We found several gender differences between depressed men and depressed women in both our original sample4
and our present sample. Our finding of greater symptom severity in women replicates most4,25
but not all 6
previous studies. We found that men had more MDEs in this sample than in our previous report.4
It is worth noting, however, that the number of episodes by self-report may be a major limitation of this finding. This contrasts with the higher rates of relapse and recurrence for women that have been reported in other clinical population studies.27,28
However, in the National Comorbidity Survey, rates of relapse and chronicity were not associated with gender.29
Rates of concurrent comorbid Axis I disorders were similar to those from our previous report (i.e. more generalized anxiety, bulimia and somatization disorder in women, and more alcohol and substance abuse and dependence in men). Similar findings have been reported in previous studies. In one longitudinal epidemiological study, the prevalence of MDD and of one or two anxiety disorders was about two-fold higher in women than in men.30
In epidemiologic samples, greater rates of substance abuse/dependence comorbid with depression have been reported previously in men31
as has the greater frequency of eating disorders in clinical populations of women.32
Epidemiological data have found that completed suicide is more common in men, while suicide attempts are more common in women.33,34
In line with this, more women attempted suicide in both STAR*D samples, though men reported more suicidal ideation in the current sample.
The striking consistency of these findings across two large cohorts of depressed outpatients suggests that these differences are robust, although not all of them were expected on a theoretical basis. More depressive episodes in men coupled with their greater substance abuse may reflect low treatment-seeking in men, which may lead to more episodes before entering treatment. However, the finding of more episodes in men was not explained by a longer total illness in this sample. In the previous sample, men did have a longer length of illness and a younger age at onset of the first MDE than women. Consequently, the finding of more MDEs in men may be explained by a greater propensity by men to view the MDE as having ended when it had not, or by factors in women that prolong episodes.
Some investigators have questioned whether there may be unique gender-based patterns of depressive illness. Hypotheses have been put forward that suggest there may be “male depression” that differs from classic depression.35
In neither analysis did irritable mood emerge as more common in men, despite clinical lore that men show more mood irritability. In fact, both genders showed high rates of self-reported irritable mood (79% of men and 83% of women). It is possible that men may show more externalizing behaviors with their irritable mood, and this leads clinicians to conclude that men demonstrate more irritability. But these data do suggest that depressed men are more likely to engage in alcohol and substance abuse during their depressive illness.
In contrast to the findings in men, our current and previous reports show that a number of symptoms emerged as more common in women. Many of these findings, including increased appetite and weight, somatization and interpersonal sensitivity, have been previously reported in women.26,3,36
While we found that atypical depression was more common in women, it was only increased by 1.3 fold in women over men and was present in less than 20% of depression cases. Likewise, anxious depression was more common in women and present in 47.3% of women. Melancholic depression was equally common in men and women.
There are several aspects of these STAR*D gender findings that are of clinical and therapeutic importance. For males, the greater number of depressive episodes which appear to precede treatment, suggest that increased attention to treatment engagement strategies and psychoeducation targeting males may be helpful to increase their connection to care. Moreover, the findings of increased substance abuse in men, corroborated in numerous other studies, highlights the importance of substance abuse screening for all men treated for depression. The findings of the STAR*D study suggest that irritability is not a prominent feature which reliably predicts depression in men any more often than in women.
Women more frequently complain of appetite increase and weight gain during episodes of depression. In some studies this increase in weight, and particularly abdominal weight, has been linked to increases in cortisol, which may increase insulin resistance.37
This symptom is disturbing for many women and contributes to the demoralization that accompanies depression. It is imperative that the clinicians caring for women take this symptom into consideration when prescribing antidepressants. Coupling cognitive and behavioral treatment with medication, specifically targeting food intake, and suggesting that women maintain food and dietary logs when beginning antidepressants, may help to maintain normal weight. Moreover, exercise may reduce weight gain associated with depression, and has been demonstrated to improve mood symptoms and augument depression treatment in some studies.38
Screening for eating disorders in women, is also necessary, given the increased frequency of bulimia in depressed women. Careful monitoring for suicidality is essential when treating both genders, given the increased frequency of attempts in women, and completions in men. The anxiety more often reported by women, may be one of the symptoms that contributes to suicidality. Appropriately targeting anxiety symptoms with appropriate pharmacologic and psychotherapeutic treatments should be paramount in all women reporting anxiety. Finally, increased symptom severity reported by women, suggests the needs for aggressive management, using evidence-based psychotherapies such as cognitive behavioral treatment, interpersonal therapy, and pharmacotherapy. Many studies suggest that there is many women receive treatment that is suboptimal; as such it is essential that clinicians carefully monitor mood symptoms throughout treatment to promote full remission.