GENDER AND DEPRESSION: GENDER AND DEPRESSION: TYPICAL AND ATYPITCAL TYPICAL AND ATYPITCAL

SYMPTOMS AND SUICIDAL SYMPTOMS AND SUICIDAL IDEATIONIDEATION

Dissertation Dissertation

Presented to the Faculty of the College of Health Presented to the Faculty of the College of Health SciencesSciences

of Touro University Internationalof Touro University Internationalin Partial Fulfillment of the Requirements for the in Partial Fulfillment of the Requirements for the

Degree ofDegree ofDoctor of Philosophy in Health Sciences Doctor of Philosophy in Health Sciences

ByByJed DiamondJed Diamond

March 14, 2008March 14, 2008

Dissertation Chair: Mihaela Tanasescu MD, ScDDissertation Chair: Mihaela Tanasescu MD, ScDCommittee Member: Frank Gomez, PhDCommittee Member: Frank Gomez, PhD

Committee Member: Anne Maria Möller-Leimkühler, Committee Member: Anne Maria Möller-Leimkühler, PhDPhD

Significance and Rationale For Significance and Rationale For StudyStudy

“Women seek help—men die.”

This conclusion was drawn from a study of suicide prevention by Angst & Ernst (1990). They found that 75% of those who sought professional help in an institution for suicide prevention were female. Conversely 75% of those who committed suicide in the same year were male.

Since depression is a significant risk factor for suicide and men receive less treatment for depression than do women, it is vitally important that we have a better understanding of the way depression manifests itself in males.

Age

Socioeconomic status

Chronic disease (heart disease, stroke, diabetes, cancer, other)

Marital status (and marital happiness)

Previous depression

Family history of depression and suicide

Loss, trauma, life changes

Alcohol use, etc.

Suicidal Ideation

Depression(Typicalsymptoms)

Gender

Atypicalsymptomsofdepression

CONCEPTUAL MODELCONCEPTUAL MODELRisk FactorsRisk Factors

Research HypothesesResearch Hypotheses There will be a significant positive relationship between typical There will be a significant positive relationship between typical

depression (CES-D) and atypical depression (DMDS).depression (CES-D) and atypical depression (DMDS).

Depressed men will score significantly higher for atypical Depressed men will score significantly higher for atypical symptoms (DMDS) than depressed women.symptoms (DMDS) than depressed women.

Non-depressed men will score significantly higher for atypical Non-depressed men will score significantly higher for atypical symptoms (DMDS) than non-depressed women.symptoms (DMDS) than non-depressed women.

There will be a significant relationship between known There will be a significant relationship between known depressive risk factors and atypical depression.depressive risk factors and atypical depression.

There will be a significant positive relationship between atypical There will be a significant positive relationship between atypical symptoms (DMDS) and suicide risk.symptoms (DMDS) and suicide risk.

Atypical symptoms of depression will be positively related to Atypical symptoms of depression will be positively related to suicide risk when controlled for typical depression.suicide risk when controlled for typical depression.

There will be a significant positive relationship between atypical There will be a significant positive relationship between atypical symptoms (DMDS) and scores on the Gotland scale.symptoms (DMDS) and scores on the Gotland scale.

Demographics of Study Demographics of Study PopulationPopulation

323 females and 749 males (1072 total).323 females and 749 males (1072 total).

Age range 18-80, Mean 51, 58% over 50.Age range 18-80, Mean 51, 58% over 50.

76% employed, 64% income > 76% employed, 64% income > $50,000/year.$50,000/year.

48% of the males and 40% of the females 48% of the males and 40% of the females depressed (CES-D 20).depressed (CES-D 20).

53%, 1+ relatives have mood disorder.53%, 1+ relatives have mood disorder.

Factor Analysis of Diamond Male Factor Analysis of Diamond Male Depression Scale (DMDS)Depression Scale (DMDS)

Factor 1: Emotional Acting-In Depression, Factor 1: Emotional Acting-In Depression, Chronbach’s alpha = .93Chronbach’s alpha = .93

Negative, withdrawn, stressed, numb.Negative, withdrawn, stressed, numb.

Factor 2: Emotional Acting-Out Depression,Factor 2: Emotional Acting-Out Depression, Chronbach’s alpha = .89Chronbach’s alpha = .89

Short-fuse, impatient, irritable, angry.Short-fuse, impatient, irritable, angry.

Factor 3: Physical Acting-Out DepressionFactor 3: Physical Acting-Out Depression Chronbach’s alpha = .73Chronbach’s alpha = .73

Alcohol abuse, reckless, explosive, violent.Alcohol abuse, reckless, explosive, violent.

Correlation of Typical Depression (CES-D Correlation of Typical Depression (CES-D 20) with DMDS Factors20) with DMDS Factors

Factor Pearson Correlation P-value

Factor 1, Emotional Acting-In

.700 < .001

Factor 2, Emotional Acting-Out

.474 < .001

Factor 3, Physical Acting-Out

.319 < .001

The first hypothesis--There will be a significant positive relationship between typical depression (CES-D) and atypical depression (DMDS)—was answered affirmatively.

DMDS Factors in Depressed and Non-Depressed Men and DMDS Factors in Depressed and Non-Depressed Men and WomenWomen

Predicting Factor 1 Emotional Acting-In Unstandardized Coefficient

P-value

Depressed Men vs. Women 1.15 .208

Non-depressed Men vs. Women .47 .510

Predicting Factor 2 Emotional Acting-Out

Depressed Men vs. Women 1.47 .002

Non-depressed Men vs. Women 1.19 .001

Predicting Factor 3 Physical Acting-Out

Depressed Men vs. Women 1.52 < .001

Non-depressed Men vs. Women .86 .003

The second and third hypotheses-- Depressed men will score significantly higher for atypical symptoms (DMDS) than depressed women and non-depressed men will score significantly higher for atypical symptoms (DMDS) than non-depressed women was answered affirmatively for Factor 2 and Factor 3.

Atypical Symptoms of Depression and Known Depressive Risk Atypical Symptoms of Depression and Known Depressive Risk FactorsFactors

There was a There was a negativenegative relationship between atypical depression (DMDS) relationship between atypical depression (DMDS) factors and the following risk factors:factors and the following risk factors:

Age ( Factor 1, p = < .001, Factor 2, p = < .001, Factor 3, p = Age ( Factor 1, p = < .001, Factor 2, p = < .001, Factor 3, p = < .001)< .001)

Gross family income ( Factor 1, p = .015, Factor 2, p = .001, Gross family income ( Factor 1, p = .015, Factor 2, p = .001, Factor 3, was not significant).Factor 3, was not significant). Relationship happiness ( Factor 1, p = < .001, Factor 2, p = Relationship happiness ( Factor 1, p = < .001, Factor 2, p =

< .001, < .001, Factor 3, p = < .001).Factor 3, p = < .001).

There was a There was a positivepositive relationship between atypical depression (DMDS) relationship between atypical depression (DMDS) factors and the following risk factors:factors and the following risk factors:

Comorbid medical conditions ( Factor 1, p = < .001, Factor 2, p Comorbid medical conditions ( Factor 1, p = < .001, Factor 2, p = .001, = .001,

Factor 3, p =.006).Factor 3, p =.006). Having relatives who were depressed ( Factor 1, p = .034, Having relatives who were depressed ( Factor 1, p = .034, Factor 2, p = .031, Factor 3, p =.002). Factor 2, p = .031, Factor 3, p =.002).

The forth hypothesis, There will be a significant relationship The forth hypothesis, There will be a significant relationship between known depressive risk factors and atypical depression, was between known depressive risk factors and atypical depression, was answered affirmatively for the risk factors previously noted.answered affirmatively for the risk factors previously noted.

Logistic Regression for DMDS Factors and Beck Suicide Risk Logistic Regression for DMDS Factors and Beck Suicide Risk Adjusted for Psychiatric Diagnoses, Age, Gender, and Gross Adjusted for Psychiatric Diagnoses, Age, Gender, and Gross

Family IncomeFamily Income 95.0% C.I. for Exp(B)

P-value Odds Ratio Lower Upper

Factor 1, Emotional Acting-In < .001 1.258 1.219 1.299

Factor 2, Emotional Acting-Out .221 .968 .919 1.020

Factor 3, Physical Acting-Out .560 .984 .933 1.038

Psychiatric diagnoses .714 1.031 .959 1.306

Age .075 1.013 .861 1.235

Gender .035 1.497 1.029 1.178

Gross family income .004 .804 .692 .933

R Squared = .563

The fifth hypothesis--There will be a significant positive relationship between atypical symptoms (DMDS) and suicide risk--was answered affirmatively for Factor 1, Emotional Acting-In, but not for Factor 2, Emotional Acting-Out, or for Factor 3, Physical Acting-Out.

Logistic Regression for DMDSLogistic Regression for DMDS Factors and Beck Suicide Risk Factors and Beck Suicide Risk Adjusted for Psychiatric Diagnoses, Age, Gender, Gross Family Adjusted for Psychiatric Diagnoses, Age, Gender, Gross Family

Income, and Typical Depression (CES-D 20)Income, and Typical Depression (CES-D 20) 95.0% C.I. for Exp(B)

P-value Odds Ratio Lower Upper

Factor 1, Emotional Acting-In < .001 1.237 1.195 1.281

Factor 2, Emotional Acting-Out .316 .973 .924 1.026

Factor 3, Physical Acting-Out .506 .982 .931 1.036

Psychiatric diagnoses .917 1.010 .841 1.213

Age < .001 1.033 1.016 1.051

Gender .047 1.467 1.006 2.139

Gross family income .006 .809 .697 .940

CES-D 20 .027 1.547 1.050 2.281 R Squared = .566

The six hypothesis--Atypical symptoms of depression will be positively related to suicide risk when controlled for typical depression--was answered affirmatively for Factor 1, Emotional Acting-In, but not for Factor 2, Emotional Acting-Out, or for Factor 3, Physical Acting-Out.

Gotland Scale Correlations and Gotland Scale Correlations and Factors 1, 2, and 3 of the Factors 1, 2, and 3 of the

DMDSDMDSFactor Pearson Correlation P-value

Factor 1, Emotional Acting-In

.794 < .001

Factor 2, Emotional Acting-Out

.584 < .001

Factor 3, Physical Acting-Out

.393 < .001

The seventh hypothesis--There will be a significant positive relationship between atypical symptoms (DMDS) and scores on the Gotland scale--was answered affirmatively

Implications for TheoryImplications for Theory

This study adds to the body of knowledge This study adds to the body of knowledge regarding gender and depression. By evaluating a regarding gender and depression. By evaluating a larger set of atypical depression symptoms (DMDS) larger set of atypical depression symptoms (DMDS) than had previously been used by Rutz (1999) with than had previously been used by Rutz (1999) with the Gotland Scale for Assessing Male Depression, the the Gotland Scale for Assessing Male Depression, the study added to our understanding of male-type study added to our understanding of male-type depression.depression.

The study expands our understanding of the The study expands our understanding of the

relationship between gender and atypical symptoms relationship between gender and atypical symptoms for depression. It addressed a gap in the research for depression. It addressed a gap in the research literature on gender and depression by clarifying literature on gender and depression by clarifying three separate factors or subscales that are three separate factors or subscales that are associated with depression and suicide risk. associated with depression and suicide risk.

Potential BiasPotential Bias There were selection biases since the study population was recruited through websites that were focused on people with an interest in gender issues and depression and thus not representative of the general population.

There were measurement biases since assessment of important variables such as depression and suicide risk were based on respondent’s answers to an on-line questionnaire. No outside, professional assessments were conducted.

Subjects were rated as being depressed or non-depressed based on their answers to a traditional depression scale (CES-D). Since one of the theoretical assumptions of the study was that depressed males might be missed using a traditional scale, this may have introduced additional measurement bias.

Recommendations for Future Recommendations for Future ResearchResearch

Future research will be needed to validate the Future research will be needed to validate the results of the study and to develop numerical scores for results of the study and to develop numerical scores for evaluating depression and suicide risk using the DMDS. evaluating depression and suicide risk using the DMDS.

It would be helpful to conduct research with a It would be helpful to conduct research with a general population to see if results were consistent in a general population to see if results were consistent in a population representative of the general community. population representative of the general community. Particular attention should be focused on including men Particular attention should be focused on including men and women from different ethnic groups, cultural and women from different ethnic groups, cultural backgrounds, economic levels, and age groups. backgrounds, economic levels, and age groups.

Recommendation for Clinical Recommendation for Clinical PracticePractice

The belief that depression is a disease primarily affecting women The belief that depression is a disease primarily affecting women has left too many males undiagnosed and untreated.has left too many males undiagnosed and untreated.

Many clinicians believe that depressed males are undiagnosed Many clinicians believe that depressed males are undiagnosed because the evaluation scales being used do not address the because the evaluation scales being used do not address the symptoms of depression that are more common in men.symptoms of depression that are more common in men.

Based on the results of the present study, it is recommended that Based on the results of the present study, it is recommended that clinicians use scales that include atypical symptoms such as those clinicians use scales that include atypical symptoms such as those found on the DMDS and Gotland Scales. found on the DMDS and Gotland Scales.

SurprisesSurprises

Though the study was originally designed for U.S. clients, men Though the study was originally designed for U.S. clients, men and women from 44 other countries participated.and women from 44 other countries participated.

Based on clinical experience it was expected that it would be Based on clinical experience it was expected that it would be difficult to recruit depressed males. This was not the case.difficult to recruit depressed males. This was not the case.

Only Factor 1, Emotionally-Acting In, was significantly related to Only Factor 1, Emotionally-Acting In, was significantly related to suicide risk when all three factors were used together.suicide risk when all three factors were used together.

There was actually a negative relationship between suicide risk There was actually a negative relationship between suicide risk and Factors 2 and 3, though the relationship was not significant.and Factors 2 and 3, though the relationship was not significant.

Thank You!Thank You!

The three of you, each in your own The three of you, each in your own way, have made this study much way, have made this study much better than it would have been.better than it would have been.