Depression in women

Depression is defined in the dictionary as a feeling of sadness and hopelessness, but it is a lot more than that. Depression can manifest itself in symptoms such as having low energy levels, lack of concentration, low self-esteem, disturbances in sleep and eating patterns and thoughts of suicide. Though it is generally accepted that there is a biochemical imbalance in depression, the diagnosis of depression relies mainly on the patient's reporting of their symptoms.
 
Until puberty, depression in both sexes develops at the same rate, but after its onset girls become twice as prone to depression than boys. This gender difference disappears after females reach their fifties, which indicates that it is highest during the child bearing years. However, it is not solely due to hormonal factors and there are many cultural, socio-economic, dietary and psychological factors that influences whether a woman develops depression. Another important factor in the diagnosis of depression in women is that they are more in touch with their emotions and therefore are more willing to seek help from health care professionals. 

The DSM-IV recently classified premenstrual symptoms, including depression, as Pre-menstrual Dysphoric Disorder (PMDD) — the criteria being that the remission of symptoms must occur a few days after the onset of menstruation. However, it fails to take into consideration that at adolescence, emerging sexuality, separating from parents and making decisions about the future constitutes a huge stress. 

Gunn et al (1987) found that in girls hormone levels only accounted for 1% of mood changes. Kendler (2003) found that men and women view a stressful event in a different light. For example, a man would see a loss of a job as a huge stress, while a woman would react similarly to a relationship break up. Nazoo et al (1998) found that depression was linked to the role identities of women and a woman who suffered a crisis that affected her role as a mother or wife was more likely to suffer depression. 

Alternatively, Zubenko et al (2005) showed that the interaction of the CREB1 gene with oestrogen receptors in women made them susceptible to depression. Grey, on the other hand, in his book "The Mars Venus Diet and Exercise Solution" postulates that there is a gender difference in the processing of amino acids and that this in turn affects the Serotonin and Dopamine levels in the individual.  
    
Pregnancy in the past was viewed as making women feel  biologically whole and therefore protected from psychiatric disorders. However, depression in pregnant women is similar to that in the rest of the female population and factors such as PMDD, limited social support, number of children, marital conflict, and ambivalence about pregnancy are a few of the factors that contribute to depression in pregnant women.

It is vitally important how a woman feels about herself during pregnancy. One of the women in Dana Jack's book "Silencing the Self" talks about how she feels about her body changing and her identification with her own mother, who curbed her self-expression to maintain the role of a good wife and mother. 
 
Postpartum depression that follows birth can range from crying and irritability to a full blown psychosis. O'Hara (1995) found lower levels of progesterone in breast feeding mothers who were depressed, and there is obviously hormonal and biochemical imbalances that occur after giving birth. However, Nicholson (1999) found that new mothers experienced a loss of time and autonomy where the care of the child was paramount together with a feeling of not being as attractive as before. The latter impacts on their sexuality which in turn affects relationships. Giving birth can lead to pain during intercourse due to scar tissue, and nipples become sore after breast feeing coupled with a general tiredness that leads to not wanting sex.

Furthermore, sometimes there is a loss of occupational identity among women who opt to be full time mothers and a feeling of isolation resulting from the lack of adult companionship often provided by colleagues. Others who do return to work may also feel guilty about abandoning the care of their babies to child minders and find it hard to get a balance between spending quality time with their baby and working,

Depression can also result from a miscarriage or infertility. Schaleksky (2001) in her book "Empty Womb, Aching Heart" talks of her own infertility and how each month you are reminded you failed again. Women who undergo fertility treatments have to cope with extreme hormonal fluctuations and have to inject themselves daily, and refrain from drinking or having sex when they feel like it. Domar (1999) believes that depression in itself can contribute to infertility, in such that women who are depressed are less able to care for an infant and nature ensures that conception does not occur.

Neugebauer et al (1997) found that women who miscarried in the first six months had a higher risk of depression, especially if it was their first pregnancy. There is also a high degree of shame and guilt as some of these women believe they had done something to precipitate the miscarriage. They also feel guilty for being jealous of other women who have successfully had children. Furthermore, Boyce et al (2002) stresses the need for these women to be able to grieve openly - something they find hard to do as there is no actual baby to mourn. I find this a common occurrence among my clients who have miscarried in  that they say cannot mourn their loss openly as others cannot relate to it.

Women more than men are also expected to retain their youthful looks. This has something to do with nature and fertility as a younger woman is more fertile than an older one. Youthful women are seen as more attractive, and Feingold (1999) found that they receive more preferential treatment. Cosmetic surgery is a way of maintaining youthful good looks, but research shows that 17% of women in Sweden who had breast enhancements committed suicide and an article in the British Medical Journal also highlighted a correlation between breast enhancement and suicide. It may be that these women had psychological problems that became heightened after cosmetic surgery leading to depression. 

There is an ideal body image portrayed in the media and among celebrities and many women become dissatisfied with their body shape. Grubb et al (1993) found there was a link between body size, eating disorders and depression. Though McCarthy (1990) found that depression linked to body image was prevalent mainly among younger women, now that the divorce rates are higher, and older women are dating in later life, depression relating to their bodies can occur at a later age. Though being slim or attractive has nothing to do with a woman's intelligence there is often an expectation that a woman must not only be good at what she does, but also look good.

Depression can also occur in older women due to the menopause and the fluctuations in oestrogen levels with the onset of menopausal symptoms such as hot flushes. Also during this time their can be depression due to the empty nest, where the last child leaves home and the woman experiences the loss of her role as a full time mother. 

Women are also physically weaker than men and are more likely to become victims of physical and sexual abuse. Mezey et al (1996) found high rates of depression and increased risk of suicide among women who have been raped. Women suffering from domestic abuse admitted to the Emergency and Accident wards also show a high degree of depression. McGrath et al (1990) found that ethnic discrimination, lower educational and income levels, marital problems and single parenthood are all factors in depression. Also, some women find it hard to leave a situation which is causing them to be depressed even if there is a way out. Repeated exposure to negative events leads to a feeling of helplessness, which Seligman termed Learned Helplessness.

Another reason why women tend to suffer higher degrees of depression is because they try to live up to the expectations of society and deny their own personal needs, McMullen (1999) found that women often defined themselves in terms of personal flaws describing themselves as "too mothering" or "too childlike". Most women are also taught that anger is not "nice" and angry women are often perceived as hysterical and irrational. No wonder another definition for depression is anger that is swallowed! 

It is beyond this article to discuss in depth all the reasons as to why women are more likely to suffer from depression than men, but it can be said that there are both biological and environmental factors involved. However, depression in women should not only be recognised in terms of an illness, but seen as being equally embedded in relationships with one's self and others and seen in the context of social settings. 

References 
Kendler.K (2003) Psychology Today Jul/Aug 2003 issue. 
Nazoo J Y et al (1997) Gender Differences in the onset of depression Pssy Med 27(1) 9-19.
Gray J The Mars Venus Diet and Exercise Solution Pan 2003.
Jack D Silencing the Self Harper 1993.
O'Hara M et al. Prospective Study of postpartum depression prevalence course and predictive factors Ab, Psychology 1984 91:158-171.                         
Nicholson P (1999) Postpartum Depression Psychology, Science and Transition to Motherhood, London Routledge.
Schalesky (2001) Empty Womb Aching heart.
Domar A (1999) Conquering infertility Viking 2002.
Neugebauer R(1997) AMA 277: 383-388.
Mcgrath E ed. (1990) Women and Depression Risk Factors and tTreatment Issues. 
McMullen L (1999) Metaphors In The Talk of Depressed Women in Psychotherapy 102-111.

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