Depression: A Female Malady?

“It’s a fact that in almost every clinical situation and almost every organized health care system, women are diagnosed as depressed three times as frequently as are men. This is a fact not only in this country, but in virtually every health care system around the world — in industrial and urban and even in non-industrial and rural settings — there are going to be three cases of female depression for every male who comes in for treatment of depressive symptoms…”

(From a Harvard Medical School lecture delivered by Dr. Gerald L. Klerman, an expert in the field of Depression and currently Director of ADAMHA (Alcohol, Drug Abuse and Mental Health Administration.)

“Depression is, you know, a bit like a trick mirror,” one physician told me. “I mean that it blows up, enlarges — displays in fantastic disproportion — those psychological issues and problems that are normal, that are expectable, that are simply endemic to the various ages and stages of the life-arc.”

An adolescent girl, a woman in her late twenties, or at mid-life, or in her sixties: all may come in for treatment of the same disorder-depression — but, he remarked, those depressions will have fundamentally different underlying motifs. In adolescence, the issues would focus around separation from parents, problems of changing body-image, problems of self-esteem; in the mid-twenties, the issues would have to do with sexual identity, intimacy, issues relating to “committing oneself”; in midlife, they might concern the fading of physical attractiveness (often perceived as the sole or most important source of inter-personal power) or the loss of the “nurturing, mothering” role, etc.

A depressive disorder is a failure in adaptation (or what Samuel Butler called “accommodation” to ongoing inner and outer changes). But by analyzing what isn’t happening, in its proper progression, one can discern what ought, normally, to be happening.

Such “personality changes during the course of adult life” have recently become a hot topic in psychology. But most of the studies done, and much of what is now known about adult development, has focused upon the adult male. Female personality development, over the course of the life-arc, must be assumed to be somewhat, if not radically, different. Little is known, however, about the psychological shifts women undergo during the course of their lives. Nor has there been a great effort to link psychological insights with the moving wheel of physical changes that occur from menstruation to motherhood to menopause and beyond.

In the book Women and Madness, author Phyllis Chester contends that the biases of (male) clinicians lead to a situation in which women tend to get diagnosed (i.e., called) “depressed”, “disturbed”, “crazy”, “mad”, with somewhat sinister readiness. Such diagnoses are mainly psychiatric put-downs, she suggests; they are nothing other than a covert societal mechanism, a means of punishing those women who may be deviant about and refusing to adjust to “accepting their feminity.” The woman, who fails to accept her feminine role, and its attendant inferior social status, gets socked with a psychiatric diagnosis. And diagnosis itself is, in Chester’s view, a handy “medical” and scientifically respectable device for keeping women in their place.

What Chester is suggesting is, in other words, that the huge sex differential in the “numbers of persons seeking treatment” for depression reflects only the ease with which women receive this label-which in turn reflects social discrimination.

Might this be so? Might the high rates of depression among women be nothing other than a social phantasmagoria, a statistic that relates to nothing real-aside, that is, from the prejudices of clinicians?

Chester’s argument has, I will say, a certain compelling quality; and she brings in daunting empirical evidence to support the things that she says. My own problem with it is that during my own tours of duty, in a wide assortment of clinical settings, I didn’t encounter any women whom I thought suffered from a primary problem that I could call “psychiatric labeling”. The women that I came to know slightly or to know well, whom I talked with little or at great length, whom I spent short periods of time with or saw over a period of months they were suffering. They were in pain, and in need of help. When Ellie de Pino, a graduate student in biochemistry, was brought into a Boston crisis-clinic by her roommates — she’d been having uncontrollable crying fits, and was terrified and ashamed about “feeling so lost, so alone, so vulnerable” — the diagnosis she was given had nothing to do with psychiatric stigmatization. When Kay Ellenberger, the slender, handsome pale haired mother of two pre-school children, came home after successfully playing in a tennis tournament, and felt precipitously “as if the bottom were dropping out of everything; that I was a nothing; that I’d promised to do too many things I didn’t care about for too many people I didn’t give a damn about, and it was all stupid and meaningless; I wanted to quit, to be dead…” her misery, her psychological hurting were real.

One investigator’s experiences, i.e., my own, are not and can’t pretend to be anything like an overview of the treatment women are given in the entire mental health care system. Mine is the short view, the close-up look at what can be seen and heard at close hand… which may be open to charges of particularity, of quirkiness, of biases of all kinds.

Dr. Maria Guttentag an epistemologist directed a nationwide study on the problem of women and depression a few years ago and found that the seemingly cockeyed figures on depression among women represented a “true finding.”

Some experts have taken hearty exception to the Guttentag viewpoint: other kinds of explanations of what appears to be much more depression among women abound. There is, for instance, one school of thought, which has it that women simply consult doctors more often. For it is true that women do so and that they see their physicians for many more trivial kinds of disabilities. As recent studies done at the National Institute of Mental Health have indicated, this sex differential in “doctor-going” apparently springs into being sometime around puberty. Before that time, males and females see doctors about the same amount; in childhood, the males may take a slight lead in numbers of visits. But after puberty, the picture shifts rapidly: there is a sharp increase on the part of the girls, and a decrease on the part of the boys. And this changed pattern — with women seeing doctors more frequently and with more minor symptoms — will persist throughout adult life. “Going to the doctor” seems to be, in essence, a particularly “feminine” way of dealing with stress, and of coping with all kinds of difficulties.

And a person who comes to a doctor for any reason is, obviously, likelier to receive a diagnosis than is someone who never comes for treatment at all. If, furthermore, the person is freely expressive about her sorrows, her sadnesses, her life-disappointments, she may more easily be diagnosed as “depressed.” And given medications- tranquilizers or antidepressants — to help her weather her current difficulties as well. A man, with the same minor symptoms, the same degree of distress and unhappiness, would be less likely to go to the doctor in the first place; and if he did, less inclined to discuss any emotional components of his physical complaint. The masculine sex-role stereotype dictates more stoicism, less free expression of one’s sadnesses and weaknesses, less owning-up-to both physical and mental difficulties. Men are far more reluctant to take on, even on a transitory basis, the “sick role”; it’s inconsistent with the standard culture ideal of “rugged masculinity.”

Is the sexual disparity in “numbers of depressed women” and “numbers of depressed men” then nothing other than a numerical mirage? There is now very powerful evidence, coming from so-called “community studies”, that suggests that irrespective of who goes, or doesn’t go, to doctors, women are really more depressed than are men.

Community studies are studies of the community at large. After selecting random, or representative, samples of the population, interviewers fan out to go and carefully and systematically question “respondents” in their homes. (The people interviewed are thus, obviously, not being selected on the basis of anything they do or don’t do — such as consulting a physician.) If the study happens to be an assessment of “psychiatric symptoms” in the members of the community, then the research interviewer will fill out a comprehensive questionnaire on many aspects of mental health and psychological functioning. To elicit information about a possible depressive disorder, for instance, there may be questions such as: “Did you ever have a period that lasted at least one week when you were bothered by feeling depressed, sad, blue, hopeless, down in the dumps, that you just didn’t care any more, or worried about a lot of things that could happen? What about feeling irritable or easily annoyed?…” If the — person’s answer to these queries happens to be in the affirmative, other questions follow — about sudden changes in appetite, in sleeping patterns, in energy levels, in interest in customary activities, in sexual functioning. There are questions about “feeling guilty”, “worthless”, “down on oneself”; and about problems in concentrating and making decisions . . . and in general, ability to “think”. There are, finally, inquiries about thoughts of death and/or suicide…whether the “respondent” has had such thoughts…whether he or she has actually made a plan or attempted suicide.