Are Gender Disparities in Depressive Disorders Real? A Study of an Incarcerated Population

Many studies have shown higher rates of depressive disorders in women than in men, with a female-to-male ratio of approximately 2:1. We examined gender characteristics in a jail setting to test the hypothesis that depression is much more common in men than has previously been reported. This setting provided a unique opportunity to diagnose and treat men with depressive disorders who would be less likely to be diagnosed with depression outside prison.

Kiran S. Lulla, MDAttending Child Psychiatrist

Boston, Mass

Director

Austin Medical Education Program

Austin, Tex

Research Consultant

Consulting, Com 1

Austin, Tex

PRACTICE POINTS

• The results of this study suggest that depression in men is probably more common than previously reported; other studies have shown, however, that men are less likely to seek treatment for it.
• Physicians must increase their suspicion of depression in their male patients, especially in those with substance abuse problems or with a history of violent behavior.

Epidemiologic data point to a female preponderance in the prevalence, incidence, and morbidity risk of depressive disorders.¹ Most investigators have reported a female-to-male ratio of 2:1 for depressive disorders²; a ratio of nearly 2.7:1 has been reported for major depressive disorder.³ Many factors have been proposed to account for this gender discrepancy, including endocrine physiology and genetics.⁴ Although the endocrine system of women is different from that of men, there is no consistent endocrinologic theory to account for the gender differences in depressive disorders.⁴ Adverse experiences in childhood, depression and anxiety disorders in childhood and adolescence, sociocultural roles with related adverse experiences, and psychological attributes related to vulnerability to life events and coping skills are also likely to increase women's preponderance.⁴ Others have noted that women have higher rates of treatment for depression than men,⁵ and the greater propensity of women to seek professional help for their mental health problems may contribute to an underreporting of depression in men.^4,6

Inmate populations present a unique opportunity to evaluate for depression in men who are unlikely to seek treatment. In this confined setting, men are much more likely to be recognized and treated for episodes of anger, violence, and substance abuse?all of which may be symptoms of depression. Men with clinical depression, bipolar disorder, posttraumatic stress disorder, grief reactions, and other mood disorders also have a better chance of receiving treatment when they are observed by correctional officers, counselors, and medical personnel.

Many studies have found that alcohol and substance abuse are more common in depressed men than in depressed women. For example, in a study of 320 men and 867 women who told primary care physicians that they had symptoms of depression, more than twice as many men self-reported "hazardous drinking" (19% vs 8%, respectively).⁷ Men were also slightly more likely than women to report problematic drug use (29% vs 23%, respectively).⁷ Another study of 563 men and 1321 women who were treated for depression indicated that men increased sports activities and consumed alcohol to cope with their depression, whereas women used emotional release and religion.⁸ A third study of 218 depressed outpatients showed that subjective feelings of anger were the same in men and women, but that significantly more men than women were predisposed to perceive situations as annoying and to respond angrily.⁹ Some authors have suggested that men are also more likely to endorse recklessness as a coping strategy for depression.¹⁰

The goal of our study was to evaluate the gender differences in depressive disorders. We hypothesized that depression is much more common in men than has previously been reported, and that when men are placed in a setting where their behaviors can be more closely observed, their rates of depression may approach those of women.

Data Collection and Categorization

Diagnostic and Statistical Manual of Mental

Disorders, Fourth Edition (DSM-IV)

The Austin Travis County Jail in Texas provided records of 2729 inmates?585 women and 2144 men?representing all inmates diagnosed with a psychiatric condition between January and July 2001. Based on the criteria of the ,¹¹ 1535 inmates?1135 men and 400 women?were diagnosed with at least 1 depressive spectrum disorder, including depressive disorder not otherwise specified (NOS), dysthymic disorder, major depressive disorder, schizoaffective disorder, and bipolar disorder. Because only a few cases of dysthymic disorder were found, these were grouped with depressive disorder NOS to enhance statistical validity. Inmates with depressive symptoms secondary to incarceration were given the diagnosis of adjustment disorder and were not included in our study.

Statistical Analysis

We used a ?² analysis to assess gender differences. Data were combined for all 7 months, and cases were entered by gender and depression subtype. The number of men and women with a specific depression type was referred to as "the observed count." Expected counts were what would be predicted based on the assumption that an equal number of men and women would have each depression type (a 1:1 ratio). To test whether observed counts differed significantly from expected counts, we calculated adjusted standardized residuals, with an adjusted standardized residual value of more than 2 indicating a significant difference.

Results

P

As shown in Table 1, no gender differences were found in the rates of depressive disorders (?² = 2.384; degrees of freedom [df; ie, the number of possible outcomes minus 1] = 3, = .497). Even though the proportions of men and women of the total number of inmates in the sample were 73.9% and 26.1%, respectively (Table 2), each depression type was equally prevalent in both genders when proportion was taken into account. Furthermore, all adjusted standardized residuals were less than 2, indicating no significant differences between any of the observed and expected counts.

DSM-IV

P

Based on the , the symptoms of schizoaffective disorder and bipolar disorder can vary from mania, to depression, to mixed mania and depression. To reduce their confounding influence, we conducted a second ?² analysis after omitting these 2 disorders. Again, no differences were found in the expression of major depression or depression NOS between genders (?² = 0.09, df = 1, = .765). It is interesting that all adjusted standardized residuals were still less than 2, indicating no significant difference between any of the observed and expected counts (Table 3).

In contrast to previously reported epidemiologic findings showing at least a 2:1 female-to-male ratio, the rates of depressive disorders in our study were equal for men and women. One explanation for this discrepancy may be differences in gender-based treatment and diagnosis rather than characteristics inherent to the study population.

Discussion

Depression affects more than 18 million people annually in the United States.¹² The World Health Organization has categorized depression as among the most disabling clinical diagnoses in the world, estimated to affect nearly 340 million people worldwide and 18 million people in the United States at any one time.¹³ Depression may be the second most common chronic medical disorder seen in outpatient clinics in the United States, after hypertension.¹⁴ The annual cost of depression in this country is approximately $83.1 billion.¹⁵ The US National Comorbidity Survey reported a higher prevalence for current (past 30-day), past year, and lifetime major depression in women.¹⁶

Physicians tend to diagnose and treat psychiatric problems in women more often than in men, probably because women are more likely to seek professional help for it than are men.¹⁷ Women use outpatient health care and mental health care services more than men, hence increasing the likelihood of detection of depression.¹⁸ In contrast to the general population, the men in our study were much more likely to be recognized and treated for episodes of substance abuse, anger, and violence?all of which may be symptoms of depression.

Men are generally more susceptible to substance use disorders than women,⁵ and depressed men tend to have more substance abuse problems than depressed women. Men may use drugs and alcohol as coping strategies for their depression.¹⁰ Anger and violence may also be symptoms of their depression.¹⁰ Since substance use disorders and violent and aggressive behaviors are more common in men and often result in incarceration, it is likely that more depressed men will be found in prisons.

Major depression is one of the most common mood disorders reported in the literature.¹¹ It accounted for a total of 610 men and women of a population of 1535 depression cases (about 40%) in our study. The point prevalence of major depression in the general population is 5% to 9% for women and 2% to 3% for men.¹¹ Of the 18,458 individuals who entered the Austin Travis County Jail between January and July 2001, only about 3% were diagnosed with major depression. Although data were not available to calculate the frequency of major depression by gender, our finding of a 3% prevalence is at the upper limit for men and is below the lower limit for women in the general population. Therefore, major depression in our incarcerated subjects was as common as or less common than in the general population.

Amore equal female-to-male ratio of depressive disorders would have considerable public health implications. Depressive disorders are one of the most common risk factors for suicide and suicidal behavior. Suicide rates among blacks are increasing. They are also increasing among persons aged 10 to 19 years as well as among persons older than 75 years.¹⁸ Although women have higher rates of suicidal ideation and behavior than men, mortality from suicide is typically higher in men.⁵ In fact, men are more than 4 times more likely to commit suicide than women.¹⁸ Nonfatal suicidal behavior in men may be underreported because of cultural attitudes about masculinity and suicide.⁴ Men who suffer from depression are at higher risk of death by suicide. Could the higher suicide rates in men reflect higher rates of depression than have been previously reported, as our results seem to suggest? Additional research on depression in men is clearly warranted.

Conclusion

The results of our study suggest that depression in men may be more prevalent than previously reported. The male-to-female ratio of depressive disorders in our study population was 1:1. Our review of medical records failed to reveal a difference in rates of depression between men and women treated in a criminal justice facility. Since depression is such a common risk factor for suicide, the higher rate of depression in male inmates may help explain why men are more than 4 times as likely as women to die by suicide.

Substance use disorders and violent and aggressive behaviors are more common in men and often result in incarceration. As a result, jails and prisons may be better catchment areas to recognize depressive disorders in men. Enhanced recognition and treatment of depression in men may reduce the incidence of substance use disorders and violent behaviors as well as successful suicides.

It is our hope that this study will promote further research into depression in both men and women so we can more effectively address the high mortality and morbidity associated with this devastating illness.

Acknowledgments

We wish to thank Beverly Sutton, MD, program director, Austin Psychiatric Residency Program, Amy Mashberg, MLS, clinical librarian, Austin State Hospital, and Shelley Pulliam, LSW, mental health coordinator, Austin Travis County Jail, Austin, Tex, for their help with the preparation of the manuscript.

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