DEPRESSION THE LANCET Depression David Meagher, Declan Murray “Sex discrimination is not only a function of society, it is a function of disease”.’ This seems to be the case with depression, which is twice as common in women as in men. There are also differences between the sexes in clinical profile and course, and in treatment response- relevant to all branches of medicine. Depression is a major health concern not only because of personal distress, excess mortality, impaired interpersonal relationships, and restriction of work activities but also because of the economic burden it imposes. In 1990, the estimated cost to American society was $53 billion-comparable with that of diseases such as cancer, coronary heart disease, and AIDS.2 Prevalence The finding that depression is twice as prevalent in women as in men is not accounted for by different patterns of help-seeking behaviour since it has been consistently confirmed in general population studies.3 The female preponderance is evident from puberty onwards and is found across a range of cultures and countries. How can we account for this increased prevalence? Several factors are relevant. The reproductive cycle In the month after childbirth there is a 22-fold increase in the incidence of affective psychosis4 and a less dramatic rise in non-psychotic depression.5 The affective psychoses are associated with primiparity, caesarean section, and perinatal death, but the main trigger is thought to be neurophysiological-possibly related to increased dopamine sensitivity. Non-psychotic postnatal depression is related more to psychosocial stressors,6 although oestrogen seems to be an effective treatment.7 Overall, childbirth does not fully account for the disproportionate expression of depressive disorders in women. The association of depression with other aspects of the reproductive cycle-premenstrual syndrome,8 termination of pregnancy’-is less clearly demonstrated and remains controversial. With regard to the menopause, it now seems that neither hormonal nor psychosocial changes are aetiologically related to depression.‘o Social factors Social factors undoubtedly contribute to the genesis and maintenance of depression in both sexes. Women may be at special risk because of gender-related stressors together with different coping styles; lack of a confiding relationship with a husband or lover is one of the most important vulnerability factors. In men, core relationships are less critical: vulnerability to depression only emerges when the bonds of intimacy come under great stress.” Departmerd of Psychiatry, St Vincent’s Hospital, Dublin 4, &eland (D Meagher Mwssych) and St Ita’s Hospital, Portrane, Co Dublin (D Murray MRCPsych) Vol349 - March. 1997 SIl’J What about work? Work outside the home is beneficial to women’s mental health except when it creates difficulties with housework and childcare.‘” Certain activities where women pre.

1. DEPRESSION THE LANCET
Depression
David Meagher, Declan Murray
“Sex discrimination is not only a function of society, it is a
function of disease”.’ This seems to be the case with
depression, which is twice as common in women as in
men. There are also differences between the sexes in
clinical profile and course, and in treatment response-
relevant to all branches of medicine. Depression is a major
health concern not only because of personal distress,
excess mortality, impaired interpersonal relationships, and
restriction of work activities but also because of the
economic burden it imposes. In 1990, the estimated cost
to American society was $53 billion-comparable with
that of diseases such as cancer, coronary heart disease, and
AIDS.2
Prevalence
The finding that depression is twice as prevalent in women
as in men is not accounted for by different patterns of
help-seeking behaviour since it has been consistently
confirmed in general population studies.3 The female
preponderance is evident from puberty onwards and is
found across a range of cultures and countries. How can
we account for this increased prevalence? Several factors
are relevant.
The reproductive cycle
In the month after childbirth there is a 22-fold increase in

2. the incidence of affective psychosis4 and a less dramatic
rise in non-psychotic depression.5 The affective psychoses
are associated with primiparity, caesarean section, and
perinatal death, but the main trigger is thought to be
neurophysiological-possibly related to increased
dopamine sensitivity. Non-psychotic postnatal depression
is related more to psychosocial stressors,6 although
oestrogen seems to be an effective treatment.7 Overall,
childbirth does not fully account for the disproportionate
expression of depressive disorders in women.
The association of depression with other aspects of the
reproductive cycle-premenstrual syndrome,8 termination
of pregnancy’-is less clearly demonstrated and remains
controversial. With regard to the menopause, it now seems
that neither hormonal nor psychosocial changes are
aetiologically related to depression.‘o
Social factors
Social factors undoubtedly contribute to the genesis and
maintenance of depression in both sexes. Women may be
at special risk because of gender-related stressors together
with different coping styles; lack of a confiding
relationship with a husband or lover is one of the most
important vulnerability factors. In men, core relationships
are less critical: vulnerability to depression only emerges
when the bonds of intimacy come under great stress.”
Departmerd of Psychiatry, St Vincent’s Hospital, Dublin 4,
&eland
(D Meagher Mwssych) and St Ita’s Hospital, Portrane, Co
Dublin
(D Murray MRCPsych)
Vol349 - March. 1997 SIl’J

3. What about work? Work outside the home is beneficial
to women’s mental health except when it creates
difficulties with housework and childcare.‘” Certain
activities where women predominate-care of the elderly,
mentally ill, mentally handicapped, and physically
disabled-are linked with increased rates of depression.13
Women, it seems, are more likely than men to subordinate
their needs to the needs of someone they look after.14
Another factor widely thought to increase psychiatric
morbidity in adult life, which is much more frequent in
women than in men, is childhood sexual abuse. 25% of
depressed women report a history of such abuse compared
with 6% of controls.” Women are also afraid of sexual and
other violence in their present lives and some are
described as having a virtual curfew after dark.16 However,
most violence against women is domestic;17 often it goes
undetected and it leads to health and social problems
including depression.
Low self-esteem is a risk factor for depression,” and
girls are more likely than boys to display poor self-
confidence, to rely on the opinion of others, and to blame
themselves for failure.18 Self-esteem is related to factors
such as early parental loss, rearing style of parents,
unemployment, and degree of social support, but a study
of female twins indicates a strong genetic contribution.19 A
similar study in men would be of great interest.
Melancolia I
By Albrecht Dhrer, 1471- 1528
THE LANCET DEPRESSION

4. Panel 1: JCD 10 symptoms of depression
At least two (mild/moderate) or three (Severe), Of:
Depressed mood
LOSS of interest and enjoyment
Increased fatiguabikty
And at least two (mild), three (moderate), or four (severe) of:
Reduced concentration and attention
Reduced self-esteem and self-confidence
Ideas of guilt and unworthiness
Bleak and pessimistic views of the future
Ideas or acts of self-harm or suicide
Disturbed sleep
Diminished appetite
We have referred to differences in coping style but the
precise nature of these is unclear. One study indicated that
women rate the degree of stress similarly to men but
respond with a greater intensity of symptoms.” Another
showed that women rate the impact of stressors more
severely and that men are more insulated from depression
by cognitive distortionzl Certain types of behaviour may
enhance stress adaptation or act as a substitute for
depression; for example, one suggestion is that a man
might express distress through antisocial behaviour or
alcohol abuse where a woman would become depressed.
This notion is consistent with the finding that, although
depression is commoner in women, overall rates of
psychiatric morbidity are similar in the two sexes.
There is some evidence that, where social roles are
controlled for, gender differences in depression rates are
absent. Among entrants to the teaching profession, when
educational attainment, social class, marital status, and
professional rank were matched, there was no difference in
depression rates between men and women.22 In the Amish

5. community, which strictly prohibits alcohol and antisocial
behaviour, men and women have almost the same rates of
depression.23 In matriarchal societies such as that in Papua
New Guinea prevalence sex ratios may even be reversed.‘”
Ethology
The study of behavioural patterns in other species has
given rise to a “social competition hypothesis” which
proposes that depressive states serve a useful evolutionary
function.25 Social withdrawal and psychomotor inhibition
are judged to represent a mechanism whereby an organism
can adapt to failure in competitive situations and come to
terms with low rank. Such a theory readily accommodates
the social role commonly allocated to women in society
and explains why where women have equal oppotunities
the excess of female depression does not occur. Low rank
has been linked to disturbances in indolamine
metabolism, perhaps mirroring the neurochemical
mechanisms of depression.
Neurobiology
Gender differences are evident in the metabolism of
noradrenergic and serotoninergic neurotransmitters
implicated in depressive illness.z6 Moreover, the
interaction of these systems with sex and stress hormones
also varies according to sex. Morphologically, regions of
the central nervous system involved in emotional or
cognitive processing differ according to sex
(hypothalamus, amygdala, and frontal cortex).” These
neurobiological differences may be a source of altered
vulnerability to various factors that precipitate mood
disturbances. Although this has not been directly tested,
such a theory would account for the observed roles of both
genetic and social factors in the genesis of depression.

6. A comprehensive theory of mood disorders must
integrate findings from sociology, psychology, ethology,
and the neurosciences. The potential overlap between
these areas is illustrated by evidence that environmental
complexity and social stimulation affect morphological
development of the central nervous system.‘* The two
sexes can experience quite different social environments
even in the same classroom; for instance, teachers give
more corrective feedback, individual instruction, praise,
and encouragement to boys. Girls experience “relative
deprivation” in the classroom.zy These and other variations
in the social environment during development may
contribute to neurobiological diiferences relevant to
emotional processing.
Detection and diagnosis
Panel 1 summarises internationally agreed diagnostic
criteria for defiression.30 Depression is diagnosed where
symptoms are present most of every day for 2 weeks or
more. However, 50% of patients with depression do not
consult their doctors and even in those who do the
diagnosis is missed in around half.” Factors associated
with reduced detection are listed in panel 2. Greater
advantage could be taken of women’s contacts with health
professionals in general practice, family planning services,
and gynaecology clinics. An excellent example is the
project in Edinburgh whereby health visitors were trained
to detect postnatal depression and provide counselling.32
Course
Depression has an earlier onset, higher rate of recurrence,
longer duration, and lower rate of spontaneous remission
in women than in men.33,34 This picture may result from a
combination of the specific female stressors and the fact
that, once the threshold for first episode of depression is
crossed, “illness begets illness”.35 The course of depression

7. is further complicated by the fact that depressed women
have more concomitant medical and psychiatric disorders
which are associated with lower detection rates and poorer
prognosis.36 Depressed women are less likely than
depressed men to commit suicide, and are six times less
likely to commit suicide during the first postnatal year
than during any other year, despite high rates of
psychiatric morbidity during this time.37
Treatment
Depression is a syndrome for which drug treatment is
effective irrespective of aetiology. Doctors may be
reluctant to prescribe antidepressants when symptoms are
Panel 2: Factors associated with decreased detection of
depression
Patient factors
Somatic symptoms of depression
Physical disease
Longstanding depression
Atypical symptoms (eg, without overt depressed mood)
Doctor factors: poor interview technique
Less eye contact
Early and frequent interruption
Premature use of dosed questions (which can be answered
yes/no)
Poor listeners
Fewer direct questions about psychological symptoms
Fewer direct questions about social circumstances
sI18 Vol349. March. 1997
DEPRESSION THE LANCET

8. c1ear1y related to life circumstances but drug therapy
should not be withheld for this reason.38 In addition to
medication, psychotherapy is important. Specific
Psychotherapies, including cognitive therapy and
interpersonal psychotherapy, enhance the effect of
antidepressants and in some circumstances (eg,
pregnancy) may be an appropriate alternative to drugs.39
Attention to level of social support can be of enormous
therapeutic value, especially in women with dependent
children.
Those who respond to an antidepressant should
continue on a full therapeutic dose, for a minimum of 4
months4’ Maintenance therapy may be necessary for those
with recurrent illness;4* and sometimes long-term
psychotherapy is also required to prevent symptom
recurrence.
What other factors influence treatment response? Oral
contraceptives induce liver enzymes and thus decrease
concentrations of tricyclic antidepressants (the reverse is
also true). There is some evidence that antidepressants
work more slowly in women than in met-P and that
women are more prone to side-effects from tricyclic
compounds, monoamine oxidase inhibitors, and lithium.”
Particular difficulties arise with use of medication around
the time of conception, during pregnancy, and during
breastfeeding. Group therapieP and problem-solving
individual therapie? may suit women better than men.
A gap remains between what is agreed to be appropriate
treatment and what happens in clinical practice.45Tricyclic
antidepressants are often used in subtherapeutic doses,
though this happens less with the serotonin-specific
reuptake inhibitors which can usually be started at a

9. therapeutic dose.45 Duration of treatment is often
inadequate; most patients abandon medication in less than
2 months4h-not surprisingly, in the light of a MORI
survey revealing that 78% of the public believe
antidepressants to be addictive and only 16% think that
depressed people should receive them.47 Effective
psychological treatments may likewise also be underused.
They languish, some say, because thay have not been
developed and marketed by profit-making companies.48
Provision of inpatient treatment for women is difficult,
since they are more likely than men to take early discharge
from hospital for social or domestic reasons.36
In view of the consequences for the patient and her
family, these shortfalls in delivery of effective treatments
should be a major concern to health and social services.
Conclusion
Development of mental health services and clinical
practice should be informed by a better understanding of
gender differences in clinical phenomena and service
requirements. Clearly, diverse biological and social
variables are interacting. From existing evidence, our
judgment is that sex discrimination as much a function of
depression as depression is a function of sex
discrimination.
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Vize CM, Cooper PJ. Sexual abuse in patients with eating
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Mezey G, Stanko EA. Women and violence. In: Abel K,
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Ruble DN, Greulich F, Pomerantz EM, Gochberg B. The role of
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Hormones and bones
Rent? Rizzoli, Jean-Philippe Bonjour
Of the various hormones that can affect the metabolism
and structural integrity of bone, oestrogen is undoubtedly

17. the most important in women, at least after puberty.
Observations in disorders associated with low oestrogen
production or inadequate oestrogen action, and in delayed
puberty, suggest that sex hormones are a key factor in
acquisition of bone mass. However, we do not yet know
whether differences in sex hormone secretion or action
during pubertal maturation in healthy adolescents
contribute to the large biological variability in bone mass
gain observed at sites at special risk of osteoporotic
fractures such as lumbar spine and proximal femur.
After puberty, males have larger bones with greater
cortical thickness than females, and the main reason for
this gender difference seems to be the longer bone
maturation period in males. Puberty affects bone size
much more than volumetric mineral density; indeed, at
the end of pubertal maturation males and females differ
very little in volumetric trabecular density. In healthy
Caucasian females with adequate intakes of energy and
calcium, bone mass accumulation in both lumbar spine
and femoral neck seems virtually complete before the end
of the second decade.“’
Once peak bone mass has been achieved, the amount of
bony tissue remains constant throughout reproductive life
except possibly in the femoral neck, where a slight
decrease has been reported in cross-sectional studies from
the third decade on. Female sex hormones, physiologically
integrated in a regular menstrual cycle, seem crucial not
only to acquisition of maximum bone mass after menarche
but also to maintenance of this mass by control of bone
Division of Bone Diseases, WHO Collaborating Centre for
Osteoporosis and Bone Diseases, Department of Internal
Medicine,
University Hospital, 1211 Geneva 14, Switzerland (R Rizzoli

18. MD,
Prof J-P Bonjour !m)
remodelling during reproductive life.3 Even a shortening of
the luteal phase may be associated with abnormal bone
loss.4
The susceptibility of bone to sex hormone deprivation
was recognised more than 50 years ago by Albright, who
noticed an association between osteoporosis and
menopause.s Since then, the concept of a causal link
between oestrogen deficiency and accelerated bone loss
has been supported by observations in various states of
premature oestrogen deficiency, such as anorexia nervosa,
secondary amenorrhoea due to strenuous exercise, and use
of gonadotropin inhibitors.6J Some might object that, in
exercise-induced amenorrhoea, eating disorders are a
likely factor in the low bone mass, but in female marathon
runners we observed that bone loss was essentially
attributable to oestrogen deficiency rather than alterations
in calorie, calcium, or protein intake (Gremion G, Rizzoli
R, Slosman D, et al, unpublished).
Whereas in the mid-nineteenth century female life
expectancy was under 50 years, a western woman today
can expect to reach age 80 or more. This phenomenon is
predicted to progress and the world projection for the year
2050 is a five-fold increase in the population aged 65 and
over.* Since the age of menopause has not greatly
changed, today a woman can anticipate spending about 30
years, one-third of her life, in a postmenopausal state.
Pathophysiology of bone loss in oestrogen
deficiency
Oestrogen deficiency increases the rate of bone
remodelling and leads to an imbalance between bone

19. resorption and formation, resulting in a net bone loss and
possibly osteoporosis.9 Cytokines such as interleukin-1
(IL-l), tumour necrosis factor-a (TNF-a), interleukin-6,
interleukin-I 1, and macrophage colony-stimulating factor
may be involved in bone resorption by facilitating the
recruitment and maturation of osteoclast precursors.
SIZO Vo1349 . March * 1997
DepressionPrevalenceThe reproductive cycleSocial
factorsEthologyNeurobiologyDetection and
diagnosisCourseTreatmentConclusionReferences
Anti-Drug Legislation Matrix
CJA/354 Version 4
1
University of Phoenix Material
Anti-Drug Legislation Matrix
Complete the matrix by selecting three states to add below
Federal. Then, answer each question listed in the first row for
each corresponding law.
Is marijuana illegal?
What are the penalties for possession of cocaine?
What are the penalties for possession of heroin?
What are the penalties for possession of prescription drugs?
What is the blood alcohol level for a driving while intoxicated
(DWI) or driving under the influence (DUI) crime?
Is there extreme DWI or DUI? If so, what is the punishment?
Federal

20. <State 1>
<State 2>
<State 3>
1. Where do you see the largest variance between federal and
state anti-drug legislation?
2. What is the purpose of anti-drug legislation in relation to
public order crime?