May 17, 2001 -- Depression can be a vague word, too often used to describe a whole range of emotions. There are many causes, for both men and women; but for women, the causes are oftentimes gender-specific, whether it be the rigors of being a woman in the new millennium, biology, or a haunting past.
Although depression is not always easy to define, when you're in it, you know it -- even if you don't know what to call it. For Alice, depression started nearly 20 years ago, when she was a senior at Yale University and a part-time waitress. Sure, she came from a dysfunctional family (one parent was an "abusive raging alcoholic"), but she was "the happy middle child, caretaker of the others," she tells WebMD. "At Yale, I had a great life."
Then one day -- out of the blue -- "a huge gray cloud of self-hatred moved into my forehead," Alice explains. "I couldn't breathe. I was dizzy. For some unknown reason, I wanted to kill myself. I didn't know what to do."
At the university health service, "I told them honestly I'd never felt depressed in my life," and was told in return "you're having a panic attack. Relax. Go home." She didn't sleep for five days. "It was like an alien invaded my head," Alice tells WebMD.
Over the years, Alice had been told to buck up, that she was going through a phase, that there's nothing wrong with her. She tried acupuncture, biofeedback, homeopathy. Nothing helped. She got on with her life, showing no outward evidence of her emotional pain. "None of it was apparent to anyone," Alice tells WebMD.
Finally, she found a therapist who helped her discover her truth. "I was in huge denial about my childhood, how painful it was," Alice says. She's also taking an antidepressant, after much trial and error to find the right one, at the best dose. "Don't give up," she tells other women. "Pain is part of life, but suffering is optional."
Symptoms of Depression
The point that Alice makes is an important one. Depression can be treated. But first, people have to recognize the signs -- and accept that they are depressed.
Depression is actually a cluster of symptoms lasting two weeks or more, involving much more than sadness:
- Feelings of persistent sadness, worthlessness and guilt
- Difficulties concentrating, organizing thoughts, remembering
- Fatigue, loss of interest in previously pleasurable activities
- Changes in eating and sleeping habits (either increases or decreases)
- Loss of interest in sex, a disconnection from loved ones
- Thoughts of death or suicide
- Persistent physical complaints for which no other medical reason can be found.
If these last for two weeks or more, experts suggest seeing a doctor for help.
Women at Risk
During a woman's lifetime -- from the day she enters puberty through menopause -- she is at a higher risk of depression than a man. Genetics seem to play a role, as do hormonal changes throughout a woman's life, even at a young age.
"Hormonal changes at puberty -- changes in estrogen, progesterone, oxytocin -- seem to prime some women for first onset of depression," says Vivien K. Burt, MD, PhD, professor of psychiatry at University of California, Los Angeles (UCLA) School of Medicine and director of the Women's Life Center of UCLA's Neuropsychiatric Institute and Hospital.
Early life experiences also take a toll, she tells WebMD.
"Trauma suffered by women early in childhood may put them at risk for depression later in life." A woman may have been the victim of incest, domestic violence, or abuse -- perhaps has sustained a major loss in childhood, such as the loss of a parent -- or has never had a good give-and-take role model in her life, says Burt.
And one episode of depression greatly increases likelihood of another, says Burt. "Depression feeds on itself. Every time someone has a single episode of depression, their likelihood of a subsequent episode increases by 50%. If they have two episodes, there's approximately 70% chance of a third episode. After three episodes, one is almost surely going to have a [long-term] course."
Reeling Through the Years
Adolescence, aside from the hormonal changes, places special stresses on girls that lead to depression. "When she is faced with interpersonal demands -- the demands of adolescence -- she may have a difficult time meeting the expectations that society sets for adolescent girls," Burt tells WebMD. "If you add to that a family history of depression as well as the hormonal changes, you may have young woman who is at tremendously increased risk."
Reproductive events -- her menstrual cycle, pregnancy, the post-pregnancy period, menopause - all can cause mood changes that include depression. Premenstrual dysphoric disorder, a more severe form of premenstrual syndrome, includes depressed feelings and irritability.
And depression after the birth of a child, or postpartum depression, is common, ranging from mild blues to severe and incapacitating depression, even in women with no previous problems with depression, says Julie Barnes, PhD, a psychologist in private practice in New York City. "It seems to be triggered strictly by hormonal and chemical fluctuations immediately before and after birth," Barnes tells WebMD. "It can be really devastating."
Sex and the City
Then there are the "psychosocial stresses" that lead women to depression.
Depression strikes many young women after college, says Barnes. "They've left the structured environment of school, are dealing with societal stereotyping in the workplace," she tells WebMD. "Meeting men and dating in large cities is also hard for young women. A lot of young women are struggling with that problem -- how to meet people. They're shy. They don't like bars. They find it hard to meet people when not in the college environment."
Career frustrations also become a source of anxiety and depression. "Women still face societal stereotyping," says Barnes. "They still start out as administrative assistants and secretaries whereas young men make bigger career leaps into sales or specialized training. Plus women aren't taught how to network. It's very hard for young women."
As her biological clock ticks away, a young woman must deal with decisions about having children. If she is not married, can she go it alone, raise a child herself -- in a society where women earn 70 cents for every dollar a man earns. If she has infertility problems, she must deal with those. And once children are born, she must decide whether to return to her career or not -- not an easy choice given the isolation of motherhood and the guilt faced by working mothers.
After age 40, hormonal fluctuations plus life changes -- children leaving home, parents becoming ill and dying, illness in spouse or themselves, financial worries -- place women at continued high risk for depression, says Susan G. Kornstein, MD, associate professor of psychiatry and obstetrics and gynecology and director of the Institute for Women's Health at Virginia Commonwealth University in Richmond.
It's a myth that menopause itself causes depression, Kornstein tells WebMD. "Culture contributes to the experience of menopause. In some societies where older age is more respected than ours, women have an easier time." Many women have minor depressive symptoms -- anxiety, insomnia -- but not severe mood changes, she tells WebMD.
Taking Its Toll
Left untreated, depression has a seriously disabling affect on women's lives, relationships -- and on their children, says Burt. "[People who work in mental health] are only just beginning to acknowledge how disabling depression is," she tells WebMD.
"Women may not be able to look after themselves as well as they should," Burt says. "Maybe they have more difficulty in being productive in the roles they assume, whether in the workplace, in the home -- there's a ripple effect. Children of depressed mothers tend to be depressed. They tend to have behavioral problems. They tend to be depressed as adults."
In fact, a mother's depression may even have a negative impact on her child's IQ, Burt tells WebMD. "Depressed mothers ... isolate themselves, they can't concentrate, they're less available to others, they can't think as well."
Depression can also result in increased irritability, Burt says. "Some depressed mothers can be very critical, very demanding -- and that has a negative impact."
Depression also takes its toll on a woman's career.
"Women often postpone their careers, often take time off for their families during early years," she tells WebMD. "Then, in [the period around menopause] and menopause, they are at the height of their productivity. But if they are depressed, that productivity is very diminished."
A Way Out
"Depression is one of the most treatable illnesses in all of medicine," says Kornstein. "The problem is that most people don't get treatment."
For women with a range of depressive symptoms, antidepressants and psychotherapy are very effective, Kornstein tells WebMD. In a study published last year in The New England Journal of Medicine, she tested the effectiveness of a 12-week program for major depression, looking at whether psychotherapy, antidepressants, or both were most effective. Fifty-three percent responded to therapy, 55% responded to medication, and 85% responded to the combination therapy, she says. "Unbelievable. I think this is convincing evidence for the combination treatment."
In fact, researchers are learning more about this estrogen-depression link, and the long-term health effects of depression.
Women with a history of depression go into perimenopause earlier than other women, says Lee S. Cohen, MD, director of the Center for Women's Mental Health at Massachusetts General Hospital in Boston, and associate professor of psychiatry at Harvard Medical School. His current studies of women between ages 36 and 44 show that depressed women enter perimenopause 30% earlier, says Cohen.
"Depression may have a dampening effect on ovarian function -- putting the breaks on it," Cohen tells WebMD. "The more years you don't have estrogen, the more you are at risk of bones breaking, cardiovascular disease, less overall good health."
New research is showing that estrogen replacement therapy -- in the form of transdermal estrogen patches -- may be a good option, says Cohen. In a large, recent study of perimenopausal women with major depression, researchers reported "a very, very positive finding" that an estrogen transdermal patch can dramatically improve the disorder, he tells WebMD.
In other words, there is a way out.