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Women and Depression
What is depression?
Everyone occasionally feels blue or sad, but these feelings
are usually fleeting and pass within a couple of days. When
a woman has a depressive disorder, it interferes with daily
life and normal functioning, and causes pain for both the
woman with the disorder and those who care about her.
Depression is a common but serious illness, and most who
have it need treatment to get better.
Depression affects both men and women, but more women
than men are likely to be diagnosed with depression in any
given year.1 Efforts to explain this difference are ongoing, as
researchers explore certain factors (biological, social, etc.)
that are unique to women.
Many women with a depressive illness never seek treatment.
But the vast majority, even those with the most
severe depression, can get better with treatment.
What are the different forms of depression?
There are several forms of depressive disorders that occur in
both women and men. The most common are major depressive
disorder and dysthymic disorder. Minor depression is
Major depressive disorder, also called major depression, is
characterized by a combination of symptoms that interfere
with a person’s ability to work, sleep, study, eat, and enjoy
once-pleasurable activities. Major depression is disabling and
prevents a person from functioning normally. An episode of
major depression may occur only once in a person’s lifetime,
but more often, it recurs throughout a person’s life.
Dysthymic disorder, also called dysthymia, is characterized
by depressive symptoms that are long-term (e.g., two years or
longer) but less severe than those of major depression. Dysthymia
may not disable a person, but it prevents one from
functioning normally or feeling well. People with dysthymia
may also experience one or more episodes of major depression
during their lifetimes.
Minor depression may also occur. Symptoms of minor
depression are similar to major depression and dysthymia,
but they are less severe and/or are usually shorter term.
Some forms of depressive disorder have slightly different
characteristics than those described above, or they may
develop under unique circumstances.
However, not all scientists
agree on how to characterize and define these forms
of depression. They include the following:
- Psychotic depression occurs when a severe depressive illness
is accompanied by some form of psychosis, such as
a break with reality; seeing, hearing, smelling or feeling
things that others can’t detect (hallucinations); and having
strong beliefs that are false, such as believing you are the
- Seasonal affective disorder (SAD) is characterized by a
depressive illness during the winter months, when there is
less natural sunlight. The depression generally lifts during
spring and summer. SAD may be effectively treated with
light therapy, but nearly half of those with SAD do not
respond to light therapy alone. Antidepressant medication
and psychotherapy also can reduce SAD symptoms, either
alone or in combination with light therapy.2
What are the basic symptoms of depression?
Women with depressive illnesses do not all experience the
same symptoms. In addition, the severity and frequency
of symptoms, and how long they last, will vary depending
on the individual and her particular illness. Symptoms of
- Persistent sad, anxious or "empty" feelings
- Feelings of hopelessness and/or pessimism
- Irritability, restlessness, anxiety
- Feelings of guilt, worthlessness and/or helplessness
- Loss of interest in activities or hobbies once
pleasurable, including sex
- Fatigue and decreased energy
- Difficulty concentrating, remembering details and
- Insomnia, waking up during the night, or excessive
- Overeating, or appetite loss
- Thoughts of suicide, suicide attempts
- Persistent aches or pains, headaches, cramps
or digestive problems that do not ease even
What causes depression in women?
Scientists are examining many potential causes for and contributing
factors to women’s increased risk for depression.
It is likely that genetic, biological, chemical, hormonal,
environmental, psychological, and social factors all intersect
to contribute to depression.
If a woman has a family history of depression, she may be
more at risk of developing the illness. However, this is not a
hard and fast rule. Depression can occur in women without
family histories of depression, and women from families
with a history of depression may not develop depression
themselves. Genetics research indicates that the risk for
developing depression likely involves the combination of
multiple genes with environmental or other factors.
Chemicals and hormones
Brain chemistry appears to be a significant factor in depressive
disorders. Modern brain-imaging technologies, such
as magnetic resonance imaging (MRI), have shown that
the brains of people suffering from depression look different
than those of people without depression. The parts
of the brain responsible for regulating mood, thinking,
sleep, appetite and behavior don’t appear to be functioning
normally. In addition, important neurotransmitters—chemicals
that brain cells use to communicate—appear to
be out of balance. But these images do not reveal WHY the
depression has occurred.
Scientists are also studying the influence of female hormones,
which change throughout life. Researchers have
shown that hormones directly affect the brain chemistry
that controls emotions and mood. Specific times during a
woman’s life are of particular interest, including puberty;
the times before menstrual periods; before, during, and just
after pregnancy (postpartum); and just prior to and during
Stressful life events such as trauma, loss of a loved one,
a difficult relationship or any stressful situation—whether
welcome or unwelcome—often occur before a depressive
episode. Additional work and home responsibilities, caring
for children and aging parents, abuse, and poverty also may
trigger a depressive episode. Evidence suggests that women
respond differently than men to these events, making them
more prone to depression. In fact, research indicates that
women respond in such a way that prolongs their feelings
of stress more so than men, increasing the risk for depression.
14 However, it is unclear why some women faced with
enormous challenges develop depression, and some with
similar challenges do not.
What illnesses often coexist with depression
Depression often coexists with other illnesses that may
precede the depression, follow it, cause it, be a consequence
of it, or a combination of these. It is likely that the interplay
between depression and other illnesses differs for every
person and situation. Regardless, these other coexisting
illnesses need to be diagnosed and treated.
Depression often coexists with eating disorders such as
anorexia nervosa, bulimia nervosa and others, especially
among women. Anxiety disorders, such as post-traumatic
stress disorder (PTSD), obsessive-compulsive disorder, panic
disorder, social phobia and generalized anxiety disorder,
also sometimes accompany depression.15,16 Women are more
prone than men to having a coexisting anxiety disorder.17
Women suffering from PTSD, which can result after a person
endures a terrifying ordeal or event, are especially prone to
Although more common among men than women, alcohol
and substance abuse or dependence may occur at the
same time as depression.17,15 Research has indicated that
among both sexes, the coexistence of mood disorders and
substance abuse is common among the U.S. population.18
Depression also often coexists with other serious medical
illnesses such as heart disease, stroke, cancer, HIV/AIDS,
diabetes, Parkinson’s disease, thyroid problems and
multiple sclerosis, and may even make symptoms of the
illness worse.19 Studies have shown that both women and
men who have depression in addition to a serious medical
illness tend to have more severe symptoms of both illnesses.
They also have more difficulty adapting to their medical
condition, and more medical costs than those who do
not have coexisting depression. Research has shown that
treating the depression along with the coexisting illness
will help ease both conditions.
How does depression affect adolescent girls?
Before adolescence, girls and boys experience depression at
about the same frequency.13 By adolescence, however, girls
become more likely to experience depression than boys.
Research points to several possible reasons for this
The biological and hormonal changes that occur
during puberty likely contribute to the sharp increase in
rates of depression among adolescent girls. In addition,
research has suggested that girls are more likely than
boys to continue feeling bad after experiencing difficult
situations or events, suggesting they are more prone to
depression.21 Another study found that girls tended to
doubt themselves, doubt their problem-solving abilities and
view their problems as unsolvable more so than boys. The
girls with these views were more likely to have depressive
symptoms as well. Girls also tended to need a higher degree
of approval and success to feel secure than boys.22
Finally, girls may undergo more hardships, such as poverty,
poor education, childhood sexual abuse, and other traumas
than boys. One study found that more than 70 percent of
depressed girls experienced a difficult or stressful life event
prior to a depressive episode, as compared with only 14
percent of boys.
How does depression affect older women?
As with other age groups, more older women than older
men experience depression, but rates decrease among
women after menopause.13 Evidence suggests that
depression in post-menopausal women generally occurs
in women with prior histories of depression. In any case,
depression is NOT a normal part of aging.
The death of a spouse or loved one, moving from work
into retirement, or dealing with a chronic illness can leave
women and men alike feeling sad or distressed. After a
period of adjustment, many older women can regain their
emotional balance, but others do not and may develop
depression. When older women do suffer from depression,
it may be overlooked because older adults may be less
willing to discuss feelings of sadness or grief, or they may
have less obvious symptoms of depression. As a result, their
doctors may be less likely to suspect or spot it.
For older adults who experience depression for the first
time later in life, other factors, such as changes in the
brain or body, may be at play. For example, older adults
may suffer from restricted blood flow, a condition called
ischemia. Over time, blood vessels become less flexible.
They may harden and prevent blood from flowing normally
to the body’s organs, including the brain. If this occurs, an
older adult with no family or personal history of depression
may develop what some doctors call "vascular depression."
Those with vascular depression also may be at risk for a
coexisting cardiovascular illness, such as heart disease
or a stroke.
How is depression diagnosed and treated?
Depressive illnesses, even the most severe cases, are highly
treatable disorders. As with many illnesses, the earlier that
treatment can begin, the more effective it is and the greater
the likelihood that a recurrence of the depression can
The first step to getting appropriate treatment is to visit a
doctor. Certain medications, and some medical conditions
such as viruses or a thyroid disorder, can cause the same
symptoms as depression. In addition, it is important to
rule out depression that is associated with another mental
illness called bipolar disorder. (For more information about
bipolar disorder, visit the National Institute of Mental
Health’s (NIMH) Web site at http://www.nimh.nih.gov).
A doctor can rule out these possibilities by conducting
a physical examination, interview, and/or lab tests,
depending on the medical condition. If a medical condition
and bipolar disorder can be ruled out, the physician should
conduct a psychological evaluation or refer the person to a
mental health professional.
The doctor or mental health professional will conduct a
complete diagnostic evaluation. He or she should get a
complete history of symptoms, including when they started,
how long they have lasted, their severity, whether they have
occurred before, and if so, how they were treated. He or she
should also ask if there is a family history of depression.
In addition, he or she should ask if the person is using
alcohol or drugs, and whether the person is thinking about
death or suicide.
Once diagnosed, a person with depression can be treated
with a number of methods. The most common treatment
methods are medication and psychotherapy.
Antidepressants work to normalize naturally occurring
brain chemicals called neurotransmitters, notably serotonin
and norepinephrine. Other antidepressants work
on the neurotransmitter dopamine. Scientists studying
depression have found that these particular chemicals are
involved in regulating mood, but they are unsure of the
exact ways in which they work.
The newest and most popular types of antidepressant medications
are called selective serotonin reuptake inhibitors
(SSRIs) and include:
- fluoxetine (Prozac)
- sertraline (Zoloft)
- paroxetine (Paxil)
- escitalopram (Lexapro)
- fluvoxamine (Luvox)
- duloxetine (Cymbalta)
Serotonin and norepinephrine reuptake inhibitors
(SNRIs) are similar to SSRIs and include:
- venlafaxine (Effexor)
- duloxetine (Cymbalta)
SSRIs and SNRIs tend to have fewer side effects and are
more popular than the older classes of antidepressants,
such as tricyclics – named for their chemical structure –
and monoamine oxidase inhibitors (MAOIs). However,
medications affect everyone differently. There is no onesize-
fits-all approach to medication. Therefore, for some
people, tricyclics or MAOIs may be the best choice.
People taking MAOIs must adhere to significant food and
medicinal restrictions to avoid potentially serious interactions.
They must avoid certain foods that contain high
levels of the chemical tyramine, which is found in many
cheeses, wines and pickles, and some medications including
decongestants. Most MAOIs interact with tyramine in
such a way that may cause a sharp increase in blood pressure, which may lead to a stroke. A doctor should give a
person taking an MAOI a complete list of prohibited foods,
medicines and substances
For all classes of antidepressants, people must take regular
doses for at least three to four weeks, sometimes longer,
before they are likely to experience a full effect. They should
continue taking the medication for an amount of time
specified by their doctor, even if they are feeling better, to
prevent a relapse of the depression. The decision to stop
taking medication should be made by the person and her
doctor together, and should be done only under the doctor’s
supervision. Some medications need to be gradually
stopped to give the body time to adjust.
Although they are
not habit-forming or addictive, abruptly ending an antidepressant
can cause withdrawal symptoms or lead to a
relapse. Some individuals, such as those with chronic or
recurrent depression, may need to stay on the medication
In addition, if one medication does not work, people should
be open to trying another. Research funded by NIMH
has shown that those who did not get well after taking a
first medication often fared better after they switched to a
different medication or added another medication to their
Sometimes other medications, such as stimulants or antianxiety
medications, are used in conjunction with an antidepressant,
especially if the person has a coexisting illness.
However, neither antianxiety medications nor stimulants
are effective against depression when taken alone, and both
should be taken only under a doctor’s close supervision.
Is it safe to take antidepressant medication
At one time, doctors assumed that pregnancy was accompanied
by a natural feeling of well being, and that depression
during pregnancy was rare, or never occurred at all.
However, recent studies have shown that women can have
depression while pregnant, especially if they have a prior
history of the illness. In fact, a majority of women with a
history of depression will likely relapse during pregnancy
if they stop taking their antidepressant medication either
prior to conception or early in the pregnancy, putting both
mother and baby at risk.
However, antidepressant medications do pass across the
placental barrier, potentially exposing the developing fetus
to the medication. Some research suggests the use of SSRIs
during pregnancy is associated with miscarriage and/or
birth defects, but other studies do not support this.28 Some
studies have indicated that fetuses exposed to SSRIs during
the third trimester may be born with "withdrawal" symptoms
such as breathing problems, jitteriness, irritability,
difficulty feeding, or hypoglycemia. In 2004, the U.S. Food
and Drug Administration (FDA) issued a warning against
the use of SSRIs in the late third trimester, suggesting that
clinicians gradually taper expectant mothers off SSRIs in
the third trimester to avoid any ill effects on the baby.
Although some studies suggest that exposure to SSRIs in
pregnancy may have adverse effects on the infant, generally
they are mild and short-lived, and no deaths have been
reported. On the flip side, women who stop taking their
antidepressant medication during pregnancy increase their
risk for developing depression again and may put both
themselves and their infant at risk.
In light of these mixed results, women and their doctors
need to consider the potential risks and benefits to both
mother and fetus of taking an antidepressant during pregnancy,
and make decisions based on individual needs and
circumstances. In some cases, a woman and her doctor
may decide to taper her antidepressant dose during the last
month of pregnancy to minimize the newborn’s withdrawal
symptoms, and after delivery, return to a full dose during
the vulnerable postpartum period.
Is it safe to take antidepressant medication while
Antidepressants are excreted in breast milk, usually in very
small amounts. The amount an infant receives is usually so
small that it does not register in blood tests. Few problems
are seen among infants nursing from mothers who are
taking antidepressants. However, as with antidepressant use
during pregnancy, both the risks and benefits to the mother
and infant should be taken into account when deciding
whether to take an antidepressant while breastfeeding.
What are the side effects of antidepressants?
Antidepressants may cause mild and often temporary side
effects in some people, but usually they are not long-term.
However, any unusual reactions or side effects that interfere
with normal functioning or are persistent or troublesome
should be reported to a doctor immediately.
The most common side effects associated with SSRIs
and SNRIs include:
- Headache—usually temporary and will subside.
- Nausea—temporary and usually short-lived.
- Insomnia and nervousness (trouble falling asleep or
waking often during the night)—may occur during the
first few weeks but often subside over time or if the dose
- Agitation (e.g., feeling jittery).
- Sexual problems—women can experience sexual problems
including reduced sex drive, or inability to have an
Tricyclic antidepressants also can cause side effects
- Dry mouth—it is helpful to drink plenty of water, chew
gum, and clean teeth daily.
- Constipation—it is helpful to eat more bran cereals,
prunes, fruits, and vegetables.
- Bladder problems—emptying the bladder may be difficult,
and the urine stream may not be as strong as
- Sexual problems—sexual functioning may change, and
side effects are similar to those from SSRIs and SNRIs.
- Blurred vision—often passes soon and usually will not
require a new corrective lenses prescription.
- Drowsiness during the day—usually passes soon, but
driving or operating heavy machinery should be avoided
while drowsiness occurs. These more sedating antidepressants
are generally taken at bedtime to help sleep
and minimize daytime drowsiness.
FDA warning on antidepressants
Despite the fact that SSRIs and other antidepressants
are generally safe and reliable, some studies have shown
that they may have unintentional effects on some people,
especially young people. In 2004, the FDA reviewed data
from studies of antidepressants that involved nearly 4,400
children and teenagers being treated for depression. The
review showed that 4% of those who took antidepressants
thought about or attempted suicide (although no suicides
occurred), compared to 2% of those who took sugar pills
This information prompted the FDA, in 2005, to adopt a
"black box" warning label on all antidepressant medications
to alert the public about the potential increased risk
of suicidal thinking or attempts in children and teenagers
taking antidepressants. In 2007, the FDA proposed
that makers of all antidepressant medications extend the
black box warning on their labels to include young patients
up through age 24 who are taking these medications for
depression treatment. A "black box" warning is the most
serious type of warning on prescription drug labeling.
The warning also emphasizes that children, teenagers and
young adults taking antidepressants should be closely
monitored, especially during the first four weeks of treatment,
for any worsening depression, suicidal thinking or
behavior. These include any unusual changes in behavior
such as sleeplessness, agitation, or withdrawal from normal
Results of a review of pediatric trials between 1988 and
2006 suggested that the benefits of antidepressant medications
likely outweigh their risks to children and adolescents
with major depression and anxiety disorders. The
study was funded in part by NIMH.
What about St. John’s wort?
The extract from the herb St. John’s wort (Hypericum perforatum),
a bushy, wild-growing plant with yellow flowers,
has been used for centuries in many folk and herbal
remedies. Today in Europe, it is used extensively to treat
mild to moderate depression. In the United States, it is a
top-selling botanical product.
To address increasing American interest in St. John’s wort,
the National Institutes of Health (NIH) conducted a clinical
trial to determine the effectiveness of the herb in treating
adults suffering from major depression. Involving 340
patients diagnosed with major depression, the eight-week
trial randomly assigned one-third of them to a uniform
dose of St. John’s wort, one-third to a commonly prescribed
SSRI, and one-third to a placebo. The trial found that St.
John’s wort was no more effective than the placebo in treating
major depression.32 Another study is underway to look
at the effectiveness of St. John’s wort for treating mild or
Other research has shown that St. John’s wort can interact
unfavorably with other drugs, including drugs used to control
HIV infection. On February 10, 2000, the FDA issued a
Public Health Advisory letter stating that the herb appears
to interfere with certain drugs used to treat heart disease,
depression, seizures, certain cancers, and organ transplant
rejection. The herb also may interfere with the effectiveness
of oral contraceptives. Because of these and other potential
interactions, people should always consult their doctors
before taking any herbal supplement.
Several types of psychotherapy—or "talk therapy"—
can help people with depression.
Some regimens are short-term (10 to 20 weeks) and other
regimens are longer-term, depending on the needs of the
individual. Two main types of psychotherapies—cognitive-
behavioral therapy (CBT) and interpersonal therapy
(IPT)—have been shown to be effective in treating depression.
By teaching new ways of thinking and behaving,
CBT helps people change negative styles of thinking and
behaving that may contribute to their depression. IPT helps
people understand and work through troubled personal
relationships that may cause their depression or make it
For mild to moderate depression, psychotherapy may be
the best treatment option. However, for major depression
or for certain people, psychotherapy may not be enough.
Studies have indicated that for adolescents, a combination
of medication and psychotherapy may be the most effective
approach to treating major depression and reducing
the likelihood for recurrence.33 Similarly, a study examining
depression treatment among older adults found that
patients who responded to initial treatment of medication
and IPT were less likely to have recurring depression
if they continued their combination treatment for at least
For cases in which medication and/or psychotherapy does
not help alleviate a person’s treatment-resistant depression,
electroconvulsive therapy (ECT) may be useful. ECT, formerly
known as "shock therapy," used to have a negative
reputation. But in recent years, it has greatly improved and
can provide relief for people with severe depression who
have not been able to feel better with other treatments.
Before ECT is administered, a patient takes a muscle relaxant
and is put under brief anesthesia. She does not consciously
feel the electrical impulse that is administered. A
person typically will undergo ECT several times a week,
and often will need to take an antidepressant or mood stabilizing
medication to supplement the ECT treatments and
prevent relapse. Although some people will need only a few
courses of ECT, others may need maintenance ECT, usually
once a week at first, then gradually decreasing to monthly
treatments for up to one year.
ECT may cause some short-term side effects, including
confusion, disorientation and memory loss. But these side
effects typically clear shortly after treatment. Research has
indicated that after one year of ECT treatments, patients
showed no adverse cognitive effects.35 A person should
weigh the potential risks and benefits of ECT and discuss
them with her doctor before deciding to undergo ECT
What efforts are underway to improve
Researchers are looking for ways to better understand,
diagnose and treat depression among all groups of people.
New possible treatments, such as faster-acting antidepressants,
are being tested that give hope to those who live with
difficult-to-treat depression. Researchers are studying the
risk factors for depression and how it affects the brain.
NIMH continues to fund cutting-edge research into this
debilitating disorder. For more information on NIMH funded
research on depression visit http://www.nimh.nih.gov.
How can I help a friend or relative who is
If you know someone who has depression, the first and
most important thing you can do is to help her get an
appropriate diagnosis and treatment. You may need to
make an appointment on her behalf and go with her to see
the doctor. Encourage her to stay in treatment, or to seek
different treatment if no improvement occurs after six to
In addition, you can also:
- Offer emotional support, understanding, patience and
- Engage her in conversation, and listen carefully.
- Never disparage feelings she expresses, but point out
realities and offer hope.
- Never ignore comments about suicide, and report them
to your friend’s or relative’s therapist or doctor.
- Invite your friend or relative out for walks, outings and
other activities. Keep trying if she declines, but don’t
push her to take on too much too soon. Although diversions
and company are needed, too many demands may
increase feelings of failure.
- Remind her that with time and treatment, the depression
How can I help myself if I am depressed?
You may feel exhausted, helpless and hopeless. It may be
extremely difficult to take any action to help yourself. But
it is important to realize that these feelings are part of the
depression and do not reflect actual circumstances. As you
recognize your depression and begin treatment, negative
thinking will fade. In the meantime:
- Engage in mild activity or exercise. Go to a movie, a
ballgame, or another event or activity that you once
enjoyed. Participate in religious, social or other activities.
- Set realistic goals for yourself.
- Break up large tasks into small ones, set some priorities
and do what you can as you can.
- Try to spend time with other people and confide in a
trusted friend or relative. Try not to isolate yourself, and
let others help you.
- Expect your mood to improve gradually, not immediately.
Do not expect to suddenly "snap out of " your
depression. Often during treatment for depression, sleep
and appetite will begin to improve before your depressed
- Postpone important decisions, such as getting married
or divorced or changing jobs, until you feel better. Discuss
decisions with others who know you well and have
a more objective view of your situation.
- Be confident that positive thinking will replace negative
thoughts as your depression responds to treatment.
Where can I go for help?
If you are unsure where to go for help, ask your family
doctor. Others who can help are:
- Mental health specialists, such as psychiatrists,
psychologists, social workers, or mental health
- Health maintenance organizations (HMOs).
- Community mental health centers.
- Hospital psychiatry departments and outpatient clinics.
- Mental health programs at universities or medical
- State hospital outpatient clinics.
- Family services, social agencies or clergy.
- Peer support groups.
- Private clinics and facilities.
- Employee assistance programs.
- Local medical and/or psychiatric societies.
You can also check the phone book under "mental health,"
"health," "social services," "hotlines," or "physicians" for
phone numbers and addresses. An emergency room doctor
also can provide temporary help and can tell you where
and how to get further help.
What if I or someone I know is in crisis?
Women are more likely than men to attempt
suicide. If you are thinking about harming yourself
or attempting suicide, tell someone who can help
- Call your doctor.
- Call 911 for emergency services.
- Go to the nearest hospital emergency room.
- Call the toll-free, 24-hour hotline of the
National Suicide Prevention Lifeline at
1-800-273-TALK (1-800-273-8255); TTY:
1-800-799-4TTY (4889) to be connected to
a trained counselor at a suicide crisis center
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