Maggie Scarf
Maggie Scarf

Fellowship Title:

Depression: A Female Malady?

Maggie Scarf
March 6, 1978

Fellowship Year

“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.

A woman is saved from suicide
A woman is saved from suicide

And according to Dr. Myrna Weissman, who is now carrying out a community survey in New Haven, Connecticut, such interviews of representative samples of the population “turn up an almost frightening amount of depression among women respondents.” Weissman, the director of the Yale Depression Unit, told me that survey after survey “discovers” the same phenomenon. “When you get out there and look at what’s happening in the community — regardless of who is or who isn’t getting treatment-women are far more depressed than men.”

Much of the depression among women uncovered by the community surveys does, observed Weissman, include milder forms of disturbance. “When you got to peoples’ homes, get out in the community, you draw in these somewhat less severe cases too. Because, you see, for a person to get into treatment — well, he or she has to be hurting, has to be in real pain. Getting help takes energy, and it can be expensive, and some feel it’s still a bit of a stigma. And so what our nets take in are these individuals who are doing some suffering, but who aren’t in real torment. They’re mildly symptomatic, perhaps more transiently symptomatic. But they don’t feel awful enough — or maybe don’t know enough to go for help.”

In terms of overall volume, Weissman spoke of a steady rise over the course of the past decade. Her own research on suicide attempts among females indicates a similar surge upwards; and primarily among women under thirty. “This has been well-documented in several countries over the past ten years,” she said. “And while all suicide attempters may not be depressed, I would say that most of them are.”

As rates of depression among women have increased, she added, the age at which they come to clinics for treatment has been inching downwards. Psychiatric texts printed before World War II described the “peak age” for depression among females as occurring at age 40 or beyond. “Right now,” said Weissman, “the typical person coming to the Yale Depression Unit is a young woman under the age of 35.” This age shift may be due to the fact that women who might have come in later in their lives are now appearing earlier, and with far less serious symptoms. “Or,” observed Dr. Weissman, “it may be due to the fact that help is more available, that getting treatment is more acceptable, and that the treatments themselves are radically improved.”

If women suffer so much more from depression than do men, one would naturally assume more unhappiness among members of the one sex than among the other. An “epidemic of depression” would be, it seems to me, synonymous with an “epidemic of unhappiness.” In the mid-1960s, though, a group of social researchers at the National Opinion Research Council set out to assess “happiness” in the American population. Using four very different types of communities as their “random” or “representative” sample, they went around asking people: “Would you describe yourself as Very Happy? Pretty Happy? Not too Happy?”

These researchers were interested in finding out whether it was true, as was widely believed, that men are happier than women. And they wanted to know how age might correlate with happiness. Did marital status — i.e., whether one was single, divorced, widowed, married show a predictable link with “being happy”? And how did things like educational level and personal income match up with happiness?

In their REPORTS ON HAPPINESS, this research group — directed by Norman Bradburn and David Caplovitz — noted that men and women fell into the Very Happy, Pretty Happy, Not Too Happy categories in roughly the same percentages. The importance of these findings need to be emphasized, they noted, “because they contradict some generally held notions — that women, for example, tend to be unhappier than men.” Far more linked to “being unhappy” were things like aging, having little education, having a low income. Being married seemed to correlate with more happiness; and there was less happiness among the unmarried groups of respondents.

But sex didn’t seem to relate to being happy. It didn’t appear to be true that women were in any way worse off than were men. Among certain groups in the population women were, in fact, better off. Single men were twice as unhappy as single women; divorced or separated men were unhappier than divorced or separated women; widowers showed far higher levels of distress and misery than did widows. Among these “unattached” individuals, there seemed to be something protective about being a woman. (Perhaps having to do with the feminine “permission” to be more emotionally expressive in a wide variety of relationships, and most of all, in friendship. Men tend to have “buddy” kinds of friendships with one another; relationships that are centered around an activity that they’re engaged in, working at side by side. But these are more guarded, as a rule, than women’s friendships; there is far less self-revelation, far less likelihood of free discussion of one’s concerns, problems, inadequacies. Women, freer to form intimate emotional bonds and readier to be more open with one another, are frequently more able to develop gratifying and support-giving relations with others.) And so the REPORTS ON HAPPINESS would suggest, it appears, that the statistics on women and depression might be the “Big Lie”.

But the social researchers did report a most peculiar phenomenon. And this was that while men and women described themselves as Very Happy or Not Too Happy or Pretty Happy in roughly equal numbers, they responded quite differentially to a “symptoms” checklist included in the extended interview.

Thus, when asked such questions as: “How often last week did you have . . . Back pains? Cold sweats? Common cold? Constipation? Diarrhea? Dizziness? Fever? General aches and pains? Loss of appetite? Headaches? Muscle twitches or trembles? Nervousness or tenseness? Rapid heart beat? Skin rashes? Upset stomach?…” it developed that women had had twice as many such symptoms in the course of the previous week! If general levels of happiness were roughly similar in the two sexes, why should the women be experiencing so many more minor symptoms-symptoms, which are, moreover, often believed psychogenic in origin — than did men respondents? General “unhappiness” must, one assumes, be the psychological soil in which many of these emotionally — related disturbances take root and proliferate. So if men and women are equally happy (which implies that they’re equally unhappy) why don’t both sexes show the same amounts of symptomatology?

The Bradburn-Caplovitz researchers made note of — but couldn’t explain — this odd conundrum. Men and women were, generally speaking, ”equals in happiness”. It was just that women had so many more of the common kinds of psycho — physiological symptoms than men reported having. And prominent among those symptoms were the very common, very widespread symptoms of depression.

©1978 Maggie Scarf

Maggie Scarf is spending her APF Fellowship writing about ” Depression Among Women.”