GENDER AND DEPRESSION: TYPICAL AND ATYPITCAL SYMPTOMS AND SUICIDAL IDEATION

Dissertation Presented to the Faculty of the College of Health Sciences of Touro University International in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy in Health Sciences By Jed Diamond March 14, 2008 Dissertation Chair: Mihaela Tanasescu MD, ScD Committee Member: Frank Gomez, PhD Committee Member: Anne Maria Mller-Leimkhler, PhD

Significance and Rationale For Study

Women seek helpmen die.
This conclusion was drawn from a study of suicide prevention by Angst & Ernst (1990). They found that 75% of those who sought professional help in an institution for suicide prevention were female. Conversely 75% of those who committed suicide in the same year were male. Since depression is a significant risk factor for suicide and men receive less treatment for depression than do women, it is vitally important that we have a better understanding of the way depression manifests itself in males.

CONCEPTUAL MODEL
Risk Factors

Age Socioeconomic status Chronic disease (heart disease, stroke, diabetes, cancer, other) Marital status (and marital happiness) Previous depression Family history of depression and suicide

Atypical symptoms of depression

Suicidal Ideation

Depression (Typical symptoms)

Loss, trauma, life changes

Alcohol use, etc.
Gender

Research Hypotheses

There will be a significant positive relationship between typical depression (CES-D) and atypical depression (DMDS). Depressed men will score significantly higher for atypical symptoms (DMDS) than depressed women. Non-depressed men will score significantly higher for atypical symptoms (DMDS) than non-depressed women.

There will be a significant relationship between known depressive risk factors and atypical depression.
There will be a significant positive relationship between atypical symptoms (DMDS) and suicide risk.

Atypical symptoms of depression will be positively related to suicide risk when controlled for typical depression.
There will be a significant positive relationship between atypical symptoms (DMDS) and scores on the Gotland scale.

Demographics of Study Population

323 females and 749 males (1072 total). Age range 18-80, Mean 51, 58% over 50. 76% employed, 64% income > $50,000/year. 48% of the males and 40% of the females depressed (CES-D 20). 53%, 1+ relatives have mood disorder.

Factor Analysis of Diamond Male Depression Scale (DMDS)

Factor 1: Emotional Acting-In Depression,
Chronbachs alpha = .93

Negative, withdrawn, stressed, numb.

Factor 2: Emotional Acting-Out Depression,

Chronbachs alpha = .89

Short-fuse, impatient, irritable, angry.

Factor 3: Physical Acting-Out Depression

Chronbachs alpha = .73

Alcohol abuse, reckless, explosive, violent.

Correlation of Typical Depression (CES-D 20) with DMDS Factors

Factor Factor 1, Emotional Acting-In Factor 2, Emotional Acting-Out Factor 3, Physical ActingOut Pearson Correlation .700 P-value < .001

.474

< .001

.319

< .001

DMDS Factors in Depressed and Non-Depressed Men and Women

Predicting Factor 1 Emotional Acting-In Depressed Men vs. Women Non-depressed Men vs. Women Unstandardized Coefficient 1.15 .47 P-value .208 .510

Predicting Factor 2 Emotional Acting-Out Depressed Men vs. Women Non-depressed Men vs. Women 1.47 1.19 .002 .001

Predicting Factor 3 Physical Acting-Out Depressed Men vs. Women Non-depressed Men vs. Women 1.52 .86 < .001 .003

The second and third hypotheses-- Depressed men will score significantly higher for atypical symptoms (DMDS) than depressed women and non-depressed men will score significantly higher for atypical symptoms (DMDS) than non-depressed women was answered affirmatively for Factor 2 and Factor 3.

Atypical Symptoms of Depression and Known Depressive Risk Factors

There was a negative relationship between atypical depression (DMDS) factors and the following risk factors:

Age ( Factor 1, p = < .001, Factor 2, p = < .001, Factor 3, p = < .001) Gross family income ( Factor 1, p = .015, Factor 2, p = .001, Factor 3, was not significant). Relationship happiness ( Factor 1, p = < .001, Factor 2, p = < .001, Factor 3, p = < .001).

There was a positive relationship between atypical depression (DMDS) factors and the following risk factors:

Comorbid medical conditions ( Factor 1, p = < .001, Factor 2, p = .001, Factor 3, p =.006). Having relatives who were depressed ( Factor 1, p = .034, Factor 2, p = .031, Factor 3, p =.002). The forth hypothesis, There will be a significant relationship between known depressive risk factors and atypical depression, was answered affirmatively for the risk factors previously noted.

Logistic Regression for DMDS Factors and Beck Suicide Risk Adjusted for Psychiatric Diagnoses, Age, Gender, and Gross Family Income
95.0% C.I. for Exp(B)

P-value
Factor 1, Emotional Acting-In Factor 2, Emotional Acting-Out Factor 3, Physical Acting-Out Psychiatric diagnoses Age Gender Gross family income
R Squared = .563

Odds Ratio
1.258 .968 .984 1.031 1.013 1.497 .804

Lower
1.219 .919 .933 .959 .861 1.029 .692

Upper
1.299 1.020 1.038 1.306 1.235 1.178 .933

< .001 .221 .560 .714 .075 .035 .004

The fifth hypothesis--There will be a significant positive relationship between atypical symptoms (DMDS) and suicide risk--was answered affirmatively for Factor 1, Emotional Acting-In, but not for Factor 2, Emotional Acting-Out, or for Factor 3, Physical ActingOut.

Logistic Regression for DMDS Factors and Beck Suicide Risk Adjusted for Psychiatric Diagnoses, Age, Gender, Gross Family Income, and Typical Depression (CES-D 20)
95.0% C.I. for Exp(B)

P-value Factor 1, Emotional Acting-In Factor 2, Emotional Acting-Out Factor 3, Physical Acting-Out Psychiatric diagnoses Age Gender Gross family income CES-D 20
R Squared = .566

Odds Ratio 1.237 .973 .982 1.010 1.033 1.467 .809 1.547

Lower 1.195 .924 .931 .841 1.016 1.006 .697 1.050

Upper 1.281 1.026 1.036 1.213 1.051 2.139 .940 2.281

< .001 .316 .506 .917 < .001 .047 .006 .027

The six hypothesis--Atypical symptoms of depression will be positively related to suicide risk when controlled for typical depression--was answered affirmatively for Factor 1, Emotional Acting-In, but not for Factor 2, Emotional Acting-Out, or for Factor 3, Physical Acting-Out.

Gotland Scale Correlations and Factors 1, 2, and 3 of the DMDS

Factor Factor 1, Emotional ActingIn Factor 2, Emotional ActingOut Factor 3, Physical ActingOut Pearson Correlation .794 .584 .393 P-value < .001 < .001 < .001

The seventh hypothesis--There will be a significant positive relationship between atypical symptoms (DMDS) and scores on the Gotland scale--was answered affirmatively

Implications for Theory

This study adds to the body of knowledge regarding gender and depression. By evaluating a larger set of atypical depression symptoms (DMDS) than had previously been used by Rutz (1999) with the Gotland Scale for Assessing Male Depression, the study added to our understanding of male-type depression.
The study expands our understanding of the relationship between gender and atypical symptoms for depression. It addressed a gap in the research literature on gender and depression by clarifying three separate factors or subscales that are associated with depression and suicide risk.

Potential Bias
There were selection biases since the study population was recruited through websites that were focused on people with an interest in gender issues and depression and thus not representative of the general population.
There were measurement biases since assessment of important variables such as depression and suicide risk were based on respondents answers to an on-line questionnaire. No outside, professional assessments were conducted. Subjects were rated as being depressed or non-depressed based on their answers to a traditional depression scale (CES-D). Since one of the theoretical assumptions of the study was that depressed males might be missed using a traditional scale, this may have introduced additional measurement bias.

Recommendations for Future Research

Future research will be needed to validate the results of the study and to develop numerical scores for evaluating depression and suicide risk using the DMDS.
It would be helpful to conduct research with a general population to see if results were consistent in a population representative of the general community. Particular attention should be focused on including men and women from different ethnic groups, cultural backgrounds, economic levels, and age groups.

Recommendation for Clinical Practice

The belief that depression is a disease primarily affecting women has left too many males undiagnosed and untreated. Many clinicians believe that depressed males are undiagnosed because the evaluation scales being used do not address the symptoms of depression that are more common in men. Based on the results of the present study, it is recommended that clinicians use scales that include atypical symptoms such as those found on the DMDS and Gotland Scales.

Surprises

Though the study was originally designed for U.S. clients, men and women from 44 other countries participated.
Based on clinical experience it was expected that it would be difficult to recruit depressed males. This was not the case. Only Factor 1, Emotionally-Acting In, was significantly related to suicide risk when all three factors were used together. There was actually a negative relationship between suicide risk and Factors 2 and 3, though the relationship was not significant.

Thank You!
The three of you, each in your own way, have made this study much better than it would have been.