Society and ‘good woman’: A critical review of gender difference in depression

Abstract

Background:

Worldwide, women are found to suffer from depression significantly more than men. This has puzzled the scientists since no biological explanation can completely resolve the matter.

Method:

Extant empirical work has been conducted to solve the mystery of the issue. However, most of the research has pivoted their attention to biology. Therefore, based on the previous literature from the disciplines of medicine, psychology and sociology, the author aimed at looking and reviewing the matter critically. Specifically, the present critical review aims at conceptualising the psychological, social and cultural factors in the context of gender difference in depression.

Discussion:

The work reveals that psychological variables such as women’s unique attachment patterns, relational self-construal, as well as a macro-level issue like power dynamics based on gender, and the skewed division of labour play an important role in gender difference in depression. The work also suggests that focusing solely on biological underpinnings may result in losing the entire scenario; therefore, social and cultural issues that place women in a socially disadvantaged position are equally important.

Keywords

Depression division of labour self-silencing attachment relational self

Introduction

I don’t feel as if it was worthwhile to turn my hand over for anything, and I’m getting dreadfully fretful and querulous. I cry at nothing, and cry most of the time.

( Gilman, 1994 , p. 650)

Being the ‘common cold of psychiatry’ (H. Miller, 1969), depression has always been at the centre of attention of mental health researchers as well as laymen. Interest in understanding the root causes and consequences of depression is present from as long as the period of Greek thinker Hippocrates. He attributed the causes of ‘melancholia’ to excess of black bile in the human body and considered it as a condition of fear and sadness. Whereas this ‘humoral theory’ of melancholy dominated the world of mental health for centuries, Thomas Willis (1621–1675) is the first who argued against this. The journey of modern classification and diagnostic system of ‘depression’ started significantly later, with the fundamental contribution of Emil Kraepelin (1856–1926). This present form of depression is different from the ancient form of melancholia in some aspects (Berrios & Luque, 1995; Rousseau, 2000). Presently, multiple perspectives and approaches are used for assessment of depression. Some of the classificatory systems consider depression to be a single state, whereas others understand depression in terms of an affective state along with a number of biological, behavioural and cognitive processes (Angold, 1988). Classification of depression has therefore created a ‘contemporary confusion’ (Cole, McGuffin, & Farmer, 2008; Farmer & McGuffin, 1989; Kendal, 1976) among the mental health researchers and practitioners. Among the recent classificatory systems, International Classification of Diseases, Tenth Revision (ICD-10) includes a number of disorders having depressive episodes, such as bipolar affective disorder, mild depressive episode, moderate depressive episode, severe depressive episode, recurrent depressive episode, cyclothymia, dysthymia, mixed-affective episode and recurrent brief depressive disorder. In terms of diagnostic codes of ICD-10, the depressive episode must be at least 2 weeks long with no hypomanic or manic symptoms sufficient to meet the criteria for hypomanic or manic episode at any time in the individual’s life in order to be diagnosed, and the symptoms should not be attributable to psychoactive substance use or to any organic mental disorder. Besides these, all the depressive episodes must have

Depressed mood,

Loss of interest and enjoyment,

Reduced energy leading to increased fatigability and diminished activity as typical symptoms.

Other common symptoms are

Reduced concentration and attention,

Reduced self-esteem and self-confidence,

Ideas of guilt and unworthiness (even in mild type of episode),

Bleak and pessimistic views of the future,

Ideas or acts of self-harm or suicide,

Disturbed sleep,

Diminished appetite.

The classification of depressive episodes (mild, moderate and severe) is based on the number of seven common symptoms, severity of the symptoms and type of symptoms. Depressive episodes, according to ICD-10, might be with or without somatic symptoms; these symptoms are characterised by loss of interest or pleasure in activities that are normally enjoyable, lack of emotional reactivity to normally pleasurable surroundings and events, waking in the morning 2 hours or more before the usual time, depression worse in the morning, objective evidence of definite psychomotor retardation or agitation, marked loss of appetite, weight loss and marked loss of libido.

The history of psychology is quite unfortunate because, until 1980s, psychological theories were based on studies and observations of male behaviours, and hence could only depict male psychology (J. B. Miller, 1986a).

The psychologists successfully neglected the one-half of the society and yet developed theories of human behaviour, even when the neglected half often suffered more. For instance, across the world, epidemiological studies have reported significantly higher depression incidence rate among women compared to men (Petersen et al., 1993; Weissman & Klerman, 1977). Table 1 gives an account of existing epidemiological data related to sex difference in lifetime prevalence of depression.

Table 1.

Literature showing Sex Difference in Lifetime Prevalence of depression

Researchers	Country	Sample size and age group	Diagnostic criterion	Gender ratio (women: men)
Viana and Andrade (2012)	Brazil	5,037; 18–65 + years	DSM-IV, Major Depressive Disorder	2.3
Viana and Andrade (2012)	Brazil	5,037; 18–65 + years	DSM-IV, Dysthymia	2.44
Bromet et al. (2011)	18 countries, high-, low- and middle-income countries worldwide	89,037; > 18 years	DSM-IV, Major Depressive Disorder	1.8 for high-income countries and 2.1 for low- and middle-income countries
Seedat et al. (2009)	15 countries worldwide	72,933; −	DSM-IV, Major Depressive Disorder	1.9
Seedat et al. (2009)	15 countries worldwide	72,933; −	DSM-IV, Dysthymia	1.9
Chen et al. (1993)	Hong Kong	7,229; 18–64 years	DSM-III, Major Depressive Episode (both single and recurrent)	1.9

DSM-IV: Diagnostic and Statistical Manual of Mental Disorders (4th ed.); DSM-III: Diagnostic and Statistical Manual of Mental Disorders (3rd ed.).

A great deal of work has been done in order to connect biology (Cyranowski, Frank, Young, & Shear, 2000) to increased risk of depressive symptoms among women, especially in terms of hormonal changes during childbirth and pregnancy (Brown & Harris, 1978), and pubertal transition (Bebbington, 1996; Silberg et al., 1999). Few of the researchers have also emphasised the role of gender bias in depression (Landrine, Klonoff, Gibbs, Manning, & Lund, 1995; Silverstein, Perlick, Clauson, & McKoy, 1993) since such biases, most of the time, put women in an unfavourable position. Bargaining theory of depression (Hagen, 2003), for instance, suggests that being in a socially disadvantageous position in a social conflict leads women to suffer from depression.

Besides these research traditions, psychologists also put light on relational patterns of women as a determinant of depression, since it is often found to be one of the most important aspects of women’s life due to their relational self-construal. In the process of searching for an answer regarding whether the relational strategy and attachment pattern of women have any impact on their high predisposition to depression, Jack, in 1991, introduced a new concept, namely, self-silencing. Building on ‘Silencing the Self Theory’, ‘women suppress their thoughts and opinions due to the perception that self-expression would lead to the loss of their intimate partner and relationship’ (Harper & Welsh, 2007, p. 100). This kind of strategy to suppress one’s emotion not only makes women more vulnerable to depression but also impacts a number of other aspects of life. It can be easily inferred that self-silencing, as a relationship strategy, has a lot to do with the socially prescribed roles for women in our society; as Jack and Ali put it, ‘Self-silencing is hypothesized to represent an attempt to fill a gender role marked by passivity, body shame, fear and vulnerability, and niceness’ (p. 141).

Whether it is self-silencing, skewed division of labour inside the family or interpersonal violence, channels of women’s vulnerability to depression are not devoid of the social power structure and the prescribed gender norms. The present work aims at understanding how socially imposed gender-based power structure and socially prescribed gender roles determine women’s higher predisposition to depression.

Biological underpinnings

Biologists have been researching for years to reach at a precise biological explanation of gender difference in depression. In terms of genetics, Sullivan, Neale, and Kendler (2000), through their meta-analysis of familial studies, revealed high level of genetic predisposition of depression, but they could not find any gender difference in terms of genetic influence in this context. In fact, Faraone, Lyons, Tsuang, and Rao (1987) found no significant association between location of dominant gene in X chromosome and high incidence rate of depression in women.

In terms of neurotransmitter, one of the most popular aetiological explanations of depression is monoamine hypothesis. Although the major proposition of this hypothesis has changed greatly over the years, the major assumption remains that depression is a result of deficiency of monoamine neurotransmitters such as catecholamines (Schildkraut, 1965) or indolamines (Ashcroft et al., 1966). The journey of this well-known hypothesis began in 1960s, and the major contribution to the development of this hypothesis came from the work of Schildkraut (1965). Interestingly, the discovery came serendipitously from the administration of antimycobacterial medicine iproniazid, which had inhibitory effects on monoamine oxidase enzyme (MAO). However, no research finding could appropriately connect gender to MAO level in body.

Many researchers like Deecher, Andree, Sloan, and Schechter (2008) worked towards getting an explanation of higher incidence rate of depression in women from a hormonal perspective. This has especially interested researchers since women are found to suffer from low-mood problems during different phases of life with hormonal fluctuations such as puberty (Angold, Costello, Erkanli, & Worthman, 1999), menopausal transition (Avis & McKinlay, 1995) and post-delivery conditions (Buckwalter, Buckwalter, Bluestein, & Stanczyk, 2001). Sichel and Driscoll (1999) took an ‘earthquake model’ for explaining sudden increase in vulnerability of mood disorders in these critical phases of life. Among these phases, depression after childbirth or post-partum depression (Kaplan & Sadock, 2007) is the most frequently reported psychological complication (Robertson, Grace, Wallington, & Stewart, 2004), and it affects around 10%–15% of women of childbearing age (Beck, 2001; Robertson et al., 2004). Endocrinological factors are most commonly linked with post-partum depression. Some of the researchers attribute post-partum depression to lack of naturally found progesterone in body immediately after delivery (Harris et al., 1994), which is mostly caused by rapid withdrawal of placental corticotrophin-releasing hormone (CRH), and therefore initiates a process of re-equilibration (O’Keane et al., 2011). However, post-partum depression, also, is not a product of singly biology, some of the researchers have strongly suggested the importance of social support (Beck, 2001; O’hara, 2009; Noriko, Megumi, Hanako, & Yasuko, 2007; Robertson et al., 2004) or perceived social isolation during pregnancy (Nielsen, Videbech, Hedegaard, Dalby, & Secher, 2000) as strong predictors of post-partum depression. Besides that, marital discords with the partner are also found to be a moderator predictor of post-partum depression (Robertson et al., 2004).

The connection between monoamine neurotransmitter serotonin and ovarian hormones is again tried to be linked since serotonergic neurons in the raphe nuclei tend to have receptors with oestrogen-inducing property (Bethea, 1993). Moreover, Bethea and colleagues (2000), in a more detailed review, mentioned mechanisms through which oestrogen and progestin have some direct impacts on the regulation of serotonin. These researches on the hormone system explain to a great extent the higher prevalence of depression of women, but are those sufficient to explain such huge difference between genders in depression?

Interpersonal processes

The science of who you are – your unique biology and biography – explains why some of us have mental illness, while others do not. (Serani, 2011, p. 20)

Building on ‘Diathesis-Stress’ model (Abramson, Metalsky, & Alloy, 1989; Brown & Harris, 1978, 1989; Ingram & Luxton, 2005; Rosenthal, 1963), depression, like other mental disorders, is a manifestation of the combined effects of constitutional factors (biological and genetic) and stress (life events). In fact, Zubin and Spring (1977) take a titration-like model to explain the link between diathesis and stress; that is, if one has highly negative cognitive style (diathesis), then even a less negative life event may make him develop a full-blown mental disorder. These theorists consider vulnerability or stress to be a continuum. One might ask whether the stress or vulnerability is always a life event or not; in fact, the social structures and processes and their interaction with the constitutional factors may be a relevant thing to study in this matter. The importance of society in depression is apparent since Sanderson, Beck, and Beck (1990) found very high level of social anxiety among the depressive patients. Taking that inference, Paul Gilbert (2000) developed a rank theory of depression which states that submissive behaviour and social rank of a person are associated to a person’s vulnerability to depression. The low social rank of women and their submissive nature may make women more likely to suffer from depression compared to men.

Masking emotions to be socially appropriate

People often hold a stereotype that women are more emotionally expressive than men, but women do mask their emotion to a great extent, especially when it comes to emotions which are socially defined to be ‘unfeminine’, such as anger (Jack, 2001; 2003). Moreover, unlike men, women are more likely to have arousal and expression of anger in an interpersonal context (Lohr, Hamberger, & Bonge, 1988; Thomas & Atakan, 1993; Fehr, Baldwin, Collins, Patterson, & Benditt, 1999).

Explanations of masking of such emotions come from a number of sources. According to Carol Gilligan, for instance, women generally avoid hurting others by expressing their aggression and anger due to their strong morality of care. According to Gilligan and Attanucci (1988), the care orientation of women ‘draws attention to problems of detachment or abandonment and holds up an ideal of attention and response to need’ (p. 225). Echoing Gilligan, Nel Noddings (1989) linked the tendency to avoid hurting others with women’s caretaking behaviour. She states,

because female experience has been so often and so intimately confined to persons for whom we must care (or for whom we do care), the feeling should arise in us that we must relieve pain when it is in our power to do so, and certainly we must not inflict pain unless we have an excellent reason. (p. 99)

This empathy is not free from the social prescriptions, expectancies and norms. Coghlan (1996), for example, suggested that women are taught to avoid conflicts, since they need to stay alive and unharmed in order to give birth to children.

Similarly, J. B. Miller (1986a) believes that the empathy of women aroused from such social expectations is unidirectional in nature, that is, the empathy and care are directed towards others to the extent that care is often defined by women as a form of self-sacrifice (Jack & Dill, 1992; 2010). Jack also found that women avoid hurting others due to six major relational reasons. And surprisingly, the most frequently reported reason was not related to empathy, but it was merely a fear of aggressive retaliation, again supporting the power dynamics. The power dynamics are so obvious that Jack compares such adult attachment with ‘parent-child relationships’, characterised by power inequality where women feel the fear of being abandoned.

However, the masked emotions take their outlet through the channels of either manipulation or silence, both of which are threats for the mental health of women. Masking of the emotions in order to fit in to the social norms is accompanied by a feeling of ‘loss of self’ among them. They don’t express their real self to their partners driven by a fear of ‘catastrophe’; and over the years, such lack of expression leads to lack of confrontation to their authentic self, and this may eventually lead to a feeling of ‘loss of self’. Besides that, women perceive to lose themselves since they don’t get the scope to express the real persons they are and are often the human forms of the social norms and expectations. This kind of lack of connection with the real self, as well as large gap between the real and presented self over the years, leads to anguish and despair.

Although maintaining a relationship often requires suppressing one’s real emotions, especially when it is negative in nature, this is surely not helpful for a good psychological functioning. Building on classical Freudian theory, repression of traumatic memories as well as emotional inhibition is the core of neurosis, and psychoanalytic therapy aims at the release of such ‘strangulated affect’ and unconsciously repressed parts through the process of catharsis. In self-silencing, the inhibition is conscious in nature; therefore, it is suppression, and fatal impacts of repression may not happen in self-silencing. However, Gross and Levenson (1997) found that even if people suppress their negative feelings, they do not get rid of the negative experiences associated with it; therefore, a person behaves in a socially acceptable manner and manages to maintain relationships but the negative impacts of the emotions are still there.

The link between depression and masking of emotions even becomes more explanatory in the context of divided self, which is defined as ‘the experience of presenting an outer compliant self to live up to feminine role imperatives while the inner self grows angry and hostile’ (Jack & Dill, 1992). Due to the presence of implicit power hierarchy in heterosexual relationships and being located at the less powerful end, women choose a ‘compliant relatedness’, but they have a covert rebellion self. Jack (2003), in her study, found that some of her patients imagine a scene in which she speaks her emotions out in front of her partner. These are surely nothing but Freudian defence mechanism ‘fantasy’ as a result of women’s feeling of incapability to physically rebel their ‘strong’ partners. Divided self also leads to self-condemnation for not fighting for herself and guilt for having socially unacceptable emotions like anger. Both the feelings are at the core of depressive cognition.

Attachment and relational self

Jean Baker Miller, in 1986, through her classic feminist text Towards a New Psychology of Women, shunned at the view of previous psychologists who perceived women’s need for connection as a weakness. J. B. Miller’s (1986a) work as well as the stone centre model by her colleagues (Jordan, Kaplan, Miller, Stiver, & Surrey, 1991) considered connection and maintaining relationship to be important parts of a woman’s life. She mentions, ‘women’s sense of self becomes very much organized around being able to make and then to maintain affiliation and relationships’ (p. 83). Echoing that, Surrey (1985), through self-in-relation theory, revealed that connection with others and empathy are parts of self-concept for women. This view is in contradiction to developmental theorists like Erikson (1963) and cross-cultural theorists Markus and Kitayama (1991), since it suggests that a woman’s self is relational in nature and the development of other aspects of self, such as autonomy and creativity, occurs only in the context of that.

Relational cultural theory (RCT) also provides with much insight regarding the importance of connections and mutuality in human growth, lack of which can lead to suffering through separation, humiliation, shame and marginalisation (Miller & Stiver, 1997; Jordan, 2001). Miller (1986b) mentioned ‘five good things’ related to connections, such as ‘sense of zest’, sense of worth and motivation; all of these act as characteristics of growth-fostering relationships (Jordan & Dooley, 2000). Therefore, when such connections are lost, it results in condemned isolation, which is a sense of ‘locked out of the possibility of human connection’ (Miller & Stiver, 1997, p. 72).

Every individual has yearnings for connections, but people also use strategies of disconnection. This ‘Central Relational Paradox’ is used to avoid the real or perceived threats of rejection (Miller & Stiver, 1997). Grounded on Karen Horney’s (1937), it is evident that rejection or anticipation of it leads to anxiety and aggression. Hypervigilance to rejection makes people perceive more negative signs in interpersonal relationships (Ayduk, Downey, Testa, Yen, & Shoda,1999) and led them overreact; therefore, it works like a ‘vicious cycle which is difficult to escape from’ (Horney, 1937, p. 137). But, apart from aggression, rejection sensitivity, especially in the context of romantic relationships, may also predict depression among women (Ayduk, Downey, & Kim, 2001) possibly through the perception of lack of control. Primarily, two strategies are used by people to avoid rejection threat. Some people explicitly and directly express their aggression (Ayduk et al., 1999; Downey, Bonica, & Rincon, 1999). The other approach may involve withdrawing oneself or avoid confronting differences in opinions through self-silencing. Women use self-silencing as a strategy of avoiding rejections in relationships in intimate relationships, and since their need for maintaining relationship is very high, they are highly likely to use this (Eagly & Chrvala, 1986; London et al., 2012). Harper, Dickson, and Welsh (2006) connected rejection sensitivity to self-silencing behaviour in the context of relationships with intimate partners and found high rejection sensitivity among adolescents was positively correlated to self-silencing and also to depressive symptomatology.

Society and family

Violence

The implicit power structure in a marital relationship sometimes even takes the form of direct violence towards women. A handful of studies have established a close link between experience of familial violence from husband and depression among wives (Cascardi, O’Leary, & Schlee, 1999; Golding, 1999; Kamimura, Christensen, Tabler, Ashby, & Olson, 2014; Kuehner, 2017; Varma, Chandra, Thomas, & Carey, 2007). To be specific, Golding (1999) observed that 46.7% of abused women in his study are victims of depression.

Whereas masking of emotion is mostly determined by the fear of angry outburst, it is obvious that women, who have experienced direct expression of rage, aggression and anger in terms of violence, are highly prone to suppress and mask their emotions. Internalisation of anger again explains high rates of self-harming behaviours and suicidal attempts among battered women. For example, in a study of Kermode et al. (2007), marital conflict was the most frequently reported cause behind suicide attempts among Indian women. Moreover, experiencing violence for a longer time often leads to a sense of learned helplessness and perception of powerlessness among battered women. These are one of the most relevant underlying mechanisms of depression (LoLordo, 2001; Seligman & Beagley, 1975).

Witnessing familial violence is not only harmful for the wife, daughters are also affected and moved towards depression as a result of experiencing the trauma of familial violence since they also have the same tendency to internalise such trauma (Stagg, Wills, & Howell, 1989).

Division of labour inside family and depression

And indeed the unequal distribution, both quantitative and qualitative, of labour and its products, hence property: the nucleus, the first form, of which lies in the family, where wife and children are the slaves of the husband. (Marx & Engels, 1998)

With the recent trend of dual earning families, there is a change in the division of labour in the economic spheres, but the division of labour inside the family, unfortunately, remains broadly unchanged (Jacobs & Gerson, 2004; Yavorsky, Kamp Dush, & Schoppe-Sullivan, 2015). In this condition, a typical married working woman takes both the house and office responsibilities, whereas a male manages only the office responsibilities, although, sometimes, they may engage themselves in family responsibilities when the wife is not available (Coverman, 1985). This is largely rooted in the socially prescribed unequal power distribution between males and females (Pateman, 1988) and the gender role attitudes (Coverman, 1985). For example, taking care of children and husband is ingrained in the gender roles for women. Consequently, married men get significantly more personal time for leisure and self-care as compared to women (Bittman & Wajcman, 2000; Colbeck, 2006). Although there is a scarcity of research that significantly predicts the direct link between lack of leisure hours and depression, but there is definitely requirement of leisure hours for the mental well-being of women (Ponde & Santana, 2000).

Depression is often linked with childbirth since post-partum depression is one of the commonest types. Post-delivery hormonal fluctuations increase one’s biological vulnerability to depression. Besides that, motherhood comes with some added expectations in terms of gender roles of the society. Child care–related responsibilities in most of the cultures are divided unequally between parents (Bittman & Wajcman, 2000; Major, 1993).

Besides such added responsibilities, motherhood often comes with a lot of adjustments and compromises that are required to be made in terms of work life and career. In fact, Ross and Mirowsky (1988) suggested that it is not the children but the adjustments a woman makes in her career after motherhood is related to depression. A large percentage of working women choose to leave their jobs to deal with the overload of the roles (Becker & Moen, 1999) for which they often feel overburdened (Goldsteen & Ross, 1989). In addition to tremendous work load, some mothers decide to quit their jobs in order to conform to the socially constructed ‘good mother’ role (Holmes, 1997), who stays at home to provide intensive mothering to her children (Arendell, 1999). Intensive mothering, which has traditionally been portrayed in the media as the ideal one, reinforces and maintains the existing division of labour (Hartsock, 1998).

Furthermore, employed women are less likely to be depressed (Bromberg & Matthews, 1994) since their employment status provides them with opportunities to socialise, and once they learn to adjust to multiple roles, the mental health status is better with employment and family roles (Reid & Hardy, 1999). Therefore, women who are bound to take the decision of quitting their job may make themselves even more vulnerable to depression. In fact, research reveals that performing paid work decreases the chances of depression in both the parents, whereas work and responsibilities inside house are quite consistently linked to increased risk of depression (Glass & Fujimoto, 1994). However, unfortunately, most of the time, wives get the part of family responsibilities.

Motherhood is so frequently associated with womanhood that it has become immediately a part of women’s gender identity (McMahon, 1995), which explains high risk of depression among infertile women (Domar, Broome, Zuttermeister, Seibel, & Friedman, 1992).

If one plans to continue her career and work roles after childbirth, the guilt of not being able to be always available for their children often causes women significant amount of distress. Mothers of toddlers and infants, reportedly, feel guilty and ambivalence when they need to use day-care for care giving of their offspring (Mann & Thornberg, 1987). They are also subjected to ‘mother-blaming’ (Caplan, 2013; Turkel, 1996) and judgements from the society as well as from herself even if often working mothers put more efforts and spend more quality time with their children than non-working mothers (Bianchi & Robinson, 1997).

Therefore, work–family conflict is expected to be more frequently found among married women in comparison with married men (Duxburry & Higgins, 1991; Duxbury, Higgins, & Lee, 1994), mostly because of the different social expectations from males and females (Gutek, Searle, & Klepa, 1991). Work–family conflict is often found to be associated with psychiatric problems (Poms, Fleming, & Jacobsen, 2016), including depression (Greenberg, Kessler, Nells, Finkelstein, & Berndt, 1996; MacEwen & Barling, 1994); in fact, Frone (2000) revealed that for women, depression is significantly linked with work-to-family conflict.

Search strategy for the present work

For the present study, two search engines, PubMed and PsycINFO, were used till 3 August 2017. Since the present piece of work is a critical understanding of the gender gap in the prevalence of depression, a straightforward approach of direct searching was difficult. In PsycINFO, for instance, combining ‘women’ AND ‘depression’ in the last 20 years (1997–2017) led to more than 35,000 results, whereas in PubMed, it led to around 30,000 results. However, most of these articles were less focused on the purpose of the present research. Therefore, combining words like ‘epidemiological data’, ‘multi country study’, ‘culture’, ‘violence’, ‘social causes’, ‘motherhood’, ‘self-silencing’, ‘division of labour’, ‘family’, ‘hormonal explanation’, ‘endocrinology’, ‘brain structure’, ‘rejection sensitivity’, ‘women’s development’, ‘growth’, ‘role learning’, ‘social origin’, ‘emotional regulation’, ‘economic inequality’, ‘work family conflict’, ‘biology’, ‘genetic factors’, ‘adjustment’ and ‘gender discrimination’ was necessary. Besides that, cross referencing was also done for further detailing. The studies included theoretical reviews, meta-analysis and empirical papers from both qualitative and quantitative aspects. Besides psychiatry and psychology, some of the resources reviewed were from sociological background.

Discussion

From the present review, one can easily understand that gender difference in depression is not simply a matter of biological difference; rather, it is the product of social forces, psychological processes, and biology. Where depression has powerlessness at its core, the lack of power that women have been suffering from time immemorial cannot be ignored. Besides their attachment pattern and relational self-construal, the economic reality of women often makes them feel powerless and made them to silence their voices. Financial dependence and insecurity is still a large problem for most of the women population across the globe. Although providing financial security is expected to have some strong impacts on the perceived powerlessness among women, it does not guarantee to have complete control over the gender difference in depression. A comprehensive understanding of the link between financial security and depression among women is required in future.

There is a number of work on how power dynamics and relational nature of married couples influence their depression and other mental health issues. However, how the other relationships inside a family may serve as a buffer to save one from a full-blown depression is also important, especially in the context of collectivist cultures.

The gender difference of depression is not a straightforward issue that can be solved drawing a simple equation; it is complex integration of biology, society and culture. Therefore, more extant and elaborative research is required to cover the depth of the issue.

Footnotes

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

References

Abramson

L. Y.

Metalsky

G. I.

Alloy

L. B.

(1989). Hopelessness depression: A theory-based subtype of depression. Psychological review, 96(2), 358.

Angold

(1988). Childhood and adolescent depression: II. Research in clinical populations. The British Journal of Psychiatry, 153, 476–492.

Angold

Costello

E. J.

Erkanli

Worthman

C. M.

(1999). Pubertal changes in hormone levels and depression in girls. Psychological Medicine, 29, 1043–1053.

Arendell

(1999). Mothering and motherhood: A decade review (Berkeley Collection of Working and Occasional Papers, 4). Berkeley: University of California.

Ashcroft

G. W.

Crawford

T. B. B.

Eccleston

Sharman

D. F.

Macdougall

Stanton

J. B.

Binns

J. K.

(1966). 5-Hydroxyindole compounds in the cerebrospinal fluid of patients with psychiatric or neurological diseases. The Lancet, 288, 1049–1052.

Avis

N. E.

McKinlay

S. M.

(1995). The Massachusetts women’s health study: An epidemiologic investigation of the menopause. Journal-American Medical Womens Association, 50, 45–45.

Ayduk

Downey

Kim

(2001). Rejection sensitivity and depressive symptoms in women. Personality and Social Psychology Bulletin, 27, 868–877.

Ayduk

Downey

Testa

Yen

Shoda

(1999). Does rejection elicit hostility in rejection sensitive women? Social Cognition, 17, 245–271.

Bebbington

(1996). The origins of sex differences in depressive disorder: Bridging the gap. International Review of Psychiatry, 8, 295–332.

10.

Beck

C. T.

(2001). Predictors of postpartum depression: An update. Nursing Research, 50, 275–285.

11.

Becker

P. E.

Moen

(1999). Scaling back: Dual-earner couples’ work-family strategies. Journal of Marriage and Family, 61, 995–1007.

12.

Berrios

G. E.

Luque

(1995). Cotard’s syndrome: Analysis of 100 cases. Acta Psychiatrica Scandinavica, 91, 185–188.

13.

Bethea

C. L.

(1993). Colocalization of progestin receptors with serotonin in raphe neurons of macaque. Neuroendocrinology, 57(1), 1–6.

14.

Bethea

C. L.

Gundlah

Mirkes

S. J.

(2000, August). Ovarian steroid action in the serotonin neural system of macaques. In Novartis Foundation Symposium, Vol. 230, pp. 112–130.

15.

Bianchi

S. M.

Robinson

(1997). What did you do today? Children’s use of time, family composition, and the acquisition of social capital. Journal of Marriage and Family, 59, 332–344.

16.

Bittman

Wajcman

(2000). The rush hour: The character of leisure time and gender equity. Social Forces, 79, 165–189.

17.

Bromberg

Mathews

(1994). ‘Employment status and depressive symptoms in middle aged women: a longitudinal investigation’, American Journal of Public Health, 84(2), 202–206.

18.

Bromet

Andrade

L. H.

Hwang

Sampson

N. A.

Alonso

de Girolamo

… Kessler

R. C.

(2011). Cross-national epidemiology of DSM-IV major depressive episode. BMC Med, 9, 90.

19.

Brown

G. W.

Harris

(1978). Social origins of depression: A reply. Psychological Medicine, 8, 577–588.

20.

Brown

G. W.

Harris

T. O.

(Eds.). (1989). Life events and illness. Guilford Press.

21.

Buckwalter

J. G.

Buckwalter

D. K.

Bluestein

B. W.

Stanczyk

F. Z.

(2001). Pregnancy and postpartum: Changes in cognition and mood. Progress in Brain Research, 133, 303–319.

22.

Caplan

(2013). Don’t blame mother: Then and now. Gender and women’s studies in Canada: Critical terrain, 99–106.

23.

Cascardi

O’Leary

K. D.

Schlee

K. A.

(1999). Co-occurrence and correlates of posttraumatic stress disorder and major depression in physically abused women. Journal of Family Violence, 14, 227–249.

24.

Chen

C. N.

Wong

Lee

Chan-Ho

M. W.

Lau

J. T. F.

Fung

(1993). The Shatin community mental health survey in Hong Kong: II. Major findings. Archives of General Psychiatry, 50, 125–133.

25.

Coghlan

(1996). Why women don’t start wars. New Scientist 2048, 13.

26.

Cole

McGuffin

Farmer

(2008). The classification of depression: Are we still confused? British Journal of Psychiatry, 192(2): 83–85.

27.

Colbeck

C. L.

(2006). How female and male faculty with families manage work and personal roles. The balancing act: Gendered perspectives in faculty roles and work lives, 31–50.

28.

Coverman

(1985). Explaining husbands’ participation in domestic labor. The sociological quarterly, 26(1), 81–97.

29.

Cyranowski

J. M.

Frank

Young

Shear

M. K.

(2000). Adolescent onset of the gender difference in lifetime rates of major depression: A theoretical model. Archives of General Psychiatry, 57, 21–27.

30.

Deecher

Andree

T. H.

Sloan

Schechter

L. E.

(2008). From menarche to menopause: Exploring the underlying biology of depression in women experiencing hormonal changes. Psychoneuroendocrinology, 33(1), 3–17.

31.

Domar

A. D.

Broome

Zuttermeister

P. C.

Seibel

Friedman

(1992). The prevalence and predictability of depression in infertile women. Fertility and Sterility, 58, 1158–1163.

32.

Downey

Bonica

Rincon

(1999). Rejection sensitivity and adolescent romantic relationships. The development of romantic relationships in adolescence, 148–174.

33.

Duxbury

L. E.

Higgins

C. A.

(1991). Gender differences in work-family conflict. Journal of Applied Psychology, 76, 60–74.

34.

Duxbury

Higgins

C. A

Lee

(1994). Work-family conflict: A comparison by gender, family type, and perceived control. Journal of Family Issues, 15, 449–466.

35.

Eagly

A. H.

Chrvala

(1986). Sex differences in conformity: Status and gender role interpretations. Psychology of Women Quarterly, 10, 203–220.

36.

Erikson

E. H.

(1963). Childhood and Society. Norton: New York.

37.

Faraone

S. V.

Lyons

M. J.

Tsuang

M. T.

Rao

D. C.

(1987). Sex differences in affective disorder: Genetic transmission. Genetic Epidemiology, 4, 331–343.

38.

Farmer

McGuffin

(1989). The classification of the depressions: Contemporary confusion revisited. The British Journal of Psychiatry, 155, 437–443.

39.

Fehr

Baldwin

Collins

Patterson

Benditt

(1999). Anger in close relationships: An interpersonal script analysis. Personality and Social Psychology Bulletin, 25, 299–312.

40.

Frone

M. R.

(2000). Work–family conflict and employee psychiatric disorders: The national comorbidity survey. Journal of Applied Psychology, 85, 888–895.

41.

Gilbert

(2000). The relationship of shame, social anxiety and depression: The role of the evaluation of social rank. Clinical Psychology & Psychotherapy, 7(3), 174–189.

42.

Gilligan

Attanucci

B. J.

(1988). Two moral orientations: Gender differences and similarities. Merrill-Palmer Quarterly, 343, 223–237.

43.

Gilman

C. P.

(1994). The yellow wallpaper. Austin, TX: Slough Press.

44.

Glass

Fujimoto

(1994). Housework, paid work, and depression among husbands and wives. Journal of Health and Social Behavior, 35, 179–191.

45.

Golding

J. M.

(1999). Intimate partner violence as a risk factor for mental disorders: A meta-analysis. Journal of Family Violence, 14, 99–132.

46.

Goldsteen

Ross

C. E.

(1989). The perceived burden of children. Journal of Family Issues, 10(4), 504–526.

47.

Greenberg

P. E.

Kessler

R. C.

Nells

T. L.

Finkelstein

S. N.

Berndt

E. R.

(1996). Depression in the workplace: an economic perspective. Selective serotonin re-uptake inhibitors: advances in basic research and clinical practice. New York: John Wiley & Sons, pp. 327–363.

48.

Gross

J. J.

Levenson

R. W.

(1997). Hiding feelings: The acute effects of inhibiting negative and positive emotion. Journal of Abnormal Psychology, 106, 95–103.

49.

Gutek

B. A.

Searle

Klepa

(1991). Rational versus gender role explanations for work-family conflict. Journal of Applied Psychology, 76, 560–568.

50.

Hagen

E. H.

(2003). The bargaining model of depression. Genetic and cultural evolution of cooperation, 95–123.

51.

Harper

M. S.

Dickson

J. W.

Welsh

D. P.

(2006). Self-silencing and rejection sensitivity in adolescent romantic relationships. Journal of Youth and Adolescence, 35, 435–443.

52.

Harper

M. S.

Welsh

D. P.

(2007). Keeping quiet: Self-silencing and its association with relational and individual functioning among adolescent romantic couples. Journal of Social and Personal Relationships, 24, 99–116.

53.

Harris

Lovett

Newcombe

R. G.

Read

G. F.

Walker

Riad-Fahmy

(1994). Maternity blues and major endocrine changes: Cardiff puerperal mood and hormone study II. The BMJ, 308, 949–953.

54.

Hartsock

N. C.

(1998). The feminist standpoint revisited and other essays.

55.

Holmes

(1997). Women, language and identity. Journal of Sociolinguistics, 1, 195–223.

56.

Horney

(1937). The neurotic personality of our time. WW Norton & Company.

57.

Ingram

R. E.

Luxton

D. D.

(2005). Vulnerability-stress models. Development of psychopathology: A vulnerability-stress perspective, 32–46.

58.

Jack

D. C.

(1991). Silencing the self: Women and depression. Cambridge, MA: Harvard University Press.

59.

Jack

D. C.

(2001). Understanding women’s anger: A description of relational patterns. Health Care for Women International, 22, 385–400.

60.

Jack

D. C.

(2003). The anger of hope and the anger of despair. Situating sadness: Women and depression in social context, 62–87.

61.

Jack

D. C.

Ali

(Eds.). (2010). Silencing the self across cultures: Depression and gender in the social world. Oxford, UK: Oxford University Press.

62.

Jack

D. C.

Dill

(1992). The silencing the self scale: Schemas of intimacy associated with depression in women. Psychology of Women Quarterly, 16, 97–106.

63.

Jacobs

J. A.

Gerson

(2004). The time divide: Work, family, and gender inequality. Cambridge, MA: Harvard University Press.

64.

Jordan

J. V.

(2001). A relational-cultural model: Healing through mutual empathy. Bulletin of the Menninger Clinic, 65(1: Special issue), 92–103.

65.

Jordan

J. V.

Dooley

(2000). Relational practice in action: A group manual. Stone Center, Wellesley College.

66.

Jordan

J. V.

Kaplan

A. G.

Miller

J. B.

Stiver

I. P.

Surrey

J. L.

(1991). Women’s growth in connection. New York, NY: Guilford Press.

67.

Kamimura

Christensen

Tabler

Ashby

Olson

L. M.

(2014). Prevalence of intimate partner violence and its impact on health: Female and male patients using a free clinic. Journal of Health Care for the Poor and Underserved, 25, 731–745.

68.

Kendal

R. E.

(1976). The classification of depression: A review of the contemporary confusion. The British Journal of Psychiatry, 129, 15–, 28.

69.

Kermode

Herrman

Arole

White

Premkumar

Patel

(2007). Empowerment of women and mental health promotion: a qualitative study in rural Maharashtra, India. BMC public health, 7(1), 225.

70.

Kuehner

(2017). Why is depression more common among women than among men? The Lancet Psychiatry, 4, 146–158.

71.

Landrine

Klonoff

E. A.

Gibbs

Manning

Lund

(1995). Physical and psychiatric correlates of gender discrimination. Psychology of Women Quarterly, 19, 473–492.

72.

Lohr

J. M.

Hamberger

L. K.

Bonge

(1988). The relationship of factorially validated measures of anger-proneness and irrational beliefs. Motivation and Emotion, 12(2), 171–183.

73.

LoLordo

V. M.

(2001). Learned helplessness and depression. Animal research and human health: Advancing human welfare through behavioral science, 63–77.

74.

London

Downey

Romero-Canyas

Rattan

Tyson

(2012). Gender-based rejection sensitivity and academic self-silencing in women. Journal of Personality and Social Psychology, 102(5), 961.

75.

MacEwen

K. E.

Barling

(1994). Daily consequences of work interference with family and family interference with work. Work & Stress, 8, 244–254.

76.

Major

(1993). Gender, entitlement, and the distribution of family labor. Journal of Social Issues, 49(3), 141–159.

77.

Mann

M. B.

Thornburg*

K. R.

(1987). Guilt of working women with infants and toddlers in day care. Early Child Development and Care, 27(3), 451–464.

78.

Markus

H. R.

Kitayama

(1991). Culture and the self: Implications for cognition, emotion, and motivation. Psychological Review, 98, 224–253.

79.

McMahon

(1995). Engendering motherhood: Identity and self-transformation in women’s lives. New York, NY: Guilford Press.

80.

Miller

(1969). The ‘Common Cold’ of Psychiatry. British Medical Journal, 2(5656), 563.

81.

Miller

J. B.

(1986a). Toward a new psychology of women (2nd ed.). Boston: Beacon Press.

82.

Miller

J. B.

(1986b). What do we mean by relationships? (Vol. 22). Wellesley, MA: Stone Center for Developmental Services and Studies, Wellesley College.

83.

Miller

J. B.

Stiver

I. P.

(1997). The healing connection. Boston: Beacon Press.

84.

Nielsen

Videbech

Hedegaard

Dalby

Secher

N. J.

(2000). Postpartum depression: Identification of women at risk. BJOG: An International Journal of Obstetrics and Gynaecology, 107, 1210–1217.

85.

Noddings

(1989). Women and evil. Berkeley: University of California Press.

86.

Noriko

Mequmi

Hanako

Yasuko

(2007). Birth experience and postnatal depression: Women’s negative evaluation as a risk factor. Asian Journal of Nursing, 10(4), 257–264.

87.

O’Hara

M. W.

(2009). Postpartum depression: What we know. Journal of Clinical Psychology, 65, 1258–1269.

88.

O’Keane

Lightman

Patrick

Marsh

Papadopoulos

A. S.

Pawlby

… Moore

(2011). Changes in the maternal hypothalamic-pituitary-adrenal axis during the early puerperium may be related to the postpartum ‘blues’. Journal of Neuroendocrinology, 23, 1149–1155.

89.

Pateman

(1988). The patriarchal welfare state. The welfare state reader, 134–151.

90.

Petersen

A. C.

Compas

B. E.

Brooks-Gunn

Stemmler

Grant

K. E.

(1993). Depression in adolescence. American Psychologist, 48(2), 155.

91.

Poms

L. W.

Fleming

L. C.

Jacobsen

K. H.

(2016). Work–Family Conflict, Stress, and Physical and Mental Health: A Model for Understanding Barriers to and Opportunities for Women’s Well-Being at Home and in the Workplace. World Medical & Health Policy, 8(4), 444–457.

92.

Ponde

M. P.

Santana

V. S.

(2000). Participation in leisure activities: Is it a protective factor for women’s mental health? Journal of Leisure Research, 32, 457–472.

93.

Robertson

Grace

Wallington

Stewart

D. E.

(2004). Antenatal risk factors for postpartum depression: A synthesis of recent literature. General Hospital Psychiatry, 26, 289–295.

94.

Reid

Hardy

(1999). Multiple roles and well-being among midlife women: Testing role strain and role enhancement theories. The Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 54(6), S329–S338.

95.

Rosenthal

(1963). A suggested conceptual framework.

96.

Ross

C. E.

Mirowsky

(1988). Child care and emotional adjustment to wives’ employment. Journal of Health and Social Behavior, 29, 127–138.

97.

Rousseau

(2000). Depression’s forgotten genealogy: Notes towards a history of depression. History of Psychiatry, 11(41 Pt 1), 71–106.

98.

Sadock

B. J.

(2007). Kaplan & Sadock’s synopsis of psychiatry (10th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

99.

Sanderson

W. C.

Beck

A. T.

Beck

(1990). Syndrome comorbidity in patients with major depression. The American Journal of Psychiatry, 147, 1025–1028.

100.

Schildkraut

J. J.

(1965). The catecholamine hypothesis of affective disorders: A review of supporting evidence. The American Journal of Psychiatry, 122, 509–522.

101.

Seedat

Scott

K. M.

Angermeyer

M. C.

Berglund

Bromet

E. J.

Brugha

T. S.

… Kessler

R. C.

(2009). Cross-national associations between gender and mental disorders in the World Health Organization World Mental Health Surveys. Archives of General Psychiatry, 66, 785–795.

102.

Seligman

M. E.

Beagley

(1975). Learned helplessness in the rat. Journal of comparative and physiological psychology, 88(2), 534.

103.

Serani

(2011). Living with Depression: Why Biology and Biography Matter Along the Path to Hope and Healing. Rowman & Littlefield Publishers.

104.

Sichel

Driscoll

J. W.

(1999). Women’s Moods: What every woman must know about hormones, the brain, and emotional health. New York, NY: William Morrow and Company.

105.

Silberg

Pickles

Rutter

Hewitt

Simonoff

Maes

… Eaves

(1999). The influence of genetic factors and life stress on depression among adolescent girls. Archives of General Psychiatry, 56, 225–232.

106.

Silverstein

Perlick

Clauson

McKoy

(1993). Depression combined with somatic symptomatology among adolescent females who report concerns regarding maternal achievement. Sex Roles, 28, 637–653.

107.

Stagg

Wills

G. D.

Howell

(1989). Psychopathology in early childhood witnesses of family violence. Topics in Early Childhood Special Education, 9, 73–87.

108.

Sullivan

P. F.

Neale

M. C.

Kendler

K. S.

(2000). Genetic epidemiology of major depression: Review and meta-analysis. The American Journal of Psychiatry, 157, 1552–1562.

109.

Surrey

J. L.

(1985). The ‘self-in-relation’: A theory of women’s development. Wellesley, MA: Wellesley College, Stone Center for Developmental Services and Studies.

110.

Thomas

S. P.

Atakan

(1993). Trait anger, anger expression, stress, and health status of American and Turkish midlife women. Health Care for Women International, 14(2), 129–143.

111.

Turkel

A. R.

(1996). Hiding behind motherhood. Journal of the American Academy of Psychoanalysis, 24, 163–177.

112.

Varma

Chandra

P. S.

Thomas

Carey

M. P.

(2007). Intimate partner violence and sexual coercion among pregnant women in India: Relationship with depression and post-traumatic stress disorder. Journal of Affective Disorders, 102, 227–235.

113.

Viana

M. C.

Andrade

L. H.

(2012). Lifetime prevalence, age and gender distribution and age-of-onset of psychiatric disorders in the São Paulo metropolitan area, Brazil: Results from the São Paulo Megacity Mental Health Survey. Revista Brasileira De Psiquiatria, 34, 249–260.

114.

Weissman

M. M.

Klerman

G. L.

(1977). Sex differences and the epidemiology of depression. Archives of General Psychiatry, 34, 98–111.

115.

Yavorsky

J. E.

Kamp Dush

C. M.

Schoppe-Sullivan

S. J.

(2015). The production of inequality: The gender division of labor across the transition to parenthood. Journal of Marriage and Family, 77(3), 662–679.

116.

Zubin

Spring

(1977). Vulnerability: A new view of schizophrenia. Journal of Abnormal Psychology, 86, 103–126.