Our society is experiencing significant demographic changes that are altering the profile of late-life depression in the United States. Both men and women are living longer, but the gender gap in longevity is widening. This disparity introduces a puzzling paradox: In the United States, women report more illnesses and health care utilization on average than men, despite the consistently greater life expectancy of women (Riley, 1990). Given the greater prevalence of depression in women compared to men, we are likely to see a correspondingly greater prevalence of geriatric depression in years to come. Similarly, data from the Centers for Disease Control and Prevention (2002) show that men have higher rates of completed suicide, despite the fact that women suffer from depression more frequently. There are many proposed explanations for these paradoxes, including sociocultural, biological and genetic causes.
Diagnosing depression in the elderly may be difficult in late life due to the presence of medical comorbidity, cognitive impairment, multiple losses, heterogeneity and atypical features. Reported prevalence rates for clinical depression in individuals older than 65 years of age range from 11% to 25% among patients in primary care and nursing home settings and at about 3% among healthy elderly living in the community (Brown et al., 2002; Lebowitz et al., 1997).
Differences in Prevalence Among Men and Women
Large epidemiologic studies report higher rates of depression among women, with about 4% of women and 1.7% of men carrying the diagnosis of major depression. The Epidemiologic Catchment Area-reported prevalence of major depression is 0.1% to 0.8% for men and 0.6% to 1% for women after age 65 (Nolen-Hoeksema, 1995). The differences appear to be age-specific with little difference in childhood, a considerable difference in mid-life (due to a sharp rise of depression in females), and a decrease in this difference in older age (Jorm, 1987). Some data suggest that the incidence of depression for women in the postmenopausal period may decrease relative to its incidence in men, although earlier research suggested that the difference in rates of depression between men and women become progressively smaller and may disappear among members of older age groups (Blazer and Williams, 1980). The explanation for this reduction is not yet available.
Gender Differences in Risk Factors
The pattern of depressive symptoms does not appear to be different between men and women (Sonnenberg et al., 2000), although the course and outcomes may differ. While higher rates of chronicity and recurrence of depression in younger adult women has been reported in several longitudinal studies (Kornstein, 1997), the male gender is reportedly associated with poorer outcomes of late-life depression in patient sample-based longitudinal studies (Baldwin and Jolley, 1986).
Research on gender differences in risk factors for late-life depression is limited. Family history of depression remains the best-known genetic risk factor for depression in both genders, but even this factor has limited predictive value. In a community-based study of depression in Australian twins, only moderate familial aggregation of depression occurred in women, "with heritability estimates ranging from 36% to 44%. In men, depression was only modestly familial, and thus, individual environmental factors played a larger role in the development of depression" (Bierut et al., 1999).
Biological theories point to the hormonal changes that occur in women during the critical periods of puberty, childbirth and menopause in explaining gender differences in depression rates. Gender differences in affective disorders' prevalence have been ascribed to variations in the levels or activity of monoamine transmitters, which are themselves changed by gonadal hormones. Halbreich et al. (1984) wrote, "Several aspects connected with the monoamine biosynthesis, availability, uptake and metabolism were found to be more abnormal in normal women and depressed women, as compared to men." However, many studies failed to confirm increased rates of depression in postmenopausal women.
Differences in Patterns of Attachment and Loss
Behavioral theories try to explain differences in rates of depression according to gender differences in attachment patterns: women base their self-esteem on their relationships with others; they are less assertive and lack confidence in controlling their lives. Stressors of late life include multiple losses/negative changes in relationships, employment, financial status and health problems. Retirement has been considered a major stressor for men as widowhood has been for women. In a recent community study of widowhood and depression, however, widowhood was more "depressogenic" in men compared to women (van Grootheest et al., 1999). Maciejewski et al. (2001) examined gender differences in event-related risk for major depression and found a three times greater likelihood for women to develop depression in response to stressful events as compared to men. With the dramatic changes in the workforce, most of these theories may change.
Medical Comorbidity and Late-Life Depression
Geriatric depression often occurs concurrently with a variety of chronic medical illnesses. Depression associated with the presence of chronic medical illness also increases the incidence of premature mortality, primarily from increased rates of cardiovascular and cancer deaths. Okiishi and colleagues (2001) reviewed the literature on gender differences in depression associated with neurological illness. They found a female preponderance of depression in diffuse neurological disease but not in focal neurological disease.
Men are generally known to have higher gender-specific mortality rates caused by smoking, heart disease, atherosclerosis and cerebrovascular disease, which may contribute to a changing sex-ratio in rates of late-onset depression with onset after age 60 (Lavretsky, 1998).
References
1. Alexopoulos GS, Meyers BS, Young RC et al. (1997), 'Vascular depression' hypothesis. Arch Gen Psychiatry 54(10):915-922 [see comment].
2. Baldwin RC, Jolley DJ (1986), The prognosis of depression in old age. Br J Psychiatry 149:574-583.
3. Bierut LJ, Heath AC, Bucholz KK et al. (1999), Major depressive disorder in a community-based twin sample: are there different genetic and environmental contributions for men and women? Arch Gen Psychiatry 56(6):557-563.
4. Blazer D, Williams CD (1980), Epidemiology of dysphoria and depression in an elderly population. Am J Psychiatry 137(4):439-444.
5. Brown MN, Lapane KL, Luisi AF (2002), The management of depression in older nursing home residents. J Am Geriatric Soc 50(1):69-76.
6. Centers for Disease Control and Prevention (2002), Suicide in the United States. Available at: www.cdc.gov/ncipc/factsheets/suifacts.htm. Accessed Aug. 15.
7. Coffey CE, Wilkinson WE, Weiner RD et al. (1993), Quantitative cerebral anatomy in depression. A controlled magnetic resonance imaging study. Arch Gen Psychiatry 50(1):7-16.
8. Fujikawa T, Yokota N, Muraoka M, Yamawaki S (1996), Response of patients with major depression and silent cerebral infarction to antidepressant drug therapy, with emphasis on central nervous system adverse reactions. Stroke 27(11):2040-2042.
10. Gur RC, Gunning-Dixon FM, Turetsky BI et al. (2002), Brain region and sex differences in age association with brain volume: a quantitative MRI study of healthy young adults. Am J Geriatr Psychiatry 10(1):72-80.
11. Halbreich U, Vital-Herne J, Goldstein S, Zander K (1984), Sex differences in biological factors putatively related to depression. J Affect Disord 7(3-4):223-233.
12. Jorm AF (1987), Sex and age differences in depression: a quantitative synthesis of published research. Aust N Z J Psychiatry 21(1):46-53.
13. Khaw KT (1996), Gender and cardiovascular risk. J Hum Hypertens 10(6):403-407.
14. Kornstein SG (1997), Gender differences in depression: implications for treatment. J Clin Psychiatry 58(suppl 15):12-18.
15. Krishnan KR, Hays JC, Blazer DG (1997), MRI-defined vascular depression, Am J Psychiatry 154(4):497-501.
16. Kumar A, Bilker W, Jin Z, Udupa J (2000), Atrophy and high intensity lesions: complementary neurobiological mechanisms in late-life major depression. Neuropsychopharmacology 22(3):264-274.
17. Lavretsky H (1998), Late-life depression: risk factors, treatment, and sex differences. Clinical Geriatrics 6(3):13-30.
18. Lavretsky H, Lesser IM, Wohl M, Miller BL (1998), Relationship of age, age at onset, and sex to depression in older adults. Am J Geriatr Psychiatry 6(3):248-256.
19. Lavretsky H, Kumar A (2002), Depressive disorders and cerebrovascular disease. In: Vascular Disease and Affective Disorders, Chiu E, Ames D, Katona C, eds. London: Martin Dunitz Ltd., pp127-147.
20. Lavretsky H, Kumar A, Pham D et al. (2002), Gender differences in brain structure on MRI in patients with geriatric depression. Presented at the 2002 Annual Meeting of the Society of Biological Psychiatry. Philadelphia; May 16-18.
21. Lebowitz BD, Pearson JL, Schneider LS et al. (1997), Diagnosis and treatment of depression in late life. Consensus statement update. JAMA 278(14):1186-1190.
22. Maciejewski PK, Prigerson HG, Mazure CM (2001), Sex differences in event-related risk for major depression. Psychol Med 31(4):593-604.
23. Nolen-Hoeksema S (1995), Epidemiology and theories of gender differences in unipolar depression. In: Gender and Psychopathology, Seeman MV, ed. Washington, D.C.: American Psychiatric Press, pp63-88.
24. Okiishi CG, Paradiso S, Robinson RG (2001), Gender differences in depression associated with neurologic illness: clinical correlates and pharmacological response. J Gend Specif Med 4(2):65-72.
25. Riley MW (1990), The gender paradox. In: Gender, Health, and Longevity: Multidisciplinary Perspectives, Ory MG, Warner HR, eds. New York: Springer, ppvii-xii.
26. Sackeim HA (2001), Brain structure and function in late-life depression. In: Advances in Brain Imaging (Review of Psychiatry, Vol. 20), Morihisa JM, ed. Washington, D.C.: American Psychiatric Publishing Inc., pp83-122.
27. Sheline YI, Wang PW, Gado MH et al. (1996), Hippocampal atrophy in recurrent major depression. Proc Natl Acad Sci U S A 93(9):3908-3913.
28. Simpson SW, Baldwin RC, Burns A, Jackson A (2001), Regional cerebral volume measurements in late-life depression: relationship to clinical correlates, neuropsychological impairment and response to treatment. Int J Geriatr Psychiatry 16(5):469-476.
29. Sonnenberg CM, Beekman AT, Deeg DJ, van Tilburg W (2000), Sex differences in late-life depression. Acta Psychiatr Scand 101(4):286-292.
30. Vakili K, Pillay SS, Lafer B et al. (2000), Hippocampal volume in primary unipolar major depression: a magnetic resonance imaging study. Biol Psychiatry 47(12):1087-1090.
31. van Grootheest DS, Beekman AT, Broese van Groenou MI, Deeg DJ (1999), Sex differences in depression after widowhood. Do men suffer more? Soc Psychiatry Psychiatr Epidemiol 34(7):391-398.
32. Videbech P, Ravnkilde B, Pedersen AR et al. (2001), The Danish PET/depression project: PET findings in patients with major depression. Psychol Med 31(7):1147-1158.