Depression in Girls and Women Across the Lifespan

Treatment Essentials for Mental Health Professionals

Laura H. Choate

• Publisher: Routledge
• Year: 2019
• ISBN:
  9781351802468
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy Counselling
• Index: Psychology

Depression in Girls and Women Across the Lifespan takes a broad biopsychosocial approach to understanding the onset and experience of depression in women.

The book is structured around four major life transitions: depression during puberty and the transition to adolescence; Premenstrual Dysphoric Disorder and a woman's transition through monthly cycles of depression; depression during pregnancy, postpartum, and the transition to motherhood; and depression during perimenopause and the transition to menopause. Integrating cutting-edge research with a wealth of case examples and specific evidence-based interventions, the book expands our understanding of depression by taking into account the biological realities, psychological vulnerabilities, life stressors, and gendered cultural messages and expectations that intersect to shape the onset of depression in women's lives.

Written in a clear, applicable style, Depression in Girls and Women Across the Lifespan enables mental health professionals to provide effective, gender-informed, depression-focused treatments that are tailored to girls' and women's unique needs.

1
Foundations for Conceptualizing and Treating Depression in Girls and Women

Depression hurts. It’s the “black dog” of the night that robs you of joy, the unquiet mind that keeps you awake. It’s a noonday demon that only you can see, the darkness visible only to you.

(Williams, Teasdale, Segal, & Kabat-Zinn, 2007, p. 1)

Depression is a serious illness, with high prevalence rates and a far-reaching impact on impairment and disability. As characterized by the quote opening the chapter, depression is not a problem that merely results in a few days of sadness. Rather, a hallmark feature of depression is a sense of profound hopelessness—that nothing will ever get better, that the emotional pain will never have an end. It is clear that depression can pervade all aspects of functioning, and as described in the quote, it can cause clients to feel numb and disengaged with life, while their internal distress may remain invisible to others.

It is eye-opening to note how many individuals live with depression: it will affect up to 7–13% of all adults ages 18 and over. In addition, adolescents also experience high rates of depression. In 2017, the National Survey of Drug Use and Health results showed 13.5% of all U.S. adolescents between the ages of 12 and 17 had experienced at least one episode of Major Depressive Disorder (MDD) during the past year (National Institute of Mental Health, 2019).

While depression prevalence in the general population is concerning, it is important to examine gender differences in interpreting these statistics. Twice as many women are diagnosed with depression than men, with particularly stark gender differences for adolescents and young women. Overall 8.7% of all women (vs. 5.3% of men) were diagnosed with depression during the past year; however, 20% of adolescent girls experienced an episode of MDD in the past year compared to 6.8% of boys. Further, recent data show 16.5% of females ages 12 and up took an antidepressant in the past month, compared to 8.6% of males (CDC, 2017).

It is noteworthy that the male-to-female ratio for depression during childhood is 1:1, but that by age 13 (around the time of puberty) it increases to 1:2 (American Academy of Child and Adolescent Psychiatry, ACAP, 2007) and this two-fold gender difference persists throughout adolescence and adulthood.

Providing effective, gender-informed, evidence-based assessment and treatment for depression is important because of its level of potential lifetime impairment. Women with depression are at significantly higher risk of developing other chronic diseases, and 9 out of 10 women with depression have one or more risk factors (e.g., smoking, heavy drinking, and physical inactivity) that increase their vulnerability to chronic disease or chronic conditions like diabetes and obesity (NIMH, 2019). Depression is also a known risk factor for suicide. Over 50% of suicide victims have a depressive disorder at the time of death (Thapar, Collishaw, Pine, & Thapar, 2012).

Effective treatment is also essential because of the chronic nature of depression. As 20% of adolescent girls have already experienced an episode of depression by age 17, they are also highly likely to experience recurrent episodes throughout adolescence and adulthood. It is alarming that up to 72% of adolescents experience another episode of MDD within five years of their first episode, and they have a two to four times greater risk for depression as an adult (AACAP, 2007). Adults who experience recurrent depressive episodes recall their first episode of depression as occurring in early adolescence (Weersing, Jeffreys, Do, Schwartz, & Bolano, 2017).

It is clear that depression is a mental disorder that is particularly relevant for therapists who work with girls and women due to the two-fold gender difference in prevalence rates. This chapter will provide an introduction to the foundations that underlie the rest of the book. I will first address assessment and diagnostic issues related to depression in girls and women to provide an overview of understanding Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria and for accurately diagnosing Major Depressive Disorder. I will then provide a biopsychosocial overview of risk factors for depression in girls and women. Throughout the book I pay particular attention to biological factors (e.g., hormone shifts), psychological factors (e.g., temperament, negative affect, interpersonal orientation), negative life events and stressors that disproportionately impact girls and women, and cultural influences that serve to devalue women (e.g., oppression, poverty, relational violence) and that create unrealistic standards and expectations (e.g., adhering to cultural beauty ideals; perfectionism in relationships and motherhood). In this chapter I provide an overview of some of these factors that will be expanded upon in the book. Finally, in this chapter I provide a review of guidelines for effective mental health practice for girls and women, followed by specific evidence-based guidelines for the treatment of depression. These guidelines and treatments will be the approaches emphasized in each of the subsequent chapters of the book. See Box 1.1 to reflect on the themes in this chapter.

Box 1.1 Questions for Self-Exploration

1. What is your reaction to the opening quote? In your personal or professional experiences, can you relate to their described feelings of numbness and hopelessness?
2. Were you surprised to read these statistics about girls and women? And the gender difference between males and females in rates of depression? Why or why not?
3. What are the current cultural expectations for girls and women? What are some of the ways in which they are socialized that might eventually contribute to feelings of hopelessness, helplessness, and depressive episodes?

Assessment and Diagnostic Criteria for Major Depressive Disorder

While many people utter the expression, “I am so depressed!” they usually mean they are feeling temporarily sad or “down in the dumps.” As mental health professionals, we know that sadness is only one aspect of depression, but in the general population, many people are not aware of the nuances and breadth of depressive symptoms. In fact, it is possible to meet diagnostic criteria for MDD without experiencing depressed mood. The DSM-5 defines MDD as the experience of five or more symptoms that have occurred in the previous two weeks; to meet the criteria for the diagnosis, at least one of the five needs to be either depressed mood or loss of interest/pleasure in previously enjoyed activities. Other symptoms can include weight loss or weight gain; insomnia or hypersomnia; psychomotor agitation or retardation; fatigue; feelings of worthlessness or guilt; diminished decisiveness and concentration; or recurrent thoughts of death, suicidal ideation, or suicide attempt. The impact of these symptoms should cause clinically significant distress or impairment in multiple areas of functioning (APA, 2013). The reader is referred to the DSM-5 for more specific information about the diagnostic criteria for MDD.

In addition, in the DSM-5, MDD is also coded according to whether it is a single or recurrent episode, its severity (mild, moderate, severe), whether or not psychosis is present, whether the episode is in remission or not, and whether one of the following specifiers should be included:

• With anxious distress
• With mixed features
• With melancholic features
• With atypical features
• With mood-congruent psychotic features
• With mood-incongruent psychotic features
• With catatonia
• With peripartum onset
• With seasonal pattern (with recurrent episode only)

Note: Because the peripartum onset specifier is the only specifier that is gender specific, it is explored in depth in Chapter 4 (Treatment for Perinatal Depression).

In addition to MDD, there are related mood disorders in the Depressive Disorders chapter in DSM-5:

• Persistent Depressive Disorder
• Premenstrual Dysphoric Disorder
• Substance/Medication Induced Depressive Disorder
• Depressive Disorder Due to Another Medical Condition
• Other Specified Depressive Disorder
• Unspecified Depressive Disorder

Note: Because PMDD is the only gender-specific disorder (i.e., only occurs in women) it is the only other mood disorder covered in this book, and will be explored fully in Chapter 3.

Coding and Diagnostic Issues

Coding is based on whether the client is experiencing a single episode or recurrent episode; the level of severity (mild, moderate, severe); the presence of psychotic features; and remission status (partial remission, full remission, or unspecified).

Coding Severity

• Mild: Few if any symptoms in excess of those required to make the diagnosis are present, the intensity of symptoms is distressing, and the symptoms result in minor impairment in functioning.
• Moderate: The number of symptoms experienced, the intensity of symptoms, and/or resulting functional impairment are in-between those specified for “mild” and “severe.”
• Severe: The number of symptoms is substantially in excess of that required for the diagnosis, the intensity of the symptoms is seriously distressing and unmanageable, and the symptoms markedly interfere with functioning.

Coding Remission Status

• Partial Remission: Symptoms of immediately previous major depressive episode (MDE) are present, but full criteria are not met, or there is a period lasting less than two months without any significant symptoms of a MDE following the end of such an episode
• Full Remission: During past 2 months no significant signs or symptoms of disturbance were present.

Diagnostic Reporting

Clinicians should place diagnosis and coding in the following order:

Major Depressive Disorder, single or recurrent episode, severity/psychotic/remission status, followed by one of the following specifiers:

• With anxious distress
• With mixed features
• With melancholic features
• With atypical features
• With mood-congruent psychotic features
• With mood-incongruent psychotic features
• With catatonia
• With peripartum onset
• With seasonal pattern (with recurrent episode only)

Why Girls and Women? Biopsychosocial Risk Factors for Depression

Women’s vulnerability to depression is influenced by multiple biological, psychological, and sociocultural factors, including multiple life stressors; there is no one pathway to explain why depression occurs so much more often in females as compared to males. Before exploring specific influences, I will start with a discussion of two broad sociocultural messages that impact all girls and women to some degree and that play a unique role in the development of depression.

The first theme is related to sociocultural messages about gender, starting in early girlhood. The cultural landscape for girlhood is rapidly changing, and it is worth noting that girls’ depression levels are sharply increasing along with these changes. Never before have girls experienced so many cultural pressures about how they should look and act. From a very young age, they learn that they should have a sexualized appearance, to gain as much attention as possible (both online and in person) and to excel in multiple academic and extracurricular pursuits (Choate, 2016). They learn that they are to perform at top levels in school and athletics, while also being nice, maintaining their relationships, and appearing as attractive as possible (Johnson, 2015).

As girls are socialized to adhere to these standards, they may internalize these cultural expectations as their own standard of worth, and subsequently believe they cannot ever measure up to what is expected of them. As they measure themselves against these standards, they may believe “I’m not ever good enough”—a negative cognitive pattern known to contribute to depressive symptoms. As they internalize these standards of perfection, they are also more likely to develop low self-worth and negative body image, both of which are also linked to the development of depression.

In addition to messages about unrealistic expectations for girls and women, a second major cultural theme is that women should value themselves in terms of their ability to maintain close relationships. If a girl or woman is overly invested in the success of her relationships, she may put her own needs aside in order to keep others around her happy with her; she will learn not to speak up about what she needs in the relationship and instead prioritize the demands of others. Jack (1991) referred to this process as becoming a self-sacrificing caregiver who relinquishes her sense of self and learns to “self-silence” in order to maintain close relationships. As a woman learns to devalue her own voice and to sacrifice her own needs, she becomes vulnerable to depression (Ali, Caires, & Wash, 2017). Read the following quote by a teen girl:

You become so much less of a person when all you are doing is trying to please others. You’re not being who you are, and after a while, you lose who you were. You become that other person. So nothing ever feels quite right, because some part of you knows that’s not really you. So, you’re never happy.

—Anonymous, (Machoian, 2006, p. 41)

When a girl such as the one quoted here bases her worth solely on her relationships, she is also more impacted by relational conflict; when there are negative family, friend, or social events swirling around her, these can cause distress for her even in cases where she is not directly involved. Unfortunately these dynamics (being enmeshed with others’ problems, silencing her own needs in order to stay close to others) can begin in childhood, are perpetuated in adolescence, impact her romantic relationships, and can influence her own experience of motherhood. This process is exemplified in the following quote:

Women know all too well what it’s like to give up your self in service of others, to please someone else, to take care of someone else, to not rock the boat to keep your mouth shut, to not lose your job, your friends, your boyfriend, your partner, your husband. This dynamic is a central dilemma in the psychology of women, and it begins to wreak its havoc on females in adolescence (just as depression does).

(Machoian, 2006, p. 40)

This socialization process can leave women feeling objectified and disrespected within relationships, a dynamic that can become a risk factor for relational violence. Sexual assault, intimate partner violence, and sexual abuse are all twice as likely to happen to females than to males, and this type of violence leads to an increased lifet...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Dedication
• Contents
• Preface: Why Girls, Women, and Depression?
• Introduction: An Overview of the Book
• 1 Foundations for Conceptualizing and Treating Depression in Girls and Women
• 2 Treatment for Depression in Adolescent Girls: Navigating Puberty and the Transition to Adolescence
• 3 Treatment for Premenstrual Dysphoric Disorder: Navigating the Transition Through Depression and Menstrual Cycles
• 4 Treatment for Perinatal Depression: Navigating the Transition to Motherhood
• 5 Treatment for Depression in Perimenopausal Women: Navigating the Transition to Menopause
• Index