GENDER AND DEPRESSION: GENDER AND DEPRESSION:

TYPICAL AND ATYPITCAL TYPICAL AND ATYPITCAL

SYMPTOMS AND SUICIDAL SYMPTOMS AND SUICIDAL
IDEATION IDEATION
Dissertation Dissertation
Presented to the Faculty of the College of Health Sciences Presented to the Faculty of the College of Health Sciences
of Touro University International of Touro University International
in Partial Fulfillment of the Requirements for the Degree of in Partial Fulfillment of the Requirements for the Degree of
Doctor of Philosophy in Health Sciences Doctor of Philosophy in Health Sciences
By By
Jed Diamond Jed Diamond
March 14, 2008 March 14, 2008
Dissertation Chair: Mihaela Tanasescu MD, ScD Dissertation Chair: Mihaela Tanasescu MD, ScD
Committee Member: Frank Gomez, PhD Committee Member: Frank Gomez, PhD
Committee Member: Anne Maria Mller Committee Member: Anne Maria Mller--Leimkhler, PhD Leimkhler, PhD
Significance and Rationale For Study Significance and Rationale For Study
Women seek helpmen die.
This conclusion was drawn from a study of suicide prevention by Angst & Ernst
(1990). They found that 75% of those who sought professional help in an
institution for suicide prevention were female. Conversely 75% of those who
committed suicide in the same year were male.
Since depression is a significant risk factor for suicide and men receive less
treatment for depression than do women, it is vitally important that we have a
better understanding of the way depression manifests itself in males.
yAge
ySocioeconomic status
yChronic disease (heart disease,
stroke, diabetes, cancer, other)
yMarital status (and marital
happiness)
yPrevious depression
yFamily history of depression
and suicide
yLoss, trauma, life changes
yAlcohol use, etc.
Suicidal
Ideation
Depression
(Typical
symptoms)
Gender
Atypical
symptoms
of
depression
CONCEPTUAL MODEL CONCEPTUAL MODEL
Risk Factors Risk Factors
Research Hypotheses Research Hypotheses
There will be a significant positive relationship between typical There will be a significant positive relationship between typical
depression (CES depression (CES--D) and atypical depression (DMDS). D) and atypical depression (DMDS).
Depressed men will score significantly higher for atypical symptoms Depressed men will score significantly higher for atypical symptoms
(DMDS) than depressed women. (DMDS) than depressed women.
Non Non--depressed men will score significantly higher for atypical symptoms depressed men will score significantly higher for atypical symptoms
(DMDS) than non (DMDS) than non--depressed women. depressed women.
There will be a significant relationship between known depressive risk There will be a significant relationship between known depressive risk
factors and atypical depression. factors and atypical depression.
There will be a significant positive relationship between atypical There will be a significant positive relationship between atypical
symptoms (DMDS) and suicide risk. symptoms (DMDS) and suicide risk.
Atypical symptoms of depression will be positively related to suicide risk Atypical symptoms of depression will be positively related to suicide risk
when controlled for typical depression. when controlled for typical depression.
There will be a significant positive relationship between atypical There will be a significant positive relationship between atypical
symptoms (DMDS) and scores on the Gotland scale. symptoms (DMDS) and scores on the Gotland scale.
Demographics of Study Population Demographics of Study Population
323 females and 749 males (1072 total). 323 females and 749 males (1072 total).
Age range 18 Age range 18--80, Mean 51, 58% over 50. 80, Mean 51, 58% over 50.
76% employed, 64% income > $50,000/year. 76% employed, 64% income > $50,000/year.
48% of the males and 40% of the females 48% of the males and 40% of the females
depressed (CES depressed (CES--D 20). D 20).
53%, 1+ relatives have mood disorder. 53%, 1+ relatives have mood disorder.
Factor Analysis of Diamond Male Factor Analysis of Diamond Male
Depression Scale (DMDS) Depression Scale (DMDS)
Factor 1: Emotional Acting Factor 1: Emotional Acting--In Depression, In Depression,
Chronbachs alpha = .93 Chronbachs alpha = .93
Negative, withdrawn, stressed, numb. Negative, withdrawn, stressed, numb.
Factor 2: Emotional Acting Factor 2: Emotional Acting--Out Depression, Out Depression,
Chronbachs alpha = .89 Chronbachs alpha = .89
Short Short--fuse, impatient, irritable, angry. fuse, impatient, irritable, angry.
Factor 3: Physical Acting Factor 3: Physical Acting--Out Depression Out Depression
Chronbachs alpha = .73 Chronbachs alpha = .73
Alcohol abuse, reckless, explosive, violent. Alcohol abuse, reckless, explosive, violent.
Correlation of Typical Depression (CES Correlation of Typical Depression (CES--D 20) D 20)
with DMDS Factors with DMDS Factors
Factor Pearson Correlation P-value
Factor 1, Emotional
Acting-In
.700 < .001
Factor 2, Emotional
Acting-Out
.474 < .001
Factor 3, Physical Acting-
Out
.319 < .001
DMDS Factors in Depressed and Non DMDS Factors in Depressed and Non--Depressed Men and Women Depressed Men and Women
Predicting Factor 1 Emotional Acting-In Unstandardized
Coefficient
P-value
Depressed Men vs. Women 1.15 .208
Non-depressed Men vs. Women .47 .510
Predicting Factor 2 Emotional Acting-Out
Depressed Men vs. Women 1.47 .002
Non-depressed Men vs. Women 1.19 .001
Predicting Factor 3 Physical Acting-Out
Depressed Men vs. Women 1.52 < .001
Non-depressed Men vs. Women .86 .003
The second and third hypotheses-- Depressed men will score significantly higher
for atypical symptoms (DMDS) than depressed women and non-depressed men will
score significantly higher for atypical symptoms (DMDS) than non-depressed women
was answered affirmatively for Factor 2 and Factor 3.
Atypical Symptoms of Depression and Known Depressive Risk Factors Atypical Symptoms of Depression and Known Depressive Risk Factors
There was a There was a negative negative relationship between atypical depression (DMDS) factors relationship between atypical depression (DMDS) factors
and the following risk factors: and the following risk factors:
Age ( Factor 1, p = < .001, Factor 2, p = < .001, Factor 3, p = < .001) Age ( Factor 1, p = < .001, Factor 2, p = < .001, Factor 3, p = < .001)
Gross family income ( Factor 1, p = .015, Factor 2, p = .001, Gross family income ( Factor 1, p = .015, Factor 2, p = .001,
Factor 3, was not significant). Factor 3, was not significant).
Relationship happiness ( Factor 1, p = < .001, Factor 2, p = < .001, Relationship happiness ( Factor 1, p = < .001, Factor 2, p = < .001,
Factor 3, p = < .001). Factor 3, p = < .001).
There was a There was a positive positive relationship between atypical depression (DMDS) factors relationship between atypical depression (DMDS) factors
and the following risk factors: and the following risk factors:
Comorbid medical conditions ( Factor 1, p = < .001, Factor 2, p = .001, Comorbid medical conditions ( Factor 1, p = < .001, Factor 2, p = .001,
Factor 3, p =.006). Factor 3, p =.006).
Having relatives who were depressed ( Factor 1, p = .034, Having relatives who were depressed ( Factor 1, p = .034,
Factor 2, p = .031, Factor 3, p =.002). Factor 2, p = .031, Factor 3, p =.002).
The forth hypothesis, There will be a significant relationship between The forth hypothesis, There will be a significant relationship between
known depressive risk factors and atypical depression, was answered known depressive risk factors and atypical depression, was answered
affirmatively for the risk factors previously noted. affirmatively for the risk factors previously noted.
Logistic Regression for DMDS Factors and Beck Suicide Risk Adjusted Logistic Regression for DMDS Factors and Beck Suicide Risk Adjusted
for Psychiatric Diagnoses, Age, Gender, and Gross Family Income for Psychiatric Diagnoses, Age, Gender, and Gross Family Income
95.0% C.I. for Exp(B)
P-value Odds Ratio Lower Upper
Factor 1, Emotional Acting-In < .001 1.258 1.219 1.299
Factor 2, Emotional Acting-Out .221 .968 .919 1.020
Factor 3, Physical Acting-Out .560 .984 .933 1.038
Psychiatric diagnoses .714 1.031 .959 1.306
Age .075 1.013 .861 1.235
Gender .035 1.497 1.029 1.178
Gross family income .004 .804 .692 .933
R Squared = .563
The fifth hypothesis--There will be a significant positive relationship between atypical
symptoms (DMDS) and suicide risk--was answered affirmatively for Factor 1, Emotional
Acting-In, but not for Factor 2, Emotional Acting-Out, or for Factor 3, Physical Acting-
Out.
Logistic Regression for DMDS Logistic Regression for DMDS Factors and Beck Suicide Risk Adjusted Factors and Beck Suicide Risk Adjusted
for Psychiatric Diagnoses, Age, Gender, Gross Family Income, and for Psychiatric Diagnoses, Age, Gender, Gross Family Income, and
Typical Depression (CES Typical Depression (CES--D 20) D 20)
95.0% C.I. for Exp(B)
P-value Odds Ratio Lower Upper
Factor 1, Emotional Acting-In < .001 1.237 1.195 1.281
Factor 2, Emotional Acting-Out .316 .973 .924 1.026
Factor 3, Physical Acting-Out .506 .982 .931 1.036
Psychiatric diagnoses .917 1.010 .841 1.213
Age < .001 1.033 1.016 1.051
Gender .047 1.467 1.006 2.139
Gross family income .006 .809 .697 .940
CES-D 20 .027 1.547 1.050 2.281
R Squared = .566
The six hypothesis--Atypical symptoms of depression will be positively related to
suicide risk when controlled for typical depression--was answered affirmatively for
Factor 1, Emotional Acting-In, but not for Factor 2, Emotional Acting-Out, or for Factor
3, Physical Acting-Out.
Gotland Scale Correlations and Gotland Scale Correlations and
Factors 1, 2, and 3 of the DMDS Factors 1, 2, and 3 of the DMDS
Factor Pearson Correlation P-value
Factor 1, Emotional Acting-
In
.794 < .001
Factor 2, Emotional Acting-
Out
.584 < .001
Factor 3, Physical Acting-
Out
.393 < .001
The seventh hypothesis--There will be a significant positive relationship
between atypical symptoms (DMDS) and scores on the Gotland scale--was
answered affirmatively
Implications for Theory Implications for Theory
This study adds to the body of knowledge regarding This study adds to the body of knowledge regarding
gender and depression. By evaluating a larger set of gender and depression. By evaluating a larger set of
atypical depression symptoms (DMDS) than had atypical depression symptoms (DMDS) than had
previously been used by Rutz (1999) with the Gotland previously been used by Rutz (1999) with the Gotland
Scale for Assessing Male Depression, the study added to Scale for Assessing Male Depression, the study added to
our understanding of male our understanding of male--type depression. type depression.
The study expands our understanding of the The study expands our understanding of the
relationship between gender and atypical symptoms for relationship between gender and atypical symptoms for
depression. It addressed a gap in the research literature depression. It addressed a gap in the research literature
on gender and depression by clarifying three separate on gender and depression by clarifying three separate
factors or subscales that are associated with depression factors or subscales that are associated with depression
and suicide risk. and suicide risk.
Potential Bias Potential Bias
There were selection biases since the study population was recruited through
websites that were focused on people with an interest in gender issues and
depression and thus not representative of the general population.
There were measurement biases since assessment of important variables such as
depression and suicide risk were based on respondents answers to an on-line
questionnaire. No outside, professional assessments were conducted.
Subjects were rated as being depressed or non-depressed based on their answers
to a traditional depression scale (CES-D). Since one of the theoretical assumptions of
the study was that depressed males might be missed using a traditional scale, this
may have introduced additional measurement bias.
Recommendations for Future Research Recommendations for Future Research
Future research will be needed to validate the results of the Future research will be needed to validate the results of the
study and to develop numerical scores for evaluating study and to develop numerical scores for evaluating
depression and suicide risk using the DMDS. depression and suicide risk using the DMDS.
It would be helpful to conduct research with a general It would be helpful to conduct research with a general
population to see if results were consistent in a population population to see if results were consistent in a population
representative of the general community. Particular attention representative of the general community. Particular attention
should be focused on including men and women from different should be focused on including men and women from different
ethnic groups, cultural backgrounds, economic levels, and age ethnic groups, cultural backgrounds, economic levels, and age
groups. groups.
Recommendation for Clinical Practice Recommendation for Clinical Practice
The belief that depression is a disease primarily affecting women has left too The belief that depression is a disease primarily affecting women has left too
many males undiagnosed and untreated. many males undiagnosed and untreated.
Many clinicians believe that depressed males are undiagnosed because the Many clinicians believe that depressed males are undiagnosed because the
evaluation scales being used do not address the symptoms of depression that evaluation scales being used do not address the symptoms of depression that
are more common in men. are more common in men.
Based on the results of the present study, it is recommended that clinicians Based on the results of the present study, it is recommended that clinicians
use scales that include atypical symptoms such as those found on the DMDS use scales that include atypical symptoms such as those found on the DMDS
and Gotland Scales. and Gotland Scales.
Surprises Surprises
Though the study was originally designed for U.S. clients, men and Though the study was originally designed for U.S. clients, men and
women from 44 other countries participated. women from 44 other countries participated.
Based on clinical experience it was expected that it would be Based on clinical experience it was expected that it would be
difficult to recruit depressed males. This was not the case. difficult to recruit depressed males. This was not the case.
Only Factor 1, Emotionally Only Factor 1, Emotionally--Acting In, was significantly related to Acting In, was significantly related to
suicide risk when all three factors were used together. suicide risk when all three factors were used together.
There was actually a negative relationship between suicide risk and There was actually a negative relationship between suicide risk and
Factors 2 and 3, though the relationship was not significant. Factors 2 and 3, though the relationship was not significant.
Thank You! Thank You!
The three of you, each in your own way, The three of you, each in your own way,
have made this study much better than it have made this study much better than it
would have been. would have been.