Understanding Depression

Feminist Social Constructionist Approaches

Janet Stoppard

• Publisher: Routledge
• Year: 2014
• Print ISBN: 9780415165624
• eBook ISBN: 9781317725084
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

Women are particularly vulnerable to depression. Understanding Depression provides an in-depth critical examination of mainstream approaches to understanding and treating depression from a feminist perspective. Janet Stoppard argues that current approaches give only partial accounts of womens' experiences of depression and concludes that a better understanding will only be achieved when womens' experiences and lived realities are considered in relation to the material and social conditions in which their everyday lives are embedded. The impact of this change in approach for modes of treatment are discussed and solutions are suggested.
Understanding Depression offers new insights into the problem and its treatment. It will prove useful to those with an interest in depression and gender as well as mental health practitioners.

Part I
Introduction

1
Depression

A gendered problem

The aim of this book is to explore feminist social constructionist approaches to understanding depression in women. A central reason for focusing on depression is that, for several decades, both researchers and mental health professionals have repeatedly identified depression as being a problem that particularly afflicts women (McGrath et al. 1990, Nolen-Hoeksema 1987, Ussher 1991, Weissman and Klerman 1977, Weissman and Olfson 1995). In drawing this conclusion, experts in mental health and related fields point to evidence that depression is probably the most common mental health problem among women and that depressed individuals are predominantly female (Bebbington 1996, Nolen-Hoeksema 1990, Weissman et al. 1993). A proviso which should be attached to this statement is that the bulk of the research on depression in women has been conducted in western, industrialized regions of the world, particularly in the United States of America, Britain, Canada, and Australia.¹ This limitation is also reflected in the current work, which focuses primarily on depression in women in western countries. With this caveat in mind, to the extent that depression can be said to be a woman’s “problem”, it is one that falls within the domain of mental health professionals (e.g. counsellors, nurses, psychiatrists, psychologists, psychotherapists, social workers). This means that a substantial part of the work of many of those engaged in the mental health professions is likely to involve contact with depressed women. Thus, responding to the problem of depression in women comprises a major component of the work of many of those involved in the “helping professions” and accounts, in turn, for a sizeable proportion of resources allocated in society for responding to the mental health problems of individuals (e.g. treatment services of various kinds located in the community and within hospitals). These, then, are some reasons why the topic of depression in women would seem to me to be an important one to address.

What is the basis of the claim that depression is a problem which particularly afflicts women?

In reaching the conclusion that depression is a particular problem among women, several sources of evidence have been drawn upon by researchers and mental health professionals who work in this field. One type of evidence is based on statistics maintained by hospitals providing treatment services for people diagnosed with mental disorders. These statistics provide a count of the number of people who receive such services (based on records of individuals admitted to and subsequently discharged from hospital), categorized according to diagnosis and other characteristics including gender. Findings from analyses of such statistics derived from mental health systems in various countries (e.g. Busfield 1996, McGrath et al. 1990, Stark-Adamec et al. 1986) converge on the conclusion that the most common diagnosis among women hospitalized for treatment of a mental health problem is some form of depressive disorder. Women are also disproportionately represented among those diagnosed with depression, usually outnumbering men to a large extent (Bebbington 1996, Culbertson 1997, Nolen-Hoeksema 1990).

Although statistics based on people’s actual admissions to hospital inpatient services provide one kind of information suggesting that depression is a problem particularly experienced by women, interpretation of such information is not a straightforward matter. A serious limitation of hospital-based statistics is that someone has first to be admitted to a hospital in order to be counted and admission to a hospital usually requires referral by a physician. Perhaps depressed women, for some reason, are more likely than depressed men to be admitted to hospital. Another suggestion has been that women may be more likely than men to seek professional help for their mental health problems and are therefore more likely to be admitted to a hospital. Clearly, then, hospital statistics do not provide a direct index of the prevalence of mental health problems, such as depression, among those living in the community. Indeed, the argument has been made that hospital statistics may tell us more about the diagnostic practises of mental health professionals than about the problems experienced by women (Smith 1990). Nevertheless, such statistics do indicate that when women are hospitalized for treatment of a mental health problem, the problem is often diagnosed as depression.

Because of the limitations of statistics derived from hospital admissions as a basis for estimating how many people in a given population are likely to have various types of mental health problems, researchers have utilized other methods, which are considered more appropriate for this purpose. The methods most commonly employed are those developed within the field of epidemiology.² In this epidemiological approach, a large sample of individuals is selected randomly from a population of interest (e.g. people living in a particular city, region or “catchment area”). Individuals in this sample are then contacted by researchers and asked to complete a structured survey instrument designed to assess their mental health status. Two broad strategies have been followed in epidemiological research on depression.

In the first, referred to as a community mental health survey, people comprising the selected sample are asked to complete a structured questionnaire. An example of this kind of questionnaire, one used widely in the US, is the Center for Epidemiological Studies Depression Scale (Radloff 1977). People’s answers on questionnaires like the CES-D yield information about their experiences of depressive symptoms. Findings with this research strategy indicate that fairly high levels of depressive symptomatology are reported by women in the general population and that overall levels for women are higher than those for men (Nolen-Hoeksema 1990). Moreover, this gendered pattern in the level of reported depressive symptoms is present among adolescents as well as in older age groups (Nolen-Hoeksema and Girgus l994). Recent evidence from the US suggests that the gender gap in level of reported depressive symptoms may actually increase with age throughout adulthood (Mirowsky 1996).

Although people’s answers on symptom questionnaires provide some information about their mental health status, findings from community surveys are considered to have limited utility for understanding depression diagnosed as a mental disorder. This concern arises because the questionnaires used are thought to measure nonspecific psychological distress rather than a specific disorder that would be diagnosed as depression. In response to this criticism, a second method has been employed in epidemiological research. In this approach, people in a selected sample are asked a series of structured questions by a trained interviewer. People’s answers to these questions then provide the basis for determining whether their experiences meet the diagnostic criteria for various mental disorders, including depression. Thus, one aim of this research strategy is to determine the proportion of people in a given population whose symptoms fit the diagnostic criteria for depression.

Results derived from several large-scale epidemiological studies conducted within the last decade or so have consistently revealed that depression is one of the more common mental disorders diagnosed among women and also that women predominate among those who meet diagnostic criteria for this disorder (Weissman et al. 1993). When studies of this kind have been conducted in western countries, sex ratios (female:male) in the range 2 or 3 to 1 are typically reported (Culbertson 1997, Nolen-Hoeksema 1990, Weissman and Olfson 1995). There is now a consensus among epidemiological researchers that depression is one of the more prevalent mental health problems among women and also one that is more prevalent among women than men (Bebbington 1996).

A similarity of the research approaches described so far is that each depends on someone other than a woman herself to determine whether she is depressed. When hospital statistics are used, a diagnosis is provided by a mental health professional; in community mental health surveys using depressive symptom questionnaires, items are devised by researchers; and, in the case of epidemiological studies using structured diagnostic interviews, diagnosis is determined by researchers. A less frequently used approach has been to inquire from women themselves about the health and mental health problems which concern them. In a study conducted by Walters (1993) in which this strategy was employed with a large sample of women living in an urban area in central Canada, depression was one of the problems most frequently reported by women. About a third of the women in Walters’ study reported that they had experienced depression. Among other problems reported by a sizeable proportion of women were stress, anxiety, tiredness and disturbed sleep. This study did not focus specifically on women’s depressive experiences, so it is not known what the word “depression” meant to the women who reported it as a problem. Nevertheless, it would appear that the term “depression” is meaningful to women, one that many draw on when asked about the health problems which concern them.

A less direct source of information about the gender–depression link is provided by information on prescription of antidepressant drugs, the most common form of medical treatment for depression. Available evidence indicates that women are the major recipients of antidepressant medications (Ashton 1991, Hamilton and Jensvold 1995, Olfson and Klerman 1993). For instance, Baum et al. (1988) reported that about two-thirds of all prescriptions for antidepressant drugs in the US went to women, “a finding that appears to be in keeping with the sex ratio for depressive illness” (Hamilton and Jensvold 1995: 11). Issues concerning the safety of antidepressant drugs when used by adolescent and older women, particularly women of child-bearing age, have also been identified as important topics in need of research (Antonuccio et al. 1995, Weissman and Olfson 1995).

Thus, information from a range of sources, based on various ways of defining depression, seems to converge on the conclusion that depression indeed is a problem that particularly afflicts women. An important implication of this conclusion, one acknowledged by researchers and mental health professionals whose work focuses on depression, is that an adequate explanation of this problem must also involve an understanding of its gendered dimensions (Bebbington 1996, Coyne and Downey 1991). Any theory proposed to explain depression, the nature of the problem and why particular people experience this problem, must therefore be able to accommodate findings indicating that depression is a common problem among women and that women predominate among the depressed.

What does the term “depression” mean?

Before going any further, the meaning of the term depression needs to be considered, not least because how this term is defined has important implications for the way depression in women is explained and understood. This topic, explored in greater detail in Chapter 2, is one that has been, and continues to be, a source of considerable debate among researchers and professionals interested in depression. At this point, issues central to this debate will be outlined, in order to clarify the terminology used in the rest of this book.

The meaning of the word depression (and other words derived from it, such as depressive, depressed) depends to a large extent on the context in which it is used. A significant aspect of this context is who is using the word. One distinction is between the way the word depression is used by researchers and mental health professionals in their work, and how it is used by ordinary people in their everyday lives. When mental health professionals and researchers use the term depression, typically it is used in a technical sense, as a kind of shorthand to refer to a condition within an individual. This condition is further defined by a particular set of features which are reported by the individual or can be observed by others (such as a mental health professional or a relative of the individual). Thus, the term depression refers to a condition characterizing an individual that encompasses a set of experiences which include “symptoms” such as the following: feelings of sadness, dejection, hopelessness or despair, coupled with extremely pessimistic thoughts about one’s self, situation and future prospects; lack of interest or pleasure in activities usually engaged in, along with social withdrawal; various bodily complaints including aches and pains, difficulty sleeping, fatigue, loss of appetite (or sometimes overeating); and in some cases suicidal thoughts or actions. Some of these features might be reported by a depressed individual herself whereas others may be inferred by a mental health professional based on observing, for instance, that a woman has a sad facial expression, slumped body posture, or lethargic demeanor.

A complicating factor in understanding the meaning of the term depression is that when this word is used by professionals and researchers, it also carries with it certain implications about how the condition referred to is best explained or understood. Thus, implicit in much use of the word depression is the assumption that the features (experiences, thoughts, feelings, behavior) subsumed under this label are manifestations of an underlying “illness” or “disorder”, a form of “psychopathology”. Because the features of depression tend to have some coherence, typically occurring in the same person at the same time, they are presumed to have the same source, some kind of disorder or dysfunction within the individual. In medically-oriented theoretical approaches, the origins of this disorder are generally located within the biochemistry of the brain. Although researchers and professionals who work from a non-medical perspective (e.g. psychologists, social workers, counsellors) may not attribute depressive symptoms to a biological disorder, the cause of such symptoms is still likely to be attributed to something called depression, a condition that lies within the individual.

Thus, depression has been considered a form of mental disorder or a mental illness, terms having similar meanings within the technical vocabulary of researchers and mental health professionals. As a mental disorder or illness, depression is diagnosed when a recognizable constellation of symptoms is present and the symptoms are reported by the person experiencing them to have been present for an extended period of time (usually at least two weeks). The symptoms used to diagnose depression are those listed already as the particular features that individuals report experiencing or things that others may observe about them. An added implication when the word depression is used in this diagnostic sense is that the disorder is presumed to be either present or absent. That is, a person either does or does not have the disorder of depression. From this diagnostic perspective, to say that a person’s problem is depression is analogous to the situation when a person is diagnosed with a medical disorder such as diabetes or cancer. The person may have the disorder to a mild or more severe degree, but it is still present. When the word depression is used as a diagnostic label, it refers to a type or category of disorder, which also may be present in mild to more severe forms.

One area of debate concerns the particular features of a person’s experiences that should be specified as symptoms of the disorder of depression. At the present time, among both mental health professionals and researchers, particularly in North America, the symptoms considered diagnostic for depression are those listed in the volume published by the American Psychiatric Association (APA), entitled the Diagnostic and Statistical Manual of Mental Disorders (DSM) (APA 1994).³ Whether a person has a depressive disorder usually would be determined by a mental health professional, most often a psychiatrist (a medical doctor who specializes in psychiatric medicine), based on a series of structured questions asked in a clinical interview.

This categorical meaning of the word depression can be contrasted with another way in which this term is used by mental health professionals and researchers. Depression has also been conceptualized as a dimension or continuum. In this second usage, a person is considered to be more or less depressed. In this case, relatively greater emphasis is placed on a person’s subjective experiences, particularly depressed mood or feelings of sadness, although attention is given to other depressive symptoms as well. When use of the word depression refers to a continuum, it is usually based on the experiences a person reports on a structured questionnaire or checklist devised specifically for this purpose by researchers who study depression. Such questionnaires are also widely used by mental health professionals. A well-known example of this kind of questionnaire is the Beck Depression Inventory (BDI) (Beck and Steer 1987). On such questionnaires, the more depressive symptoms a person indicates she is experiencing and the more severely each symptom is experienced, the higher the overall score and the more depressed she is said to be.

An issue that has been the focus of considerable debate in the academic and professional literature on depression is the relationship between depression defined as a category of mental disorder and depression defined as a continuum. Are these two ways of defining depression addressing the same phenomenon? Can a cut-off point be identified using the continuum approach, so that scores above that point indicate that a person would be diagnosed with a depressive disorder? Currently, there is some consensus among experts who specialize in depression (at least in North America) that depressive disorder is most appropriately defined by the diagnostic criteria listed in the DSM and the self-report questionnaires are measuring something different and should not be used to diagnose depression (Coyne 1994). Instead, questionnaires like the BDI, are generally considered to provide an assessment of something called “dysphoria”. The term “dysphoria” (which might be thought of as the opposite of euphoria) refers to a subjective experience characteriz...

Table of contents

• Cover Page
• Half Title page
• Series Editor
• Title Page
• Copyright Page
• Contents
• Acknowledgements
• Part I Introduction
• 1 Depression: a gendered problem
• What Is Depression? Definitional debates
• Explaining Depression in Women Mainstream frameworks
• Looking for Sources of Depression within Person—Environment Interactions Diathesis—stress models
• Depression and Women's Psychology Susceptibility or specificity?
• Social Models of Depression Sources of adversity and stress in women's lives
• Women's Bodies, Women's Lives and Depression Exploring material—discursive approaches
• Embodied Lives Understanding depression in women in context
• Depression in Adolescence Negotiating identities in a girl-poisoning culture1
• Women's Lives and Depression Marriage and motherhood
• Women and Aging Depression in midlife and old age
• Implications for Theory and Practise Feminist social constructionist approaches
• Women Overcoming Depression Coping, treatment and politics
• Why New Perspectives Are Needed for Understanding Depression in Women1
• References
• Author Index
• Subject Index