Depression
1997; Elsevier BV; Volume: 349; Linguagem: Inglês
10.1016/s0140-6736(97)90006-4
ISSN1474-547X
Autores Tópico(s)Eating Disorders and Behaviors
Resumo"Sex discrimination is not only a function of society, it is a function of disease".1Roberts DF Sex differences in disease and mortality.in: Carter CO Peel J Equalities and inequalities. Academic Press, London1976: 13-34Google Scholar This seems to be the case with depression, which is twice as common in women as in men. There are also differences between the sexes in clinical profile and course, and in treatment response–relevant to all branches of medicine. Depression is a major health concern not only because of personal distress, excess mortality, impaired interpersonal relationships, and restriction of work activities but also because of the economic burden it imposes. In 1990, the estimated cost to American society was $53 billion–comparable with that of diseases such as cancer, coronary heart disease, and AIDS.2Greenberg PE Kessler RC Nells TL Finkelstein SN Berndt ER Depression in the workplace: an economic perspective.in: Feighner JP Boyer WF Selective serotonin re-uptake inhibitors. 2nd ed. Wiley, New York1996Google Scholar The finding that depression is twice as prevalent in women as in men is not accounted for by different patterns of help-seeking behaviour since it has been consistently confirmed in general population studies.3Paykel ES Depression in women.Br J Psychiatry. 1991; 158: 22-29Google Scholar The female preponderance is evident from puberty onwards and is found across a range of cultures and countries. How can we account for this increased prevalence? Several factors are relevant. In the month after childbirth there is a 22-fold increase in the incidence of affective psychosis4Kendell RE Chalmers JC Platz C Epidemiology of puerperal psychoses.Br J Psychiatry. 1987; 150: 662-673Crossref PubMed Scopus (900) Google Scholar and a less dramatic rise in non-psychotic depression.5Cox JL Murray D Chapman G A controlled study of the onset, duration and prevalence of postnatal depression.Br J Psychiatry. 1993; 163: 27-31Crossref PubMed Scopus (599) Google Scholar The affective psychoses are associated with primiparity, caesarean section, and perinatal death, but the main trigger is thought to be neurophysiological–possibly related to increased dopamine sensitivity. Non-psychotic postnatal depression is related more to psychosocial stressors,6Harris B Biological and hormonal aspects of postpartum depressed mood.in: Working towads strategies for prophylaxis and treatment. 3rd ed. Br J Psychiatry. 164. 1994: 288-292Google Scholar although oestrogen seems to be an effective treatment.7Gregoire AJ Kumar R Everitt B Henderson AF Studd JW Transdermal oestrogen for treatment of severe postnatal depression.Lancet. 1996; 347: 930-933Summary PubMed Scopus (360) Google Scholar Overall, childbirth does not fully account for the disproportionate expression of depressive disorders in women. The association of depression with other aspects of the reproductive cycle–premenstrual syndrome,8Pearlstein TB Hormones and depression: what are the facts about premenstrual syndrome, menopause, and hormone replacement therapy?.Am J Obstet Gynecol. 1995; 173: 646-653Summary Full Text PDF PubMed Scopus (115) Google Scholar termination of pregnancy9Gilchrist AC Hanna PC Frank P Kay CR Termination of pregnancy and psychiatric morbidity.Br J Psychiatry. 1995; 167: 243-248Crossref PubMed Scopus (97) Google Scholar–is less clearly demonstrated and remains controversial. With regard to the menopause, it now seems that neither hormonal nor psychosocial changes are aetiologically related to depression.10Nicol-Smith L Causality, menopause, and depression: a critical review of the literature.BMJ. 1996; 313: 1229-1232Crossref PubMed Scopus (103) Google Scholar Social factors undoubtedly contribute to the genesis and maintenance of depression in both sexes. Women may be at special risk because of gender-related stressors together with different coping styles; lack of a confiding relationship with a husband or lover is one of the most important vulnerability factors. In men, core relationships are less critical: vulnerability to depression only emerges when the bonds of intimacy come under great stress.11Brown GW A psychogicial view of depression.in: Bennett DH Freeman HL Community psychiatry. Churchill Livingstone, London1991: 71-114Google Scholar What about work? Work outside the home is beneficial to women's mental health except when it creates difficulties with housework and childcare.12Parry G Paid employment, life events, social support and mental health in working class mothers.J Health Soc Behav. 1986; 27: 193-208Crossref PubMed Scopus (60) Google Scholar Certain activities where women predominate–care of the elderly, mentally ill, mentally handicapped, and physically disabled–are linked with increased rates of depression.13Twigg J Aitken K Cancers perceived: policy and practice in informal care. Open University Press, Buckingham1994Google Scholar Women, it seems, are more likely than men to subordinate their needs to the needs of someone they look after.14Johnson S Buszewicz M Women's mental health in the UK.in: Abel K Buszewicz M Davison D Johnson S Staples E Planning community mental health services for women. Routledge, London1996: 6-19Google Scholar Another factor widely thought to increase psychiatric morbidity in adult life, which is much more frequent in women than in men, is childhood sexual abuse. 25% of depressed women report a history of such abuse compared with 6% of controls.15Vize CM Cooper PJ Sexual abuse in patients with eating disorder, patients with depression and normal controls.in: A comparative study. 3rd ed. Br J Psychiatry. 167. 1995: 80-85Google Scholar Women are also afraid of sexual and other violence in their present lives and some are described as having a virtual curfew after dark.16Mezey G Stanko EA Women and violence.in: Abel K Buszewicz M Davison D Johnson S Staples E Planning community mental health services for women. Routledge, London1996: 160-175Google Scholar However, most violence against women is domestic;17Home OfficeCriminal statistics of England and Wales. HMSO, London1992Google Scholar often it goes undetected and it leads to health and social problems including depression. Low self-esteem is a risk factor for depression,11Brown GW A psychogicial view of depression.in: Bennett DH Freeman HL Community psychiatry. Churchill Livingstone, London1991: 71-114Google Scholar and girls are more likely than boys to display poor self-confidence, to rely on the opinion of others, and to blame themselves for failure.18Ruble DN Greulich F Pomerantz EM Gochberg B The role of gender-related processes in the development of sex differences in self-evaluation and depression.J Affect Disord. 1993; 29: 97-128Summary Full Text PDF PubMed Scopus (84) Google Scholar Self-esteem is related to factors such as early parental loss, rearing style of parents, unemployment, and degree of social support, but a study of female twins indicates a strong genetic contribution.19Roy MA Neale MC Kendler KS The genetic epidemiology of self esteem.Br J Psychiatry. 1995; 166: 813-820Crossref PubMed Scopus (69) Google Scholar A similar study in men would be of great interest. We have referred to differences in coping style but the precise nature of these is unclear. One study indicated that women rate the degree of stress similarly to men but respond with a greater intensity of symptoms.20Uhlenhuth EH Paykel ES Symptom intensity and life events.Arch Gen Psychiatry. 1973; 28: 473-477Crossref PubMed Scopus (68) Google Scholar Another showed that women rate the impact of stressors more severely and that men are more insulated from depression by cognitive distortion.21Sowa CJ Lustman PJ Gender differences in rating stressful events, depression, and depressive cognition.J Clin Psychol. 1984; 40: 1334-1337Crossref PubMed Scopus (38) Google Scholar Certain types of behaviour may enhance stress adaptation or act as a substitute for depression; for example, one suggestion is that a man might express distress through antisocial behaviour or alcohol abuse where a woman would become depressed. This notion is consistent with the finding that, although depression is commoner in women, overall rates of psychiatric morbidity are similar in the two sexes. There is some evidence that, where social roles are controlled for, gender differences in depression rates are absent. Among entrants to the teaching profession, when educational attainment, social class, marital status, and professional rank were matched, there was no difference in depression rates between men and women.22Wilhelm WK Parker G Is sex necessarily a risk factor to depression.Psychol Med. 1989; 19: 101-113Google Scholar In the Amish community, which strictly prohibits alcohol and antisocial behaviour, men and women have almost the same rates of depression.23Egeland JA Hotstetter AM Amish study I: affective disorder among the Amish, 1976–80.Am J Psychiatry. 1983; 140: 56-61Crossref PubMed Google Scholar In matriarchal societies such as that in Papua New Guinea prevalence sex ratios may even be reversed.24Weissman MM Klermann GL Sex differences and the epidemiology of depression.Arch Gen Psychiatry. 1977; 34: 98-111Crossref PubMed Scopus (1363) Google Scholar The study of behavioural patterns in other species has given rise to a "social competition hypothesis" which proposes that depressive states serve a useful evolutionary function.25Price J Sloman L Gardner R Gilbert P Rohde P The social competition hypothesis of depression.Br J Psychiatry. 1994; 164: 309-316Crossref PubMed Scopus (352) Google Scholar Social withdrawal and psychomotor inhibition are judged to represent a mechanism whereby an organism can adapt to failure in competitive situations and come to terms with low rank. Such a theory readily accommodates the social role commonly allocated to women in society and explains why where women have equal oppotunities the excess of female depression does not occur. Low rank has been linked to disturbances in indolamine metabolism, perhaps mirroring the neurochemical mechanisms of depression. Gender differences are evident in the metabolism of noradrenergic and serotoninergic neurotransmitters implicated in depressive illness.26Halbreich U Lumley LA The multiple interactional biological processes that might lead to depression and gender differences in its appearance.J Affect Disord. 1993; 29: 159-173Summary Full Text PDF PubMed Scopus (93) Google Scholar Moreover, the interaction of these systems with sex and stress hormones also varies according to sex. Morphologically, regions of the central nervous system involved in emotional or cognitive processing differ according to sex (hypothalamus, amygdala, and frontal cortex).27Kelly DD Sexual differentiation of the nervous system.in: Kandel ER Schwartz JH Jessell TM Principles of neural science. 3rd ed. Elsevier, New York1991Google Scholar These neurobiological differences may be a source of altered vulnerability to various factors that precipitate mood disturbances. Although this has not been directly tested, such a theory would account for the observed roles of both genetic and social factors in the genesis of depression. A comprehensive theory of mood disorders must integrate findings from sociology, psychology, ethology, and the neurosciences. The potential overlap between these areas is illustrated by evidence that environmental complexity and social stimulation affect morphological development of the central nervous system.28Heller W Gender differences in depression: perspectives from neuropsychology.J Affect Disord. 1993; 29: 129-143Summary Full Text PDF PubMed Scopus (78) Google Scholar The two sexes can experience quite different social environments even in the same classroom; for instance, teachers give more corrective feedback, individual instruction, praise, and encouragement to boys. Girls experience "relative deprivation" in the classroom.29Kimball MM A new perspective on women's math achievement.Psychol Bull. 1989; 105: 198-214Crossref Scopus (244) Google Scholar These and other variations in the social environment during development may contribute to neurobiological diiferences relevant to emotional processing. Panel 1 summarises internationally agreed diagnostic criteria for defiression.30World Health OrganizationThe ICD-10 classification of mental and behavioural disorders.in: Clinical descriptions and diagnostic guidelines. WHO, Geneva1992Google Scholar Depression is diagnosed where symptoms are present most of every day for 2 weeks or more. However, 50% of patients with depression do not consult their doctors and even in those who do the diagnosis is missed in around half.31Bridges K Goldberg D Somatic presentation of depressive illness in primary care.in: Freeling P Downey LJ Malkin JC The presentation of depression: current approaches. Royal College of General Practitioners, London1987Google Scholar Factors associated with reduced detection are listed in panel 2. Greater advantage could be taken of women's contacts with health professionals in general practice, family planning services, and gynaecology clinics. An excellent example is the project in Edinburgh whereby health visitors were trained to detect postnatal depression and provide counselling.32Holden JM Sagovsky R Cox JL Counselling in a general practice setting: a controlled study og health visitor intervention in treatment of postnatal depression.BMJ. 1989; 298: 223-226Crossref PubMed Google ScholarPanel 1JCD10 symptoms of depressionAt least two (mild/moderate) or three (Severe), Of:Depressed moodloss of interest and enjoymentIncreased fatiguabilityAnd at least two (mild), three (moderate), or four (severe) of:Reduced concentration and attentionReduced self-esteem and self-confidenceIdeas of guilt and unworthinessBleak and pessimistic views of the futureIdeas or acts of self-harm or suicideDisturbed sleep:Diminished appetitePanel 2Factors associated with decreased detection of depressionPatient factorsSomatic symptoms of depressionPhysical diseaseLongstanding depressionAtypical symptoms (eg, without overt depressed mood)Doctor factors: poor interview techniqueLess eye contactEarly and frequent interruptionPremature use of closed questions (which can be answered yes/no)Poor listenersFewer direct questions about psychological symptomsFewer direct questions about social circumstances At least two (mild/moderate) or three (Severe), Of: Depressed mood loss of interest and enjoyment Increased fatiguability And at least two (mild), three (moderate), or four (severe) of: Reduced concentration and attention Reduced self-esteem and self-confidence Ideas of guilt and unworthiness Bleak and pessimistic views of the future Ideas or acts of self-harm or suicide Disturbed sleep: Diminished appetite Patient factors Somatic symptoms of depression Physical disease Longstanding depression Atypical symptoms (eg, without overt depressed mood) Doctor factors: poor interview technique Less eye contact Early and frequent interruption Premature use of closed questions (which can be answered yes/no) Poor listeners Fewer direct questions about psychological symptoms Fewer direct questions about social circumstances Depression has an earlier onset, higher rate of recurrence, longer duration, and lower rate of spontaneous remission in women than in men.33Yonkers KA Chantilis SJ Recognition of depression in obstetric/gynecology practices.Am J Obstet Gynecol. 1995; 173: 632-638Summary Full Text PDF PubMed Scopus (49) Google Scholar, 34Sargeant JK Bruce ML Florio LP Weissman MM Factors associated with one year outcome of major depression in the community.Arch Gen Psychiatry. 1990; 47: 519-526Crossref PubMed Scopus (196) Google Scholar This picture may result from a combination of the specific female stressors and the fact that, once the threshold for first episode of depression is crossed, "illness begets illness".35Post RM Transduction of psychosocial stress into the neurobiology of recurrent affective disorder.Am J Psychiatry. 1992; 149: 999-1009Crossref PubMed Scopus (1487) Google Scholar The course of depression is further complicated by the fact that depressed women have more concomitant medical and psychiatric disorders which are associated with lower detection rates and poorer prognosis.36Pajer K New strategies in the treatment of depression in women.J Clin Psychiatry. 1995; 56: 30-37PubMed Google Scholar Depressed women are less likely than depressed men to commit suicide, and are six times less likely to commit suicide during the first postnatal year than during any other year, despite high rates of psychiatric morbidity during this time.37Appleby L Suicide during pregnancy and in the first postnatal year.BMJ. 1991; 302: 137-140Crossref PubMed Scopus (206) Google Scholar Depression is a syndrome for which drug treatment is effective irrespective of aetiology. Doctors may be reluctant to prescribe antidepressants when symptoms are c1ear1y related to life circumstances but drug therapy should not be withheld for this reason.38Priest RG Improving the management and knowledge of depression.Br J Psychiatry. 1994; 164: 285-287Crossref PubMed Scopus (35) Google Scholar In addition to medication, psychotherapy is important. Specific Psychotherapies, including cognitive therapy and interpersonal psychotherapy, enhance the effect of antidepressants and in some circumstances (eg, pregnancy) may be an appropriate alternative to drugs.39Weissman M Psychotherapy in the maintenance treatment of depression.Br J Psychiatry. 1994; 165: 42-50Summary Full Text PDF Scopus (105) Google Scholar Attention to level of social support can be of enormous therapeutic value, especially in women with dependent children. Those who respond to an antidepressant should continue on a full therapeutic dose, for a minimum of 4 months;40Paykel ES Priest RG Recognition and management of depression in general practice: consensus statement.BMJ. 1992; 305: 1198-1202Crossref PubMed Scopus (490) Google Scholar Maintenance therapy may be necessary for those with recurrent illness;41Montgomery SA Efficacy in long-term treatment of depression.J Clin Psychiatry. 1996; 57: 24-30PubMed Google Scholar and sometimes long-term psychotherapy is also required to prevent symptom recurrence. What other factors influence treatment response? Oral contraceptives induce liver enzymes and thus decrease concentrations of tricyclic antidepressants (the reverse is also true). There is some evidence that antidepressants work more slowly in women than in men42Frank E Carpenter LL Kupfer DJ Sex differences in recurrent depression: are there any that are significant?.Am J Psychiatry. 1988; 145: 41-45Crossref PubMed Scopus (225) Google Scholar and that women are more prone to side-effects from tricyclic compounds, monoamine oxidase inhibitors, and lithium.43Leibenluft E Women with bipolar illness: clinical and reasearch issues.Am J Psychiatry. 1996; 153: 163-173Crossref PubMed Scopus (226) Google Scholar Particular difficulties arise with use of medication around the time of conception, during pregnancy, and during breastfeeding. Group therapies36Pajer K New strategies in the treatment of depression in women.J Clin Psychiatry. 1995; 56: 30-37PubMed Google Scholar and problem-solving individual therapies44Thase ME Reynolds CF Frank E et al.Do depressed men and women respond similarly to cognitive behaviour therapy?.Am J Psychiatry. 1994; 151: 500-505Crossref PubMed Scopus (100) Google Scholar may suit women better than men. A gap remains between what is agreed to be appropriate treatment and what happens in clinical practice.45Donoghue J Tylee A Wildgust H Cross sectional database analysis of antidepressant prescribing in general practice in the United Kingdom, 1993–95.BMJ. 1996; 313: 861-862Crossref PubMed Scopus (89) Google Scholar Tricyclic antidepressants are often used in subtherapeutic doses, though this happens less with the serotonin-specific reuptake inhibitors which can usually be started at a therapeutic dose.45Donoghue J Tylee A Wildgust H Cross sectional database analysis of antidepressant prescribing in general practice in the United Kingdom, 1993–95.BMJ. 1996; 313: 861-862Crossref PubMed Scopus (89) Google Scholar Duration of treatment is often inadequate; most patients abandon medication in less than 2 months46MacDonald TM MacMahon AD Reid IC Fenton GW McDevitt DG Antidepressant drugs use in primary care: a record linkage study in Tayside Scotland.BMJ. 1996; 313: 860-861Crossref PubMed Scopus (80) Google Scholar–not surprisingly, in the light of a MORI survey revealing that 78% of the public believe antidepressants to be addictive and only 16% think that depressed people should receive them.47Priest RG Vize C Roberts A Roberts M Tylee A Lay people's attitudes to the treatment of depression: results of an opinion poll for the Defeat Depression Campaign just before its launch.BMJ. 1996; 313: 858-859Crossref PubMed Scopus (338) Google Scholar Effective psychological treatments may likewise also be underused. They languish, some say, because thay have not been developed and marketed by profit-making companies.48Andrews G Talk that works: the rise of cognitive behaviour therapy.BMJ. 1996; 313: 1501-1502Crossref PubMed Scopus (30) Google Scholar Provision of inpatient treatment for women is difficult, since they are more likely than men to take early discharge from hospital for social or domestic reasons.36Pajer K New strategies in the treatment of depression in women.J Clin Psychiatry. 1995; 56: 30-37PubMed Google Scholar In view of the consequences for the patient and her family, these shortfalls in delivery of effective treatments should be a major concern to health and social services. Development of mental health services and clinical practice should be informed by a better understanding of gender differences in clinical phenomena and service requirements. Clearly, diverse biological and social variables are interacting. From existing evidence, our judgment is that sex discrimination as much a function of depression as depression is a function of sex discrimination.
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