Australian Psychologist, September 2007; 42(3): 187 197

Integrated review of the social and psychological gender differences in depression

SANDRA BOUGHTON & HELEN STREET

School of Psychiatry and Clinical Neurosciences, University of Western Australia, Perth, Western Australia, Australia

Abstract A range of theories has been proposed to explain the well-documented nding that women are twice as likely as men to be diagnosed with depression. Theories offering psychological and sociological explanations are reviewed in this paper. The possibility that this nding is an artefact of differences in the ways in which men and women demonstrate depression is examined. A discussion of the implications of establishing a broader systemic perspective of depression for understanding the gender difference in depression is presented.

The nding that women are twice as likely as men to experience a lifetime episode of major depression has been described as the most robust in all of psychiatric epidemiology (Cyranowski, Frank, Young, & Shear, 2000). This gender difference begins in adolescence, persists through adulthood, and occurs across many countries and cultures (Hankin & Abramson, 2001). A wide range of theories has been proposed to explain the discrepancy, emphasising biological, sociological, or intrapsychic variables. While several major review articles have appeared (McGrath, Keita, Strickland, & Russo, 1990; Nolen-Hoeksema, 1990; Piccinelli & Wilkinson, 2000; Sprock & Yoder, 1997; Weissman & Klerman, 1977), discussion of the broad range of explanations offered for the gender difference in depression is scattered across a diverse range of published material (e.g., Bebbington, 1998; Braverman, 1986; Culbertson, 1997; Hammen, 1997; Hankin & Abramson, 2001; Nolen-Hoeksema & Girgus, 1994). The goal of this paper was to comprehensively review the diverse range of descriptive and etiological theories that have been proposed to explain why more women than men are depressed. The paper begins by examining the nature of the gender difference in depression. It goes on to look at the way in which gender relates to the changes in the conceptualisation of depression over time. A range of biological, intrapsychic and interpersonal

explanations have been offered to explain the gender difference. This paper will focus specically on psychological and social theories. The inuence of the current intrapsychic conceptualisation of depression, derived from psychiatric classication, is examined. An interpersonal construction of depression is proposed that acknowledges the social and relationship context. The implications for future research of this shift to a systemic focus are considered. What is the nature of the gender difference? It is generally accepted that the ratio of women to men with a diagnosis of depression is 2:1 (Kessler et al., 1994; Klerman & Weissman, 1989). There is some suggestion that this rate varies across cultures (Culbertson, 1997), between age groups (Cyranowski, et al., 2000), and between cohorts (Silverstein & Perlick, 1991). Gender differences in depression appear to be absent in childhood, but emerge between 11 and 13 years of age (Cyranowski et al., 2000; NolenHoeksema & Girgus, 1994). During adolescence, girls rates of depression are double that of boys (Kashani et al., 1987). This increase in depression in adolescent girls has been attributed to both social and biological factors, with pubertal status being a better predictor of the sex difference in depression

Correspondence: Dr S. Boughton, 22 Barry Street, Brunswick, Vic. 3056, Australia. E-mail: sandraboughton@bigpond.com ISSN 0005-0067 print/ISSN 1742-9544 online The Australian Psychological Society Ltd Published by Taylor & Francis DOI: 10.1080/00050060601139770

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S. Boughton & H. Street range of variables has been proposed that may be broadly grouped into intrapsychic, social, interactive and artefactual.

than age (Angold, Costello, & Worthman, 1998). There is some evidence that the preponderance of female sufferers does not persist beyond age 55 (Bebbington et al., 1998). The populations in which sex differences in depression have not been consistently found include university students, the bereaved, the Old Order Amish, and residents of some rural, non-modern cultures (Nolen-Hoeksema, 1987). Measuring depression The medicalisation of depression arguably dates from the psychiatric conceptualisation of Kraepelin & Diefendorf (1904/1907). Once depression became part of a psychiatric classication system it became constructed within the constraints of that system. In parallel, the urge to measure depression resulted in a shift so that, regardless of how depression was conceptualised, pragmatically it was construed as the result of assessment by a formal assessment measure. Virtually all research ndings that create what is known about depression are underpinned by an understanding of depression that is scale specic. In practice, depression becomes whatever is measured by the Hamilton Depression Rating Scale and the Beck Depression Inventory (BDI), the two most commonly used measures of depression. There is an interesting parallel between the apparent emergence of the gender difference in depression in recent cohorts (Silverstein & Perlick, 1991) and the use of formal scales to dene depression. In a comparison of two depression screening instruments, the BDI and the authors own Depression Scale (DEPS), subscales showing a consistent difference between genders were identied (Salokangas, Vaahtera, Pacriev, Sohlman, & Lehtinen, 2002). These BDI items, crying and loss of interest in sex, were described as gender-related role behaviour more prevalent in women. This may lead to an over-estimation of depression in women (Salokangas et al., 2002). The possibility that the apparent gender difference in depression is a function of the way in which depression is operationally dened in terms of classication and measurement remains an open question. Certainly this denition of depression is very much focused on the individual experience of the depressed person and conceptualises depression primarily in terms of the individuals intrapsychic functioning. This conceptualisation would be expected to impact on theories of the gender difference in depression. Theories of gender differences in depression While recognising that biological factors play a part in an explanatory model, this article focuses on the range of social/psychological explanations. A diverse

Psychological explanations Intrapsychic variables: Personality traits Given the current focus on individual experience in the classication and measurement of depression, it is perhaps not surprising that there is a predominance of theories derived from intrapsychic variables. A variety of explanations for the gender difference in depression has been proposed based on these intrapsychic factors such as personality traits, cognitive vulnerability and coping strategies. Differences between male and female individuals in self concept, embracing self-esteem, self-worth, and competence, have all been recognised in a range of theoretical orientations (Beck, 1987). It has been proposed that female subjects are more at risk for a negative view of self and associated depression than are male subjects (Sakamoto, 2000). By adolescence, girls, as compared to boys, demonstrate lower selfcompetence and perceived attractiveness. However, these ndings do not appear to be independent of the social context. Although there is some variability across cultures, for Caucasian girls, self-worth is highly related to physical appearance (Ben Hamida, Mineka, & Bailey, 1998). These ndings suggest that at least some apparently intrapsychic explanations may in fact be context dependent. Girls who mature early in a social context of mixed-sex rather than same-sex friends seem most vulnerable (Ge, Conger, & Elder, 1996). Girls who associate selfworth with physical appearance report low selfesteem and high levels of depressive affect (Hankin & Abramson, 2001). Due to greater reinforcement for relationship-oriented behaviours in childhood, girls have a more relational concept of self than boys (Seidlitz & Diener, 1998). This nding has been central to many feminist theories of depression. Miller (1984), for example, has proposed that if a womans sense of self-worth is grounded in her connection with others, she is more likely than a man to experience a sense of failure of the self leading to depression when relational needs are threatened. Decreased self-esteem related to body image, and self in relationships may provide some understanding of the emergence of gender differences in adolescent depression. Conceptually related to the nding that women are more likely to have a relational self concept is the nding that women are more likely than men to have personality styles that place greater value on relationships (Cyranowski et al., 2000). The trait of dependency has been seen as a signicant vulnerability

Gender differences in depression factor for depression, particularly within the psychodynamic tradition (Arieti & Bemporad, 1980). It has been argued that different developmental pressures on women and men lead to different vulnerabilities to depression, with women demonstrating greater dependency (Blatt & Maroudas, 1992). A second type of depression-prone individual has been proposed who is concerned with achievement and is self critical in response to failure. These personality types have also been identied by cognitive theorists (e.g., Beck, 1983), resulting in considerable research associated with two types of personal vulnerability to depression: sociotropic or dependent, and autonomous or self-critical. There has been little research attention relating these variables to gender differences in depression. A focus on the dominant, intrapersonal conceptualisation may obscure an alternative perspective. It has been suggested that the reduction of relatedness to a pathogenic personality trait deects attention from the individuals experience of what may be an insecure and undependable relationship (Coyne & Whiffen, 1995, p.368). This shift from a focus on the apparent internal experience of the individual to a consideration of the broader social context leads to a very different way of thinking about an experience that has previously been labelled as a personality trait. Another trait that receives considerable support as a predictor of the gender difference in depression is neuroticism (Parker & Brotchie, 2004; Widiger & Anderson, 2003). Neuroticism, involving heightened sensitivity, worry and negative emotions, is more common in women (Roberts & Gotlib, 1997). Previously dysphoric individuals reported higher levels of neuroticism than did never dysphoric subjects (Roberts, Gilboa, & Gotlib, 1998). Neuroticism has been shown to be a predictor of rst episodes of depression (Hirschfeld, Klerman, Lavori, Keller, Grifth, & Coryell, 1989). The trait of masculinity/femininity has also been considered, with masculine gender-role orientation associated with lower levels of depression than feminine gender-role orientation (Sanlipo, 1994). Endorsement of feminine-typed traits on the Bem Sex Role Inventory is a predictor of depressive symptom levels in adolescents and seems to account for a substantial amount of the observed gender differences in depression (Allgood-Merton, Lewinsohn, & Hops, 1990). The apparent diversity of personality traits identied suggests greater support for this approach than is in fact justied. In practice, most of the traits identied are correlated with neuroticism. The conceptualisation of these variables as personality traits locates the search for difference within the individual, resulting in a loss of information about context. Intrapsychic variables: Coping strategies

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It has been suggested that differences in the way in which men and women cope with life stress account for at least some of the variance in the gender difference in depression (Hanninen & Aro, 1996; Nolen-Hoeksema & Girgus, 1994). One of the most widely researched coping strategies is rumination. Rumination refers to behaviours and thoughts that focus ones attention on ones depressive symptoms and on the implications of these symptoms (Nolen-Hoeksema, 1991, p. 569). Rumination is more common in women than in men and results in longer, more severe episodes of depression (Nolen-Hoeksema, Morrow, & Fredrickson, 1993). In support of this view, male subjects are more likely than female subjects to actively distract themselves from their negative moods (Nolen-Hoeksema, 1987; Nolen-Hoeksema et al., 1993), and their coping strategies are more action focused or instrumental than are those of women (Nolen-Hoeksema & Girgus, 1994). Proposed differences between men and women in the processing of affect are central to a range of theories. Womens superior recall of affectively valenced life events reects a greater tendency for women, relative to men, to have intense emotional experiences. It has been proposed that greater affect intensity contributes to womens relatively greater risk for depression (Fujita, Diener, & Sandvik, 1991; Seidlitz & Diener, 1998). Coping styles with a primary focus on emotion are more common in women while problem-focused coping styles are more common in men. Hanninen and Aro (1996) argue that the greater tendency of women to be more depressed might be due partly to their less effective, emotion-based, coping such as making unhealthy blaming attributions towards themselves, or venting anger on others. The gender difference in depression was eliminated when (dysfunctional) coping was controlled for, suggesting that the greater chance of women becoming depressed essentially reected their less effective coping strategies. Another coping style that has been correlated with depression is cognitive avoidance coping, involving denying and minimising stressors. Cognitive avoidance coping is associated with increases in depression in women, but not in men (Blalock & Joiner, 2000). Not only do women appear to cope less effectively than men with negative life events, they also have been found to be less resilient. The capacity to manage negative life events well is often referred to as resilience. Hanninen and Aro (1996) found that women scored lower than men on a resilience scale, and that low resilience was associated with dysfunctional coping. This focus on coping deects awareness away from the kinds of

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S. Boughton & H. Street with the intrapsychic model is the loss of information associated with the lack of context. What is frequently omitted in these theories is the interpersonal environment in which personality, coping strategies and vulnerability are embedded. For example, coping strategies may be less effective, not because of their style but because of what they are required to manage. It may be that many women interact in contexts that allow them to have little control over their lives. A focus on intrapsychic processes may lead to a neglect of contextual factors and a loss of signicant information. In this way, systemic issues may be incorrectly labelled as qualities of the individual.

experiences with which individuals have to cope. Such recognition of the context raises the interesting possibility that these apparently intrapyschic styles are a function of the nature of the difculties these individuals are confronting. What happens to rumination, for example, if more open communication is available in a relationship? Intrapsychic variables: Cognitive vulnerability Cognitive vulnerability refers to attributional styles or styles of thinking, attitudes and beliefs that are negatively biased or dysfunctional (Abramson, Metalsky, & Alloy, 1989). Women are more likely than men to make complex attributions in the construction of causality. A person who tends to use complex attributions might hypothesise about and investigate a variety of dimensions when considering a problem. Women and people who are depressed have more complex attributions than men. Greater complexity in attributions does not imply greater accuracy, because considerable bias and self-reection may be involved (Sprock & Yoder, 1997). A tendency to internal, as opposed to external, attributional style or locus of control has been found to be more common in men than in women. People who attribute failure to more internal global states are especially vulnerable to depression (Abramson & Andrews, 1982). A perception of lack of control over their environment leads people to develop a generalised expectation that they cannot control events. This situation then leads to the symptoms of depression: lowered motivation, passivity, self-esteem loss, and the inability to see opportunities to control the environment. Because some women do not believe that they have control over their lives, they may not be able to utilise the control they do have, leading to more negative life events (Nolen-Hoeksema, Larson, & Grayson, 1999). Learned helplessness, resulting from the expectation that the outcome of events will be uncontrollable, is more likely to be experienced by women than by men (Nolen-Hoeksema, 1987). Previous experiences of victimisation, restricted opportunities and more passive social roles result in women being less equipped to manage negative life events and more vulnerable to hopelessness and depression (Zlotnick, Shea, Pilkonis, Elkin, & Ryan, 1996). In summary, a range of theories has been proposed to describe differences between men and women in the way in which they process their experiences. In particular, women demonstrate a greater tendency to rely on affective coping styles and to make internal attributions for negative life events. Both of these factors appear to make a signicant contribution to depression vulnerability. A fundamental problem

Social explanations Problematic relationships The social context of depression has been seen as signicant in a range of theories. While these theories shift the focus from the individual to the impact of social variables, particularly relationships, rarely do these theories focus on the interaction between individual and environment. The explicit or implicit assumption is that these variables are signicant because of their impact on intrapsychic variables. Interpersonal explanations have focused on poor early parenting, problematic relationships and marital quality (e.g., Bebbington, 1998; Coyne & Whiffen, 1995). The available evidence suggests that women may be more vulnerable to problematic interpersonal relationships than men across the life span (Hammen, 1999). The discrepancy begins in early childhood. The experience of being poorly parented as a child is more likely to be manifested in depressive symptoms for women than for men (Cummings, DeArth-Pendley, Du Rocher Schudlich, & Smith, 2001). Girls exposed to poor mothering qualities may be particularly liable to develop insecure attachments, giving rise to low self-esteem and poor relational skills; they may have less in the way of academic aspirations and will seek a solution in early partnering (Sadowski, Ugarte, Kolvin, Kaplan & Barnes, 1999). Female subjects tend to show a stronger afliative style than male subjects, resulting in adolescent girls being more vulnerable than boys to relationship stressors. Positive parental relationships act as a buffer against the negative effects of transitional stressors (Cyranowski et al., 2000). Negative, conictual relationships may be more stressful for women because women experience greater interpersonal connectedness (Seidlitz & Diener, 1998). The tendency to have more intensive and extensive emotional involvement in relationships makes women more vulnerable to negative,

Gender differences in depression conictual relationships than men (Turner, 1994). This focus on womens needs for support may equally be seen in terms of the threat women perceive to be present in their male partners. This threat is conveyed in the following belief about men: unless one hovers close by, worries about offending, and tries to please them, they will no longer be available (Coyne & Whiffen, 1995). Early research ndings suggested that married women have higher rates of mental illness than do unmarried women and married men (Gove, 1972; Radloff, 1975). Weissman (1987) reports data showing that the gender-related difference in 6-month prevalence rates for major depression was more pronounced for married than for separated/ divorced or single men and women. However, more recent studies have demonstrated that married men and women in fact have a lower risk for major depression compared to separated, divorced or single individuals (Aseltine & Kessler, 1993; Coryell, Endicott, & Keller, 1991). Poor marital quality, rather than marriage per se, appears to be the key risk factor for increased depressive symptoms (OLeary & Cano, 2001). Emotional support of marital partners may be less available for women and thus marital conict is more likely to have an impact on womens emotional wellbeing. Support and conict within the marital relationship may function differently for men and women, with husbands contributing to conict but not being sought as a condant. However, men may be less inuenced by marital conict, and are more likely to seek their wives as condants (Turner, 1994). This is consistent with ndings of the greater signicance of affective coping for women. Caring for others The observed greater importance of relationships to womens wellbeing results in a number of behaviours that increase the risk of depression for women. Kessler and McLeod (1984) and Turner and Avison (1989) developed the cost of caring hypothesis, which proposes that women care more for others and are more affected by events which impact on others rather than themselves. They found that women were equally vulnerable to self-focused events, but more so than men to events affecting others. A recent large-scale twin study using data from individual interviews produced ndings inconsistent with the cost of caring hypothesis (Kendler, Thornton, & Prescott, 2001). Maintaining a large support network may be helpful for women with more personal resources whereas low-resource women have more problems trying to respond to the needs of others and are more likely to be distressed by their difculties (Riley & Echenrode, 1986). Veiel (1993)

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found that family support networks had a negative effect on recovery from major depressive episodes for women who were homemakers, but not for men or working women. Homemakers may be overloaded by the demands of others but lack the positive feedback from others that is more available in the work context. Alternatively, supportive families may inadvertently reinforce behaviours associated with depressive symptoms (Sprock & Yoder, 1997). This tendency of women to put the needs of others before their own has led to several theories relevant to the gender difference in depression. Silencing the self (silencing ones own desires and feelings in order to nurture and meet the needs of a partner) is proposed to be more common in women, placing them at greater risk for depression (Jack, 1991). According to Jacks model, the factors that increase womens vulnerability to depression include women silencing their own desires and feelings in order to nurture and meet the needs of their partners. It has been suggested that caring for others is a part of the experience of self for many women. Because women have learned to dene themselves in terms of others they are more likely to bear the stress of problems in a relationship; disruption in relationships is for women a disruption in the experience of self. Braverman (1986) proposes that it is extremely difcult for women to design and participate in activities for their own development and enhancement without causing themselves psychic and physical pain (p. 95). Her sociocultural legacy of giving priority to others may conict with a womans own needs, resulting in the unfortunate solution of depression. Social support While providing care and social support to others may be problematic for women, receiving support from others appears to function differently for men and women. Social support appears to buffer the impact of negative events but have little impact under low stress for men, while low social support may itself be depressogenic for women (Barnett & Gotlib, 1990). The support of marital partners is often less available for women and low social support has a greater negative impact on coping for women. Brugha et al. (1990) found that recovery from depression was associated with different aspects or, possibly, with different perceptions of the social network in male and female patients. For women, the signicant predictors of recovery appeared to be the availability of close supports and their satisfaction with support. For men, predictors included living in a marital relationship, absence of negative social interactions and number of friends or acquaintances. There is some evidence to suggest that ruminative

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S. Boughton & H. Street the home may provide a wider range of roles from which to obtain reinforcement. These roles may also encourage a practical focus rather than the emotional focus characteristic of the homemaker/carer role. Negative life events Not only do women appear to have personality traits, coping strategies and cognitive styles which may increase their vulnerability to negative events, they may in fact be exposed to a greater incidence of stressful experiences. However, the proposal that, overall, women are subject to more, or more upsetting, life events than men remains contentious (Bebbington, 1998; Weissman & Klerman, 1977). Numerous investigators (Cyranowski et al., 2000) have concluded that negative life events are reported more frequently by women. However, a recent welldesigned, large-scale study found that there was no difference in the rates of reported stressful life events between men and women (Kendler et al., 2001). Irrespective of whether there is a gender difference in the level of negative life events, it has been suggested that gender moderates the effect of negative life events on depression (Hankin & Abramson, 2001). In other words, this research suggests that it is the experience of the event, or the coping strategies used, rather than the event per se that contributes to depression. However, there are differences in the nature of the traumatic events experienced by men and women. One highly signicant negative life event that is more common in female than male subjects is childhood sexual abuse. Nolen-Hoeksema and Girgus (1994) review evidence to suggest that up to 35% of the differences in rates of depressive disorders in adult women and men might be attributable to the higher rate of sexual abuse before age 18, and subsequent depression, in women (p. 436). Sexual abuse in childhood leads to depression, low self-esteem, hopelessness, and external locus of control (Brewin, Hunter, Carroll, & Tata, 1996). Behavioural and feminist theories of womens greater vulnerability to depressive symptoms compared with that of men generally attribute this vulnerability to the negative consequences of womens lower social status and economic power in a patriarchal society (Nolen-Hoeksema, Larson, & Grayson, 1999). Women are seen as being in a less powerful position than men, which leads them to develop styles of coping previously discussed. These styles are already akin to depression, such as compliance, passivity and helplessness (Loewenthal et al., 1995). These theories focus on aspects of the negative context of individuals, highlighting a range of social pressures that impact on the individuals experience.

coping style, which was discussed previously, is correlated with response to social support. Individuals with a ruminative coping style, who are more likely to be women, tend to focus excessively on their own emotional reactions. They seek and benet more from social support but report receiving less than those without a ruminative coping style (Nolen-Hoeksema & Davis, 1999). It is believed that social networks may be more demanding than supportive for women who have fewer personal resources. Social roles Role-related behaviour has frequently been linked to depression, with the restrictions, conicts, overload, stresses and devaluation of the role of women being emphasised (e.g., Bebbington, 1998; Braverman, 1986). Beginning in adolescence, women may face increased expectations to conform to a more restrictive social role than men, deemed appropriate for females, and such expectations may contribute to their tendencies toward depression (NolenHoeksema & Girgus, 1994). For women who are homemakers, depression has been linked to the increasing devaluation of this traditional female role in comparison to the elevation of the traditional male role of breadwinner (Schwartz, 1991). In societies such as orthodox Jewish communities in which the homemaker role is valued, the gender difference in depression has not been demonstrated (Loewenthal et al., 1995). Traditional female roles are seen as resulting in greater stress and fewer coping resources than traditional male roles. More recent research refutes earlier ndings that married women have a higher degree of depression than single women and men (Aseltine & Kessler, 1993; Coryell et al., 1991). This change in research outcomes over time correlates with increased female workforce participation. This may have positive or negative implications for women. Some workers have suggested that the conict between work and familial roles coupled with sex discrimination resulted in higher rates of depression for women (Greenglass, 1985). Employed women are more likely to experience depression than employed men because they have primary responsibility for household chores and childcare in addition to paid employment, resulting in work and role overload (Gove & Tudor, 1973; Schwartz, 1991). Other research suggests that multiple roles may insulate women from depression by moderating family stresses (Nolen-Hoeksema, 1990; Sprock & Yoder, 1997). Women with employment outside the home have been found to be less depressed than women who are fulltime homemakers (Radloff, 1975). There are a number of possible explanations for this nding. Employment outside

Gender differences in depression There is some indication that, with the focus on an earlier age of onset than previously documented, the emphasis has moved from pressures associated with caring for others to adolescent issues such as body image. However, these theories remain primarily hypotheses about the impact of social variables on the individuals experience. The possibility that there may be an interaction between social variables and the individual has received limited attention. Multifactorial theories The available evidence suggests that no single variable accounts for a signicant amount of the variance in the relationship between gender and depression. It is likely that the relationship between gender and depression is multifactorial. Indeed, there are probably multiple pathways to depression. A number of multifactorial theories have been developed, proposing an interaction between intrapsychic factors and interpersonal stresses. Many of these diathesis/stress theories aim to explain one of the most important aspects of the gender difference, its onset in early adolescence. Women are more likely than men to experience the onset of depression in adolescence (Hankin & Abramson, 2001; Nolen-Hoeksema, 1990). The impact of this age of onset is far reaching. Initial high levels of adolescent depression in girls create a vulnerability to subsequent negative thoughts and negative life experiences in adult women (Nolen-Hoeksema & Girgus, 1994). Nolen-Hoeksema and Girgus (1994) propose a broad vulnerability stress framework, suggesting that, in early adolescence, pre-existing gender differences interact with increased challenges and changes in the conditions of girls lives to yield the gender differences in depression that emerge at that time (p. 439). For Cyranowski et al. (2000) the pubertal timing of the adolescent transition coincides with biologically and socially mediated increases in afliative need for adolescent girls. Insecure attachments to parents, an anxious inhibited temperament, and low instrumental coping skills independently (and interactively) contribute to placing certain girls at risk for a difcult adolescent transition. These workers propose a model of correlated consequences, in which intensied afliative need experienced in combination with adolescent transition difculty may create an increased likelihood that negative life events trigger the onset of depressive episodes. Hankin and Abramson (2001) present an elaborated cognitive vulnerability transactional stress theory to explain the emergence of gender differences in depression during adolescence. This model

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proposes that adolescent girls are more likely than boys to experience negative life events, leading to increases in initial negative affect. They are more cognitively vulnerable than boys and are more likely to demonstrate pre-existing vulnerabilities in personality traits such as neuroticism and environmental adversity. The key role of neuroticism as a vulnerability factor is also posited in the work of Parker and Brotchie (2004). They hypothesise a primary postpubertal effect of gonadal hormones on limbic system hyperactivity, predisposing women to potentially higher rates of certain anxiety and depressive disorders. These hormonal inuences activate a diathesis that interacts with socialisation and sex role factors to generate the increased likelihood that women will experience depression. In the hopelessness model of depression (Abramson et al., 1989) the interaction of an attributional style characterised by the tendency to make stable and global attributions (depressive diathesis) with negative interpersonal events more commonly leads to hopelessness in women than in men. Women are at greater risk than men to experience hopelessness depression, particularly when the depressive diathesis interacts with interpersonal stress. While most of these multifactorial theories link individual differences to relevant stressors, retaining a focus on the experience of the individual, the work of Hammen (1999) proposed an interpersonal model of depression based on stress generation. This theory argues that many individuals contribute to the occurrence of stressful events through their behaviours, characteristics, attitudes, and levels of competencies. These factors contribute to both the recurrence of depression and the intergenerational transmission of depression in families. Women may be at greater risk for depression than men because they have more vulnerability factors and are more responsive to interpersonal negative life events (Hammen, 1999). Although multifactorial theories vary in the emphasis they place on biological factors, they consistently postulate an association between external pressures and psychological coping styles. Neuroticism, with its biological basis and links to variables such as dependency and rumination, is frequently proposed as a vulnerability factor (Hankin & Abramson, 2001; Parker & Brotchie, 2004; Widiger & Anderson, 2003). The greater likelihood of past and current adversity, particularly in the context of relationships, is also a recurring feature (Hammen, 1999; Hankin & Abramson, 2001; Parker & Brotchie, 2004). With the exception of the Hammen (1999) work, the dominant trend in theorising has been to propose internal vulnerabilities that are triggered by relevant external pressures.

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S. Boughton & H. Street not been supported by the research (Zlotnick et al., 1996). Similarly, the hypothesis that female subjects who have been depressed at least once are more likely than once-depressed male subjects to have recurrences of depression has not been substantiated (Hankin, Abramson, Silva, McGee, & Angell, 1998; Kessler, McGonagle, Swartz, Blazer, & Nelson, 1993; Simpson, Nee, & Endicott, 1997). Current thinking about depression has placed these theories on the periphery of the dominant view, relegating them to the status of artefacts of measurement. If the context is restored they come to have a different meaning. From the perspective of context they say a great deal about the social construction of depression. These theories reect the constraints of the current system of classication and measurement. Conclusion Major depression is an aetiologically complex disorder reecting a broad array of risk factors. It is unlikely that any simple combination of variables will account for the greater frequency with which depression is diagnosed in women than in men. Beyond this wide range of risk factors is the question of the nature of depression itself. The wide variety of measuring scales and diagnostic classications point to variability in the construction and measurement of depression over time. The way in which this disorder is experienced and expressed may differ between men and women. Existing theories vary in the extent to which they have generated testable hypotheses and been supported by well-designed research. The trend in theory development is towards models that integrate a variety of biological, sociological, and intrapsychic variables that distinguish between men and women in their experience of depression (Hankin & Abramson, 2001; Parker & Brotchie, 2004). These approaches conceptualise depression in terms of the impact of stressors on a vulnerable individual. The variety of factors proposed is extensive, as outlined in this paper. These theories are linked to a denition of depression derived from psychiatric classication criteria or formal rating scales. These measures derive from an intrapsychic conceptualisation of depression. It is important not to lose sight of the way in which psychiatric classication shapes and constrains our understanding of depression. If the focus shifts from the individual to include the social context in which depression occurs then a different, more systemic understanding of depression becomes possible. This would involve constructing depression as an interpersonal rather than intrapsychic process. A shift in perspective

Artefact theories Several other investigators have suggested that the sex difference in depression is an artefact of differences in the ways in which men and women demonstrate the common symptoms of depression (e.g., Loewenthal et al., 1995; Sprock & Yoder, 1997). As previously discussed, the sex difference may also be a function of the questions asked in assessing depression. These questions may reect too narrow a denition of depression that fails to include symptoms associated with depression in men (Wilhelm & Parker, 1994). Depressive spectrum disorder may manifest itself as excessive alcohol use or acting-out and anti-social behaviours in men (Schwartz, 1991; Sprock & Yoder, 1997). Certainly, one well-supported nding is that depression is both underdiagnosed in men and overdiagnosed in women (Wilhelm & Parker, 1994; Wrobel, 1993). This may be due to the expectations of clinicians but may also reect the nding that men are judged more harshly and seen as more impaired than depressed women for displaying the same behaviours (Hammen & Peters, 1977). The sex difference might also be due to higher likelihood of comorbid disorders in women. Comorbid disorders such as anxiety, eating disorders, somatisation disorder, agoraphobia, panic disorder, and borderline personality disorder can increase vulnerability to depression (Ochoa, Beck, & Steer, 1992). Women seem to respond differently to their experiences, resulting in depression being recognised and labelled more readily among women than among men (Gotlib & Whiffen, 1989; Yoder, Shute, & Tryban, 1990). Women are also more likely to report depressive symptoms than are depressed men, even when they have been judged equally depressed, raising the possibility that self-report assessments of depression may overestimate depression for women and/or underestimate depression for men (Sprock & Yoder, 1997). Less well-supported is the proposal that men are more reluctant to seek help for depression, require greater severity of symptomatology before seeking help, and are more likely to report that they would never seek psychotherapy for depression (Hammen & Padesky, 1977). Studies of actual help-seeking behaviour, however, have found that men and women with similar levels of self-reported depressive symptoms were equally likely to seek help and to be diagnosed as depressed in a clinical interview (Nolen-Hoeksema, 1990; Zlotnick et al., 1996). The suggestion that the response to treatment interventions for depression is poorer in women, resulting in more sustained disability and greater vulnerability to relapse in women than in men, has

Gender differences in depression would challenge the view of what have previously been described as artefact theories. These theories can be seen as deriving from a perspective of depression and the gender difference that acknowledges the social or conceptual context in which depression occurs. The omission of context from much of the current thinking on depression both skews and constrains theories of the gender difference. The possibilities of an interactional perspective of depression have yet to be explored (Coyne, 1999). An interactional perspective suggests that research should focus on the relationship context in which symptoms of depression occur. Understanding depression as a systemic experience and the way in which this differs between men and women provides challenging direction for future research. References
Abramson, L. Y., & Andrews, D. E. (1982). Cognitive models of depression: Implications for sex differences in vulnerability to depression. International Journal of Mental Health, 11, 77 94. Abramson, L. Y., Metalsky, G. I., & Alloy, L. B. (1989). Hopelessness depression: A theory-based subtype of depression. Psychological Review, 96, 358 372. Allgood-Merton, B., Lewinsohn, P. M., & Hops, H. (1990). Sex differences and adolescent depression. Journal of Abnormal Psychology, 99, 55 63. Angold, A., Costello, E. J., & Worthman, C. M. (1998). Puberty and depression: The roles of age, pubertal status and pubertal timing. Psychological Medicine, 28, 51 61. Arieti, S., & Bemporad, J. (1980). The psychological organization of depression. American journal of Psychiatry, 137, 1360 1365. Aseltine, R. H., & Kessler, R. C. (1993). Marital disruption and depression in a community sample. Journal of Health and Social Behaviour, 34, 237 251. Barnett, P. A., & Gotlib, I. H. (1990). Cognitive vulnerability to depressive symptoms among men and women. Cognitive Therapy and Research, 14, 47 61. Bebbington, P. E. (1998). Editorial. Sex and depression. Psychological Medicine, 28, 1 8. Bebbington, P. E., Dunn, G., Jenkins, R., Lewis, G., Brugha, T., Farrell, M., et al. (1998). The inuence of age and sex on the prevalence of depressive conditions: Report from the National Survey of Psychiatric Morbidity. Psychological Medicine, 28, 9 19. Beck, A. T. (1983). Cognitive therapy of depression: New perspectives. In: P. J. Clayton, & J. E. Barrett (Eds.), Treatment of depression: Old controversies and new approaches (pp. 265 290). Raven Press, New York. Beck, A. T. (1987). Cognitive models of depression. Journal of Cognitive Psychotherapy: An International Quarterly, 1, 5 37. Ben Hamida, S., Mineka, S., & Bailey, J. M. (1998). Sex differences in perceived controllability of mate value: An evolutionary perspective. Journal of Personality and Social Psychology, 75, 953 966. Blalock, J. A., & Joiner, T. E. (2000). Interaction of cognitive avoidance coping and stress in predicting depression/anxiety. Cognitive Therapy and Research, 24, 47 65. Blatt, S. J., & Maroudas, C. (1992). Convergence of psychoanalytic and cognitive behavioural theories of depression. Psychoanalytic Psychology, 9, 157 190. Braverman, L. (1986). The depressed woman in context: A feminist family therapists analysis. Family Therapy Collections, 16, 90 101.

195

Brewin, C. R., Hunter, E., Carroll, F., & Tata, P. (1996). Intrusive memories in depression. Psychological Medicine, 26, 1271 1276. Brugha, T. S., Bebbington, P. E., MacCarthy, B., Sturt, E., Wykes, T., & Potter, J. (1990). Psychological Medicine, 20, 147 156. Coryell, W., Endicott, J., & Keller, M. (1991). Major depression in a nonclinical sample: Demographic and clinical risk factors for rst onset. Archives of General Psychiatry, 49, 117 125. Coyne, J. C. (1999). Thinking interactionally about depression: A radical restatement. In T. Joiner, & J. C. Coyne (Eds.), The interactional nature of depression. advances in interpersonal approaches (pp. 365 392). Washington, DC: American Psychological Association. Coyne, J. C., & Whiffen, V. E. (1995). Issues in personality as diathesis for depression. The case of Sociotropy/Dependency and Autonomy/Self-Criticism. Psychological Bulletin, 118, 358 378. Culbertson, F. M. (1997). Depression and gender. An international review. American Psychologist, 52, 25 31. Cummings, E. M., DeArth-Pendley, G., Du Rocher Schudlich, T., & Smith, D. A. (2001). Parental depression and family functioning: Toward a process-oriented model of childrens adjustment. In S. R. H. Beach (Ed.), Marital and family processes in depression (pp. 89 110). Washington, DC: American Psychological Association. Cyranowski, J. M., Frank, E., Young, E., & Shear, K. (2000). Adolescent onset of the of the gender difference in lifetime rates of major depression. Archives of General Psychiatry, 57, 21 27. Fujita, F., Diener, E., & Sandvik, E. (1991). Gender differences in negative affect and well-being: The case for emotional intensity. Journal of Personality and Social Psychology, 61, 427 434. Ge, X., Conger, R. D., & Elder, Jr G. H. (1996). Coming to age too early: Pubertal inuences on girls vulnerability to psychological distress. Child Development, 67, 3386 3400. Gotlib, I., & Whiffen, V. (1989). Depression and marital functioning: An examination of specicity and gender differences. Journal of Abnormal Psychology, 98, 23 30. Gove, W. R. (1972). Sex, marital status, and mental illness. Social Forces, 51, 34 55. Gove, W. R., & Tudor, J. F. (1973). Adult sex roles and mental illness. American Journal of Sociology, 78, 812 835. Greenglass, E. R. (1985). Psychological implications of sex bias in the workplace. Special Issue: Gender roles. Academic Psychology Bulletin, 7, 227 240. Hammen, C. (1997). Depression. Hove, UK: Psychological Press Erlbaum (UK) Taylor & Francis. Hammen, C. (1999). The emergence of an interpersonal approach to depression. In T. Joiner, & J. C. Coyne (Eds.), The Interactional Nature of Depression (pp. 21 35). Washington, DC: American Psychological Association. Hammen, C. L., & Padesky, C. A. (1977). Sex differences in the expression of depressive responses on the Beck Depression Inventory. Journal of Abnormal Psychology, 86, 609 614. Hammen, C. L., & Peters, S. D. (1977). Differential responses to male and female depressive reactions. Journal of Consulting and Clinical Psychology, 45, 994 1001. Hankin, B. L., & Abramson, L. Y. (2001). Development of gender differences in depression: An elaborated cognitive vulnerability-transactional stress theory. Psychological Bulletin, 127, 773 796. Hankin, B. L., Abramson, L. Y., Silva, P. A., McGee, R., & Angell, K. E. (1998). Development of depression from preadolescence to young adulthood: Emerging gender differences in a 10-year longitudinal study. Journal of Abnormal Psychology, 107, 128 140.

196

S. Boughton & H. Street

OLeary, K. D., & Cano, A. (1991). Marital discord and partner abuse: Correlates and causes of depression. In: S. R. H. Beach (Ed.). Marital and family processes in depression (pp. 163 182). Washington, DC: American Psychological Association. Parker, G. B., & Brotchie, H. L. (2004). From diathesis to dimorphism: The biology of gender differences in depression. Journal of Nervous and Mental Disease, 192, 210 216. Piccinelli, M., & Wilkinson, G. (2000). Gender differences in depression. Critical Review. British Journal of Psychiatry, 177, 486 492. Radloff, L. S. (1975). Sex differences in depression: The effects of occupation and marital status. Sex Roles, 1, 249 265. Riley, D., & Echenrode, J. (1986). Social ties: Subgroup differences in costs and benets. Journal of Personality and Social Psychology, 51, 770 778. Roberts, J. E., Gilboa, E., & Gotlib, I. H. (1998). Ruminative response style and vulnerability to episodes of dysphoria: Gender, neuroticism, and episode duration. Cognitive Therapy and Research, 22, 401 423. Roberts, J. E., & Gotlib, I. H. (1997). Temporal variability in global self-esteem and specic self-evaluation as prospective predictors of emotional distress: Specicity in predictors and outcome. Journal of Abnormal Psychology, 106, 521 529. Sadowski, H., Ugarte, B., Kolvin, I., Kaplan, C., & Barnes, J. (1999). Early life family disadvantages and major depression in adulthood. British Journal of Psychiatry, 174, 112 120. Sakamoto, S. (2000). Self-focus and depression: The threephase model. Behavioural and Cognitive Psychotherapy, 28, 45 61. Salokangas, R. K. R., Vaahtera, K., Pacriev, S., Sohlman, B., & Lehtinen, V. (2002). Gender differences in depressive symptoms. An artefact caused by measurement instruments? Journal of Affective Disorders, 68, 215 220. Sanlipo, M. P. (1994). Masculinity, femininity, and subjective experience of depression. Journal of Clinical Psychology, 50, 144 157. Schwartz, S. (1991). Women and depression: A Durkheimian perspective. Social Science and Medicine, 32, 127 140. Seidlitz, L., & Diener, E. (1998). Sex differences in the recall of affective experiences. Journal of Personality and Social Psychology, 74, 262 271. Silverstein, B., & Perlick, D. (1991). Gender differences in depression: historical changes. Acta Psychiatrica Scandinavia, 84, 327 331. Simpson, H. B., Nee, J. C., & Endicott, J. (1997). First-episode major depression: Few sex differences in course. Archives of General Psychiatry, 54, 633 639. Sprock, J., & Yoder, C. Y. (1997). Women and depression: An update on the report of the APA Task Force. Sex Roles, 36, 268 303. Turner, H. A. (1994). Gender and social support: Taking the bad with the good. Sex Roles, 30, 521 541. Turner, R. J., & Avison, W. R. (1989). Gender and depression: Assessing exposure and vulnerability to life events in a chronically strained population. Journal of Nervous and Mental Disease, 177, 443 455. Veiel, H. O. F. (1993). Detrimental effects of kin support networks on the course of depression. Journal of Abnormal Psychology, 102, 419 429. Weissman, M. M. (1987). Advances in psychiatric epidemiology: Rates and risks for major depression. American Journal of Public Health, 77, 445 451. Weissman, M. M., & Klerman, G. L. (1977). Sex differences and the epidemiology of depression. Archives of General Psychiatry, 34, 98 111.

Hanninen, V., & Aro, H. (1996). Sex differences in coping and depression among young adults. Social Science in Medicine, 43, 1453 1460. Hirschfeld, R., Klerman, G., Lavori, P., Keller, M., Grifth, P., & Coryell, W. (1989). Premorbid personality assessments of rst onset of major depression Archives of General Psychiatry, 46, 345 350. Jack, D. C. (1991). Silencing the self: Women and depression. Cambridge: Harvard University Press. Kashani, J. H., Carlson, G. A., Beck, N. C., Hoeper, E. W., Corcoran, C. M., McAllister, J. A., et al. (1987). Depression, depressive symptoms, and depressed mood among a community sample of adolescents. American Journal of Psychiatry, 144, 931 934. Kendler, K. S., Thornton, L. M., & Prescott, C. A. (2001). Gender differences in the rates of exposure to stressful life events and sensitivity to their depressogenic effects. American Journal of Psychiatry, 158, 587 593. Kessler, R. C., McGonagle, K. A., Swartz, M., Blazer, D. G., & Nelson, C. B. (1993). Sex and depression in the National Comorbidity Survey. I. Lifetime prevalence, chronicity and recurrence. Journal of Affective Disorders, 29, 85 96. Kessler, R. C., McGonagle, K. A., Zhao, S., Nelson, C. B., Hughes, M., Eshleman, S., et al. (1994). Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Archives of General Psychiatry, 51, 8 19. Kessler, R. C., & McLeod, J. D. (1984). Sex differences in vulnerability to undesirable life events. American Sociological Review, 49, 620 631. Klerman, F. L., & Weissman, M. M. (1989). Increasing rates of depression. Journal of the American Medical Association, 261, 2229 2235. Kraepelin, E., & Diefendorf, A. R. (1904/1907). Clinical psychiatry: A text-book for students and physicians (7th ed). New York: The MacMillan Press. Loewenthal, K., Goldblatt, V., Gorton, T., Lubitsch, G., Bicknell, H., Fellowes, D., et al. (1995). Gender and depression in Anglo-Jewry. Psychological Medicine, 25, 1051 1063. McGrath, E., Keita, G. P., Strickland, B. R., & Russo, N. F. (Eds.). (1990). Women and depression: Risk factors and treatment issues. Washington, DC: American Psychological Association. Miller, J. B. (1984). The development of womens sense of self: Work in Progress 12 (Working Paper Series). Wellesley, MA: Stone Centre. Nolen-Hoeksema, S. (1987). Sex differences in unipolar depression: Evidence and theory. Psychological Bulletin, 101, 259 282. Nolen-Hoeksema, S. (1990). Sex differences in depression. Stanford, CA: Stanford Press. Nolen-Hoeksema, S. (1991). Responses to depression and their effects on the duration of depressive episodes. Journal of Abnormal Psychology, 100, 569 582. Nolen-Hoeksema, S., & Davis, C. G. (1999). Thanks for sharing that: Ruminators and their social support networks. Journal of Personality and Social Psychology, 77, 801 814. Nolen-Hoeksema, S., & Girgus, J. S. (1994). The emergence of gender differences in depression during adolescence. Psychological Bulletin, 115, 424 443. Nolen-Hoeksema, S., Larson, J., & Grayson, C. (1999). Explaining the gender difference in depressive symptoms. Journal of Personality and Social Psychology, 77, 1061 1072. Nolen-Hoeksema, S., Morrow, J., & Fredrickson, B. L. (1993). Response styles and the duration of episodes of depressed mood. Journal of Abnormal Psychology, 102, 20 28. Ochoa, L., Beck, A. T., & Steer, R. A. (1992). Gender differences in comorbid anxiety and mood disorder. American Journal of Psychiatry, 149, 1409 1410.

Gender differences in depression

Widiger, T. A., & Anderson, K. G. (2003). Personality and depression in women. Journal of Affective Disorders, 74, 59 66. Wilhelm, K., & Parker, G. (1994). Sex differences in lifetime depression rates: Fact or artefact? Psychological Medicine, 24, 97 111. Wrobel, N. H. (1993). Effect of patient age and gender on clinical decisions. Professional Psychology Research and Practice, 24, 206 212.

197

Yoder, C. Y., Shute, G. E., & Tryban, G. M. (1990). Community recognition of objective and subjective characteristics of depression. American Journal of Community Psychology, 18, 547 566. Zlotnick, C., Shea, M. T., Pilkonis, P. A., Elkin, I., & Ryan, C. (1996). Gender, type of treatment, dysfunctional attitudes, social support, life events, and depressive symptoms over naturalistic follow-up. American Journal of Psychiatry, 153, 1021 1027.