January 21-27 2006 Vol 202 No 3428

The darker picture
By Bruce Ansley

Depression is much more common in New Zealand than we think. And there are at least eight reasons why women are suffering in greater numbers than men.

Depression is often described as the common cold of mental illness, but the sick list is getting worse. Some liken it to bubonic plague. David Fergusson prefers comparing it to asthma.

"Lots of people have one or two asthma attacks and get mild asthma,” says Fergusson, a professor in Otago University’s Christchurch School of Medicine. “But then there’s a population who have recurrent, frequent long-term attacks, like depression.”

The official word on depression comes from the World Health Organisation, which predicts that by 2020 depression will be the second highest cause of death and disability in the world.

New Zealand’s toll is already heavy. Conventional figures indicate that one in five women suffers from depression. It’s a women’s problem. But one in 10 men also falls victim to the disorder.

One in five patients seeing their GP have experienced depression in the year of their visit. Of those visiting their doctors, Maori are three times more likely than non-Maori to be in its throes.

Depression is affecting rising numbers here. Rates of depression are increasing for both men and women. It is hurting younger people more and more. It accounts for half of the annual 465 suicides and 5100 attempted suicides in this country.

The government, alarmed that depression is more prevalent than we believe – and that it is costing $750m a year – has mounted a national depression initiative. A new study is expected to reveal in June that depression and anxiety are far more widespread than is thought, with serious consequences for treatment agencies.

Fergusson, from the medical school’s psychological medicine department, paints an even darker picture.

His new research is based on his towering 25-year Christchurch health and development study, which for a quarter-century has tracked the lives of 1265 New Zealanders born in 1977.

He found that many adolescents showed signs of depression which fell below official criteria, so they were not recognised as suffering from the condition.

But as this group grew older, they were at increased risk of full-blown depression – as much risk as those who met the criteria for major depression.

In other words, major depression could be detected much earlier than it is and, ominously, depression is even more common than usually recognised. Says Fergusson: “There’s been a long debate over this, but psychiatry has chosen a measure: you’re either sick or you’re not.

“Yet there are a heap of people who have some symptoms but don’t meet the criteria, but who appear to be just as at-risk as those who meet the criteria. They’re at later risk of depression and anxiety disorders and suicidal behaviours to the same extent that those meeting the criteria are.”

So, the outlook grows worse. Fergusson estimates that by adding those whose symptoms may currently lie below the radar but who will develop depression, its prevalence would rise by 20 to 30 percent. That is, the current figure of about seven percent who meet the criteria each year could rise to nine or 10 percent. Over a lifetime, that translates into 30 to 40 percent of the population who will, at some time, develop a depressive disorder. The present estimate is about 20 percent.

The prospects are especially bad for women. In this country, the accepted ratio is two women with depression to every man. Researcher Janet Carter believes that the gender ratio is being squashed as increasing numbers of men become more open to treatment, especially for mild depression.

Many men simply put up with it: “They’re pushing along through life rather than embracing it and some people just think that’s the way it is,” says Carter. “They come in because they’ve got anger problems and they’re reluctant to come in the first place. Then you tell them they’re depressed. That can be quite difficult for some men to get their heads around.”

But, in the meantime, the numbers remain stacked against women.

Marina McCartney should have nothing at all to be depressed about. She is young, beautiful, talented, enterprising. She is a leading model.

Back in 1997, she was 20. And she was Miss New Zealand.

But McCartney was a different beauty queen. She was one of 11 children in a poor family from Mangere. Her catwalk campaign was funded on nothing. She planned to take on the world’s beauty queens in the Miss Universe contest on what she could borrow or beg, until the Holmes show started its own campaign and got her the money.

Right in the middle of all that excitement, she was struck by depression.

From this distance, it might be understandable. “I was naive and I was dealing with a life entirely different from my own,” she says. “It was very superficial. Fashion, beauty, money – they’re circles of the least substance, I think. I didn’t understand that world.

“When you’re a beauty queen, people like to think you’re stupid, or arrogant. At one function, a girl was laughing hysterically, ‘Oh my god, a real live Barbie doll.’ It taught me a lot about human nature. I come from a family that concentrated on education. I was deputy head girl at my school, I was a nerd, and all of a sudden I was in a world that was the opposite.

“It was the most amazing time of my life and the hardest, a weird mix.”

She didn’t recognise her depression at first. “I saw it as failure,” she says. “But as soon as I realised there was a label for what was happening to me, it made it a lot easier. That’s the start of recovery.”

But in 2003 it happened again. “I was mixing with a lot of people who weren’t really my type. And the person I was with at the time was like that. You turn a blind eye to these things when you’re in love.”

McCartney has just taken over the beauty-pageant franchise here and is the new director of Miss World New Zealand. “I have to raise my profile, and what better way than to make a fool of yourself on national television? So I’m doing one of those silly reality shows: TV3’s Sing Like a Superstar.” Two years after her last bout, she says, “I battled with depression and won.”

Young men are in a different category.The Mental Health Foundation’s Out of the Blue campaign launched a new initiative late last year aimed at men 25 to 45 who they say are one of the groups most at risk of depression.
Recognising depression is harder for men. Calling for help is even more difficult.

Stephen Denekamp knew he was gay at 13, dreaded telling anyone. He worried what his parents would think, what classmates would say about him at school. “I heard negative messages from everyone, bottled it up. That grew into really strong depression. In the sixth form I was suicidal.”

Denekamp did what many men do: “I felt if you were having a bad day, you just got on with it. That’s normally fine, but not when it’s something you do need to sort out.”

Eventually one of his friends asked him how he was going. “I couldn’t say, ‘I’m fine.’ I said, ‘I’m feeling crap.’” He came out to two of his friends, and with their support found help, saw a psychiatrist, told his parents.

Denekamp, 22, works for Rainbow Youth, a support group for gay youth, as an education officer for schools.

He says, “Young men are more ready to talk about depression now. I think.”

Why do women suffer from depression so much more than men?

That question intrigued Janet Carter, a clinical psychologist and researcher at the Christchurch medical school’s psychological medicine department.

She had found differences between men and women not only in the way depression affected them, but also in the manner in which they responded to treatment. She investigated.

Carter’s research has produced the first single, coherent narrative on the difference between men and women in a relatively unexplored area.

Between 14 and 55, the number of women suffering from depression is double that of men, although depression is becoming more common in men and stabilising among women.

Women aged between 18 and 50 are at most risk. The gender difference evens out in the young, and among older people. The reasons for the difference are still not clear. But Carter has explored most of them:

1) Women seek help more readily than men do. They use healthcare services more often and their depression is more likely to be diagnosed. One study showed that men are more likely to “forget” depression – that is, not report symptoms.

“A lot of people out there are mildly depressed and don’t seek treatment,” she says. “Labels like that don’t sit well with some men. There’s a stigma, a challenge to masculinity.

“Some men may say they’ve been feeling really irritable, angry. I had a man who wanted to throttle his wife. Loved his wife dearly. He was so angry.

“A depressed woman is more likely to come in, weep and cry, tell you how low she feels. A depressed male is more likely to be as grumpy as hell, hard to live with. A man is more likely to tell you that irritability is causing problems at home, talk about trouble at work, or problems at home with his wife.”

2) It’s in the genes. But, says Carter, studies show that major depression is equally heritable in men and women, and that both are equally at genetic risk of depression. She concedes that genetic factors might increase women’s vulnerability through other means, eg, temperament.

Professor Peter Joyce, from the psychological medicine department, has undertaken a separate study of the genetics of depression and personality. “We’re trying to find what genes may increase risk for depression. We think part of understanding depression is going to be linked to understanding personality. Certain personality styles are more vulnerable – the anxious person, for example.” The study has involved some 200 people plus their parents and siblings. Joyce expects to publish results soon.

A Dunedin study concentrated on one particular gene, the serotonin transporter (drugs like Prozac work on the serotonin transporter), which comes in two forms, short and long. That study, and others around the world since, showed that if you have the short form of the gene, then even if you experience adverse life events, your rates of depression don’t go up much. But if you’ve got the long form, and you become stressed, your rate of depression goes up markedly. “So it’s saying some are genetically vulnerable to the impact of life events and others are not,” says Joyce.

3) Hormonal fluctuations impact on women’s moods, says Carter, especially during the premenstrual and postpartum periods and menopause. Hormonal changes during puberty may predispose women to depression. Women are less prone to depression before hormones kick in at adolescence and after 55 following their reproductive years, which supports the hormonal theory. It is usually agreed that hormones play a part in gender differences, but how much of a part is uncertain.

Says Joyce: “Rates of depression increase dramatically in teenage years and it’s tied into biological puberty. It’s all the hormones turning on, and that’s when women start doubling men’s rates of depression. So one of the factors has to be something to do with female hormones.”

4) The role of neurotransmitter systems. Neurotransmitters carry information within the brain and from the brain to all the parts of the body. Gender differences have been found in the serotonin and noradrenalin systems. Serotonin release underlies the process of learning and consciousness. Carter reports that the ageing process in some serotonin systems might be more obvious in women than men, and there may be a link between serotonin disturbance, appetite, weight gain and depressed moods in women. Noradrenalin is released from the adrenal glands during stress. Low levels are related to poor concentration and depression.

5) Social roles. The theory here is that women’s roles in society contribute to depression. Their work is less valued than men’s, they have less power, less freedom to choose roles. Having young children in the house makes women more prone to depression. Research has backed this up. It also indicates that single women are less vulnerable to depression than single men, and married women more susceptible to it than married men. But married women are at low risk of depression in Mediterranean countries or in rural New Zealand homes, or if they’re British orthodox Jews. Carter notes the common factor: all value the home-making role.

6) Socialisation. When children are sex-stereotyped young, girls are vulnerable to depression and boys are resilient to it. Among girls, it’s thought to foster a sense of interdependence and concern for how they’re seen, and in boys one of mastery and control. Carter: “The way males and females are socialised from a young age in most western cultures is for young girls to be more nurturing, focused on relationships and looking after, and for boys to be independent.

“Those challenges are detrimental to women when it comes to living with most of the challenges in your life.”

7) Response style: women may be more likely than men to brood over depressive symptoms because they’re, well, women. One researcher suggests that “being emotional and inactive are part of the feminine stereotype”, just as ignoring mood and getting on with life are part of the masculine one. Carter’s summary of research: the more you mull it over, the more depressed you become.

“When women are depressed,” she says, “they tend to ruminate more, think about why they’re depressed – is it their fault or someone else’s – and analyse it. Men do more distracting things, such as drinking or picking up a hammer or whacking a ball. And the research is showing that that might be a better way of doing things. It goes against one view of psychotherapy, that if you’re depressed you need to talk about it, focus on it. But what happens is that people get depressed about being depressed.

“Meaning not everyone needs to do psychotherapy. Sometimes maybe the best thing to do is just get on with it. Ruminating is different. It gets dressed up as problem-solving. But it isn’t.”

8) Personality. Are relationships more critical to self-esteem in women than men, so that their self-esteem relies on the approval of others? Are women more likely to be unassertive, lack self-confidence and control over their lives, making them more prone overall to hopelessness and depression? These things may be true, but research on them is still inconclusive.

And there are other differences between men and women, too.

• Depressed women report more symptoms, especially changes in appetite and weight, disturbed sleep, feelings of worthlessness and guilt and health worries. Men are more likely to be disappointed in themselves, be self-critical, have to force themselves to work, be unable to cry, withdraw socially.
• Depression tends to be associated with other disorders, especially anxiety and substance abuse. Men tend to have higher rates of substance abuse, women higher rates of anxiety disorders.
• Men and women have different responses to treatment.
• Joyce’s research group is trying to understand why treatment for depression may work for one person but not for another. It’s their fourth inquiry into the treatment of depression in the last decade, work described by the Health Research Council as “groundbreaking”.

The group has carried out random trials comparing fluoxetine and nortriptyline. Fluoxetine, or Prozac, is in the class of medications called selective serotonin reuptake inhibitors, or SSRIs, which work by increasing the amount of serotonin, a substance in the brain that helps maintain mental balance. The older antidepressant nortriptyline elevates mood by raising the level of neurotransmitters in brain tissue.

“For people under 25, the new antidepressants are much better than the old ones. That is, fluoxetine is better than nortriptyline,” says Joyce. “Probably, what is happening in practice is that people are routinely being given one of the new SSRIs first.

“But we found a gender difference with side-effects. Older men, over 40, were more likely to get side-effects from fluoxetine-like drugs than women. But women were more likely to get side-effects with nortriptyline types than men.”
Joyce also discovered that many people suffering from depression fell into a daytime pattern.

“The classic pattern was that they were really slow to start, then got better as the day went on. But within our sample there was a group with the reverse: their day would start not so bad, then during the afternoon their mood would dip and they’d feel worse and worse. That second group did better with nortriptyline than with fluoxetine.

“So, doctors should recognise gender, ask whether there was a pattern during the day, and conclude maybe they shouldn’t be using one of the SSRIs even though on balance they have some advantages and they’re safer.”

The leading psychotherapies for depression are cognitive behaviour therapy (CBT) and interpersonal therapy (IPT).

Carter notes two different arguments here. The first says IPT is more effective for women because it focuses on interpersonal problems, thought to be central to women’s sense of self. And CBT is more effective for men because it is more rational; and analytical methods suit men’s self-image.

The second reverses the order. It suggests that the optimal therapy for both sexes will be the one that makes them think and act in ways that are opposite to their “nature”. So CBT may be better for women because of its analytical perspective and focus on mastery and action. And IPT might do the same for men because, for example, it emphasises unrestricted emotion.

Even emerging therapies may favour one sex or the other.

There has been a shift to a third way that Carter believes may be good for women.

Traditional cognitive theory helps someone get over depression by challenging them to get a realistic perspective. But, says Carter, the third way is called meta-cognitive therapy, and it is all about taking a step back from depression and not engaging with it.

“In the traditional way you’d engage with the thinking and challenge it,” she says. “You think you’re boring; so, what is the evidence that you’re not boring? But it’s still thinking about your thinking. The new wave, meta-cognitive stuff is about not even going there. It’s about seeing that these are just thoughts; that you can take them or leave them, you can just let them go. It is against ruminating, against engaging. I’m very excited about that direction, particularly for women.”

The accepted signs of depression include persistent sadness, or excessive anxiety, or extreme tiredness, or worthlessness, or guilt.

I suffer from none of them. But the National Depression Initiative in Australia runs checklists on depression on its website, beyondblue. I filled them in, and discovered that one of them was indicating the bottom end of “moderate distress”. They advised me to see my doctor for further assessment. Who knows? Maybe I will.

Early Burnout
Gwendoline Smith knows a lot about depression. She has been a clinical psychologist for 20 years. She has written about depression, campaigned against its stigma. She believes that the disorder is surrounded by ignorance, fear and prejudice. She speaks from experience in more than one sense: she has suffered from depression herself.

She has noticed, for example, that depressed men come to her complaining of being agitated and irritable, and that what she calls “your more Alpha females, the driven businesswomen”, come to her with the same symptoms as men.

But she believes that urban society’s real epidemic is anxiety. She deals mainly with people who are having trouble at work, usually stress, anxiety, burnout and depression. All of them have similar symptoms: stress leads to anxiety and depression, and Smith argues that the boundaries separating them are arbitrary.

“Depression is more and more common in contemporary urban society. What you’re seeing in twentysomethings now are prolonged, chronic, sub-acute anxiety disorders.”
Why?

“There’s a very difficult corporate culture now. People don’t take lunch breaks. Fifty- to 60-hour weeks are somehow acceptable, somehow expected. In a lot of thirtysomethings, you’re seeing burnout.

“It’s not gender-specific. Alpha females are the same as men, although they’re still not a large group. The mechanisms that are activated are exactly the same for both. The difference is the response to anxiety.

“Men have traditionally evaluated anxiety as weakness. You shift anxiety with adrenalin, so you maintain the sense of being in control under threat by being busier, faster, louder.”

Smith believes that depression is under-diagnosed in the elderly, and that older men are often not doing well.
“Women have been through menopause and adjusted to an empty nest. They’re much more equipped socially to start getting involved with community work.

“Statistics on male health show that with retirement and the death of a spouse, a significant percentage of men die within a short period. They lose the identity they achieved through their roles. In today’s culture, people at a party ask what you do. Take that away from a man who has been the general manager of a company for 20 years, and what does he say? ‘I’m out to pasture?’

“Everyone talks about the teenage suicide rate. I’m not saying that’s unimportant. But a lot of suicides in the elderly are seen as someone being a bit doddery, might have taken too many pills. In places like Miami and Florida – their versions of Orewa – you’ve got homicide-suicide pacts, men killing their wives, then committing suicide. It’s not an epidemic. But it’s still of interest.”

Somewhere To Run
When Tracey Richardson’s first child was four weeks old, he was diagnosed with cystic fibrosis (CF). He faced a limited life expectancy. There is no cure for CF. Her second child was born little more than a year later – also with CF. Her husband left her.

She didn’t recognise the onset of depression at first. “I didn’t see myself as depressed. Didn’t see myself as unable to get out of bed, or likely to cry all day and feel completely useless, which is how I viewed depression then.”

Instead, she got busier and busier, until her father died of cancer and the crisis was upon her.

A few weeks later, she was admitted to a psychiatric hospital.

“It doesn’t go away,” she says. “I still have to deal with depression. My grief triggers are here in front of me and full of life every day. It’s wonderful, but it’s so sad at the same time.

“The only time I’m likely to get away from it is when I don’t have them any more, and that’s not something I want to happen. It’s a real conundrum. It’s like a wave in the sea. It comes in and gets you and drags you back out and under.
“The last time I had depression, I worked out I had four choices: go under (that is, suicide); get out; soldier on; or develop ways to deal with things, change the way I lived my life.”

She took the fourth course. She started off with the gym, worked towards the Special K Triathlon, aimed at the New Zealand Ironman triathlon. She has written a book, Going the Distance. She has remarried, has two more children. Her first two children are 14 and 13.

“It has claimed me twice in my life. Once was bad enough and it came out of the blue. But the second time I could feel it and there was nothing I could do to stop it. That was worse.”

“When you’re starting to go down the slide, it’s like a vortex. But when you’re starting that slide, you only know you’re feeling off. You don’t want to go to a GP because you’re going to get drugs, that’s what they do. So, where do you go, who do you ask, talk to?

“The [Mental Health Foundation’s] Out of the Blue campaign is a good starting point. But there’s a whole level of undiagnosed depression with huge implications for workplaces, relationships, parenting.

“I think more women suffer from it because they have a nurturing and caring way. I’m watching my nearest and dearest deteriorate and suffer. I have all the responsibility for that, to care for them, love and nurture them, protect them, not let that happen to them. A lot of women’s depression revolves around their children. It’s that sense of having to do and be everything.”