum psychiatric disorders in women and their partners

This study examined the course of postpartum psychiatric disorders in a community sample of mothers and their partners to determine whether sociodemographic variables, life stress, and psychiatric history were related to persistence of mental health problems. At 6 months postpartum, 48 index couples where the wife had a psychiatric disorder at 2 months postpartum and 50 control couples with no such diagnosis underwent diagnostic interviews and completed questionnaires on psychological symptoms, life stress, and treatment history. The results indicate that at follow-up, 54% of the index mothers still had a psychiatric diagnosis, as did 60% of their partners who had had a psychiatric diagnosis at 2 months postpartum. Socioeconomic status, country of origin, and life stress were related to persistence, as were diagnosis and timing of onset of the disorder. About a third of the parents were referred for treatment. It is concluded that for many families, postpartum psychiatric disorders are not a transient phenomenon.

[Support intervention in grieving patients]

OBJECTIVES

Principal: to describe the characteristics of grievers in an urban area. SECONDARY: To describe the risk factors for pathological grief, and the distribution of those cases of grief which are resolved and those tending to become chronic.

DESIGN

Descriptive study.

SETTING

Txantrea Health Centre, Pamplona.

PATIENTS

Consecutive sampling of all the family members of people who died between January and July 1999. In 4 basic care units, a grief-monitoring procedure was followed with 62 bereaved persons for 8 months. In the 8 other basic care units, the 21 bereaved people recruited formed a control group.

INTERVENTION

Initial interview with risk factors of pathological grief described in the PAPPS. Periodical consultations for help. Final interview with test from the Texas Revised Inventory of Grief Manual to determine the evolution of grief.

MEASUREMENTS AND MAIN RESULTS

Over 90% had some risk factor. Considerable numbers were self-aware of difficulty in overcoming earlier grief. Over 50% did not attend even half their appointments, which was related to low income (p < 0.005) and background of depression (p < 0.04). Low income was related to worse evolution of grief (p < 0.01). There were high proportions of prolonged and delayed grief, without any differences found between the intervention and control groups.

CONCLUSIONS

There were large numbers of bereaved people with risk factors, frequent failure to adhere to the proposed programme, and a high number of cases of lengthy and delayed grief.

Gender and minor psychiatric morbidity: results of a case-control study in a developing country

OBJECTIVE

Women suffer from minor psychiatric disorders (MPM) more frequently than men. Most of the studies were conducted in England and in the United States and some reported the higher occurrence of MPM among women to be modified by marital status and others by sociodemographic variables. The present study intends to address this question in a developing country.

METHOD

A population based case-control study was conducted in three important urban centers in Brazil. Two hundred seventy-six individuals diagnosed as new cases of MPM and 261 controls were selected to investigate the role of a set of sociodemographic variables in the association between gender and MPM using logistic regression models.

RESULTS

Univariate analysis showed that women were more likely than men to suffer from MPM (OR = 3.34; 2.27-4.91). After controlling for other sociodemographic variables, female gender was still positively associated with MPM, but not in a homogeneous way. A multiplicative interaction of gender with age group was found (LRT = 6.01; 2 df; p = 0.05) suggesting an increment in the magnitude of the association among those older than thirty years. Odds-ratios were 2.33 (1.19-4.55), 6.85 (2.86-16.41), and 7.47 (2.90-19.22) for age groups of fourteen to twenty-nine; thirty to forty-four; forty-five or more, respectively. There was no evidence of interaction of gender with marital status or other sociodemographic variables.

CONCLUSIONS

The findings are consistent with the modification of the association between gender and MPM being mediated by social factors.

Prevalence of psychiatric morbidity in the adult population of a rural South African village

We report on the first South African two-stage community prevalence study of psychiatric morbidity, conducted in Mamre, a rural "coloured' village, 50 km from Cape Town. Randomly selected adults (N = 481) were assessed using the Self-Reporting Questionnaire (SRQ) as a first-stage screen and the Present State Examination (PSE-9) was administered to a proportion of the sample (N = 121) as the second-stage criterion. Demographic, health care utilization, and substance abuse data were also collected. Using the PSE-9 CATEGO Index of Definition of 5, the weighted prevalence of psychiatric morbidity was 27.1% (confidence interval of 19.5-34.7%), the majority of cases being given a tentative diagnosis of depressive or anxiety disorder. The CATEGO algorithm may not be fully appropriate in this cultural context as there was an apparent over-diagnosis of paranoid states. The SRQ's weighted sensitivity and specificity were 0.49 and 0.82 respectively. Overall, the SRQ correctly identified 67% of cases and non-cases. No demographic variables predicted psychiatric morbidity, but there was an indirect link between morbidity and primary care utilization. Further South African studies of the validity of both the SRQ and of criterion instruments are needed. These may contribute to knowledge regarding cultural factors affecting psychiatric diagnosis.

Life events before psychotic episodes: do clinical and social variables affect the relationship?

We have previously used data from the Camberwell Collaborative Psychosis Study to demonstrate a strong relationship between life events and subsequent episodes of schizophrenic, manic and depressive psychoses. In the current paper, we confirmed the robustness of this relationship, which was not vitiated by controlling for clinical and social variables. Thus, the event-onset association was not affected by the type of onset or the number of previous episodes. The influences of social variables, such as social class, ethnicity and marital status, did not seriously diminish the importance of events, although there may be a role for other forms of social disadvantage as reflected in these variables.

Gender and depression in Anglo-Jewry

This study found similar prevalence of case depression among men as among women in a sample of 339 Jews affiliated to orthodox synagogues (157 men and 182 women). There were significant gender differences in several social-situational factors and symptoms, mostly in the direction that would suggest that case depression would be higher among women than among men. That this was not so is suggested to be the result of the cultural milieu: social factors that have been found to be associated with depression in other groups of people did not function as risk or vulnerability factors among the Jews studied. In particular, the evidence indicates the importance of specific cultural-religious values in contributing towards the prevalences that were observed. These values included the esteem attached to women's central role in family management and the low use of alcohol and suicide as escape routes from depression.

An adoption study comparing the prevalence of psychiatric illness in women who have adoptive and natural children compared with women who have adoptive children only

The current study compares the current and lifetime prevalence of affective disorder in women who have adopted and have natural children (n = 110) with women who only have adopted children (n = 176). There was no difference in lifetime prevalence of psychiatric disorder between the two groups and a nonsignificant trend for women who had born children to have had a major depressive episode during their lifetime 48 (44%) cf 62 (35%). The increased prevalence of psychiatric illness in married women with children cannot be explained by the biological fact of bearing children. None of the social variables related to child-rearing which were examined influenced the lifetime prevalence of psychiatric disorder.

Clinical survey of a psychiatric mother and baby unit: characteristics of 100 consecutive admissions

Demographic, obstetric, clinical features and clinical outcome of 100 consecutive admissions to a psychiatric mother and baby unit are presented. Referral patterns by health services involved are also examined. 56% of admissions occurred within 2 weeks of delivery and the mean duration of admission was 2 months. Patients were categorized as having schizophrenia (n = 20), affective psychosis (n = 56) or non-psychotic disorders (n = 24) and these three groups were compared. There were few demographic and obstetric differences between diagnostic categories. The affective psychosis group were more likely to have acute illnesses with an onset and admission occurring within 2 weeks of delivery. Women with non-psychotic disorders were also most likely to become ill within 2 weeks of delivery but tended to be admitted later. Only 7% of the affective psychotic and non-psychotic women were discharged separated from their infants. Women with schizophrenia were less likely to have acute admissions and required greater input of nursing and service resources than mothers with other illnesses but 50% were discharged without their infants. More research is needed into matching models of care to the needs of mothers with different kinds of chronic, recurrent and new episodes of mental illness that present after childbirth. There are few guidelines to aid clinical staff in assessing the risk, current or future, of significant harm to an infant as a consequence of maternal mental illness, particularly of schizophrenia.

Postnatal mental illness: a transcultural perspective

The three main conditions that are associated with childbirth are the maternity blues, postnatal depression and post-partum psychosis. The prevalence of the blues, which are mild, transient and very common disturbances of postnatal mood, does not appear in a major way to be related to environmental, social or cultural factors. Postnatal depression, which has a predominantly psychosocial etiology, surprisingly does not appear to vary in incidence across different cultures in the few studies reported that permit direct comparisons. There is also no good evidence for or against the theory that postnatal depression is partly the consequence of the customs and rituals that traditionally mark the transition to parenthood being stripped away in developed Western societies. However, the lack of relevant research and limitations of method severely restrict any conclusions that can be drawn. There is much firmer evidence for a consistent incidence of post-partum psychosis across cultural and ethnic divides; this observation, together with clinical data and historical evidence of an unchanging incidence rate during the past 150 years, points to a primarily endogenous etiology for the psychoses, which may be triggered by the physiology of childbirth. The transcultural approach to postnatal psychiatric disorders provides a unique opportunity not only to test hypotheses about social and cultural contributions to the etiology of psychotic and non-psychotic reactions to childbirth, but also an opportunity to study the ways in which social factors can influence the evolution of psychopathology. It is also possible that in some cultures the family and social milieu may play a major part in buffering infants from the adverse effects of maternal postnatal illness, but the evidence is anecdotal. Systematic research across cultures will lead to better recognition of maternal illness as well as to better prevention and management.

Risk factors for depression in elderly people: a prospective study

In 1982-1983 a random sample of 1486 people aged 65 years and above was generated from general practitioner lists; 1070 were interviewed in the community using the Geriatric Mental State and a Social History questionnaire. The cohort was followed up by interview 3 years later. At year 3 the diagnostic computer program AGECAT diagnosed 44 incident cases of depression. Information from the depressed group's initial and further interviews was compared with a control group (which excluded cases of affective or organic mental illness). Univariate analysis yielded three factors that were significantly associated with the development of depression 3 years later: a lack of satisfaction with life; feelings of loneliness; and smoking. Multivariate analysis confirmed their independent effects and revealed 2 further factors attaining significance: female gender and a trigger factor, bereavement of a close figure within 6 months of the third-year diagnosis. Some other factors traditionally associated with depression, such as poor housing, marital status and living alone, failed to attain significance as risk factors.

The Dubai Community Psychiatric Survey: I. Prevalence and socio-demographic correlates

This paper describes the methods and initial sociodemographic findings of the first community psychiatric survey from an Arabian country. It was carried out on a sample of women in Dubai, one of the seven United Arab Emirates. Psychiatric status was established using the PSE-ID-CATEGO system. The overall prevalence of disorder in these women was a high 22.7% (13.7% depressive disorders; 7% anxiety states). There was little association with sociodemographic variables, except that prevalence was high in divorced, widowed and separated women, polygamously married women and single parents. The high prevalence may be related to the rapid sociocultural change in this society. Future reports will examine the influence of sociocultural change at an individual level.

The Camberwell Community Survey: a summary of results

The Camberwell Community Survey was carried out during 1978 and 1979 on a random sample of the population of Camberwell in south London. This is an inner city area with high deprivation indices. 800 members of the community and a random sample of 74 out-patients with affective symptoms were interviewed using the Present State Examination (PSE) and Life Events and Difficulties Schedule (LEDS) of Brown and Harris. The survey has resulted in many publications. The present paper summarises its aims, methods and results.

Is sex necessarily a risk factor to depression?

"To isolate and quantify possible determinants of any increased prevalence of depressive disorders in women we studied a select group of men and women, initially similar in terms of a number of putative social determinants of depression, and reviewed the sample five years later when social role diversity was anticipated. We used the Diagnostic Interview Schedule (DIS) to generate DSM-III and RDC diagnoses to estimate lifetime depressive disorders, and established (via corroborative reports) the likely accuracy of those data. Despite lifetime depression being a relatively common experience, no significant sex differences in depressive episodes were demonstrated, suggesting the possible irrelevance of biological factors in determining any sex difference. As there was not major social role divergence over the five year study, we interpret the lack of a sex difference as a consequence, and suggest that findings support the view that social factors are of key relevance in determining any female preponderance in depression described in general population studies."