After receiving my degree from the University of Evansville, I plan to attend graduate school and receive a doctorate in the field of clinical psychology. If possible, I would like to specialize in women’s studies. As a professional, I plan to conduct research and apply it in a clinical setting. The majority of my work will be with females, couples, or families. Through my research, I will investigate issues which have been found to impact individuals differently depending on sex. Depression is one such issue which has been shown to affect women more often than men. I would also address this problem in a clinical setting.
My goal in researching depression in women was to review what researchers have found regarding the differential impact of depression on the sexes. I investigated depression in general and discussed its symptoms. I also examined the possible factors underlying the higher prevalence of depression in women. Finally, I explored treatment options that have been proven effective in alleviating depression.
The finding that depression affects females twice as often as males is well established in the world of psychology. The reasons behind the disparity are yet to be determined. Particular attention has been paid to the effects of relationships on depression in women. The phenomenon of post-partum depression has also been studied with some regularity. A thorough review of the literature will integrate the findings regarding various potential causes of depression in women. The compilation of prior research regarding depression will provide an integrative picture of what has been found on the topic. It will also lead the way for future research by highlighting topics that have proven inconclusive.
Table of Contents
Personal Relevance Preface................................2
Depression is a serious psychological disorder, the effects of which are widespread. However, scientists are still struggling to determine the factors behind its development and maintenance. Research has found that depression affects women more often than men. This disparity demands the attention of researchers as women attempt to obtain a position equal to that of men in society. A thorough understanding of potential causes of this disparity is vital to the treatment of afflicted women.
The Diagnostic and Statistical Manual of Mental Disorders, a publication by the American Psychiatric Association (2000), presents three main depressive orders that can be readily differentiated. They are Major Depressive Disorder, Dysthmic Disorder, and Depressive Disorder Not Otherwise Specified. The most serious of the three depressive disorders is Major Depressive Disorder. Major Depressive Disorder is identified as the occurrence of one or more Major Depressive Episodes. A Major Depressive Episode is defined as five (or more) of nine symptoms having been present during the same 2-week period, representing a change from previous functioning. The nine symptoms are:
(1) depressed mood most of the day, nearly every day, as indicated by either subjective report or observation made by others
(2) markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day as indicated by either subjective account or observation made by others
(3) significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day
(4) insomnia or hypersomnia nearly every day
(5) psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down.
(7) feelings of worthlessness or excessive or inappropriate guilt(which may be delusional)nearly every day (not merely self-reproach or guilt about being sick)
(8) diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
(9) recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide. (DSM-IV-TR, 2000, p. 356)
In order to be considered a Major Depressive Episode, these symptoms must not meet criteria for a Mixed Episode, must not be due to the direct physiological effects of a substance or a general medical condition, and must not be better accounted for by bereavement. Also, the symptoms must cause significant distress and disrupt normal functioning. Women have a 10% - 15% chance of developing Major Depressive Disorder at some point in life, while men have a 5% - 12% chance (DSM-IV-TR, 2000).
The second depressive disorder identified is Dysthymic Disorder. Dysthymic Disorder is identified by the presence of depressed mood for “most of the day more days than not for at least two years” (DSM-IV-TR, 2000, p. 380). To be diagnosed with Dysthymic Disorder an individual must also present two (or more) of the following while suffering from depressed mood:
(1) poor appetite or overeating
(2) insomnia or hypersomnia
(3) low energy or fatigue
(4) low self-esteem
(5) poor concentration or difficulty making decisions (6) feelings of hopelessness (DSM-IV-TR, 2000, p. 380)
The final category of depressive disorders is Depressive Disorder Not Otherwise Specified (NOS) (DSM-IV-TR, 2000). This category includes depressive disorders that do not fall under the criteria for Major Depressive Disorder or Dysthymic Disorder. Examples include minor depressive disorder and premenstrual dysphoric disorder.
The problems resulting from depression extend beyond the unhappiness of those afflicted. Major depression has been identified as the fourth-ranked cause of disability and premature death worldwide (Murray et al. as cited in Wolf, Andraca, & Lozoff, 2001). Premature death comes in the form of suicide for 15% of individuals suffering from Major Depressive Disorder (DSM-IV-TR, 2000). Kessler, McGonagle, Swartz, and Blazer (1993) found that women are 1.7 times as likely as men to report an episode of major depression. Thus, women are nearly twice as likely as men to experience the negative effects of depression.
It is too large of an endeavor for any one study to attempt to expound the causes of depression in women. Research on individual aspects of depression in women, condensed into a review format, will help the reader get a grasp on the topic. The review can also point future researchers in the right direction.
Women and Depression
Biological and Genetic Etiology
A concordance rate of 65% for monozygotic twins (compared to a rate of 15% for dizygotic twins) suggests a genetic predisposition to depression (Weiten, 2004). Such statistics encourage researchers to search for biological or genetic conditions underlying depression. One common belief is that depression occurs more often in women because of their high level of hormones. However, years of research on the topic have failed to confirm this belief (Nolen-Hoeksema & Keita, 2003). Haukkala and Uutela (1998) proposed that biology might play a role in depression through a woman’s body type. By comparing waist-to-hip ratios to scores on a depression scale, a positive relationship was found. Women with higher waist-to-hip ratios did have higher levels of depression. However, one must note the possibility that the waist-to-hip ratio may not be a product of biology. It could be due to environment, or even to depression itself. The study did not control for the possibility that the depression came before the increase in waist-to-hip ratio. Thus, more research is needed to discern whether a high waist-to-hip ratio predisposes one to depression.
Twin studies have been utilized in an attempt to identify a genetic component to depression. Takkinen et al. (2004) studied gender differences in depression in older unlike-sex twins. Unlike-sex twins were used to control (to some degree) for the effects of genetics and early shared environment. The women received higher scores on the depression scale at baseline and follow-up (four years later) but the difference was significant at baseline only. The depression scores for both genders increased in the four years, with the male scores increasing more drastically. Marital status, educational level, economic status, and physical functioning were also measured. Of these variables, marital status, economic resources, and physical functioning were found to be related to depressive symptoms in both sexes. When the effects of these variables were controlled for, the gender differences disappeared. It was thus determined that the higher level of depression found in women was not due to being female, but was due to the effects of other variables that tend to effect women more than men.
Kendler, Gardner, and Prescott (2002) emphasize that depression in women is complex, originating from many factors. Their research with female twin pairs identified several variables influencing the onset of depression in women including neuroticism, early-onset anxiety disorders, conduct disorder, and substance abuse.
The Impact of Culture and Society
As with most (if not all) psychological conditions, research has revealed that genetics and biology cannot fully account for the differential presence of depression in women. Accordingly, depression must be due in part to culture, society, or perhaps some combination of the two. In their review of the literature, Nolen-Hoeksema and Keita (2003) have found it likely that depression in women is influenced by women’s lesser power and status in society. This lack of power makes women more vulnerable to significant traumas such as sexual abuse and sexual harassment (Nolen-Hoeksema, 2001).
The Study of Women’s Health Across the Nation (SWAN) set out to assess the percentage of women of different ethnic backgrounds suffering from depression and to look at variables that may be influencing the disorder. The sample included women from African American, Hispanic, White, Chinese, and Japanese backgrounds. Depression rates were relatively high among the sample, with nearly a quarter reporting depressive symptoms as determined by the Center of Epidemiological Studies Depression Scale (CES-D). The prevalence was highest among Hispanic women with an astounding 42.97% reporting depressive symptoms. African American and White participants were next in the rankings while Japanese women reported the lowest percentage of depressive symptoms (Bromberger, Harlow, Avis, Kravitz, & Cordal, 2004). This could lead some to conclude that depression is related to ethnic heritage. However, other variables were measured in this study and when controlled for, the effect of ethnicity on depression was reduced. The variables most strongly related to depression turned out to be health problems, low social support, and stress. Health problems and social support were negatively correlated with depression levels while stress was positively correlated. The researchers urge that ethnicity only be used as a predictive factor for depression with the understanding that ethnicity exerts an effect on another variable (like stress) which then affects levels of depression (Bromberger et al.).
It is easy to understand how stress and depression could be related. However, it is not easy to understand why the interaction results in depression more often in women. Research often centers on how stress differentially affects women. When faced with no stressful life events or stressful life events with little long-term threat, women have levels of depression nearly twice that of men facing similar situations. The sex difference diminished when high-threat situations were considered (Kendler, Kuhn, & Prescott, 2004). This data actually suggests that women’s differential experience of depression may not have much to do with high stress situations after all.
Marriage and Relationships
Marriage as an Institution
One area of particular interest is the influence of marriage on depression in women. The research is inconclusive, with most studies finding depression levels indirectly related to marriage through some other variable. A close study of the literature fails to find any direct and conclusive link between depression and marriage. The indirect links are still worthy of attention.
Horwitz, White, and Howell-White (1996) found that, after controlling for mental health, marriage results in higher levels of well-being for both husbands and wives when compared to controls who remain single. However, when the elements of mental health are divided out and the factor of depression is analyzed separately, results show that only married men report levels of depression lower than their single counterparts. Married and single women have similar rates of depression (Horwitz et al.). Thus, if mental health is measured solely by the presence or absence of depression, marriage does not positively affect the mental health of women. In women, the area of mental health most related to marriage is alcohol abuse. Married women are less likely to suffer from alcohol-related problems than single women. Interestingly, the same is not true for men, with married and single men having similar amounts of alcohol problems (Horwitz, et al.).
The unequal division of domestic labor in traditional marriages is another factor that influences the relationship between marriage and depression in women. Rivieres-Pigeon, Saurel-Cubizolles, and Romito (2002) found that women often indicate that they are solely responsible for most domestic tasks. The partner is indicated as the individual solely responsible for less than 3% of the tasks. It would appear however, that women are not distressed by accepting the brunt of the housework. On the other hand, accepting the brunt of the childcare responsibilities presented a problem. Psychological distress is more common with the women who fulfill more than half of the childcare responsibilities, but it is not found at higher levels among women who always do more than half of the housework (Rivieres-Pigeon et al.). The acceptance of household chores has not been found in all groups of women studied. In fact, receiving less assistance with household chores contributes to significantly lower levels of marital satisfaction among working women. This is important because marital satisfaction can lead to significantly lower levels of depression among women (Saenz, Goudy, & Lorenz, 1989).
Self-esteem is another variable that has been found to mediate the relationship between depression and marriage. Poor marital quality may result in an erosion of self-esteem, which can then lead to depression. This may be due to women allowing their self-worth to be determined by the success of their marital relationship. Husbands do not suffer the same fate. For men, self-esteem acts as a moderating variable between marital quality and depression. In other words, high self-esteem in men lessens the effect that marital quality can have on depression (Culp & Beach, 1998). The marital quality-depression cycle can also be looked at from a different perspective. Marital quality (as rated by the husband and wife) could be decreased by the presence of a depressed wife (Hammen, 2003).
The Impact of Relationships
As mentioned above, no study to date has conclusively linked the institution of marriage to depression. However, many researchers have found a link between depression in women and their relationships. An investigation of depressed women’s best friend and romantic partner relationships found that depression scores among the women were positively correlated with levels of stress in both types of relationships (Daley & Hammen, 2002). The lack of an intimate, self-disclosing relationship with the husband can also contribute to depression in wives (Culp & Beach, 1998). Thus, problems in relationships may increase a woman’s level of depression. However, relationships can have positive effects. The presence of support (instead of stress) in relationships helps reduce the risk for major depression. The amount of support received from relatives, parents, and the spouse is associated with depression in women, with more support resulting in lower levels of depression (Kendler, Myers, & Prescott, 2005). This focus on social support from close relatives and the spouse can cause depressed women to fail to notice support they are receiving from other individuals (and thus they do not benefit from it). Daley & Hammen found that depressed women viewed their romantic partners as being non-supportive and were correct (the partners affirmed this relationship by reporting that they are less supportive when their partner is suffering from a depressive episode). Best friends, on the other hand, reported providing more support in such situations. However, the depressed women did not perceive any change in support from their best friends. As a result, the level of friend support failed to have a significant effect on their depression.
Depressed women have a high likelihood of engaging in a relationship with someone clinically symptomatic. The partner could suffer from a diagnosable personality disorder (Daley & Hammen, 2002). The partner may also have a clinical condition such as depression or substance abuse. The likelihood of a depressed women engaging in a relationship with a clinically symptomatic man has been found to be as high as .50 (Hammen, 2003). The presence of disorders in both spouses may induce decreased levels of social support (Daley & Hammen) or less stability and positivity within the relationship (Hammen).
It is a common sense notion that divorced women are more depressed than married women. Lorenz et al. (1997) confirmed this belief in their study comparing 188 divorced women to 306 married women. The divorced women were significantly more depressed than the married women, with the differences gradually diminishing over time. However, many of the divorced women remained depressed two or even three years after the divorce. Throughout an entire three year period, the divorced women experienced a higher level of stressful events than did the married women. This suggests that the depression of divorced women might not simply pertain to the divorce itself, but to the increase in stressful life events experienced because of being divorced (Lorenz et al). It appears that the stressful effects of divorce could also be cumulative. Women who have been through more than one divorce are more depressed than women who have only experienced one (Kurdek, 1991).
The Diagnostic and Statistical Manual of Mental Disorders (text revision, 2000) identifies postpartum depression by adding the specifier With Postpartum Onset to a current or recent Major Depressive Episode. The onset of the disturbance must be within four weeks after childbirth to be considered postpartum. Common symptoms include mood fluctuations and preoccupation with infant well-being. Postpartum depression should be taken seriously because it puts afflicted women at higher risk for future episodes of major depression (Wolf et al., 2001).
As with any disorder (psychological or not), scientists have searched for qualities that may create a predisposition to post-partum depression. Traits that may contribute to the development of post-partum depression include being less educated, having three or more children, having previous pregnancies, and being married for six or more years. PPD symptoms were also higher in mothers of unplanned pregnancies. Certain coping patterns may put mothers at risk. Risky coping patterns include distancing, escape-avoidance, self control and confronting (Faisal-Cury, Tedesco, Kahhale, Menezes, & Zugaib, 2004).
Nicolson (1999) took a different view of post-partum depression. She viewed it as a potentially healthy expression of feelings surrounding pregnancy and motherhood. Through interviews with women during pregnancy and one, three and six months after birth, a trend was found in the experiences of women. Many of the women suffering from post-partum depression expressed a feeling of loss. The loss took many forms such as loss of freedom, loss of appearance, loss of sexuality, and loss of occupational status. Nicolson proposes that this feeling of loss represents a natural grieving process that is healthy and may help the woman integrate herself into her new life role. However, the grieving may become pathological (in the form of post-partum depression) when women feel guilt over their grief. Mothers are expected to be overjoyed at the gain of a new family member. When a mother is instead gloomy over the loss of other things, guilt may follow, resulting in depression.
Maternal Depression and Child Rearing
The presence of a depressive disorder in mothers can have a profound effect on their children. In one sample, a depressive disorder was found in 20% of the offspring of depressed mother but only in 10% of non-depressed mothers. Depression is not the only disorder influenced by maternal depression. Maternal depression is also correlated with other problems such as attention deficit disorder and eating disorders (Hammen, 2003).
The effects do not have to come in the form of a diagnosable psychological disturbance. Children of depressed mothers have been found to suffer from low birth weight, learning difficulties, poor growth, and illness (Zuckerman & Beardslee, 1987).
Maternal depression may also affect the child’s attachment to the mother. Infants of depressed mothers show insecure attachments, finding little joy in being reunited with their mother when separated (Edhborg, Lundh, Seimyr, & Widstrom, 2003).
Because women have become such an integral part of the workforce, investigations into the effect of employment on depression have increased. Depression in employed women may depend in part on occupational prestige. Women holding more prestigious occupations are found to have lower levels of depression than those in less prestigious positions (Saenz et al., 1989). Keith and Schafer (1982) found that the presence of depression in working women is mediated by their relationship status (married or divorced). Married working women report less depression than single working women. The relationship between work and depression in the two groups proved to be vastly different. The most surprising difference was in regards to time spent at work. For single women, more time at work diminished the presence of depressed symptoms. However, married women who spent more time at work ended up being more depressed (Keith & Schafer, 1982).
In 1985, Keith and Schafer conducted another study regarding employment, this time comparing homemakers to employed women. The two groups did not differ significantly in levels of depression. Negative evaluations of or dissatisfaction with family roles (such as cleaning, cooking, and being a good companion to her spouse) were linked with depression among both groups of women, but had a greater effect on the homemakers (Keith & Schafer, 1985). This could be due to unemployed mothers being forced to assume a larger majority of the child care and the housework responsibilities (Rivieres-Pigeon et al., 2002). This concept is supported by a previous study, which found that employed wives were less satisfied with their husbands than unemployed wives. Their satisfaction was increased when the husbands provided adequate aid in completing domestic responsibilities (Saenz et al., 1989).
Antidepressant medication is perhaps the most widely recognized form of treatment for depression. Tricyclic antidepressants and monoamine oxidase inhibitors are the drugs most often prescribed to depressed patients. Fluoxetine (Prozac) is particularly well known. Although the success of such drugs has been widely documented, little is known regarding whether or not psychopharmacological treatments address the differential impact of depression on women (Strickland, 1992).
Kopta, Lueger, Saunders, and Howard (1999) explored the efficacy of various forms of individual therapy on depression in general. Cognitive therapy is one form of individual therapy found to be effective. Cognitive therapy focuses on changing thoughts, attitudes, and beliefs that are causing depression in clients. One particular form of cognitive therapy, called feminist therapy, addresses social and cultural aspects of depression and the related experiences of the individual (Strickland, 1992). Cognitive therapy’s decreased chance of relapse (when compared to pharmacotherapy) indicates that it accomplishes its goal by making long term changes in thought patterns (Kopta et al. 1999).
Although its effectiveness is well established, it has been posited that cognitive therapy is no more effective than other forms of therapy. One such therapy is interpersonal therapy. Interpersonal therapy works under the assumption that interpersonal problems are the reason behind depressive disorders. Thus, treatment in interpersonal therapy focuses on interpersonal relations (Kopta et al, 1999).
Another therapy rivaling cognitive therapy in effectiveness is behavior therapy. Behavioral therapy for depression gives emphasis to increasing the number of positive experiences in the client’s day. Originally, behavior therapy was only used in conjunction with other forms of therapy. Recently, however, it has proved to be effective in treating depression on its own (Kopta et al, 1999).
Enhancing Marital Intimacy Therapy (EMIT) is an option for women suffering from depression. EMIT is an intervention used to help individuals reveal and express their personal constructs. EMIT with married couples with a depressed wife begins by asking both spouses to explain why the depression exists. Surprisingly, spouses rarely come up with the same reasons. The couple will speak in turn, first giving their own views, then commenting on each others. The therapist helps by modeling good listening skills and asking questions to direct the discussion. The goals of EMIT are to help couples see problems from a different perspective and to help each individual learn to self-disclose. Compared to a control group, wives undergoing EMIT couple’s therapy showed a significant drop in depressive symptoms. The drop in symptoms was accompanied by an increase in feelings of autonomy among the wives. There was no change in the level of depression of the husband involved (but the husbands did not have depressive symptoms when the study began). However, there was an increase in expression of affection among the husbands (Waring, Chamberlaine, Carver, Stalker, & Schaefer, 1995).
Proving that therapy has an effect is important, but it is also critical to note how long an individual must undergo therapy before there is improvement. Kopta, Howard, Lowry, and Beutler (1994) measured the rates that different symptoms were reduced to normal during psychotherapy. Symptoms were divided into three categories. Traditional symptoms of depression fell into two different categories: acute distress symptoms and chronic distress symptoms. Both of these categories responded well to psychotherapy over the span of 52 weeks. Acute distress symptoms diminished in a slightly larger percentage of patients than did chronic distress symptoms. It is important to note that individual symptoms within a dimension changed at different rates. This has implications in the treatment of depression in that certain symptoms may respond to psychotherapy more quickly than others. It is important that practitioners and patients understand this concept and do not expect all symptoms of depression to diminish at an identical rate.
One problem with the above treatment options is they all require regular consultation with a mental health professional. For some reason, many depressed women will not seek such help. Lee, Casanueva, and Martin (2005) found that, of all women referred to mental health services by their primary health clinicians, less than half follow through with the referral. Of women who saw the mental health professional and were diagnosed as depressed, only 66% chose to follow through with treatment. Lee et al. propose a variety of reasons for this disparity, including lack of motivation, guilt, fear of stigmatization, and inability to pay for such services.
For depressed women who do not wish to or cannot (for some reason) take medication or participate in traditional therapy, other options do exist. An option that has become especially popular in recent years is a self-help program. Most self-help programs instruct individuals on how to deal with certain issues (like anxiety, phobias, and depression) without the help of a professional.
There have been many studies regarding the effectiveness of such programs, with most finding self-help programs to be quite effective. However, such studies have been criticized on the grounds that studies with negative or non-significant findings may not end up being published. In order to see if this criticism was valid, Kurtzweil, Scogin, and Rosen (1996) conducted a meta-analysis of published studies regarding the effectiveness of self treatment programs. This meta-analysis indicated that self-help is better than no help. They decided it was unlikely that unpublished research would negate their findings after calculating that 53 non-significant studies would have to exist before the meta-analysis would also become non-significant.
Scogin, Bynum, Stephens, and Calhoon (1990) also used meta-analysis to compare no treatment, self-treatment, and professional treatment. It was found that self-treatment for depression is better than no treatment at all. Also, the differences between those who were self-administering treatment and those who sought the help of a mental health professional were non-significant. The researchers acknowledge that this finding may not be altogether reliable because the therapists were not using typical psychotherapy in the professional treatment condition. Instead, they were covering the same materials that were being covered in the self-help program. Thus, further studies must be conducted before it can be conclusively stated that self-help is as effective as professional treatment. However, it is clear that self treatment is better than no treatment at all.
Another alternative form of treatment is to simply exercise. If depressed women participate in a running or weight-lifting program on a regular basis their levels of depression can be significantly reduced. The exact mechanism by which exercise works is unknown. It is hypothesized that the feelings of accomplishment and self-worth experienced by a woman in a fitness program help her to affect changes similar to those that would be achieved in cognitive therapy (Doyne et al., 1987).
Dearing, Tayler, and McCartney (2004) found that, in the first three years after childbirth, depression in mothers covaries negatively with family income. This effect is especially salient in mothers living in poverty. Women whose income allowed them to move out of poverty were 1.48 times more likely to recover from depression than those who remained in poverty. Accordingly, increasing the economic resources for women in low income situations during these post-partum months could have a positive impact on their mental health. Although economic resources are not typically considered “treatment” their availability to mothers in need could be significant.
Another non-traditional “treatment” would be to correct the societal problems that have been tied to depression in women. Strickland (1992) believes that providing more opportunities for and valuing the contributions of young women will help lessen the gender gap in depression.
Depression is a complicated disease with serious implications for society. The costs of depression to individuals and to society as a whole more than warrant a continuous and intensive investigation into depression, its causes, and its treatment.
As was shown in this paper, depression does not affect just the woman suffering from it. It can also exert an effect over the lives of her children. Women are often the primary care-givers to children. If, as a mother, the woman suffers from depression, her child is likely to experience some complications that children of non-depressed mothers are less likely to face. If the child exhibits problematic behavior, the mother will notice. The problems could further fuel her depression, which would in turn reduce her ability to help the child with the problems. This vicious cycle should be stopped before it begins. Perhaps, if extra time and research is devoted to it, depression in women could be decreased. Not only would women in general profit, but theoretically, their children would to.
The differential impact of depression on women is so astounding, a study of depression in general may not be the best option. Perhaps breaking depression down by the populations it affects would be the best method for studying it. The broadest categories would obviously be male depression and female depression. However, as this paper has demonstrated, depression in women is still quite a broad area, composed of many interacting dimensions. It appears that depression may operate in different ways and for different reasons among single women, married women and divorced women. Within these groups, depression may very depending upon employment status. Social support networks could also play a role. Pregnant women and mothers present an entirely new dimension for depression to operate in. Within all the aforementioned categories, a personal or familial history of depression can exert an effect.
As far as treatment goes, each method (pharmacotherapy, individual psychotherapy, alternative therapies, etc.) should ideally be tested on each different population of depressed women. A treatment that works for depressed, working, single mothers may not work for depressed, married women working in the home.
To summarize, future research should investigate all of the above listed dimensions: marriage, pregnancy, child care, and employment. Also, researchers should continue searching for biological and genetic links. Special attention should be paid to the topics of marriage and employment. Much of the relevant literature available today is quite dated. In recent years, many things have changed in regards to marriage and especially the employment of women. An update on these topics would be wise.
It could be argued that the suggested piece-meal approach to the study of depression will result in a body of knowledge too fragmented to be of use. However, depression covers such a broad range of symptoms and affects so many different populations, taking an integrative approach to understanding it seems impossible. Such an integration of concepts will only become plausible if advances are first made in understanding depression’s many individual dimensions.
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