Another good & bigger study supports Harrington’s conclusion. Peter Lewinsohn, et al (2003) at the Oregon Research Institute & several other researchers following a large number of teenagers found that those who had suffered major depression (n=319) & later were considered “in remission” had many more psychological problems in their early adulthood than teens (n=208) who had had other psychiatric diagnoses, such as anxiety, alcohol-drug addiction, ADHD, etc. & of course, they had more problems than peers (n=324) who hadn't had any psychological disorder as a teenager.

Note: as in Harrington’s study, an alarming 62% with major depression before 18 also suffered depression again or had some other mental disorder between 19 & 24. Life just hadn't gone well for them - problems in school & at work, relationship problems, poor health, early pregnancy & using lots of mental health services. The authors conclude that having depression in adolescence was an ominous sign of possible “pervasive impairment.”

Therefore, there's a serious need for mental health professionals, families, schools & society in general to develop ways of detecting depression very early & learning to treat it more effectively. Prevention of depression early in life, particularly in Middle School, Jr High & High School, needs to be given high priority.

Surveying 15-year-olds, the United States has the highest or one of the highest rates of depression in the world; Austrian teens have the lowest rate. In our country the average age of onset is in the mid-20’s; that is earlier than most other countries. Why should this be?

How could poverty stricken countries be less depressed than we are? Some researchers speculate that the high divorce rate in the US, plus the high academic expectations & various social pressures have raised the stress level of teenagers that leads to depression.

Other speculators could come up with many other theories, including more psychological-mindedness which might make diagnosticians prone to over-diagnose depression. Likewise, where treatment is more readily available (drugs & psychotherapy) the level of depression might actually be reduced but the overall result could be an increased psychological orientation leading to an increased estimated rate of depression.

Surely, a strong stigma against having a mental problem would lower the estimated rate of prevalence.

There's a complex interaction among gaining weight, being depressed & taking anti-depressive medication. It's known that unhappy adolescents are more likely to become obese but it isn't clear whether the depression causes weight gain or obesity causes depression (Goodman & Whitaker, 2002).

Research has also shown that different cultures, races, social-economic situations & religious groups have different attitudes towards depression & respond to it differently. If you're beginning to believe that the possible antecedents of depression are very complex & murky, I think you're on the right track.

That doesn’t mean it's impossible to understand the development of depression, however.

Just as understanding depression is difficult, finding the right treatment may also be a challenge.

One problem is this: for the 3 or 4 million young people in the US needing treatment right now, the wealthiest country on earth has only 7000 child psychologists & 6000 child psychiatrists. That means that if help was given to every distressed young person, every psychologist & psychiatrist in the US specializing with children would be given a case load of over 300 young patients.

With such a case load, the treatment would be grossly inadequate.

Has the severity of other national & local concerns caused psychological problems to be overlooked? Have parents & our entire society deluded ourselves into believing that children & young people with psychological-emotional problems, especially depression, “will grow out of it?”

Do most people assume that technology & treatment methods will quickly improve to handle the problems? I think the results of the Lewinsohn, et al study should be considered seriously. Hopefully, in a few decades societies will offer treatment / counseling or psychosocial education in the early stages of any psychological problem.

Over the years many studies have explored for possible causes of depression. One large study of depressed adolescents (Kandel & Davies, 1982) found these factors were sometimes involved:

(1) low self-esteem

(2) "acting out" anti-social behavior

(3) over-involvement with peer group & little with parents

(4) over-involvement with parents & little with peers

(5) authoritarian parents or "do-what-you-want" parents

(6) depressed parents

Adolescents, in general, are happier if they have some pleasant involvement with peers & with parents who are basically democratic & happy.

Several other studies reported that specific childhood experiences have been related to adult depression:

(1) feeling guilty as a child (1/3 did) 

(2) a strained relationship with the same-sexed parent, especially if a divorce is involved

(3) a mother depressed enough that she needs help caring for the children

(4) dominant, over-protective parents using poor child-rearing practices, especially if fathers gave poor child care.

The above studies suggest that a psychologically sensitive person, family, school or society might be able to anticipate the onset of depression in many victims of the disorder. If depression is possible to predict, then shouldn’t we do it? We should certainly also improve our treatments & self-help methods as well as reduce the social stigma of having a psychological problem & getting professional help.

However, I don't intend to imply that most depressive reactions could be foreseen & prevented. Some could be, some can’t. Coryell, Endicott & Keller (1992) followed adults who had never been diagnosed as depressed or mentally ill. Within 6 years, 12% of this sample had developed major depression.

So, having emotional problems in their youth isn't always part of the history of depressed persons. Clearly, problems later in life can also set off a depressive episode. For instance, it has long been thought that going thru a divorce doubles the chances of getting depressed, particularly for women & especially whenever the breakup was traumatic or unanticipated.

A recent large (n=7,300) survey at Virginia Commonwealth University by Kenneth Kendler, et al (2003) confirms that the combination of a serious loss, e.g. a love relationship, with deep personal humiliation, e.g. the “ex” quickly flaunting an attractive new partner to your friends, can be especially devastating.

This kind of situation, being a potent mixture of sadness & anger or shame, is quite likely to occur in a divorce or breakup situation.

The very old & the quite young men both run an increased risk of depression. Younger persons (under 40) have been found 3 times more likely to get depressed than were older people. Whenever white men get to 85, however, their suicide rate becomes very high again.

Of course, having very stressful life experiences & having poor physical health, like heart disease, raise the risk of becoming depressed. Likewise, having negative feelings associated with pessimism, erectile dysfunction, early sexual abuse, early death of a parent, shame, self-criticism, having certain genes etc, etc. are also associated with the onset of depression.

If you have low self-esteem, especially during stressful times when life is filled with discouragement &/or conflict, that's associated with the onset of depression.

In the opposite direction, positive feelings about yourself help defend against depression & the blues. This leads writers in the area to encourage constant efforts to build & keep self-satisfaction as high as honestly possible. But it isn’t easy.

Getting plenty of good sleep may reduce depression (Griffin & Tyrrell, 2001-2003). Many self-help suggestions are given near the end of this chapter.

In this section we've reviewed some of the studies designed to identify events & conditions that precede depression. Such studies may yield some hints about the possible factors that contribute to depression but they don't prove any causal connection.

In fact, very little is known with certainty about depression’s causes (which is why we have so many theories - see a large section about theories coming up soon). You may find the theories simpler & more convincing…because they're based on carefully pulling together clinical experience & research findings in such a way to try to make sense of depression.

Keep in mind that this book focuses only on psychological studies & factors; however, the genes, hormones & chemical / physiological influences are also always playing a role in our behavior / feelings.

Gender differences in depression

After puberty, women are 2 to 3 times more likely than men to get depressed. Before they get to 21, about 1/3 of young women have had at least one depressive episode (Lewinsohn & Clark, 1999). Why are women more depressed then men but not less happy? The answer isn't clear.

There are several possibilities why 25% of women will be depressed sometime in their lives, but only 10% to 15% of men. Women tend to feel helpless & hopeless when they're depressed while men are more likely to be angry & irritable (which may hide their depression).

Some studies have found that depression is most likely to occur in unmarried women who are poor & have little education.

Other studies have found that higher education actually increases the risk of depression for women & decreases the risk for men. Incidentally, 37% of women psychologists with Ph.D.'s will experience depression, so being highly educated & knowing about academic psychology apparently doesn't help avoid depression.

What are possible reasons for the gender differences?

First of all, many women are still in subtle ways taught to conform, to serve & to please others in a society that truly values & rewards self-serving individualism, i.e., living your life the way you want to &/or feel is right. The phrase commonly used is "be your own man." To do otherwise is to give up your dreams & to suffer a loss of status. When someone else takes control of your life, it's likely to be stressful.

Consider, for a moment, only the sexual context of our culture, about 50% of women have been physically or sexually abused before age 21, another 25+% have been abused or coerced in relationships after 21 & 70% have at some time been sexually harassed.

Perhaps more importantly, add to these statistics the discrimination against women when selecting well-paid managers, administrators, politicians & so on.

About 75% of all people in poverty are women with children. Women living on isolated farms are prone to depression. Anyone who is disadvantaged, put down or dominated, has skills that are unused & unappreciated & given little control over one's life has some right to be unhappy.

Amazing things happen at puberty. Before developing sexually, boys are more likely to be depressed than girls, but afterwards girls become twice as likely to be depressed & boys turn to delinquency.

Naturally, not all girls get depressed. Susan Gore at University of Massachusetts reports that the adolescent girls who get depressed often become over-concerned & over-involved emotionally with their mothers' problems in a stressful home. Boys don't show this sensitivity to & involvement in family problems. (For one thing, depressed mothers interact less emotionally with sons than daughters.)

Moreover, research by Joan Girgus at Princeton suggests that it is often body image ("I'm too fat" or "too flat"), not life events, sex roles, or social popularity that causes the depression in teenage girls (while boys tend to see their adding weight as "adding muscle").

As just mentioned, many studies have found, in terms of interviews, diagnoses & test results, that twice as many women are depressed as men. However, there are other ways of assessing the severity of depression.

For instance, one might consider how many people get so miserable they decide to escape the pain by dying. In this country (& in most countries) there are about 4 times many men who kill themselves as women.

This situation is referred to as "the gender paradox," i.e., women are considered more depressed but men kill themselves much more often. Men commit 80% of the suicide deaths but women make 2 to 4 times more suicide attempts than men. Thus, women fill 60% of the hospital beds allocated to suicide-related injuries.

In some situations the gender differences are remarkable:

• 5 male teens kill themselves for every girl
• Men over 65 suicide at 6 times the rate of women over 65

By the way, the suicide rate in China is very high & it's one of the few countries where women kill themselves more frequently than men.

One reason for this is that Chinese women, especially young women in rural villages, attempt suicide more often than men (similar to western countries) & they use the same methods as men, mostly rat poison & farm chemicals. In the US, men use guns (35% of the time) or hang themselves (30%), while women mostly use less lethal drugs & poisons.

Why does gender paradox exist?

For one thing, child development specialists have long observed that males from very early ages are more aggressive than females.

This male use of stronger force is true in most cultures, so it almost looks like a genetic effect. Maybe violence is just a "man thing." But the rate of suicide could certainly be partly or completely due to cultural conditioning. In many cultures manliness is shown by strength, stoic silence, acting alone, being in control & being effective.

Admitting we feel depressed & lethargic may make a man look weak. Carefully instilled cultural attitudes may push men to quietly withdraw as they figure out how to deal with their hurts, defeats & anger. Men also seem to find guns more appealing than women do, so they use more lethal means of ending their lives resulting in a higher rate of suicide. See a later section on suicide.

It's good to remember that many men are probably not consciously denying their depressive feelings; they may not be trying to hide their hurt & look tough; they may just not think they're depressed. If the depression is there but unexpressed (& unrecognized), it may come out when drinking, using drugs, expressing anger, being antisocial & so on, all of which could contribute to the mounting depression.

Regardless of the reasons, it's pretty certain that men, in general, talk about their depressed feelings less than women. Men are more likely to talk about being tired, irritable & bored. They're less likely to report feeling sad, guilty, unworthy or regretful.

Men probably cry less & less openly. Once males get to adulthood they seek psychological help much less often than a woman (8.7% vs. 17%).

[But note that the 2002 Department of Health & Human Services Report says adolescent boys 12 to 17 were treated for emotional & behavior problems (18%) almost as often as girls (20.7%).]

Lastly, doctors don't seem to pick up on males' depression as much as they tune in on females' feelings. Someone has to recognize the presence of significant depressive feelings before the process of seeking help is set in motion.

See http://menanddepression.nimh.nih.gov for more information for men about dealing with depression.

Another factor in the gender paradox may be that genders could have different characteristics that accentuate depressive feelings & low self-esteem.

Nolen-Hoeksena & Girgus (1994) suggest that girls have certain personality traits which interact with the stresses of being a teenaged girl that, in turn, produce depression & lower self-esteem. The female personality traits, according to these researchers, are emotional dependence on relationships, less assertiveness & passivity (or an inclination to worry about a problem situation rather than do something about it quickly & decisively, as a boy might do).

Thus, maturing young girls may get distressed when interacting with desirable but sexually aggressive (scary?) young males, when they dislike or don't know how to handle their own bodily changes (breasts, pimples, over or under-weight, no butt, etc., etc.), when sexually teased, used, or abused, when their social activities are restricted more than boys & when peers, culture & parents start to emphasize attractiveness, sexiness & friendships more than intelligence, genuine caring & preparing for one's life work.

Science is gradually finding more & more childhood factors involved in teenage depression. Here's an interesting developmental phenomenon.

There's a coincidence at puberty, namely, that women who are considered to have twice as much depression as men are also about twice as likely as men to "over-think," which involves ruminating mostly about unhappy events in the past (in contrast to "worry" which often focuses on bad things that might happen in the future).

This could be another bit of evidence that negative thoughts produce negative emotions (although the above observation that females dramatically increase their negative thoughts at the time of puberty also suggests something else may be an underlying cause of both negative thoughts & depressed feelings).

Susan Nolen-Hoeksema (2003) has written a book based on her research about "over-thinking" in women, Women who think too much:

How to break free of overthinking & reclaim your life. The result of over-thinking is that women (& worrying men!) work themselves into a complex, confused emotional state where conclusions & solutions become difficult, if not impossible.

Women may be more prone to over-think because they're sensitive to others & are often expected to solve personal conflicts without offending anyone. Nolen-Hoeksema found 3 types of over-thinking:

1. Rant & Rave: they believe someone has done them wrong; they then become self-righteous & plan revenge.

2. Psycho-analyzing: they mentally replay an offending event over & over in an effort to understand why people did what they did & why they're emotionally responding as they are.

Overthinkers conjecture a huge psychological problem which defies any treatment plan.

3. Chaotic: one upsetting thought (emotion) triggers another in a chain reaction, often not directly connected at all with the current event, so that eventually there is a huge conglomeration of entangled emotional experiences in one's mind but few constructive conclusions.

Nolen-Hoeksema believes the overthinking tendencies can be countered in 2 ways:

(1) Being mindful of the onset of the process, then immediately switch to another activity, perhaps take a walk, call a friend, read a book, plan a nice weekend, etc. In short: somehow stop the mental buildup of emotions.

(2) If you're mentally absorbed with a problem, DO SOMETHING that might clarify the situation, lessen the stress, or point a way out, don't just think about how upsetting it is.

For instance, if you're dwelling on the impact of weight on your looks, health & love life, perhaps you should reduce the thinking & increase the serious long-term problem-solving, such as plan & buy the food for healthy meals, firmly commit yourself to daily exercises (no excuses!), get your doctor's advice, read references that may help you understand the emotional needs to over-eat.

For 40 years the "traditional" role of women has been considered as depressing by many.

When a woman gets married, she often is employed like her husband but also takes on more additional roles than a man: housework, solver of problems with the partner, mother, child care, hostess, social relations planner, friend, budget balancer, shopper, etc. She may also identify with her mother rather than her father; her mother was more likely to be dominated, anxious & depressed.

Therefore, she's more likely to be passive-dependent, pessimistic, doubtful of her ability to manage her own life well & depressed. Since we're a more mobile society, women may also have more sadness when leaving relatives, friends, etc. The spouse of a depressed person is more likely to become angry & blaming.

Finally, the woman must give birth, which is supposed to be a glorious experience but is time-consuming, scary & painful,

plus 50% have PMS

50%-80% have some degree of postpartum depression 

30% have surgical menopause

according to Ellen McGrath of the APA Women & Depression Task Force. Like any victim of discrimination, the female who is getting less attention in school, fewer employment opportunities & less pay for the same work is likely to be mad &/or sad (McGrath, Keita, Strickland & Russo, 1990).

The Signs of Depression

Depression is a loss of an important life goal without anyone to blame. Such a loss affects our behavior, our moods or subjective feelings, our skills, our attitudes or motivations & our physical functioning & health. Several writers (Levitt & Lubin, 1975; Beck, 1973; Lewinsohn, 1975) have summarized the signs of more severe depression:

• Behavioral excesses - complaints about money, job, housing, noise, poor memory, confusion, loneliness, lack of care & love... acting out (adolescents), running away from home, rebellious, aggressive... obsessed with guilt & concern about doing wrong, about being irresponsible, about the welfare of others & about "I can't make up my mind anymore"... crying... suicidal threats or attempts.

• Behavioral deficits - socially withdrawn, doesn't talk, indecisive, can't work regularly, difficulty communicating, slower speech & gait... loss of appetite, weight change, stays in bed... less sexual activity, poor personal grooming & doing less for fun.

• Emotional reactions - feels sad, feels empty or lacks feelings of all kinds, tired ("everything is an effort")... nervous or restless, angry & grouchy (adolescents), irritable, overreacts to criticism... bored, apathetic, "nothing is enjoyable," feels socially abandoned &/or has less interest in relationships, sex, food, drink, music, current events, etc.

• Lack of skills - poor social skills, frequently whiny or boring, critical, lack of humor... indecisive, poor planning for future & unable to see "solutions."

• Attitudes & motivations - low self-concept, lack of self-confidence & motivation, pessimistic or hopeless, feels helpless or like a failure, expects the worst... self-critical, guilt, self-blaming, "People would hate me if they knew me"... suicidal thoughts, "I wish I had never been born."

• Physical symptoms - difficulty sleeping or sleeping excessively, awaking early... hyperactivity or sluggishness, diurnal moods (worse in the morning)... low sex drive, loss of appetite, weight loss or gain, indigestion, constipation, headaches, dizziness, pain & other somatic problems or complaints.

Are you reading about these signs amid wondering how depressed you are? If so, there are several things to keep in mind. First, Levitt & Lubin (1975) listed any fairly common symptom associated with depression. There are a lot of them - 54.

These signs of depression have been found in several different kinds of sadness & depression (see the various diagnoses mentioned in the first section of this chapter). Few people would have all these signs & some depressed people would have only 2 or 3 of these symptoms. The number of symptoms you have doesn’t say much about how serious your depression is.

Different symptoms characterize different types of depression. Remember, major depression is serious enough to interfere with work & social life. In fact, a person given this diagnostic label is likely to miss twice as many days at work as a person with a diagnosis of lesser depression.

Psychiatrists often call this depression “endogenous” because it seems to arise from within & not clearly caused by external events, such as a serious loss. Major depression is likely to affect sleep, appetite, energy level, self-esteem, work & social activities & thoughts of suicide.

"Unipolar depression,” which might also be described as situational or reactional, might have somewhat different signs, since it's a serious “down” or “blue spell” following a loss but usually not disabling.

If a mild-to-moderate sad mood lasts for 2 years it may then be called dysthymia. After being chronically