Psychiatry Research 210 (2013) 1301–1303
Contents lists available at ScienceDirect
Psychiatry Research journal homepage: www.elsevier.com/locate/psychres
Brief report
Gender differences in depression and anxiety: The role of age Carlo Faravelli a,n, Maria Alessandra Scarpato b, Giovanni Castellini c, Carolina Lo Sauro a a Department of Health Sciences, Section of Psychology and Psychiatry, University of Florence, Via di San Salvi 12, Complesso di San Salvi, Padiglione 26, 50135 Florence, Italy b Studio DeA, Via P.F. Calvi 10, 50100 Florence, Italy c Psychiatric Unit, Department of Neuropsychiatric Sciences, Florence University School of Medicine, Largo Brambilla 1, 50134 Florence, Italy
art ic l e i nf o
a b s t r a c t
Article history: Received 18 June 2013 Received in revised form 17 September 2013 Accepted 25 September 2013
Although females run greater risk for affective disorders, the greater vulnerability of women for these disorders varies with the age. The present study evaluates the lifetime incidence of depressive and anxiety disorders by age and gender in a community sample (2363 subjects; 54.6% females), representative of the general population (Sesto Fiorentino Study). Lifetime prevalence of affective disorders resulted higher in females. The age–sex pattern for affective disorders was observed only before menopause. & 2013 Elsevier Ireland Ltd. All rights reserved.
Keywords: Gender Menopause Affective disorders.
1. Introduction Affective disorders, such as anxiety and depression, are disproportionately (almost doubled) prevalent in women (Cyranowski et al., 2000; Bijl et al., 2002; Kessler, 2003;Leach et al., 2008). The greater vulnerability of women varies with the age: before mid-puberty, boys are more likely than girls to be depressed, while between 15 and 19 years, the prevalence of depression is doubled in girls (Cyranowski et al., 2000; Bijl et al., 2002). This trend persists until 54 years (Cairney and Wade, 2002) and declines during older age (Bebbington et al., 1998; Cyranowski et al., 2000; Leach et al., 2008), when virtually all women have passed through the menopause. However, some authors, reported higher prevalence and incidence rates of affective disorders in women, even after menopause (Cairney and Wade, 2002; Bijl et al., 2002). Given that the excess of affective disorders in women is one of the issues in favor of the hormonal hypothesis (Solomon and Herman, 2009; Oldehinkel and Bouma, 2011), the incidence of new cases in people who were anxiety/depression-free is crucial, while a greater prevalence of females is expected even after menopause, as depression and anxiety are either chronic or recurrent conditions. However, this issue has been poorly addressed and showed not conclusive results (Bijl et al., 2002; Cairney and Wade, 2002).
n
Corresponding author. Tel.: þ 39 55 2055811; fax: þ 39 55 6236047. E-mail address: carlo.faravelli@unifi.it (Carlo. Faravelli).
0165-1781/$ - see front matter & 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.psychres.2013.09.027
The present study is therefore aimed at evaluating the incidence of depressive and anxiety disorders by age and gender in a community sample. In particular, the incidence rates are calculated separately before and after menopause. 2. Methods The present study is part of the Sesto Fiorentino Survey, described in details elsewhere (Faravelli et al., 2004). In brief, a random sample of 2500 subjects aged Z14 years, representative of the general population, was drawn from the lists of general practitioners (GPs). 2363 (94.5%) subjects were interviewed by their own GPs, by means of the MINI (Sheehan et al., 1998). All the MINI positives and a random sample of the negatives (n¼ 123) were re-interviewed by psychiatrists using the Florence Psychiatric Interview (FPI, Faravelli et al., 2001). This is a structured interview, made up of a combination of several common rating scales and diagnostic instruments, that was fully validated and showed good inter-rater and test-retest reliability, as well as a perfect concordance with the Structured Clinical Interview for DSM-IV (First et al., 1995). For the purpose of this study the lifetime diagnoses were used. The mean age of the sample was 49.9718.5 years and 54.6% were females. Considering the high rate of comorbidity within diagnoses and given that analyses within the single DSM diagnostic group reproduced the same patterns, major depressive disorder, dysthymia and depression disorder not otherwise specified were combined as “depressive disorders”, and phobic disorders, panic disorder, anxiety disorder not otherwise specified were combined as “anxiety disorders”. For between sex comparisons, χ2 was applied. The Kaplan–Meier survival analysis with a Log rank test (Mantel–Cox) was used to compare overall survival time to the combined endpoint of onset of affective disorders, between genders. Patients into gender groups were stratified by age of onset settled at menopause (“before menopause”: n¼1233, 52.2%; “after menopause”: n ¼918, 38.8%). As the mean age for menopause was 51.4 (7 2.3) years, the same age was used as cut off point for males. All analyses were performed using SPSS 20.0.
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C. Faravelli et al. / Psychiatry Research 210 (2013) 1301–1303
Fig. 1. Estimated survival distribution function of onset of affective disorders in females and males. The survival distribution function shows the probability at various time points that an individual will develop an affective disorder by that time point. The subjects were categorized according to age of onset (before and after menopause and corresponding age for males).
3. Results A DSM-IV diagnosis was produced for 25.8% of the sample [32.4% females vs 17.8% males, OR ¼2.204 (95% CI ¼ 1.81–2.68), p o0.001]. The lifetime prevalence of depressive disorders and anxiety disorders was 17% [72.4% females; OR ¼2.51(95% CI ¼ 1.99–3.18), p o0.001] and 12% [68.9% females; OR ¼1.99 (95% CI ¼1.52–2.59), p o0.001], respectively. Comorbid depression and anxiety was reported by 9.2% of the sample [70.6% females; OR ¼2.13 (95% CI ¼1.57–2.88), p o0.001]. Between 14 and 19 years, the incidence of depressive disorders was higher in females (85.7% females; χ2 ¼ 4.49, p o0.05), while no significant difference was observed for anxiety disorders. Before menopause (corresponding age for males), females reported higher incidences of both depressive [22.8% females vs 9.7% males; OR¼ 2.77 (95% CI ¼1.99–3.85), p o0.001] and anxiety disorders [17.2% females vs 7.2% males; OR¼ 2.65 (95% CI ¼1.82– 3.85), po 0.001]. After menopause, the rates of cases who experienced an affective disorder for the first time did not distinguish between the two sexes (8.6% females vs 5.8% males for depressive disorders, and 5.1% females vs 4.4% males for anxiety disorders). The cumulative survival function of the onset of affective disorders (combining depressive, anxiety and comorbid depressive and anxiety disorders) showed an higher incidence for females only before menopause (Fig. 1). The risk of onset of depressive, anxiety and comorbid depressive and anxiety disorders was higher for females only before menopause (depressive disorders: Log-rank (Mantel–Cox): χ2 ¼ 39.85, d.f. 1, po0.001; anxiety disorders: Log-rank (Mantel–Cox): χ2 ¼ 30.14, d.f. 1, po0.001; comorbid depressive and anxiety disorders: Log-rank (Mantel–Cox): χ2 ¼29.08, d.f. 1, po0.001). No difference in psychopathology existed between genders or between women, after controlling for hormonal replacement therapy (data not shown).
4. Discussion According to the literature, the lifetime prevalence of affective disorders was higher, approximately doubled, in females (Bebbington
et al., 1998; Cyranowski et al., 2000; Bijl et al., 2002; Kessler, 2003; Leach et al., 2008). The age–sex pattern for affective disorders was observed only during the fertile age, while after menopause the risk for new cases is similar in the two genders, independently of the assumption of hormonal replacement therapy, as already suggested (Bijl et al. 2002; Cairney and Wade, 2002). While the present findings are not new, they may contribute further information in an area where knowledge is not yet fully defined. Our findings may support the gonadic theory, by which hormone levels of women fluctuate cyclically over a much larger range than those of men, affecting brain regions known to be involved in the modulation of mood and behavior (e.g., prefrontal cortex, hippocampus) (Oldehinkel and Bouma, 2011). The recurrent estrogen withdrawal would interfere with the ability of estrogens to neutralize the effects of glucocorticoids released during stress, rendering women more vulnerable to stress and hence at risk for anxiety and depression (Solomon and Herman, 2009; Oldehinkel and Bouma, 2011). Other hypotheses maintain that boys and girls show different environmental risk factors (e.g., childhood adversities, psychosocial and economic factors) (Leach et al., 2008; Oldehinkel and Bouma, 2011). However, the sharp change in the risk of affective disorder for women at the menopausal age, in contrast with the slower and smaller variations of the psychosocial factors, is a factor in favor of the hormonal position. It must be considered, however, that the risk of affective disorder is reduced after the age of menopause in both sexes, thus decreasing the strength of the hormonal interpretation. Moreover, being the diagnoses retrospective and lacking bio-hormonal data, this study presents obvious limitations: it must be read as further, though limited, piece of information in a field were the findings are not univocal. References Bebbington, P.E., Dunn, G., Jenkins, R., Lewis, G., Brugha, T., Farrell, M., Meltzer, H., 1998. The influence of age and sex on the prevalence of depressive conditions: report from the National Survey of Psychiatric Morbidity. Psychological Medicine 28, 9–19. Bijl, R.V., De Graaf, R., Ravelli, A., Smit, F., Vollebergh, W.A., 2002. Gender and agespecific first incidence of DSM-III-R psychiatric disorders in the general
C. Faravelli et al. / Psychiatry Research 210 (2013) 1301–1303
population. Results from the Netherlands Mental Health Survey and Incidence Study (NEMESIS). Social Psychiatry and Psychiatric Epidemiology 37 (8), 372–379. Cairney, J., Wade, T.J., 2002. The influence of age on gender differences in depression: further population-based evidence on the relationship between menopause and the sex difference in depression. Social Psychiatry and Psychiatric Epidemiology 37 (9), 401–408. Cyranowski, J.M., Frank, E., Young, E., Shear, M.K., 2000. Adolescent onset of the gender difference in lifetime rates of major depression: a theoretical model. Archives of General Psychiatry 57 (1), 21–27. Faravelli, C., Abrardi, L., Bartolozzi, D., Cecchi, C., Cosci, F., D'Adamo, D., Lo Iacono, B., Ravaldi, C., Scarpato, M.A., Truglia, E., Rosi, S., 2004. The Sesto Fiorentino study: background, methods and preliminary results. Lifetime prevalence of psychiatric disorders in an Italian community sample using clinical interviewers. Psychotherapy and Psychosomatics 73 (4), 216–225. Faravelli, C., Bartolozzi, D., Ciminiello, L., Cecchi, C., Cosci, F., D’Adamo, D., Di Matteo, C., Di Primio, C., Fabbri, C., Lo Iacono, B., Paionni, A., Perone, A., Rosi, S., Scarpato, M.A., Serena, A., Taberna, A., 2001. The Florence Psychiatric Interview. International Journal of Methods in Psychiatric Research 10, 157–171.
1303
First, M.B., Spitzer, R.L., Gibbon, M., Williams, J.B.W., 1995. Structured Clinical Interview for DSM-IV Axis I Disorders-Patient Edition (SCID-I/P version 2.0). Biometrics Research Department, New York State Psychiatric Institute, New York. Kessler, R.C., 2003. Epidemiology of women and depression. Journal of Affective Disorders 74 (1), 5–13. Leach, L.S., Christensen, H., Mackinnon, A.J., Windsor, T.D., Butterworth, P., 2008. Gender differences in depression and anxiety across the adult lifespan: the role of psychosocial mediators. Social Psychiatry and Psychiatric Epidemiology 43 (12), 983–998. Oldehinkel, A.J., Bouma, E.M., 2011. Sensitivity to the depressogenic effect of stress and HPA-axis reactivity in adolescence: a review of gender differences. Neuroscience and Biobehavioral Reviews 35 (8), 1757–1770. Sheehan, D.V., Lecrubier, Y., Sheehan, K.H., Amorim, P., Janavs, J., Weiller, E., Hergueta, T., Baker, R., Dunbar, G.C., 1998. The Mini International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. Journal of Clinical Psychiatry 59 (suppl 20), 22–33. Solomon, M.B., Herman, J.P., 2009. Sex differences in psychopathology: of gonads, adrenals and mental illness. Physiology and Behavior 97 (2), 250–258.
Contents lists available at ScienceDirect
Psychiatry Research journal homepage: www.elsevier.com/locate/psychres
Brief report
Gender differences in depression and anxiety: The role of age Carlo Faravelli a,n, Maria Alessandra Scarpato b, Giovanni Castellini c, Carolina Lo Sauro a a Department of Health Sciences, Section of Psychology and Psychiatry, University of Florence, Via di San Salvi 12, Complesso di San Salvi, Padiglione 26, 50135 Florence, Italy b Studio DeA, Via P.F. Calvi 10, 50100 Florence, Italy c Psychiatric Unit, Department of Neuropsychiatric Sciences, Florence University School of Medicine, Largo Brambilla 1, 50134 Florence, Italy
art ic l e i nf o
a b s t r a c t
Article history: Received 18 June 2013 Received in revised form 17 September 2013 Accepted 25 September 2013
Although females run greater risk for affective disorders, the greater vulnerability of women for these disorders varies with the age. The present study evaluates the lifetime incidence of depressive and anxiety disorders by age and gender in a community sample (2363 subjects; 54.6% females), representative of the general population (Sesto Fiorentino Study). Lifetime prevalence of affective disorders resulted higher in females. The age–sex pattern for affective disorders was observed only before menopause. & 2013 Elsevier Ireland Ltd. All rights reserved.
Keywords: Gender Menopause Affective disorders.
1. Introduction Affective disorders, such as anxiety and depression, are disproportionately (almost doubled) prevalent in women (Cyranowski et al., 2000; Bijl et al., 2002; Kessler, 2003;Leach et al., 2008). The greater vulnerability of women varies with the age: before mid-puberty, boys are more likely than girls to be depressed, while between 15 and 19 years, the prevalence of depression is doubled in girls (Cyranowski et al., 2000; Bijl et al., 2002). This trend persists until 54 years (Cairney and Wade, 2002) and declines during older age (Bebbington et al., 1998; Cyranowski et al., 2000; Leach et al., 2008), when virtually all women have passed through the menopause. However, some authors, reported higher prevalence and incidence rates of affective disorders in women, even after menopause (Cairney and Wade, 2002; Bijl et al., 2002). Given that the excess of affective disorders in women is one of the issues in favor of the hormonal hypothesis (Solomon and Herman, 2009; Oldehinkel and Bouma, 2011), the incidence of new cases in people who were anxiety/depression-free is crucial, while a greater prevalence of females is expected even after menopause, as depression and anxiety are either chronic or recurrent conditions. However, this issue has been poorly addressed and showed not conclusive results (Bijl et al., 2002; Cairney and Wade, 2002).
n
Corresponding author. Tel.: þ 39 55 2055811; fax: þ 39 55 6236047. E-mail address: carlo.faravelli@unifi.it (Carlo. Faravelli).
0165-1781/$ - see front matter & 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.psychres.2013.09.027
The present study is therefore aimed at evaluating the incidence of depressive and anxiety disorders by age and gender in a community sample. In particular, the incidence rates are calculated separately before and after menopause. 2. Methods The present study is part of the Sesto Fiorentino Survey, described in details elsewhere (Faravelli et al., 2004). In brief, a random sample of 2500 subjects aged Z14 years, representative of the general population, was drawn from the lists of general practitioners (GPs). 2363 (94.5%) subjects were interviewed by their own GPs, by means of the MINI (Sheehan et al., 1998). All the MINI positives and a random sample of the negatives (n¼ 123) were re-interviewed by psychiatrists using the Florence Psychiatric Interview (FPI, Faravelli et al., 2001). This is a structured interview, made up of a combination of several common rating scales and diagnostic instruments, that was fully validated and showed good inter-rater and test-retest reliability, as well as a perfect concordance with the Structured Clinical Interview for DSM-IV (First et al., 1995). For the purpose of this study the lifetime diagnoses were used. The mean age of the sample was 49.9718.5 years and 54.6% were females. Considering the high rate of comorbidity within diagnoses and given that analyses within the single DSM diagnostic group reproduced the same patterns, major depressive disorder, dysthymia and depression disorder not otherwise specified were combined as “depressive disorders”, and phobic disorders, panic disorder, anxiety disorder not otherwise specified were combined as “anxiety disorders”. For between sex comparisons, χ2 was applied. The Kaplan–Meier survival analysis with a Log rank test (Mantel–Cox) was used to compare overall survival time to the combined endpoint of onset of affective disorders, between genders. Patients into gender groups were stratified by age of onset settled at menopause (“before menopause”: n¼1233, 52.2%; “after menopause”: n ¼918, 38.8%). As the mean age for menopause was 51.4 (7 2.3) years, the same age was used as cut off point for males. All analyses were performed using SPSS 20.0.
1302
C. Faravelli et al. / Psychiatry Research 210 (2013) 1301–1303
Fig. 1. Estimated survival distribution function of onset of affective disorders in females and males. The survival distribution function shows the probability at various time points that an individual will develop an affective disorder by that time point. The subjects were categorized according to age of onset (before and after menopause and corresponding age for males).
3. Results A DSM-IV diagnosis was produced for 25.8% of the sample [32.4% females vs 17.8% males, OR ¼2.204 (95% CI ¼ 1.81–2.68), p o0.001]. The lifetime prevalence of depressive disorders and anxiety disorders was 17% [72.4% females; OR ¼2.51(95% CI ¼ 1.99–3.18), p o0.001] and 12% [68.9% females; OR ¼1.99 (95% CI ¼1.52–2.59), p o0.001], respectively. Comorbid depression and anxiety was reported by 9.2% of the sample [70.6% females; OR ¼2.13 (95% CI ¼1.57–2.88), p o0.001]. Between 14 and 19 years, the incidence of depressive disorders was higher in females (85.7% females; χ2 ¼ 4.49, p o0.05), while no significant difference was observed for anxiety disorders. Before menopause (corresponding age for males), females reported higher incidences of both depressive [22.8% females vs 9.7% males; OR¼ 2.77 (95% CI ¼1.99–3.85), p o0.001] and anxiety disorders [17.2% females vs 7.2% males; OR¼ 2.65 (95% CI ¼1.82– 3.85), po 0.001]. After menopause, the rates of cases who experienced an affective disorder for the first time did not distinguish between the two sexes (8.6% females vs 5.8% males for depressive disorders, and 5.1% females vs 4.4% males for anxiety disorders). The cumulative survival function of the onset of affective disorders (combining depressive, anxiety and comorbid depressive and anxiety disorders) showed an higher incidence for females only before menopause (Fig. 1). The risk of onset of depressive, anxiety and comorbid depressive and anxiety disorders was higher for females only before menopause (depressive disorders: Log-rank (Mantel–Cox): χ2 ¼ 39.85, d.f. 1, po0.001; anxiety disorders: Log-rank (Mantel–Cox): χ2 ¼ 30.14, d.f. 1, po0.001; comorbid depressive and anxiety disorders: Log-rank (Mantel–Cox): χ2 ¼29.08, d.f. 1, po0.001). No difference in psychopathology existed between genders or between women, after controlling for hormonal replacement therapy (data not shown).
4. Discussion According to the literature, the lifetime prevalence of affective disorders was higher, approximately doubled, in females (Bebbington
et al., 1998; Cyranowski et al., 2000; Bijl et al., 2002; Kessler, 2003; Leach et al., 2008). The age–sex pattern for affective disorders was observed only during the fertile age, while after menopause the risk for new cases is similar in the two genders, independently of the assumption of hormonal replacement therapy, as already suggested (Bijl et al. 2002; Cairney and Wade, 2002). While the present findings are not new, they may contribute further information in an area where knowledge is not yet fully defined. Our findings may support the gonadic theory, by which hormone levels of women fluctuate cyclically over a much larger range than those of men, affecting brain regions known to be involved in the modulation of mood and behavior (e.g., prefrontal cortex, hippocampus) (Oldehinkel and Bouma, 2011). The recurrent estrogen withdrawal would interfere with the ability of estrogens to neutralize the effects of glucocorticoids released during stress, rendering women more vulnerable to stress and hence at risk for anxiety and depression (Solomon and Herman, 2009; Oldehinkel and Bouma, 2011). Other hypotheses maintain that boys and girls show different environmental risk factors (e.g., childhood adversities, psychosocial and economic factors) (Leach et al., 2008; Oldehinkel and Bouma, 2011). However, the sharp change in the risk of affective disorder for women at the menopausal age, in contrast with the slower and smaller variations of the psychosocial factors, is a factor in favor of the hormonal position. It must be considered, however, that the risk of affective disorder is reduced after the age of menopause in both sexes, thus decreasing the strength of the hormonal interpretation. Moreover, being the diagnoses retrospective and lacking bio-hormonal data, this study presents obvious limitations: it must be read as further, though limited, piece of information in a field were the findings are not univocal. References Bebbington, P.E., Dunn, G., Jenkins, R., Lewis, G., Brugha, T., Farrell, M., Meltzer, H., 1998. The influence of age and sex on the prevalence of depressive conditions: report from the National Survey of Psychiatric Morbidity. Psychological Medicine 28, 9–19. Bijl, R.V., De Graaf, R., Ravelli, A., Smit, F., Vollebergh, W.A., 2002. Gender and agespecific first incidence of DSM-III-R psychiatric disorders in the general
C. Faravelli et al. / Psychiatry Research 210 (2013) 1301–1303
population. Results from the Netherlands Mental Health Survey and Incidence Study (NEMESIS). Social Psychiatry and Psychiatric Epidemiology 37 (8), 372–379. Cairney, J., Wade, T.J., 2002. The influence of age on gender differences in depression: further population-based evidence on the relationship between menopause and the sex difference in depression. Social Psychiatry and Psychiatric Epidemiology 37 (9), 401–408. Cyranowski, J.M., Frank, E., Young, E., Shear, M.K., 2000. Adolescent onset of the gender difference in lifetime rates of major depression: a theoretical model. Archives of General Psychiatry 57 (1), 21–27. Faravelli, C., Abrardi, L., Bartolozzi, D., Cecchi, C., Cosci, F., D'Adamo, D., Lo Iacono, B., Ravaldi, C., Scarpato, M.A., Truglia, E., Rosi, S., 2004. The Sesto Fiorentino study: background, methods and preliminary results. Lifetime prevalence of psychiatric disorders in an Italian community sample using clinical interviewers. Psychotherapy and Psychosomatics 73 (4), 216–225. Faravelli, C., Bartolozzi, D., Ciminiello, L., Cecchi, C., Cosci, F., D’Adamo, D., Di Matteo, C., Di Primio, C., Fabbri, C., Lo Iacono, B., Paionni, A., Perone, A., Rosi, S., Scarpato, M.A., Serena, A., Taberna, A., 2001. The Florence Psychiatric Interview. International Journal of Methods in Psychiatric Research 10, 157–171.
1303
First, M.B., Spitzer, R.L., Gibbon, M., Williams, J.B.W., 1995. Structured Clinical Interview for DSM-IV Axis I Disorders-Patient Edition (SCID-I/P version 2.0). Biometrics Research Department, New York State Psychiatric Institute, New York. Kessler, R.C., 2003. Epidemiology of women and depression. Journal of Affective Disorders 74 (1), 5–13. Leach, L.S., Christensen, H., Mackinnon, A.J., Windsor, T.D., Butterworth, P., 2008. Gender differences in depression and anxiety across the adult lifespan: the role of psychosocial mediators. Social Psychiatry and Psychiatric Epidemiology 43 (12), 983–998. Oldehinkel, A.J., Bouma, E.M., 2011. Sensitivity to the depressogenic effect of stress and HPA-axis reactivity in adolescence: a review of gender differences. Neuroscience and Biobehavioral Reviews 35 (8), 1757–1770. Sheehan, D.V., Lecrubier, Y., Sheehan, K.H., Amorim, P., Janavs, J., Weiller, E., Hergueta, T., Baker, R., Dunbar, G.C., 1998. The Mini International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. Journal of Clinical Psychiatry 59 (suppl 20), 22–33. Solomon, M.B., Herman, J.P., 2009. Sex differences in psychopathology: of gonads, adrenals and mental illness. Physiology and Behavior 97 (2), 250–258.
