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Women account for two-thirds of patients
suffering from common depressive disorders, making the treatment of
depression in women a substantial public health concern and is often
underdiagnosed and undertreated in primary care. Women are approximately
twice as likely as men to suffer from major depression.
Factors unique to women's lives are suspected to play a role in developing
depression, especially at midlife and beyond, including reproductive and
hormonal; genetic or other biological factors; abuse and oppression;
interpersonal factors; and certain psychological and personality
characteristics.
The University of North Texas Health Science Center is helping meet the
identified need of improving clinical knowledge and skills related to the
diagnosis and treatment of Major Depressive Disorder (MDD) in women at
midlife and beyond through a polyfaceted approach call Practical
Strategies for Diagnosing & Treating Depression in Women at Midlife and
Beyond.
Live activities, satellite programs, an internet activity and patient
screening tools will all be developed to educate more than 13,000 primary
care physicians in the United States.
Major depression is a mood disorder
characterized by one or more major depressive episodes (i.e., at least two
weeks of depressed mood or loss of interest or pleasure in nearly all
activities) accompanied by at least four additional symptoms such as changes
in sleep, appetite, or weight, and psychomotor activity; decreased energy;
feelings of worthlessness or guilt; difficulty thinking, concentrating, or
making decisions; or recurrent thoughts of death or suicidal ideation,
plans, or attempts (Medline Plus).
Depression is a common and highly treatable disorder affecting more than 15
million, or up to eight percent, of American adults annually (National Alliance
on Mental Illness). Once identified, depression can almost always be
successfully treated either by psychotherapy, medication, or a combination of
both. Women constitute two-thirds of patients suffering from common depressive
disorders, making the treatment of depression in women a substantial public
health concern (Altshuler et. al. 2001). Unfortunately, depression is
underdiagnosed and undertreated by primary care and other non-mental health
practitioners (Agency for Health Care Policy and Research). Women are
approximately twice as likely as men to suffer from major depression (National
Mental Health Association, 2004) and depression has been called a significant
mental health risk for women (WHO 2000).
A
variety of factors unique to women's lives are suspected to play a role in
developing depression, especially at midlife and beyond, including reproductive
and hormonal; genetic or other biological factors; abuse and oppression;
interpersonal factors; and certain psychological and personality
characteristics. The specific causes of depression in women remain unclear, as
many women exposed to these factors do not develop depression. Stress, in
general, can contribute to depression in persons biologically vulnerable to the
illness. Some have theorized that higher incidence of depression in women is not
due to greater vulnerability, but to the particular stresses that many women
face. Working women in midlife and beyond are more likely than younger women and
working men of any age to report higher levels of stress (Mental Health Works)
due to responsibilities at home and challenges associated with balancing a
career with family life. Other stressors can include single parenthood and
caring for children and aging parents.
Investigators are focusing on the following areas in efforts to determine why
depression is mis- or underdiagnosed in women at midlife and beyond and why such
gender disparities exist. These areas include:
Adulthood: Relationships and Work Roles
A
survey conducted by the National Mental Health Association and the American
Medical Women’s Association (2003) found that 83 percent of working women with
depression found it to be the number one barrier to success in the workplace.
Depression affects about five million employed American women each year. The
women surveyed found depression to be a greater obstacle to professional success
than other barriers such as child- and elder-care responsibilities, pregnancy
and sexual harassment. Eighty-nine percent who quit or lost a job while living
with depression attribute the loss to their condition. And, nearly one-third of
respondents said their depression “completely interferes” with their ability to
do their job.
For both women and men, rates of major depression are highest among the
separated and divorced, and lowest among the married, while remaining always
higher for women than for men. The quality of a marriage, however, may
contribute significantly to depression. Lack of an intimate, confiding
relationship, as well as overt marital disputes, have been shown to be related
to depression in women. In fact, rates of depression were shown to be highest
among unhappily married women. With two-thirds of divorces at midlife and beyond
initiated by wives (Associated Press 2004), the significance of divorce and
unhappy marriages to a woman’s mental health are underscored.
Reproductive Events
Women's reproductive events, including the menstrual cycle, pregnancy, the post
pregnancy period, infertility, menopause, and sometimes, the decision not to
have children, bring fluctuations in mood that, for some women, include
depression. Researchers have confirmed that hormones have an effect on the brain
chemistry that controls emotions and mood; a specific biological mechanism
explaining hormonal involvement is not known, however. Scientists are exploring
how the cyclical rise and fall of estrogen and other hormones may affect the
brain chemistry that is associated with depressive illness. Motherhood may be a
time of heightened risk for depression because of the stresses and demands it
imposes.
 Postpartum mood changes can range from transient "blues" immediately following
childbirth to an episode of major depression to severe, incapacitating,
psychotic depression. Studies suggest that women who experience major depression
after childbirth very often have had prior depressive episodes even though they
may not have been diagnosed and treated.
Abuse
The rate of sexual and physical abuse is much higher than previously suspected
and is a major factor in women's depression. Depressive symptoms may be
long-standing effects of post-traumatic stress disorder for many women (McGrath
et al., 1990). Studies show that women molested as children are more likely to
have clinical depression at some time in their lives than those with no such
history. In addition, several studies show a higher incidence of depression
among women who have been raped as adolescents or adults. Abuse may lead to
depression by fostering low self-esteem, a sense of helplessness, self-blame,
and social isolation. There may be biological and environmental risk factors for
depression resulting from growing up in a dysfunctional family.
Depression in Later Adulthood
As
with younger age groups, more older women than men suffer from depressive
illness. Depression can be dismissed by primary healthcare providers as a normal
consequence of the physical, social, and economic problems of later life.
Conversely, studies show that most older people feel satisfied with their lives.
Depression, if misidentified in women as a consequence of aging, can go
untreated and have a greater impact on a woman’s quality of life.
About 800,000 persons are widowed each year. Most of them are older, female, and
experience varying degrees of depressive symptomatology. A third of widows meet
criteria for major depressive episode in the first month after the death, and
half of these remain clinically depressed one year later. These depressions
respond to standard antidepressant treatments, although research on when to
start treatment or how medications should be combined with psychosocial
treatments is still in its early stages.
Conclusion
Gender disparities do exist regarding the diagnosis and treatment of depression.
It is misdiagnosed approximately 30 to 50 percent of the time. Approximately 70
percent of the prescriptions for antidepressants are given to women, often with
improper diagnosis and monitoring. Prescription drug misuse is a very real
danger for women (McGrath et al., 1990).
Major depression is commonly underdiagnosed in primary care, where providers are
believed to miss the diagnosis of depression in 50 percent of their affected
primary care patients (Depression Guideline Panel 1993). Over longer periods of
time, primary care physicians may recognize depression in as many as 86% of the
persistently depressed patients seen in clinical practice (Kessler et.al. 2002).
However, the initial manifestations of depression can be subtle and might not be
recognized during routine, often brief, primary care visits focused on physical
complaints or conditions. Many office visits may occur before the physician
explores the possibility of depression. Earlier identification of women with
depression can shorten the course of the illness and improve the quality of life
for patients and families who must cope with this illness (Price 2004).
The Educational Gap
According to the 2006 Depression in Primary Care (DPC) meeting sponsored
by the Robert Wood Johnson Foundation, longitudinal chronic illness care models
can be highly effective in managing depression, but are not currently being
implemented by providers or health plans. The DPC meeting identified a
conceptual framework called the “6 Ps” to removing barriers and improving the
effectiveness of primary care in identifying and treating depression. One of
those “Ps” related to “Providers”. The report recommended that primary care
providers needed to improve knowledge and skills related to depressions
screening, diagnosis and treatment, have decision support tools available and be
linked to specialty expertise.
High-quality, empirical data on depressive disorders specific to women are
limited. As a result, there are no comprehensive evidence-based practice
guidelines on the best treatment approaches for these illnesses (Altshuler, et.
al. 2001). Depression is a complex, highly prevalent disorder that is treatable,
but is underdiagnosed in primary care (Price 2004). While the etiology of major
depressive disorder is not fully understood, the literature suggests that women
at midlife and beyond are often misdiagnosed or the condition is underdiagnosed
in the primary care setting. While a number of social and cultural factors
influence effective diagnosis and management, evidence also points to the lack
of evidence based (Burroughs 2006) and clinical treatment models (DPC 2006).
Continuing medical education, when incorporating adult learning principles and
accounting for multiple learning preferences, has been shown to change provider
behavior. The need for increased primary care education and linkages to
resources related to diagnosis and treatment of depression is documented (DPC
2006), as is the effectiveness of basic clinical screening tools and
provider/patient interaction (Price 2004).
© 2007 University of North
Texas Health Science Center. This needs assessment may be reproduced
providing acknowledgement is given to "University of North Texas Health Science
Center Office of Professional and Continuing Education" and notification prior
to use is provided to: Andy Crim at
acrim@hsc.unt.edu or telephone 817.735.2539.
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