Dr. Hankin is assistant professor in the Department of Psychology at the University of Illinois in Chicago.

Acknowledgments: The author reports no financial, academic, or other support of this work. 


 

Abstract

At what stage in life do more females become depressed than males, and why? This article reviews the gender difference in depression. On average, there is a 2:1 ratio of depressed females to males throughout the lifespan in terms of descriptive course, possible causes, and treatment response. More girls than boys begin to become depressed after 13 years of age (during puberty), and this gender divergence continues throughout adulthood. Many causal explanations for this difference have been investigated. A genetic liability for depression is stronger for pubertal girls than boys, but there is no gender difference in genetic vulnerability among children or adults.


At present, neither hormonal nor other biological factors have sufficiently explained the gender difference in depression. Females encounter more stressful negative events and sexual abuse than males. The stereotypical feminine gender role is associated with depression more than the masculine gender role. Compared with males, females have more negative cognitive vulnerabilities, and they tend to cope through rumination. These different causal explanations can be integrated into a developmental depression model to understand why more females are depressed than males. Males and females do not differ in treatment seeking or response for depression.

 

Introduction

Depression, one of the most common psychiatric disorders, is prevalent in approximately twice as many women as men.1 However, childhood depression is more common in boys than in girls.2 With the transition to adolescence, depression becomes more prevalent in girls; this trend continues until middle to late adulthood. This descriptive timeline for the development of the gender difference in depression has been found across different countries and cultures.

There are two primary reasons why it is important to understand the development of the gender difference in depression. First, depression has substantial personal, interpersonal, familial, and economic costs. As a result of their increased depression, females experience significant decreases in their quality of life and productivity. Second, elucidating why more females are depressed than males can provide a window that may help advance scientific understanding of the causes of depression in general over the lifespan.

This article reviews how the gender difference in depression emerges over the lifetime and surveys explanations for why more females than males become depressed.1,3-6
 

Descriptive Epidemiology of Depression

An important issue concerning the gender difference in depression is the possibility that, in reality, males and females do not actually differ in the prevalence of depression but simply in their willingness to report depressive feelings, or in how they describe their emotions. However, evidence does not support the reporting bias hypothesis because males are as likely as females to report and discuss their depressive symptoms and negative emotions.1 Instead, research supports the fact that the observed gender difference in depression is real and not the result of a gender difference in expressing emotion.
 

For depressive mood and symptoms, many studies converge on the fact that more boys are depressed prior to 13 years of age, while more girls are depressed after 13 years of age. Multiple longitudinal studies,7-9 ones that have prospectively followed children from preadolescence to young adulthood, show that in girls, depressive mood and symptoms increase after 13–14 years of age, whereas in boys, depression levels remain constant or do not rise as rapidly. Approximately 25% to 40% of adolescent girls and 20% to 35% of adolescent boys experience elevated levels of depressed mood.10 After adolescence and throughout adulthood, this gender divergence in depressed mood continues with adult women experiencing more depressive mood and symptoms than adult men until middle–late adulthood.1,11
 

For depressive disorder, cross-sectional studies12-14 provide evidence for the transition to increased prevalence rates of depressive disorders among females >13 years of age. Prospective research2,15 shows that more females receive a diagnosis of clinical depression beginning after 13 years of age. For example, a prospective study of a community birth cohort2 found that both boys and girls become substantially more depressed from 15–18 years of age, and significantly more girls become clinically depressed in middle–late adolescence. Figure 1 displays a graph of the development by age and by gender.


 

A longitudinal study15 of the offspring of depressed parents indicated that more girls than boys become depressed around 13 years of age for both the high-risk group of children of depressed parents as well as the group of children of nondepressed parents. As with the adult studies of depressive symptoms, approximately twice as many adult women as men experience clinical depression from middle adolescence through middle–late adulthood (55–65 years of age), when there is no longer a gender difference in depression.1,4,11
 

These studies clearly showed that the gender difference in depression emerges after 13 years of age; however, chronological age may not be the best indicator of the point at which depression becomes more common in girls than boys. Research investigating pubertal development shows that more girls become depressed around mid-puberty (after Tanner stage III).12
 

Ethnicity also interacts with pubertal status.16 Caucasian adolescent girls who have experienced menarche report greater depressed mood compared with boys and same-aged premenarcheal Caucasian girls. In contrast, pubertal level was not associated with depression among Hispanic or African American adolescents.
 

In addition, research has examined whether there are systematic gender differences in the symptomatic expression of the depression syndrome. Overall, the symptom profile for males and females tends to be very similar.17,18 The only difference noted is that women more often experience somatic and anxious symptoms in conjunction with depression compared with men.17,18 Thus, women more likely present with symptoms of anxious, somatic depression (eg, fatigue, appetite changes, and sleep disturbance), whereas there is no gender difference in the presentation of other symptoms (eg, anhedonia, depressed mood, decreased concentration).
 

Finally, depressive disorders show substantial comorbidity with other psychiatric disorders (eg, anxiety and behavioral disorders). More females experience anxiety disorders than men, and girls typically develop anxiety disorders prior to depression.14 In contrast, behavioral and substance use disorders (especially alcohol) are more prevalent among males.19,20
 

Explanations for the Gender Difference in Depression

There are many different factors that have been hypothesized to contribute to the gender difference in depression at various points during the lifespan. To date, a significant limitation in the existing research base is that most studies have only examined one mechanism or factor as a putative explanation for the gender difference in depression. Very little research has examined gender differences among the elderly, so it is not known why the gender difference in depression disappears later in life. This section will briefly review the major genetic, biological, environmental, gender role, and cognitive explanations that have been studied to date with children, adolescents, and adults.
 

Genetic Explanations

Research with children and adults21,22 shows that latent genetic factors explain a modest amount of variability in depression, although these studies cannot determine which specific genes are implicated. It is important to examine behavioral genetic factors across age groups because the genetic liability to depression may change throughout the lifespan.
 

Some studies have not found any gender difference in heritability estimates for depression among children and adolescents21,23 or adults.22 This suggests that the latent genetic factors for depression are similarly important for females and males. However, other research24 with adolescents shows that the genetic contribution for depressed mood was greater in girls than boys.
 

A more detailed analysis25 from a large twin study of children and adolescents found that postmenarcheal adolescent girls had elevated heritability for depressive disorders compared with boys or premenarcheal adolescent girls. These investigators concluded that in adolescent pubertal girls, increased risk for depressive disorder was explained by an emerging genetic liability for depression combined with an increase in stressful life events, which are partially genetically mediated during adolescence. Taken together, these twin studies suggest that genetic factors are more strongly associated with depression among pubertal adolescent girls than boys, but there is no discernible gender difference in genetic liability to depression among prepubertal children or adults.
 

Biological Explanations

Very little evidence exists to support the hypothesis that female hormone levels (eg, progesterone, estrogen) account for the gender difference in depression.1,26,27 For example, the effect of sex hormone levels was minimal in explaining the gender difference in depression compared with the impact of social factors.28 Similarly, research has not found consistent gender differences in stress hormone levels (eg, cortisol) that could explain why more females are depressed than males.4,26,28 No gender difference has been found in the levels of neurotransmitters that are implicated in the pathophysiology of depression (eg, serotonin).29 Research examining the association of depression with the menstrual cycle has been inconsistent.26
 

Last, menopause and declining levels of estrogen among the elderly do not affect vulnerability to depression. Although the existing studies have not supported biological mechanisms as an account for the gender difference in depression,27 this conclusion should be balanced against the few studies, most with small samples that have investigated biological factors as an explanation for the gender difference in depression. Moreover, most studies have tested rather simple etiological models (eg, change in hormone level directly affecting mood) that do not adequately consider the known complexity of biological systems and adaptation to stress.30,31
 

Explanations for Stressful Negative Events

More females than males experience child sexual abuse, including 7% to 19% of girls and 3% to 7% of boys.32 Research has shown that history of child sexual abuse partly explains the increase in depression levels observed in adult women.33 However, females do not experience more overall childhood adversity (eg, more males experience physical abuse), so it is important to consider the specific type of negative environmental event. Research indicates that adult women experience significantly more daily stress compared with men.34 Moreover, child and adolescent studies show that girls experience more stress than boys, especially interpersonal negative events.35 Also, adolescent girls experience more discord and stress in the family than boys, and this additional discord explained the gender difference in depressive symptoms.36 Prospective research8 that tracked level of stressful events and depressive symptoms among children and adolescents found that girls experienced significantly more stressful events than boys after 13–14 years of age. This rise in negative events closely mirrors the development of the gender difference in depression. Depressed mood in girls, but not boys, was associated with this increase in stressful life events.8

Gender Role Explanations

The gender role explanation posits that females who identify with the stereotypical feminine gender role will become more depressed because some aspects of the feminine role (eg, importance of being thin and attractive, being passive, reduced social status) may be more associated with depression compared with the masculine gender role. Research with adolescents indicates that in girls, dissatisfaction with their body shape and/ or physical appearance is associated with increased depression and accounts for the gender difference in adolescent depression.7,37-40 In adults, gender role inequality in marital relationships explained why more adult women are depressed than adult men.41 Moreover, women experienced more chronic strain related to their gender role, and this elevation in stress accounted for the adult gender difference in depression.42
 

Although supportive of a gender role explanation, this research has been conducted primarily with Caucasian samples, so it is important to consider how the feminine gender role fits into the broader cultural and ethnic context. Only pubertal Caucasian girls report increased depression compared with Hispanic and African American girls.16 Other research43 shows that believing one does not have the ideal body shape is more disappointing for Caucasian girls than for African American girls. Thus, these findings most accurately suggest that the feminine gender role is a risk factor for depression for Caucasian females; further research is needed with more ethnically diverse populations.
 

Cognitive Explanations

Cognitive vulnerability for depression posits that some individuals have a more negative self-view and explain the causes and consequence of stressful events in more negative ways. This negative cognitive style is a risk factor for depression.44 Research has investigated whether there are gender differences in cognitive vulnerability that could explain why more females are depressed than males.6 Overall, the answer to this question depends on which aspect of cognitive vulnerability is tested. No gender difference has been found for negative schemas in adults or adolescents.45 In contrast, females have a more negative self-concept46 and have lower self-esteem, on average, than males.47 Adolescent girls are more likely than boys to attribute and explain the cause of events in a negative manner.48 Females are more likely to cope with depression by ruminating on their depressed mood, whereas males are more likely to problem-solve and distract themselves.42,49
 

Integrative Models

As noted above, most studies on the potential causes of the gender difference in depression have focused on single-factor explanations. To advance a more complete understanding, future studies need to consider more complete, integrated, and developmentally sensitive accounts of why more females become depressed than males. Two recently proposed integrative explanatory models are briefly reviewed here.6,50
 

Cyranowski and colleagues50 presented an interpersonal vulnerability-stress model that addresses specifically why more girls than boys become depressed in early adolescence. They focus on an interpersonal, affiliative need as a psychological vulnerability that places adolescent girls at particular risk, especially when they encounter interpersonal negative events. Further, they posit that the feminine gender role, higher anxiety levels, and hormonal changes at puberty (ie, oxytocin) will contribute to the increasing affiliative vulnerability to depression observed in girls.
 

Hankin and colleagues48 proposed an elaborated cognitive vulnerability-transactional stress model. Females encounter more negative life events than males, and this increase in stress leads to elevations in depressed mood. Females exhibit more cognitive vulnerability to depression than males. This greater cognitive vulnerability enhances the likelihood that females will experience depression when they encounter negative events. Interpersonally, depressed females seek reassurance in close relationships to relieve their depression, but friends’ and family’s withdrawal and rejection can transactionally lead to more negative events. Finally, certain personality traits (eg, neuroticism) and forms of childhood adversity (eg, sexual maltreatment) can lead to females experiencing more stress and exhibiting more cognitive vulnerability, and, ultimately, more depression, than males.
 

Gender Differences in Treatment of Depression

Gender does not affect the likelihood that a patient’s depressive disorder will be detected.51,52 Depressed men are equally as likely as women to consult a clinician for treatment of their depression. Moreover, once in treatment, men do not differ from women in their propensity for discussing negative emotions.1 However, practicing psychiatrists are less likely to inquire about women’s, compared with men’s, sexual functioning or the sexual side effects related to medication.51
 

Many treatment-outcome studies show that psychotherapy (eg, cognitive-behavioral treatment, interpersonal psychotherapy) and pharmacotherapy (eg, antidepressant medication) are effective in reducing depressive symptoms. Treatment studies have not found evidence for substantial gender differences in response to treatment.53,54 For example, the National Institute of Mental Health’s Treatment of Depression Collaborative Research Program54 shows that the depressed patient’s gender did not affect the process or outcome of treatment (psychotherapy or pharmacotherapy). Overall, there is currently little evidence that gender affects clinical assessment, management, or treatment of depression.
 

Conclusion

Depression is more prevalent in girls than in boys beginning after 13 years of age (or mid-puberty), and this gender difference continues until middle–late adulthood. Twin studies suggest that genetic factors are associated with depression more strongly among pubertal adolescent girls than boys, but no gender difference in genetics has been found in children or adults. Biological mechanisms have not been able to account for the gender difference in depression to date. Females experience more stressful, negative events and more childhood adversity than males. The feminine gender role is associated more with depression than the masculine gender role. Females have a more negative self-view, are more likely to ruminate, and explain the cause of stressful events in a more negative manner than males. Males and females are equally likely to seek treatment for depression and respond equally well to psychotherapy and antidepressant medication.
 

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