Higher Rates of Depression in Women: Role of Gender Bias Within the Family

Jessica A. Brommelhoff, M.P.H.; Kevin Conway, Ph.D.; Kathleen Merikangas, Ph.D.; Becca R. Levy, Ph.D.

Disclosures
In This Article

Abstract and Introduction

Objective: We sought to examine whether higher rates of depression in women than in men can be explained partially by the artifact hypothesis, which suggests that when both sexes have the same depressive symptoms, women are more likely than men to be diagnosed with depression. We hypothesized that (1) this gender bias in identifying depression exists within families and (2) family members will be more likely to attribute depressive symptoms to internal causes for women and external causes for men.
Methods: Our sample consisted of 205 adults, generated from the family members of 46 probands who participated in the Yale Family Study. To determine whether bias exists in the family, we compared self-reports of depressive symptoms with family reports of depressive symptoms for the same individual.
Results: As predicted, we found that compared with men, women were more likely to be reported as depressed by a family member when they report themselves as not depressed. We also found that family members were more likely to attribute depressive symptoms of females to internal causes. We did not, however, find any differences by gender in attribution of depression to external causes.
Conclusions: Our findings suggest that gender bias within the family may contribute to the higher recorded rates of depression in women.

Beginning in adolescence and continuing throughout the entire life span, women are more likely than men to be diagnosed with depression.[1,2] Studies have shown that the prevalence of depression among women is between one and a half and three times more than the prevalence among men.[3–6] For nearly two centuries, scientists have tried to find the cause of this difference.[7] Our study examines whether reporting bias may contribute to the gender differences in rates of depression. Specifically, we seek to determine whether there is a bias within families to recognize depression more often in female rather than male family members. We also examine if there are differences in how family members perceive the causes of depression in male vs. female relatives. Family members frequently are selected to help individuals evaluate their mental health, as it has been found that primary care physicians often do not discern mental disorders in their patients.[8–11] Additionally, clinicians and researchers frequently measure depression through proxy reports from family members, especially in studies that include elderly people, children, or those who are cognitively impaired.[12]

Some contemporary theories attribute the difference in rates of depression between men and women to social causes, specifically that women may have a greater sensitivity to stressful life events and traumas.[13,14] According to the Vulnerability-Stress Model, women's social role makes them more susceptible to depression.[15] This Model posits that because the role of caretaker, which women are expected to assume, is not awarded much value in today's society, women may feel lower self-worth than men, leading to emotional vulnerability.[15,16] Several studies, however, have found results that contradict the Vulnerability-Stress Model. For example, Kendler et al.[17] found that the difference in prevalence of depression by gender is due neither to differences in experiencing stressful life events nor to differential overall sensitivity to these events.

One frequently speculated reason for the differential rates of depression is the biological differences between men and women. Some researchers believe that women are particularly prone to depression because of events associated with the reproductive cycle. Examples of such events include depression associated with oral contraceptives, the luteal phase of the menstrual cycle, the postpartum period, and menopause.[18] The importance of these findings in explaining gender differences in rates of depression has been debated, however, as the scientific evidence is inconsistent.[13,19] Furthermore, because these differences are seen across much of the life-span, it is unlikely that biological differences fully explain the differences in rates of depression.

An alternative explanation for the differential rates of depression is the artifact hypothesis. This suggests "that the rate of depression is equal among men and women but that women express and report more symptoms, seek help more frequently, and are subject to sex biases in diagnosis, thereby providing a false elevation in the measurement of the rate of depression in women."[6] Almost all studies examining the artifact hypothesis have concentrated on how women express and report symptoms. These studies found conflicting results about whether there is any significant difference between how men and women perceive depression.[20,21]

A few studies have examined the aspect of the artifact hypothesis that concerns sex bias in diagnosis in a clinical setting.[22–25] For two of these studies exploring possible gender bias among primary care physicians,[22,23] patients were asked to self-report on the presence and severity of depressive symptoms. Subsequently, the researchers reviewed each patient's medical records to ascertain the presence or absence of a clinician's diagnosis for depression. Both studies found that being female increased the likelihood of the clinician's diagnosing the patient with depression. Furthermore, in the study conducted by Bertakis et al.,[22] when the results were stratified by depression scores, they found that women with high scores were more likely to be diagnosed with depression than men with high scores, and women with low scores were more likely to be diagnosed with depression than men with low scores. Thus, women were more likely than men to get a false positive diagnosis for depression. Along similar lines, Borowsky et al.[24] found that physicians were more likely to be aware of depression in female patients than in male patients, and Stoppe et al.[25] found that this bias extends into old age.

The current study builds on these findings in a number of ways. First, we examine family member reports rather than physician reports, which is advantageous because physicians may be less familiar with the long-term history of patients. To the best of our knowledge, no study has yet compared rates of agreement between family proxy reports and self-reports by gender. Second, we look at the types of causes to which family members attribute depression. Attribution theory describes how people make inferences about the causes of negative events and behaviors in themselves and others.[26]

Some studies have found that the way depressed people make attributions is different from how nondepressed people make attributions, in that an attributional style that explains negative events by internal causes is likely to characterize someone who is depressed.[27,28] As it pertains to gender, one study found that females tend to believe that their depression is internally caused, whereas men are more likely to attribute their depression to external causes. In other words, women are more likely to hold themselves responsible for their depressed mood, and men tend to blame negative factors within their environment, such as unemployment or divorce, for their depressed mood.[29] We predict a similar dynamic might occur in families, such that individuals will be more likely to attribute depression in female family members to internal causes and, thus by implication, hold women more responsible for their mental illness than men. Furthermore, individuals will be more likely to attribute depression in male family members to external causes, therefore holding men less responsible for their depression.

This study has two hypotheses. Our first hypothesis is that when an index self-reported no depression, but a family member reported depression in the same individual, the index is significantly more likely to be female than male. Our second hypothesis explores one of the reasons for a potential gender bias in families. We predict that depressive symptoms are more likely to be attributed to external causes in men and internal causes in women.

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