Family. Career. Caring for elderly parents. Coping with menstruation, pregnancy and menopause. As a woman, you certainly have plenty of issues to handle. But there's one more you might someday face: depression.

Depression affects about 12.4 million women in the United States each year. One in five women develop depression at some point in her life - double the number of men who do.

Depression

That gender gap goes beyond numbers. Some signs and symptoms of depression are different in women, too. Women, for instance, tend to have an increased appetite, weight gain and carbohydrate cravings when they develop depression. Men tend to lose appetite and weight. Women are also more likely than men to develop another mental illness along with depression, such as an anxiety or eating disorder.

What's behind that gender gap in depression? Chalk it up to a variety of biological, psychosocial and cultural factors unique to women. The interaction of all these factors can make you more vulnerable than a man to developing depression.

Biological factors in depression

The role of biology in depression includes genetic factors and mood changes associated with female sex hormones through various stages of your life. Before girls and boys enter adolescence, for instance, they have similar rates of depression. The gender gap doesn't start until puberty. Between the ages of 11 and 13, depression rates for girls jump dramatically. By age 15, girls are almost twice as likely as boys to develop depression.

Because this gender gap occurs with puberty and disappears after menopause, some scientists believe hormonal factors can increase a woman's risk for developing depression.

Premenstrual problems. Millions of women know all too well the changes in mood that can occur just before menstruation - PMS, or premenstrual syndrome. Twenty percent to 40 percent of women experience anxiety, irritability and sadness during PMS. Many women also experience physical symptoms just before menstruation, such as bloating, breast pain, fatigue, muscle aches or headache.

But a small percentage of women - 3 percent to 5 percent - have such severe premenstrual symptoms that their lives, jobs and relationships are disrupted. This condition - which hasn't been classified as a formal psychiatric diagnosis - is called premenstrual dysphoric disorder (PMDD).

Common symptoms of PMDD:

Markedly depressed mood Sense of hopelessness Anxiety, tension and feelings of being keyed up or on edge Tearfulness Increased sensitivity to personal rejection Uncharacteristic anger or irritability and increased conflicts with others Decreased interest in usual activities Difficulty concentrating Lethargy, fatigue or lack of energy Change in appetite and sleep patterns Feelings of being overwhelmed or out of control

Talk to your doctor if you experience any of these symptoms. Your doctor might check for underlying physical problems, such as anemia or fibromyalgia.

Researchers are studying what makes some women susceptible to PMDD. Some say it might stem from an abnormal response to normal hormonal changes.

A group of antidepressant medications known as selective serotonin reuptake inhibitors (SSRIs) are often effective in treating symptoms of PMDD. You usually take these medications daily, but perhaps only during the 2 weeks before menstruation begins, when PMDD typically occurs. Other treatments for PMDD include increased exercise, dietary changes, relaxation techniques and psychotherapy. Your doctor can help determine which option or combination is best for you.

Pregnancy. Many women feel especially healthy and positive during pregnancy. Increased production of certain hormones appears to give them a mental boost. Others don't share that experience.

About 10 percent of women develop depression during pregnancy. If you've had depression in the past, you're more likely to develop it again when you're pregnant. You're also at higher risk of depression during pregnancy if you have a history of PMDD, have limited social support, marital problems, ambivalence about being pregnant, or if you live alone.

Depression can sometimes be hard to diagnose when you're pregnant because symptoms can mimic natural changes that are common during pregnancy, such as appetite changes, fatigue and decreased sex drive. Again, talk to your doctor about changes in your mood or behavior.

Deciding how to treat depression when you're pregnant involves weighing the risks and benefits of various therapies with your doctor. Standard treatments include self-help strategies, medication, psychotherapy and other biomedical therapies, such as electroconvulsive therapy (ECT) and light therapy.

Choosing an antidepressant

Light therapy: Treatment for seasonal affective disorder

If your depression is mild, self-help strategies might work well. These include eating well, staying active, getting adequate sleep, managing anger, controlling stress and maintaining family and social support networks.

For mild to moderate depression, psychotherapy might help. If you have moderate to severe depression that's interfering with your ability to care for yourself, you also might benefit from antidepressant medications.

Many women prefer (and their doctors advise them) to avoid medications during pregnancy. But SSRIs are relatively safe for both you and your unborn baby. And the risks of not treating depression, especially its more severe forms, can be serious. They can include poor nutrition for you and your baby, inadequate prenatal care, low infant birth weight and premature birth. If your depression isn't treated, it can worsen or become chronic, putting your health at risk.

For women with severe depression that doesn't improve with other treatments, ECT might be an option. Although used infrequently during pregnancy, it, like SSRIs, also is relatively safe.

Postpartum depression. Although having a new baby is generally exciting, about half of women find themselves sad, angry, irritable and prone to tears soon after giving birth. These feelings (known as the baby blues) are normal and generally subside within a week or two.

But if they haven't, or if your symptoms are severe, you might have postpartum depression. This is a more serious condition that affects 10 percent to 25 percent of new mothers. It's most likely caused by a lack of or change in sex hormones, affecting activity in the regions of your brain that regulate mood.

Symptoms of postpartum depression usually develop within the first several weeks after giving birth. In addition to the typical symptoms of depression, you might also feel a lack of concern for yourself or your baby or excessive concern for the baby. You might have unreasonably high expectations of yourself or feel trapped. Or you might feel inadequate and question your ability to be a parent.

You're at increased risk of postpartum depression if you:

Have had depression in the past Had depression during pregnancy Have marital problems Experience difficult life events during pregnancy Lack a social support system Treatment for postpartum depression can include antidepressant medications, psychotherapy, or both. If you're breast-feeding, you might be concerned that medications can pass through your milk to your baby. Studies have shown that SSRI medications don't have adverse effects on breast-fed infants, but more research is still needed to assess possible long-term effects. Estrogen supplements also may be effective in treating postpartum depression.

Some women develop postpartum psychosis, a severe but rare form of depression that requires prompt medical treatment.

Women who have a miscarriage or whose infant dies are also at risk of developing depression. It's natural to feel grief after a loss. Grief and depression are similar in many ways: feelings of sadness, lack of interest in usually pleasurable activities, and problems with eating and sleeping. But while grief is a normal and healthy process, depression is not. Grief typically lasts up to a year. If your grief is severe or lasts longer, it might be complicated by depression.

Menopause and depression. The risk of depression continues as you begin menopause. Signs and symptoms of menopause generally start while you're still menstruating and may persist for up to a year after menstruation has stopped. This transitional time, when hormone levels often fluctuate, is called perimenopause. During perimenopause, many women experience a variety of changes in body function and emotions, including hot flashes, sleep difficulties and mood swings.

Menopause and perimenopause themselves don't cause depression. But women who are at increased risk of depression because of other biological or life issues ? health problems, divorce, caring for elderly parents, for example ? might be more vulnerable to depression during their menopausal and perimenopausal years.

Hormone replacement therapy (HRT), which is commonly prescribed to relieve symptoms associated with menopause, might improve mood in women with mild depression. However, the Women's Health Initiative study reported that women taking a certain combination of estrogen and progestin might be at a higher risk of breast cancer, heart attacks, stroke and blood clots. Talk to your doctor about the pros and cons of using HRT to treat your depression.

Hormone replacement therapy alone generally isn't enough to treat moderate to severe depression. In that case, antidepressant medication and psychotherapy might be more helpful.

Social and cultural factors in depression

It's not just biology that accounts for the higher rate of depression in women. Social and cultural stresses play a role, too. Although these stresses also occur in men, it's usually at a lower rate. Women are more likely than men to shoulder the burden of both work and family responsibilities, for instance. They're also more likely to have lower incomes, be single parents and have a history of sexual or physical abuse. Unequal power and status. In general, U.S. women earn less money than men do. Single women with children have one of the highest poverty rates in the United States. Low socioeconomic status brings with it many concerns and stresses, including uncertainty about the future and less access to community and medical resources. Minority women might also face added stress from racial discrimination. These issues can make you feel as if you don't have control over your life. That, in turn, can contribute to feelings of passivity, negativism and lack of self-esteem, which all increase your risk of depression.

Work overload. Many women work outside the home but still handle the bulk of domestic chores. That means they often log more hours each week than men attending to the needs of others. Many women also find themselves dealing with the challenges and stresses that can accompany single parenthood. In addition, many find themselves caregivers sandwiched between generations: caring for their young children while also caring for sick and older family members. These kinds of stresses might make you vulnerable to depression.

Sexual and physical abuse. Women who were molested as children are more likely to experience depression at some point in their lives than those who weren't molested. Women who were raped as teenagers or young adults also have a higher incidence of depression. Although sexual abuse also occurs in boys and young men, it's more common among girls and young women.

Adult women can also experience domestic abuse (severe or ongoing physical violence, mental abuse, or both) from a partner, a spouse or another family member. Sexual and physical abuse can result in loss of self-esteem and self-worth, putting women at risk for depression and other conditions, such as post-traumatic stress disorder.

Psychological factors. Women and men may learn to handle emotions in different ways and to cope differently with stress. Some experts suggest that because of social and cultural factors, women are less inclined than men to act on their problems and more inclined to dwell on them.

With help comes hope

Although it might seem as if these biological, social, cultural and psychological issues all weigh against you, women generally respond well to treatment for depression. With the right treatment, depression improves in about eight out of 10 women.

Even severe depression often can be successfully treated; although that can be hard to believe that when you're depressed. But believing that your condition is hopeless or incurable is a classic symptom of the depression itself.

Don't let those feelings stop you from getting professional help. You might be more likely than a man to develop depression, but you don't have to simply learn to live with it.

© 1998-2003 Mayo Foundation for Medical Education and Research (MFMER). All rights reserved. A single copy of these materials may be reprinted for noncommercial personal use only. Some people say they're depressed when they're feeling sad, lonely, down or dejected. But depression as a medical condition is more than a passing case of the blues. Depression can be debilitating, affecting all aspects of your life, including relationships, jobs, finances, and even your physical health.

Depression has the following features:

Your depressed mood lasts at least 2 weeks, and often much longer

You have specific symptoms related to mood, behavior, thinking and outlook, including sadness, hopelessness, difficulty concentrating or making decisions, loss of sex drive, lack of energy, social withdrawal, and problems on the job. You might even have thoughts of death or suicide.

~ Your ability to function on a daily basis is impaired

~ You require medical or psychological treatment, or both

~ 20 percent of women experience depression at some point in their life, compared with 10 percent of men

~ Women with depression are more likely to experience increased appetite, weight gain and carbohydrate cravings

~ Women are more likely to develop seasonal depression

~ Women are more likely to develop another mental disorder, such as an anxiety or eating disorder, along with depression

~ Women are three times more likely to attempt suicide, but men are more likely to die by suicide

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