Sex Roles, Vol. 36, Nos. 5/6, 1997

Women and Depression: An Update on the Report of the APA Task Force l June Sprock2 and Carol Y. Yoder

Indiana State University

This article reviews selected research on gender differences in depression in order to update the status of the literature and address concerns raised by the APA Task Force on women and depression. Recent research continues to provide considerable evidence that women experience higher rates of depression and that a variety of biological and psychological factors and their interactions must be considered to understand gender differences. Methodological issues including the need to define homogeneous subgroups, the effect of demographic variables, and sex bias in the diagnosis and measurement of depression are discussed. Conclusions are drawn that have implications for the prevention, identification and treatment of depression, and suggestions are made for research strategies.

In 1987, the Task Force on Women and Depression was established by Bonnie Strickland, president of the American Psychological Association, to review the literature on etiological and treatment factors associated with depression in women. The resulting report, published by McGrath, Keita, Strickland and Russo (1990), represents the most comprehensive effort to organize and synthesize this vast literature. Major sections of the review addressed research on risk factors, treatment approaches, and issues related to specific subgroups of women (e.g., ethnic minorities, the elderly). The report advocated a biopsychosocial perspective, which considers biological, social, economic, and psychological factors, in understanding the etiology and treatment of depression. Reproductive hormones and their interaction 1We gratefully acknowledge the assistance of Elizabeth Meeker in the preparation of this article. 2To whom correspondence should be addressed at PsychologyDepartment, Indiana State Unio versity, Terre Haute, IN 47809. 269

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with other biochemical mechanisms, gender roles, differences in emotional expression and help-seeking behavior, cognitive styles, stress, poverty, vietimization, as well as clinicians' sex role stereotypes and gender bias, also contribute to the higher rates of depression in women, and must be considered for effective intervention. The report also discussed methodological considerations and limitations of the research as well as directions for future studies. Since publication of the Task Force report, the literature on women and depression has continued to burgeon and substantial development has occurred in some areas. The purpose of this article is to address some of the concerns raised in the McGrath et al. article using a selective review of the literature from the perspectives of clinical and social cognitive psychology in order to provide a fuller understanding of the factors that contribute to depression in women. This article emphasizes research published since the Task Force report in order to update the status of various areas in the literature.

SUBTYPES AND CLASSIFICATION OF DEPRESSION An important point made in the Task Force report was the need to make a distinction between depressed or dysphoric mood and depressive disorders. Because of the similar emotional experience, studies of normal negative mood states are often used as an analogue for clinical depression. While it may be of fundamental importance to understand how gender differences in normal emotional expression influence and may even predispose women to clinical depression, it is also likely that the two differ qualitatively as well as quantitatively. It is important that the distinction be maintained for conceptual clarity and that research address the relationship between these states. Another concern raised was that clinical depression is a heterogeneous concept that includes a group of disorders and that use of undifferentiated groups of depressives may obscure important findings. Even specific diagnostic categories such as major depressive disorder are broad and lack homogeneity (Sprock, 1985; Winokur, 1991). The Task Force report emphasized the need to utilize specific subgroups in research, as well as the need for more longitudinal studies. The publication of the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) by the American Psychiatric Association (A.RA.) in 1994 represents a major step towards identifying more homogeneous subcategories of depressive disorders. Additional specifiers have been added for major depressive and bipolar episodes (e.g., rapid cycling, atypical

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features, postpartum onset). Many of these subtypes are either specific to women (i.e., post-partum onset) or have been found to vary in frequency for men and women; seasonal affective disorder (Parry, 1989; Rosenthal & Wehr, 1987), atypical depression (Quitldn, Stewart, McGrath & Liebowitz, 1988), and rapid cycling bipolar disorder (Bauer et al., 1994; Leibenluft, 1996; Parry, 1989) are more prevalent in women. Another change is the addition of bipolar II, characterized by depression plus hypomania rather than the more severe mania of bipolar (now called bipolar I) disorder. While previous research has suggested there is not a gender difference in the prevalence of bipolar (I) disorder, there is evidence that women experience more frequent, severe depressive episodes and milder or mixed manic phases while men experience more severe mania (APA, 1994; Leibenluft, 1996). Therefore, the addition of bipolar II may further clarify gender differences in cyclic mood disorders. There is also evidence that more women demonstrate brief recurrent depressions (Angst, Merikangas, Scheidegger & Wicki, 1990), minor depressions (Bebbington, Katz, McGuffin, Tennant & Hurry, 1989), and mixed depression and anxiety (Joiner & Blalock, 1995). While these syndromes are diagnosed as depressive disorder not otherwise specified (NOS) in the DSMIV, a set o f research criteria is provided for each of them in an appendix listing diagnostic criteria needing further study. There are also research criteria sets for premenstrual dysphoric disorder and post-psychotic disorder of schizophrenia. Because specific operational criteria have been provided for these subtypes, researchers can reliably define subgroups and study homogeneous samples. Characteristics that specify the longitudinal course of recurrent mood disorders have also been included to facilitate the study of episodic mood disorders. Defining homogeneous groups also requires consideration of comorbid diagnoses. Women manifest higher rates of other disorders frequently associated with depression, including eating disorders, somatization disorder, agorophobia, panic disorder, and borderline personality disorder (A.P.A., 1994; Barlow, 1988; Gunderson & Elliot, 1985; Morrison & Herbstein, 1988; Spaner, Bland & Newman, 1994; Toner, Garfinkle & Garner, 1988). It is important to examine the relationships between depression and other axis I (clinical mental disorders) and axis II (personality disorders) disorders; since the presence of other disorders can increase the vulnerability to depression, this research may contribute to the understanding of etiology. In addition, the presence of comorbid diagnoses can complicate diagnosis and treatment (e.g., Hyler & Frances, 1985; Gunderson & Elliot, 1985). Depressed women demonstrate increased comorbidity with psychiatric and medical disorders, which may in part account for their poorer treatment response and less successful treatment outcome (Pajer, 1995).

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Winokur (1991) has made a distinction between individuals with socalled "pure depressive disorder" (i.e., only depression) and "secondary depression" (i.e., depression secondary to another axis I or II diagnosis) or "depressive spectrum disorder" (i.e., depressive disorder characterized by maladaptive personality traits and genetic links to antisocial personality disorder and alcoholism). Differences in course and prognosis have been reported for these groups. Clark and Watson's (1991) tripartite model also distinguishes between syndromes of only depression and those characterized by depression and anxiety (i.e., comorbid depression and anxiety, mixed depression and anxiety); the latter are more frequent in women (Ochoa, Beck & Steer, 1992; Rapaport et al., 1995).

EPIDEMIOLOGY Consistent with the studies reviewed by the Task Force, research on clinical depression continues to show that, compared to men, women receive 2 to 4 times more diagnoses of major depression and dysthymic disorder .(e.g., A.P.A., 1994; Spaner, Bland, & Newman, 1994; Weissman, Leaf, Bruce, & Florio, 1988; Weissman, Leaf, Tischler et al., 1988). Further, ever since Weissman and Klerman's (1977) comprehensive review, which found gender differences in epidemiological studies (i.e., United States, England, Denmark, Iran, India) and in clinical cases of depression, the evidence that differences occur cross-nationally has continued to mount. Gender differences in major depression and dysthymia have been found in as diverse cultures as New Zealand (Wells, Bushnell, Hornblow, Joyce & OakleyBrowne, 1989) and Taiwan (Hwu, Yek and Chang, 1989), and a recent crossnational study (Weissman et al., 1993) confirmed differences in the prevalence of major depression and dysthymia for men and women in four countries (i.e., United States, Canada, Germany, New Zealand). It is important to note, however, that there is less evidence for gender differences in developing nations (Culbertson, 1997; Weissman & Klerman, 1977). The Task Force also stressed the importance of examining other demographic factors, such as age and ethnicity, and their interaction with gender in the study of depression. Male-female differences in rates of major depression, minor depression, and dysthymia have been found across ethnic groups including Caucasians, African Americans, and Hispanics (e.g., Caetano, 1987; Canino et al., 1987; Kessler et al., 1994b; Potter, Rogler & Moscicki, 1995; Vernon & Roberts, 1982). Findings of differential rates of depression for minority versus majority women (e.g., Bailey, Wolfe & Wolfe, 1996; Kessler et al., 1994b; Vernon & Roberts, 1982) have been inconsistent and may disappear when other variables, such as socioeco-

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nomic status are considered (e.g., Hobfoll, Ritter, Lavin, Hulsizer & Cameron, 1995). The effect of age on the epidemiology of depressive disorders is supported by recent studies and reviews that conclude that gender differences in depression are absent in childhood, but emerge in adolescence (Angold & Worthman, 1993; Lewinsohn, Hops, Roberts, Seeley, & Andrews, 1993; Nolen-Hoeksema & Girgus, 1994), and may lessen in older age (e.g., Blazer, 1993; Lichtenberg, Gibbons, Nanna, & Blumenthal, 1993). Finally, since publication of the Task Force report, there is increasing evidence of changes in the epidemiology of depression. Longitudinal data suggest a cohort effect and provide evidence that the gender difference in rates of depression is narrowing (Kessler et al., 1994a; Leon, Klerman, & Wickramaratne, 1993; Silverstein & Perlick, 1991; Weissman, et al., 1993). Specifically, the rate of depressive disorders may be stabilizing for women but increasing for men (Weissman et al., 1993).

BIOLOGICAL INFLUENCES Findings that gender differences in depression occur across cultures, emerge in early adolescence, and lessen in older age, suggest that biological factors, particularly hormones, play a role. While the conclusion reached by McGrath et al. (1990) as well as the report on women's health by the National Institute of Mental Health (1986) is that biological factors are not sufficient to explain the gender differences in depression, recent publications provide strong support for the role of biological factors. However, the findings suggest that biological factors contribute to vulnerability or function as stressors that precipitate depression rather than directly causing depression in women. Important psychosocial changes also occur at these times and hormonal changes appear to be part of a more complex etiological process. Clinical depression (and other clinical syndromes) can occur post-parturn, although most mood disturbances at that time are transient and directly related to estrogen levels (Hamilton, 1989). Hamilton hypothesized that thyroid and pituitary function may play a role in the development of post-partum disorders, while others have focused on psychological factors, such as cognition. Condon and Watson (1987) found that post-partum depression was best predicted by pessimism in late pregnancy and occurred in women whose negative expectations were fulfilled by the actual events. Conversely, optimism may provide some resistance to post-partum depression (Carver & Gaines, 1987). Post-partum depression may be much like an adjustment reaction in response to stress that is not qualitatively different than other depressions (Whiffen, 1992). For example, post-partum de-

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pression has been found to be associated with difficult temperament and other infant-related stressors, such as medical complications (Cutrona & Troutman, 1986; Hopkins, Campbell, & Marcus, 1987). These stressors may also contribute to depression by reflecting negatively on parental self-efficacy (Cutrona & Troutman, 1986). O'Hara, Schlechte, Lewis, and Varner (1991) presented a vulnerability-stress model of post-partum depression that details an interaction between prior psychological difficulties and attitudes, and life stressors. Premenstrual syndrome (PMS), and its more severe variant, premenstrual dysphorie disorder in the DSM-IV (A.RA., 1994), refers to psychological distress, particularly depression, that correlates with changes in the menstrual cycle and is believed to be caused by changes in the level of reproductive hormones (Spitzer, Severino, Williams, & Parry, 1989). While premenstrual symptoms are common (20-50% of women), only 3-5% of women meet criteria for premenstrual dysphoric disorder (A.RA., 1994). Rubinow and Schmidt (1989) proposed a vulnerability model of premenstrual syndrome in which PMS develops from a vulnerability to the biological and psychological changes that occur during the late luteal phase of the menstrual cycle, while Halbreich and Tworek (1993) suggested that PMS may be associated with a vulnerability to hormonal changes that affect serotonergie function. Recent research has added to the literature showing an association between PMS, post-partum depression, and non-reproductive-related depressive episodes in women. Women with PMS are more likely to have histories of major depression or post-partum depression and currently depressed women are more likely to have premenstrual worsening of symptoms (Bancroft, Rennie, & Warner, 1994; Endicott & Halbreieh, 1988; Pearlstein et al., 1990). Women with seasonal affective disorder (SAD) also frequently exhibit mood changes associated with their menstrual cycle (Parry, 1989) and women with bipolar disorder are more likely to develop post-partum depression (Leibenluft, 1996). Finally, women with PMS have been found to respond to treatments typically used for non-reproductiverelated depressions including the antidepressant nortriptyline (Harrison, Endicott & Nee, 1989), serotonin agonists (Halbreich & Tworek, 1993), and light therapy (Parry et al., 1989), a treatment generally used for SAD. Reproductive hormones may have a destabilizing function that sensitizes and predisposes women to developing future episodes of depression (Parry, 1989). Alternatively, hormones may stimulate the development of depression in women with genetic vulnerability (Pajer, 1995). On the other hand, there is little evidence that hysterectomy or involutional melancholia (depression associated with menopause) are responsible for increased rates of depression in women (Gitlin & Pasnau, 1989).

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Women are not more likely to develop depression during menopause (Ballinger, 1990; Lennon, 1987), and depression that does develop at this time is associated with prior history of depression (Hunter, 1990) or multiple worries and role demands (McKinlay, McKinlay, & Brambilla, 1987). The genetic basis of mood disorders has been well established; however, research has failed to find gender differences in genetic loading for mood disorders when family history of depression is examined in male and female probands with mood disorder (Kupfer, Frank, Carpenter & Neiswanger, 1989; Merikangas, Weissman & Pauls, 1985). Genetics may play more of a role when more specific subgroupings of depression are examined. Winokur (1991) has identified a subgroup of unipolar depressives, which he labeled "depressive spectrum disorder," based on research he has conducted over several decades. Individuals with depressive spectrum disorder have a primary unipolar depression (i.e., as defined by the criteria of Feighner et al., 1972) plus a history of alcoholism or antisocial personality disorder in a first degree relative (there may also be a family history of depression but it is not necessary). Results across a number of studies have shown that depressive spectrum disorder is familial and is manifested differently in men and women, with women being more likely to be depressed and men alcoholic. Winokur (1991) noted three adoption studies and one linkage study that suggest a genetic basis for the disorder, but advised caution until these results are replicated. Winokur (1991) also reviewed the research on the relationship between heritability of bipolar disorder and color blindness. While not conclusive, results are suggestive of a possible X-linked transmission of bipolar disorder. Thus, there is some evidence that genetics may play a role in the observed gender differences in depression. Biological theories also point to abnormal levels of neurotransmitters, particularly norepinephrine, serotonin and their metabolites and precursors, in individuals with mood disorder. Recent studies suggest that monoamine biosynthesis, availability, responsivity, and metabolism differ in men and women due to the effect of reproductive hormones (e.g., Halbreich & Lumley, 1993; Halbreich & Tworek, 1993; Khan et al., 1986). Gender differences have been found in a number of biological indicators associated with depression. Andreasen et al. (1994) found a trend for women to have greater global and regional cerebral metabolic rate of glucose utilization (CMRglu), a finding seen with clinical depression and other psychiatric disorders more commonly diagnosed in women. Stangl, Pfohl, Zimmerman, Coryell and Corenthal (1986) and Rybakowski and Plocka (1992) found a differential gender response to the dexamethasone suppression test (DST). The DST is a test for depression based on findings that depressed indi-

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viduals suppress secretion of cortisol when dexamethasone, a synthetic corticosteroid, is administered. Others have found sex differences in patients with mood disorders, although these markers generally have failed to differentiate between type of mood disorder. Sleep EEG studies found that depressed men demonstrated less slow wave sleep than women (Reynolds et al., 1990) and that depressed women showed increased incidence and amplitude of fast frequency beta activity, particularly over the right hemisphere, compared to men (Armitage, Hudson, Trivedi & Rush, 1995). Cerebrospinal fluid (CSF) protein levels were higher for depressed men (Samuelson, Winokur, & Pitts, 1994) and CSF magnesium concentrations were lower for depressed women (George, Rosenstein, Rubinow, Kling & Post, 1994). Evans et al. (1992) found lower levels of natural killer (NK) cells were associated with higher levels of depression in a sample of patients with major depression and women in the study had lower levels of NK cells than men. Taken together, these results seem to provide support for the possibility of a biochemical difference in depression for men and women. Finally, there is some suggestion that depressed men and women demonstrate different pharmacokineties and clinical response to somatic treatments (e.g., Feet, Gotestam & Norman, 1993; Grota, Yerevanian, Gupta, Kruse & Zborowski, 1989; Pajer, 1995) providing further evidence for biological differences in male and female depression, although results have not been entirely consistent (Burns et al., 1995; Sehmider et al., 1995).

PSYCHOLOGICAL THEORIES A number of well-known and clearly articulated models such as learned helplessness and attributional reformulations (e.g., Abramson, Seligman & Teasdale, 1978), cognitive theory (Beck, 1967), response styles (Nolan-Hoeksema, 1987) and accumulation of life stress have been effectively applied to explaining depression. Cognitive assessment and evaluation is an important part of these socially oriented theories. One concern expressed in the Task Force report is the relevance of these models to clinical depression, since much of the support for these models has come from studies of individuals who score above some criterion on self-report measures of depression. A recent study, however, suggested that clinical and subclinical depression may fall on a continuum. Gotlib, Lewinsohn and Seeley (1994) found that individuals who had elevated scores on self-report depression scales but failed to meet criteria for depressive disorder ("false positives") were not significantly different than individuals with clinical depression on cognitive measures (e.g., attributions, pessimism). These false

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positive individuals were also predisposed to developing future episodes of depressive disorders during a one-year followup period. While further research is needed, their findings provide an empirical basis for cautiously generalizing research based on individuals with elevated depression scores to clinically depressed persons. Specific cognitive changes associated with depression and negative affective states have been identified in memory studies. Memory is facilitated when conditions of learning match conditions of recall. Considerable research also has demonstrated that depression or negative mood states are more likely to elicit negative memory retrieval (Bower, 1981). Individuals who are depressed have more difficulty organizing material, have more feelings of being overwhelmed, and are more likely to self-report cognitive difficulties than actually exhibit deficits (Otto et al., 1994; Weingartner, 1981). Some memory problems may surface especially when a task requires attention or effort (Hertel & Harden, 1990; Hertel & Milan, 1994). Not only may depressed persons suffer from memory deficits, they may also exhibit cognitive bias and distortion, attributional errors, as well as increased uncertainty and feelings of lack of control (Gotlib, 1992). Even with induced mood states, the degree of cognitive deficit increases with the severity of depression (Gilligan & Bower, 1984). Recently, Heller (1993) has suggested that consideration of gender differences in neuropsychological functioning and brain-behavior relationships (e.g., regional brain activation, brain orgamzation of cognitive functions) and their interaction with the environment may contribute to understanding male-female differences in depression. It should be noted, however, that there are few consistent gender differences in cognition; even when differences have been described they account for less than 5% of the variance (Galoti, 1994). Internal Processes

In efforts to explain women's higher rates of depression, a variety of methods have been used to explicate gender differences in depressive type cognitions. Stereotypic beliefs about women have been associated with higher depression and hopelessness in response to stressful events for women (Belk & Snell, 1989). Sayers, Baucom and Tierney (1993) examined sex role identity and exertion of interpersonal control in pairs of female college students engaged in a persuasion task. Those who were less persuasive also exhibited increases in depressed mood. Participants who scored high in masculinity and low in femininity gained interpersonal control regardless of the sex role of their partner. The outcomes suggested that high femininity is associated with giving up control and more depressive feelings when one needs to exert interpersonal control. Similarly, other recent work

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suggests that sex alone is only weakly related to depression. Although cultural influences on sex role orientation bear careful scrutiny (Bernstein, 1991-92), Sanfilipo (1994) found that greater masculinity was associated with less depressive experiences whereas greater femininity was associated with more depression in men and women. In addition to role expectations, some research suggests that there may be gender differences in attributions. Women are more likely to report maladaptive attributions and greater striving for ideal attributes associated with interpersonal relationships relative to men (Boggiano & Barrett, 1991). Analysis of attributional complexity provides a related dimension to explore possible differences. Complexity of attributions concerns the degree to which people consider the influences of others as well as the level of complexity in individual constructions of causality. A person who tends to use complex attributions might hypothesize about and investigate a variety of dimensions when considering a problem. Such a person enjoys understanding human motivations and examining how interactions between people might impact behavior. Women and people who are depressed have more complex attributions than men (Fletcher, Danilovies, Fernandez, Peterson & Reeding, 1986; Gleicher & Weary, 1991; Marsh & Weary, 1989). Greater complexity in attributions does not imply greater accuracy, as considerable bias and self-reflection may be involved (Marsh & Weary, 1989). Research has also suggested that females are more likely to blame themselves for problems (Frank, McLaughlin & Crusco, 1984) whereas males are more likely to externalize problems to others. Attributions of personal control are also important, as women who experience less control are more depressed relative to their male counterparts (Parks & Pilisuk, 1991). Women may differ from men in their intensity of affect. Using multimethod affect and memory performance scores, Fujita, Diener and Sandvik (1991) found that college student women reported more emotional intensity than men, including more negative affect. However, they also found that positive feelings balanced out negative ones for women, concluding that less than 1% of the variance in affect balance was explained by sex. Women may also perceive the same set of Circumstances differently from men (Gotlib & Whiffen, 1989; Yoder, Shute & Tryban, 1990). Yoder et al. (1990) found that women were more likely to recognize potential problems and offered a greater variety of active and passive coping strategies for depression relative to men. Women who were the most knowledgeable about clinical depression offered more suggestions as to how one might cope with depression. However, gender did not influence types of coping strategies mentioned. Indeed, Folkman and Lazarus (1980) coneluded that the source of the stress (e.g., work, family) was a more important determininant of type of coping than was gender.

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Nevertheless, other research methods have found gender differences in type of coping. For example, women were more likely to seek support from others and to increase food consumption when they felt distressed (Funabiki, Bologna, Pepping & Fitzgerald, 1980; Gruneberg & Straub, 1992). Also, distressed women used more self-deprecation, social withdrawal, and verbal and written expressiveness as compared to men (Funabiki et al., 1980). Thayer, Newman and McClain (1994) suggested that men and women rely on different methods to self-regulate bad moods. While Thayer et al.'s focus was not limited to depression, they did find that women were more reliant on passive mood management techniques whereas men were more likely to seek distraction or pleasurable activities. No consistent gender difference was found in active mood management, the most effective regulating method. Sherbourne, Hays and Wells (1995) also failed to find gender differences in active coping strategies for patients with depressive diagnoses and for those with subclinical depression. In 1987, Nolan-Hoeksema articulated her response styles theory which suggested that females are more likely to adopt a ruminative cognitive style that makes them more prone to developing and maintaining depression relative to males. Rumination may prolong depression by biasing thinking towards negativity and pessimism and by interfering with attention and instrumental behaviors such as problem solving (Nolen-Hoeksema, Morrow & Fredrickson, 1993). A growing number of studies continue to support this explanation using a variety of stimuli and participants (Nolen-Hoeksema & Morrison, 1991; Nolen-Hoeksema, Parker & Larson, 1994; Thayer et al., 1994). In a follow-up self-report study, Butler and Nolen-Hoeksema (1994) found that when differences in rumination were statistically controlled through regression, male-female differences in depression became nonsignificant, suggesting that differences in rumination mediate gender differences in depression rates. A recent study by Gjerde (1995) sheds further light on internal processes that may contribute to male-female differences. Gjerde found that psychological styles at age 7 predicted depression in young adulthood. Analyses of prospective data indicated that women who experienced depressive symptoms tended to be autocentric or inner-directed even in childhood. In contrast, men with depression were primarily allocentric (e.g., outer-directed) and demonstrated fewer intellectual skills throughout their development. Intellectual ability was not as important in predicting female depression. Gjerde concluded that depression in women was a function of more complex and variable pathways. Taken together, these studies suggest that characteristic ways of internally assessing and responding may differ between the sexes, which partially explain the differential rate of depression in women.

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External Factors and Social Conditions

The social environment also plays an important role in fostering and maintaining many internally driven differences between the sexes. External factors may exacerbate problems or facilitate evaluation and management of depression. Clearly, the distinction between internal and external factors is somewhat arbitrary and these factors are inextricably intertwined. In considering how one's internal evaluations interact with social and environmental processes, other explanations for gender differences can be identified. Some theories suggest that stressful life events may precipitate depression. Studies have examined factors that might exacerbate or buffer the impact of negative events as an explanation for gender differences. While study outcomes tend to be contradictory or inconclusive as to whether males or females report more stress (Sowa & Lustman, 1984; Zuckerman, 1989), chronic strain, rather than acute life events, is associated with depression in women (Krause, 1986; Billings & Moos, 1984). Further, the relationship between life stressors and depression may be bi-directional. There is evidence that individuals who are depressed (particularly women) view events as more stressful. Also, depressed people may actually generate negative life events through their behavior (Hammen, 1991, 1992; Pianta & Egeland, 1994; Simons, Angell, Monroe & Thase, 1993) thus perpetuating their depression. For example, Simons et al. (1993) found that depression and cognitive factors influenced the generation of negative life events in a group of patients with major depression (consisting of mostly women). Similarly, Pianta and Egeland (1994) found that initial levels of depressive symptoms predicted the occurrence of interpersonal (marital), health, financial and other problems at a later time in a community sample of disadvantaged mothers. Social support has also been explored as a variable which influences ability to cope with difficult life events. It is generally recognized that women are more likely to maintain intimate relationships with others and to provide more frequent and more effective social support than men (Belle, 1987). Having supportive social networks can protect individuals from depression (Belle, 1982; Pearlin & Johnson, t977; Sherbourne et al., 1995) but social networks can also exacerbate distress (Kessler & McLeod, 1984; Turner, 1994). Supportive aspects of social networks are most pronounced for individuals with greater personal resources, such as income, education and internal locus of control (Belle, 1983). Riley and Echenrode (1986) reported that maintaining a large support network was helpful for women with more personal resources whereas low resource women had more problems trying to respond to others' needs and were more likely to

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be distressed by their difficulties. Since women are more likely to be resource-disadvantaged relative to men, social networks may have less practical utility for many women's life circumstances. Recently, Veiel (1993) found that family support networks had a negative effect on recovery from major depressive episodes for women who were homemakers, but not for men or working women. Perhaps, women who do not work outside the home are overloaded by emotional demands and expectations to support others, or a supportive family may reinforce depressive symptoms. Women view intimacy as significantly more important than do men (Bernstein, 1991-92). However, women perceive family relationships as more stressful than men (Sowa & Lustman, 1984) and seem to be especially vulnerable to negative effects from problematic interpersonal relations. Turner (1994) found that women reported more positive and negative experiences of their relationships and that marital conflict had more of a negative impact on women. Women in unhappy marriages are three times as likely as men or single women to be depressed (McGrath et al., 1990) and marital difficulty is the single most common stressor in the six months prior to the onset of depression in women. Having young children is also associated with increased risk of depression in women (American Psychological Association, 1985; McGrath et al., 1990). Although some research has reported that men experience interpersonal roles in a similar way as women, many cultures still expect women to be the kin keepers and conflict negotiators. Consequently, failures in these interpersonal endeavors take their toll on women. In additional to these personal roles, the impact that women's work roles have on their adjustment has also been explored. While some studies have found no differences in depression between employed women and homemakers (Ensel, 1982; Warren & McEachren, 1985), other research has suggested that conflict between work and familial roles coupled with sex discrimination resulted in higher rates of depression for workers (Greenglass, 1985). However, the preponderance of research suggests multiple roles may insulate women from depression by moderating family stress (Adeimann, 1994; Aneshensel, 1986; Barnett & Marshall, 1992; Barnett, Marshall & Singer, 1992; Veiel, 1993). Aneshensel (1986) found that married employed women with high levels of stress at home and work were likely to become depressed although women with comparable marital stress who did not have outside employment were at greatest risk for depression. Women involved in family or outside jobs who experienced less strain at work or in their marriage were least likely to become depressed. Barnett et al. (1992) further noted that among single women and women without children, levels of distress increased when job quality declined; however, negative changes in one's job had little effect on part-

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nered women and women with children. When multiple roles are available to women, even when one role becomes difficult, other roles may compensate. Well-being is dependent on the quality of available roles (see also Barnett & Marshall, 1992). Thornton and Leo (1992) further observed that this may be partly impacted by sex roles. They noted that feminine-typed and undifferentiated women displayed greater depression than did androgynous or masculine-typed women. Piechowski (1992) concluded that analyzing the demands and degree of control involved in multiple roles was critical to fully understanding depression in women.

Interactive Influences Stress diathesis and vulnerability models of depression explicitly address the interaction between internal (i.e., attributional style) and external (i.e., negative life events) factors. In the hopelessness model of depression (Abramson, Alloy & Metalsky, 1988; Abramson, Metalsky & Alloy, 1989) an attributional style characterized by the tendency to make stable and global attributions (depressive diathesis) interacts with negative life events (stressors) to produce a hopelessness type of depression characterized by a specific symptom profile (e.g., loss of motivation, sad affect, suicidal ideation). The model also hypothesizes that there needs to be congruence between the content domain (e.g., achievement, interpersonal) of the attributional style and the stressors. While the hopelessness model does not purport to explain gender differences in depression, the increased importance women place on interpersonal relationships suggests that they may be especially vulnerable to negative life events in this content domain. Similarly, Hammen's (1991, 1992) vulnerability model of depression hypothesizes that vulnerability due to a variety of factors (e.g., history of depression, cognitive appraisal of self and others) interacts with characteristics of negative life events (e.g., controllability, type of stressor--particularly interpersonal for women). Recent studies found that an interaction between attributional styles and daily hassles was a predictor of hopelessness in women but not men (Bruder-Mattson & Hovanitz, 1990; Johnson, 1992). Two studies of clinically depressed patients (mostly women) found mixed support for the hopelessness and vulnerability models. Simons, Angell, Monroe and Thase (1993) found that a global, stable attributional style was related to the appraisal of negative life events but found stronger support in the achievement than in the interpersonal domain. Spangler, Simons, Monroe and Thase (1993) found a subgroup of patients in which there was a domainspecific correspondence between attributional style and negative stressors. While these individuals also reported higher levels of hopelessness, their

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symptom profile did not exactly conform to the pattern of symptoms in the hopelessness model. Neither study examined gender as a variable. Nevertheless, models that consider the interaction between internal and external processes provide a promising way to explore gender differences in depression, particularly if more specific measures of attributional style and stressors are examined (Spangler et al., 1993). Issues related to differential rates of depression are multidimensional, interactive, and dependent on idiographic factors. Internal and external factors, independently and collaboratively, account for some of the variation in rate, manifestation, and maintenance of depression. Gender expectations clearly influence how depression is dealt with; women who adopt more stereotyped feminine roles experience more depression. While women are more knowledgeable about depression and effective interventions than men, women are also more likely to make complex inferences and to engage in more ruminative self-focus which may maintain or exacerbate depression. Regardless of whether men or women experience more stress, research has clearly established that social support is more important to women than men. This differential dependence on and to others may create more distress especially for resource-disadvantaged women because of others' demands on them. Marital and child relations may have more importance for some women relative to men, especially if role availability is somewhat limited. Holding multiple roles buffers women from the negative impact of an unsatisfactory role. While there are a number of societal factors that contribute to women's greater risk for depression, ways of thinking and responding to the social milieu must be considered within the context of an individual's respective roles. Recent research efforts are targeting these variables and their interactions to better understand depression in women (Sayers et al., 1993; Thornton & Leo, 1992).

GENDER BIAS

Another concern raised by the McGrath et al. (1990) report was the role of gender bias in the diagnosis and classification of depression; however, at the time of their review, there were few empirical studies. They concluded that there is a need for research on clinical judgment, diagnostic stereotypes and the validity of diagnostic categories and criteria. Earlier, Kaplan (1983) criticized the DSM-III (A.P.A., 1980) classification for being a male-constructed system that codified a male perspective of psychological health and labeled normal behaviors in women as pathological. She cited women's higher rates of mental disorder diagnoses, including depression, as evidence of gender bias in the diagnostic system.

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Indeed, most of the members of the DSM-III Task Force were male (i.e., nearly 90%) so that a female perspective was less likely to be represented. However, a gender difference in the incidence of a disorder is not sufficient evidence of bias. In addition, bias may arise from a variety of sources, not just the diagnostic criteria, and it is essential that distinctions be made between potential sources of bias. Widiger and Spitzer (1991) delineated three types of sex bias that may occur in psychiatric diagnosis: (1) social-cultural etiological, (2) sampling, and (3) diagnostic sex bias (which includes both assessment and criterion sex bias). Although their article addressed sex bias in the diagnosis of personality disorders, their formulation provides a clear framework applicable to the diagnosis of depressive disorders. Social-cultural etiological sex bias refers to etiological factors that contribute to differential rates of a disorder in men and women due to differences in educational and occupational opportunities, negative child rearing practices, and exposure to gender-specific traumas. These influences are considered "bias" because they are due to an "arbitrary, unnecessary and/or socially created distinction between the sexes" (Widiger & Spitzer, 1991, p. 3). Widiger and Spitzer's conceptualization of these etiologic factors as sex bias is advantageous in their acknowledgment that detrimental childrearing practices, violence, and discrimination are not a necessary part of socialization. Socio-cultural factors, particularly parenting and educational practices, may promote development of the gender differences in cognition and personality (e.g., learned helplessness, ruminative response style, poor self-concept, the tendency to attribute failure to the self) that predispose women to becoming depressed. Symonds (1986) proposed that sexism in the family (e.g., favoring sons over daughters) results in the development of a "selfeffacing personality" characterized by feelings of unentitlement, nonbelonging and chronic feelings of depression in women. Similar personality constructs include Kaplan's (1986) "placating personality" and Notman's (1989) "feminine personality" (i.e., passivity, a focus on others, self-sacrifice, and resultant low self-esteem, dependency and learned helplessness) which purportedly develop in women due to socialization and place them at risk for depressive disorders. The disparate influence of poverty and violence on the sexes has been well documented. Approximately 75% of Americans living below the poverty level are women and children, and women who are young, poor and single heads of households are especially susceptible to depression (e.g., Caetano, 1987; Hobfoll et al., 1995). Females are the primary victims of gender-related abuse and women who have experienced physical violence, spousal abuse, rape, sexual assault, and childhood sexual abuse are at risk

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for developing depressive disorders (Cutler & Nolen-Hoeksema, 1991; Hamilton, 1989; Jehu, 1989). The "lhsk Force report explored the role of these social factors and their interaction with other demographic characteristics, such as age and race, as risk factors for depression in women. However, labeling these influences as "bias" may be a way of viewing them from a different perspective which might promote new approaches towards ameliorating these conditions. Sampling sex bias may be partly responsible for the preponderance of women being treated for depression in clinical settings; there is a disproportionately large number of women in psychiatric and general medical treatment settings (Cooper, Crum & Ford, 1994; Kaptan, 1983; Strickland, 1988). The increased help-seeking behaviors in women may be attributable to gender roles, differences in coping and different views of help-seeking behaviors. In addition, women may also be more likely to recognize depressive symptoms. Research has shown that women were more likely than men to recognize that the physical symptoms of'depression were an indication of an emotional problem that needed treatment (O'Neil, Lancee, and Freeman, 1985; Yoder et al., 1990). Nevertheless, sampling bias cannot explain the higher rates of depression in women found in epidemiological studies of the general population. Diagnostic sex bias refers to the systematic influence of a variable not used in defining a disorder (i.e., gender) that influences the frequency of false negatives and false positives so that the diagnosed rate deviates from the actual rate. Widiger and Spitzer (1991) noted two sources of diagnostic sex bias: (1) assessment bias and (2) criterion bias. Assessment sex bias includes bias related to psychological assessment (tests, interviews) and clinical judgment. Women are more likely to report symptoms of psychological distress, including depression, due to increased recognition of emotions, differences in socialization, or gender roles (i.e., increased willingness to report symptoms). For example, Page and Bennesch (1993) found that male undergraduates endorsed significantly fewer items on the Beck Depression Inventory (BDI) and Hopkins Symptom Checklist (depression items) when the form was labeled a depression scale than a hassles scale. The significant interaction between gender and labeling condition suggests that men and women adopt different response styles when asked to identify symptoms of depression. In addition, although few consistent gender differences have been found in undergraduates responses to BDI items (Lester & Akande, 1995; Page & Bennesch, 1993; Santor, Ramsay & Zuroff, 1994), Nolan and WiUson (1994) identified 7 items that differentiated male from female depressive analogues (students with elevated BDI scores).

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Depressed women report more symptoms of depression than do depressed men (e.g., Ashton, 1991; Frank, Carpenter, & Kupfer, 1988), even when they have been judged equally depressed (Angst & Dobler-Mikola, 1984; Ernst & Angst, 1992). As a result, self-report tests and interviews may overestimate depression for women and/or underestimate depression for men. A recent study of elderly patients with major depression revealed that both the BDI and the Geriatric Depression Scale had higher sensitivity (true positives) for women than for men (Allen-Burge, Storandt, Kinscherf, & Rubin, 1994). Finally, Wilhelm and Parker (1993) suggested that gender differences in depressive symptomatology may affect the construct validity of depression scales. They attributed gender differences in symptoms to coping styles and suggested that current depression scales may not adequately address symptoms that reflect men's experience of depression (e.g., reckless behaviors). It should be noted that findings of gender differences in depressive symptomatology have been not been consistent (e.g., Ernst & Angst, 1992; Fennig, Bromet & Jandorf, 1993; Young, Scheftner, Fawcett & Klerman, 1990). Nevertheless, quantitative and qualitative gender differences may exist that affect the validity of self-report depression measures and the structured diagnostic interviews widely used in research. Several additional issues concerning assessment sex bias warrant mention. First, Newmann (1984) suggested that the use of summated scores in research may obscure gender differences in symptoms and are misleading since women tend to report more of the least severe, but not the most severe, symptoms of depression. Another concern is that a few extreme scores may skew group depression scores for women (Golding, 1988). Finally, it is important to remember that high scores on depression rating scales do not equate with a clinical diagnosis of a depressive disorder, even if a minimum cutoff criterion is reached; clinical diagnoses must be established by meeting diagnostic criteria. The other source of assessment sex bias is clinical judgment. An early study of gender bias in diagnostic decision-making revealed that simply changing the gender of a patient in a case history altered the personality disorder diagnoses assigned by clinicians (Warner, 1978). Utilizing a similar methodology, Garrett (1991) found that gender did not affect depression ratings for vignettes of depressed children and adolescents, but pediatricians and school psychologists rated female children as more withdrawn than male children with identical symptoms. Another study (Diulus, 1994) also failed to fred an effect of gender on depressive disorder diagnoses. However, Wrobel (1993) found that gender influenced the diagnosis (women were more likely to be considered depressed) and the information that clinical psychologists reportedly utilized in their decision making for a case vignette of a patient with depression.

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Studies of physicians and medical students also provide evidence that gender may affect the diagnosis of depression. Potts, Burnam and Wells (1991) found that physicians more often identified depression in women than in men, both for patients who met diagnostic criteria for clinical depression (underdiagnosis bias for men) and for patients who did not (overdiagnosis bias for women). In a second study, physicians were better able to detect depression in a group of elderly medical patients for women than for men (Lichtenberg, et al., 1993). Finally, a study of medical students found that gender influenced treatment recommendations for an audiotaped case of a patient presenting physical and depressive symptoms (Wilcox, 1992). Medical students were more likely to recommend counseling or reassurance for depressed women and a non-psychiatric consult for depressed men. Base rates may also play a role in clinical decision-making. If rates of depression are higher in women, using gender as one piece of information to assist in diagnosis, especially in situations of uncertainty (e.g., brief case vignettes), is reasonable and is not indicative of bias. However, it must be established that gender is a relevant variable and that base rates are derived from structured interviews or measures free from bias. In addition, clinicians may lack knowledge or may not reliably apply their knowledge of base rates when assigning diagnoses (Widiger & Spitzer, 1991). Further, reliance on base rates can, over time, inflate or deflate the prevalence rates for disorders (Lopez, 1989). Bias in the diagnostic criteria that differentially affects the rate of false positives or false negatives for men and women is referred to as criterion sex bias (Widiger & Spitzer, 1991). As noted earlier, Kaplan (1983) raised concerns about sex bias in the DSM-III criteria. Franks (1986) also suggested that the criteria for three DSM-III disorders, including depression, coincided with stereotypical feminine behavior. However, there is a dearth of empirical studies examining criterion sex bias. Some support for the similarity between the DSM-III criteria for depression and stereotypes of women was provided by Landrine (1988). Previous research had shown that normal women are perceived as passive, dependent and emotional while men are seen as active, independent and rational (e.g., Broverman, Vogel, Broverman, Clarkson, & Rosenkrantz, 1972). Landrine (1988) asked undergraduates to rate how well the ten stereotypically male and female adjectives found in the Broverman et al. (1972) study fit someone described as depressed or not depressed. The depressed individual received lower ratings on all five male traits and higher ratings on three of the five female traits. In the second study, subjects were asked to predict the sex and marital status of prototypic cases of dysthymia and major depression. Both depressive cases were perceived as women and the

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major depression case was perceived as a married women. Finally, when subjects were asked to rate married and single women on the traits, the stereotype of a married woman was rated as more feminine and the ratings did not differ significantly from the ratings for the depression case in the first study. Empirical studies investigating sex bias in the current diagnostic criteria are notably absent. However, findings that depressed women report more symptoms of depression suggest that using the same number of diagnostic criteria to diagnose depression for both sexes could result in false positives for women and/or false negatives for men (Angst & Dobler-Mikola, 1984). In addition, the possibility of qualitative differences in the expression of depression and the failure of depression measures to incorporate symptoms associated with depression in men (Wilhelm & Parker, 1993) raises questions about the validity of the diagnostic criteria, i.e., whether the current criteria include symptoms equally reflective of men's and women's experiences of depression.

SPECIAL POPULATIONS The Task Force devoted the final portion of their report to examining the role of other demographic factors, such as age and ethnicity, in the etiology and treatment of depression in women. Attention was directed towards several particular demographic groups including women of color, lesbians and the elderly. However, the need to consider these and other demographic factors and how they interact with gender was noted throughout their review. While a number of issues relevant to these special populations were discussed, the report concluded that as there were few empirical studies, there was a need for research directed towards studying their unique situations. Recently published articles and studies have attempted to address some of these concerns. McGrath et al. (1990) suggested that ethnic minority women may be at increased risk for depression due to higher rates of poverty and other factors associated with their circumstances in society. A review by Barbee (1992) identified increased exposure to violence as an additional risk factor for African American women. While Hobfoll et al. (1995) found no difference in rates of depression for African American and Caucasian poor inner city pregnant and postpartum women, the rates were nearly double that of middle class samples, particularly for single mothers. Thus, higher rates reported for African American and minority women may be due to the confounding of race with other demographic factors such as low SES. Interestingly, in contrast to previous research, antepartum depression was

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only weakly predictive of postpartum depression in this sample, suggesting that demographic factors need to be considered and may interact with other risk factors for depression. For example, Bailey, Wolfe and Wolfe (1996) found differential beneficial effects of social support for Black versus White women depending on the context. Diagnostic bias (assessment bias) may also be associated with minority group status. Earlier reviews suggested that depressive disorders may be underdiagnosed in African Americans (Adibempe, 1981; Jones & Gray, 1986) due to clinician bias. More recently, Barbee (1992) questioned the cultural sensitivity of diagnostic instruments and suggested that current depression measures may not be valid for African American women. For example, race and gender differences were found in the factor structure of responses on the Center for Epidemiologic Studies Depression Scale (CESD) in a group of elderly adults (Callahan & Wolinsky, 1994). Additionally, due to financial constraints and attitudes towards mental health treatment, African American women may delay seeking treatment for depression (Barbee, 1992) and are more likely to seek help at a general medical than a mental health setting (Cooper et al., 1994), which may contribute to lower rates of diagnosis. Recent research continues to reveal fewer clinical diagnoses of depressive disorders (Strakowski, Shelton & Kolbrener, 1993) and lower prevalence rates in epidemiological studies (Kessler et al., 1994b) for African Americans compared to other racial groups. Another group of women who may present unique risk factors for depression are lesbians. A recent national survey of the mental health and mental health care of lesbians reported rates of current and lifetime depression comparable to rates for heterosexual women (Bradford, Ryan & Rothblum, 1994). However, lesbians reported a higher rate of substance abuse than is generally found for women. In addition, high rates of negative life events and stressors (e.g., rape, physical and sexual abuse, discrimination) that would place them at risk for mental health problems were reported. Although there were some limitations to the methodology (i.e., self-report survey rather than structured diagnostic interview), it is possible that there is a different profile of mental health issues for lesbian women. Also noteworthy is that lesbian women had higher rates of poverty, received lower pay relative to their level of education, and frequently cited a lack of resources as barriers to health care access. Finally, ethnic minority lesbians may face additional stressors and issues due to the influence of other cultural factors (Greene, 1994). One particular demographic group cited by the "lhsk Force as needing further research is the elderly. A number of physical and psychosocial changes occur (e.g., menopause, retirement, widowhood, financial changes) that may differentially affect men and women and risk factors for depres-

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sion. For example, due to increased longevity and societal patterns of women marrying men older than themselves, women are more likely to be widowed. Umberson, Wortman and Kessler (1992) suggested that widowhood differentially impacts men and women and that the resulting change in financial status is the primary determinant of depression for such women. As noted earlier, gender differences diminish, or may no longer exist, in older age (Blazer, 1993; Brown, Milburn & Gary, 1992; Colenda & Smith, 1993; Lichtenberg et al., 1993). The lessening of the disparity in rates of depression in older age may be due to more similar risk factors for men and women (e.g., the reduced demands of family on women) at that time (Brown et al., 1992). In addition, social roles often become more ambiguous; men may embrace more feminine aspects of themselves whereas women often assert more control and independence. Biological substrates of depression may also be affected by aging. Stangl et al. (1986) found an interaction between older age and gender in response to the dexamethasone suppression test (i.e., there was a positive relationship between age and postdexamethasone cortisol for depressed men but not women) and Keitner et al. (1992) found significantly higher rates of nonsuppression for older adults. There may also be differences in effective coping strategies for older and younger individuals who are depressed. Sherbourne et al. (1995) found that active coping strategies were associated with better outcome in depressed patients overall but provided few benefits for older patients, and that social support was the most helpful for older depressed patients regardless of sex. Assessment bias may also be associated with older age. Using an audiotape of a depressed individual identified as either middle-aged or elderly, Perlick and Atkins (1984) found that clinicians were more likely to attribute symptoms to organic causes and to be less optimistic in their treatment recommendations when the patient was described as elderly. More recently, Wilcox (1992) failed to find an effect of age on medical students' responses to an audiotape of a patient with medical complaints and depression. However, age and gender influenced diagnosis and age also affected treatment recommendations of clinical psychologists who read a case vignette of a depressed patient (Wrobel, 1993). These results suggest that certain expectations about aging may influence assessment and treatment recommendations for elders and there may be interactions between age, gender, and other variables. Two recent studies (cited earlier) found gender differences in the detection of depression in the elderly (Allen-Burge et al., 1994; Lichtenberg et al., 1992) although there was not a younger comparison group to examine the interaction with age. There is also evidence that elderly depressed women demonstrate a different pattern of symptoms than younger women who are depressed (Newman, Engel & Jensen, 1991)

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and that age and race affect the responses of the elderly on the CES-D (Callahan & Wolinsky, 1994). Finally, recent studies confirm observations that the elderly are more likely to seek treatment in general medical settings than at mental health specialty clinics (Cooper et al., 1994; Phillips & MurreU, 1994).

CONCLUSIONS AND DIRECTIONS FOR FUTURE RESEARCH AND INTERVENTION It is clear that a variety of biological and psychosocial factors contribute to the gender differences in depression. A growing number of biologically based factors related to depression differentiate males and females; no doubt research will shed further light on these distinctions. To date, most of the cognitive factors identified in depression involve subtle differences in the way depressed people process information and the manner in which they think about themselves and others. Most gender differences in cognitive processing associated with depression involve appraisal, inference and interpretational factors which are heavily influenced by the social environment. Perhaps the most promising and least investigated area focuses on the role of gender bias in diagnosing depression. While research is limited, there is a suggestion of both overdiagnosis (women) and underdiagnosis (men) biases operating in the detection and diagnosis of depression. It is likely that no one hypothesis will satisfactorily explain the higher rate of depression in women; the cause of depression in women is likely to require consideration of a variety of factors and their interactions. Increasingly, theories of psychopathology are more complex, multidimensional, and include biological, psychological and social factors. The evidence suggests that categories such as major depression are broad, heterogeneous, and likely to have multiple and varying etiologies. When the broader designation of depression as a negative mood state is included, the possibility of additional etiological factors further increases. The additional specification of subtypes of depressive and mood disorders in the DSM-IV represents a positive step toward defining and encouraging the use of more homogeneous groups in research. Studies using demographically homogeneous samples may also add to understanding of etiological factors and manifestations of depression in various groups. The interaction between demographic variables and gender needs further examination. Defining relatively narrow demographic groups (e.g., the Brown et al., 1992 study of depressive symptomatology in elderly African Americans) may be a productive avenue of research. One methodological issue that needs to be considered is the confounding of demo-

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graphic variables due to their patterns of co-occurrence (e.g., SES, race, ethnicity, gender, sexual orientation, aging, medical disorders). It is important that research be designed to examine the independent effects of these and other variables if they are to be disentangled. With the aging of the population, the need for understanding the risk factors for depression in the elderly and for accurate diagnosis and effective treatment of the elderly is of increasing importance. The interaction of biological and psychosocial factors in aging, as well as their differential effects on men and women, warrant further investigation. Additional areas needing attention are clinician bias and differential diagnosis of depression from medical disorders and dementia. The finding of age biases operating in the diagnosis of depression (i.e., Perlick & Atkins, 1984; Wrobel, 1993) is of major concern. It is also important to examine differences in the effectiveness of depression inventories for men and women and at different points in the lifespan. For example, the Geriatric Depression Scale is less reliant on the neur0vegetative symptoms of depression in order to minimize the confound of increased physical problems associated with aging, but research suggests it may have higher sensitivity for elderly women (i.e., Allen-Burge et al.; 1994). Also, there is the possibility that the elderly demonstrate a different syndrome of depression than younger adults (i.e., Newman et al., 1991). Finally, because the elderly are more likely to seek treatment at general medical settings, recent studies of the detection of depression by physicians and medical students address an important practical issue. Resuits of these studies provide direction for professional training and continuing education for physicians. Although a review of treatment is beyond the scope of this review, social-cultural causes of higher rates of depression in women point to numerous avenues for prevention and treatment. On a social level, working to reduce poverty and powerlessness in women could be implemented through sponsoring legislation for equal pay and childcare programs to allow equal access to employment, especially for young, poor women who are most susceptible to depression. Educational programs can be aimed at reducing abuse and violence towards women, encouraging childrearing practices that promote equal treatment for boys and girls, promoting nonsex role stereotyped behaviors and supporting equal opportunity in education and occupation. On a clinical level, psychologists can work with individuals who have been victims of violence. Building self-esteem and assertiveness and overcoming learned helplessness should be part of these interventions. Cognitive therapies that teach more adaptive methods of coping and problem solving and challenge maladaptive, negative cognitions are particularly effective for depression. Feminist therapy can promote in-

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dependence and empower women. Working with the abuser to change behaviors and attitudes is another means of intervention. The potential underdiagnosis of depression in men also needs careful consideration. While much attention has been focused on the higher rates of depression and other diagnoses assigned to women, both underdiagnosis/minimization of symptoms and overdiagnosis/overpathologizing biases are important (Lopez, 1989). Encouraging men to recognize and express emotions and educating the public about the signs and symptoms of depression (and mental disorders in general) may reduce the stigma and increase the likelihood of men seeking treatment. Clinicians and other health care providers need to be aware of their own biases and beliefs concerning the base rates of depression and to not overlook depression in male clients. Further research may clarify whether gender differences in depressive symptomatology exist. Research on the validity of self-report inventories and clinical interviews can address concerns of assessment sex bias. For example, Stommel et al. (1993) identified two items on the CES-D that differentiated between male and female respondents. Deleting these items, plus several with poor psychometric characteristics, resulted in a subset of items that were free of gender bias and resulted in a minimal loss of symptom information. Statistical issues (e.g., the use of group means to compare the sexes, the effect of a few extreme scores on the means) also need further consideration. Given women's tendencies to admit to more psychopathology, the use of separate cutoff scores for men and women on depression screening tests and structured interviews may be one way to minimize false positives in women and false negatives in men. Because women endorse more of the milder symptoms of depression, weighting items according to clinical significance (severity) might also address concerns of assessment sex bias. Separate data on sensitivity and specificity of tests for each gender could also be provided. It is essential that depression measures have high construct and predictive validity for men and women. Depression scales also need to be sensitive to cultural differences and to be relevant for ethnic minority, low SES, and elderly individuals. Culbertson (1997) recommended the development and use of measures that have cross-cultural and crossnational applicability. There also needs to be increased research on clinical decision-making, establishing accurate base rates, as well as assessing how base rates affect diagnosis. Lopez (1989) concluded that most diagnostic bias results from the way that clinicians process information, not from individual prejudices. Work on decision-making suggests that most of the advances here come through probability training on base rates (Nisbett, Krantz, Jepson & Kunda, 1983). In addition, assessment, psychopathology, and therapy

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courses must also provide training in working with individuals of both sexes, and different races, ethnicities, ages, and socio-economic levels. Clinical programs should incorporate training on potential diagnostic biases, and all graduate programs in mental health related fields should include education about stereotypes as well as more effective ways to process information. Finally, research should continue to examine the validity of the diagnostic criteria for depressive disorders. Empirical studies can investigate the diagnostic efficiency of the symptoms for men and for women to insure that the criteria maximize sensitivity and specificity for both sexes. The symptom content needs to be evaluated for applicability to the depressive experiences of men and women. It is also important that validity be demonstrated for the diverse range of individuals in society including ethnic minorities and the elderly. Finally, the increased number of women on the DSM- IIIR (A.P.A., 1987) and DSM-IV (A.P.A., 1994) task forces, including experienced researchers in depression and gender issues, is encouraging and is another step towards assuring that diagnostic criteria consider male and female perspectives on mental health and disorder.

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