by Alexandra Symonds, M.D.
“Blue, sad, morose, down” – just a few of the words used to describe depression, a state that can be transitory or that can last for years.
Depressions are more common in women than in men. In fact, statistics show that depression in women is two to three times as common as in men – and this finding is true at every age group. Why is this the case, and what can we do about it?
First, what do we mean by depression?
Depression covers a broad range of feelings and conditions. The term is used to describe a clinical depression with symptoms of severely lowered mood, feelings of worthlessness, reduced activity and bodily symptoms sometimes requiring hospitalization. Some people can feel so depressed that they can’t get out of bed in the morning and lose interest in food and taking care of themselves, while others may have a chronic underlying feeling which persists for years – a feeling of unhappiness and lack of enjoyment – but are able to function at work and at home.
Women are more numerous in all of these categories. In spite of this gender difference which clinicians have been aware of for many years, little effort has been made to explain it except with certain cliches, such as: it’s women’s hormones, or her biological make-up, or other assumptions such as menopausal depression or “empty-nest syndrome.”
Traditional psychoanalytic theory considered women’s predisposition to depressions to be associated with female psychosexual development in which all women, both healthy and neurotic, were characterized by masochism, low self-esteem, dependency and repressed hostility. Since Freud considered these traits to be biologically predetermined, it followed that they would be prone to depressions – biology was destiny – and there was little we could do about it.
In recent years, as a result of the women’s movement, there has been a new interest in women and mental health, both theoretical and clinical. Many of the traditional theories of feminine psychology and psychopathology have been shown to be expressions of cultural bias rather than evidence of fact. One of the most productive areas of study has been re-examining the cause of depressions in women.
It is important to verify the accuracy of these studies, and consider the causes traditionally given. Careful and intensive study of all the literature on depression since 1926, both in the U.S. and abroad, has been done by Myrna Weissman and Gerald Klerman. They found that the clinical evidence came from both patients in treatment and community surveys of non-patients, thus eliminating the possibility that the figures are unbalanced because women find it easier to seek help. They also evaluated the studies proposing hormonal influence – including both the menstrual cycle and menopause. While there are many individuals who experience transient feelings of depression at various times in their cycle, they concluded that no one sex hormone can be implicated, and “there is little evidence to relate mood changes and clinical states to altered endocrine balance or specific hormones.” In other words, we are left with the incontrovertible evidence that depressions are indeed more common in women, and there is no organic or hormonal or chemical explanation for these findings.
The explanation of the increased incidence of depressions in women is found, not in their hormones, but in an understanding of women’s role in society, and the personality which the culture assigns to women. Women are considered to be second class citizens in our society, and to adapt to this role they are taught certain behavior. The personality traits which the culture considers desirable for women are not biologically predetermined, but produced by cultural pressure. Compliance, submissiveness, fear of self-assertion, increased dependency and learned helplessness are considered feminine, and these very patterns of behavior make women vulnerable to depression. As a result of women’s upbringing which trains them to focus on caring for and pleasing others, they often grow up suppressing themselves and their development to placate and appease first their parents and later a man to whom they become attached. The need to please others leads to a loss of contact with one’s own needs and leaves women vulnerable and hypersensitive to disturbances in relationships. In addition, the need to repress anger, which is part of the cultural stereotype of femininity, causes women to accept guilt and blame in any difficulty – thus driving themselves even harder to please. The combination of denial of self, repressed anger and concern for relationships account for the majority of depressions which therapists see in their practice.
Another source of depression is some of the activities and responsibilities formerly reserved for men which many women are now entering. The competitive atmosphere of businesses, professions and government which men take for granted are relatively new for women. Often they blame themselves for being inadequate when faced with the hostility of the workplace – and they feel that they did not respond appropriately. Women also become depressed when their efforts at new areas of self development are not approved of, or supported by, the men in their lives. They find it difficult to deal with disapproval or friction.
Recent studies show the role of other psychological factors. For example, married women have a higher rate of mental illness than single women, while married men have a lower rate of mental illness than single men. Marriage is good for men but, apparently, not for women. Working women have better health – both mental and physical – than women who remain at home. This applies even to women with children, whether married or single. Those who have involvements and productive work outside the home have greater self-esteem and feelings of worth – even if it means doing two jobs, one at home and one outside the home.
Treatment of depression should be a combination of psychotherapy and, when indicated, medications. Psychotherapy is crucial. Medication alone is not enough, unless for some specific reason the patient is inaccessible to psychotherapy. New medications have accomplished a great deal in relieving the extreme suffering of severe depressions – especially those requiring hospitalization. But all depressed people need psychotherapy as well.
In treating depression in women, those therapists are most successful who have an understanding of the deeply rooted feelings of low self-esteem which women experience, no matter how successful they appear to be. Other factors to be considered are women’s tendency to accept guilt and blame, regardless of the circumstances and women’s difficulty in recognizing and dealing with anger. These are some of the most common sources of depression in women which come to the attention of therapists.
In seeking a therapist, it is not necessary that the therapist be a woman, but it is advisable that the patient feel comfortable with the therapist. Credentials are important, but I recommend that the patient trust her intuitive feelings as well. If there is a strong negative feeling about the therapist, it is best to consider someone else. This is not a reflection on the competence of the therapist – sometimes certain personalities do not do well together. In the treatment of depression, it is especially important that this be taken into consideration.
On a positive note, depressed patients generally respond well in therapy. Additionally, life experiences, new relationships, women’s groups, accomplishments at home or at work all contribute to increased self esteem, which in turn neutralizes the behavior patterns leading to depression.
We are not biologically predetermined – biology is not our destiny and we can do something about it. Dr. Freud was wrong!
ALEXANDRA SYM0NDS, M.D. is associate clinical professor of psychiatry at the NYU College of Medicine; a training and supervising analyst at the American Institute of Psychoanalysis; associate attending in psychiatry at Bellevue Hospital: and associate psychoanalyst at the Karen Horney Clinic. She has a private practice in NYC. Dr. Symonds has published extensively on the effects of feminism on women’s mental health and many other social and psychiatric topics affecting women and children.