WASHINGTON (American Psychological Association) - More than 19 million Americans suffer from depression yearly and women are twice as likely as men to experience a major depressive episode. Depression may occur at any age during a woman's life with certain events like puberty, pregnancy, perimenopause, trauma, substance abuse and quality of relationships increasing the risk, according to the leading authorities on the etiologies and treatments for depression.

Furthermore, depression can occur among women from all educational, economic and racial and ethnic groups and the consequences can include an increased risk of suicide, morbidity from medical illness and risk for poor self-care and reduced adherence to medical regimes. These findings are among those summarized in a new report, Summit on Women and Depression: Proceedings and Recommendations, just published by the American Psychological Association, and reflecting the research reviewed by 35 internationally renowned experts from a variety of disciplines who contributed papers to the Summit. By reviewing the latest research on depression, the experts offer explanations on the possible causes of depression, suggest new research directions and recommend how current research findings can be incorporated into health policy and health care practices.

Major depression can impair a person's social and physical functioning even more severely than serious medical conditions such as hypertension, diabetes or arthritis, and can result in disability and significant loss of income, according to the research cited in the report. Furthermore, a World Health Organization Report examining "The Global Burden of Disease" found that "depression presents the greatest disease burden for women when compared with other diseases."

Some of the findings that examine the possible culprits of depression are:

• Genetic Factors: Based on data that major depression clusters in families, having a first-degree relative with depression (parent, sibling) is a risk factor for depression. Although results from family or twin studies have not been definitive in showing the exact contribution of genetics to depression. Evidence is accumulating that there is a genetic risk that may be different for women and men. For women, it will be particularly instructive to understand the interaction of genetic, hormonal and experiential factors in their heightened risk for depression.
• Sex Hormones: The link between increased rates of depression and puberty, mood and the menstrual cycle as well as mood and pregnancy suggests a role of gonadal hormones in depression. Specifically, changes in gonadal hormones, disturbances in the hypothalamic-pituitary-gonadal (HPG) axis and attendant effects on neuromodulators (e.g. serotonin) may all be key mechanisms in the initiation of depression. For example, pregnancy and delivery produce dramatic changes in estrogen and progesterone levels, as well as changes in the HPG axis, that may underlie postpartum depression.
• Life Stress and Trauma: Case-control and community-based studies have shown that more than 80 percent of major depression cases were preceded by a serious adverse life event. Traumatic events, such as childhood sexual abuse, adult sexual assault, male partner violence and physical illness also can lead to depression. Initial research has suggested that early trauma has a greater impact on risk for depression than later occurring trauma. Research has also indicated that women may be more likely than men to experience depression in response to a stressful event.
• Interpersonal Relationships and Cognitive Styles: One cognitive style more common in women than men that increases the risk for depression is ruminative thinking - repetitively and passively focusing on symptoms of distress and their possible causes and consequences. Ruminative thinking is also associated with longer and more severe episodes of depression. Current research has demonstrated that relationships are more paramount to women's self-concept than men and that women are more likely to experience stress in response to adverse events occurring in the lives of others and place their needs secondary to those of others. These interpersonal orientations illustrate major psychological differences between men and women that may help account for differences in vulnerability to depression.

Common treatments for depression in women include psychotherapies and antidepressants. Both psychotherapy and antidepressant treatments are equally effective for mild to moderate depression. In particular, with regard to psychotherapy, controlled clinical trials provide evidence for the efficacy of interpersonal and cognitive behavioral interventions. Other evidence suggests that some structured behavioral marital and family therapies are effective in treating depression. There is also some evidence that psychotherapy is useful in preventing relapse or recurrence of major depression in patients who had successfully been treated with antidepressants. Cognitive behavior therapy has been shown to have a lasting effect that prevents subsequent onset or return of symptoms regardless of whether medication was used.

Approximately 30-35 percent of individuals taking antidepressants do not respond to this form of treatment. Others seek alternative treatments. Alternative therapies include meditation and relaxation, exercise, acupuncture and herbal agents, such as St. John's Wort. Despite the popularity of these alternative treatments, many are untested or not sufficiently tested, which creates a need for research to examine the efficacy, effectiveness and safety of these agents, specifically for women in different age groups.

The contributors to this report recommend more effort to develop, evaluate and implement interventions that will prevent the recurrence of major depression in women at risk by virtue of a prior episode. Targeted prevention was also recommended, focusing on times of heightened risk for depression, such as adolescence. Preventive strategies in women about to become mothers were seen as needed particularly for women who had risk by virtue of previous depression, especially previous postpartum depression.

Development of services for women with depression should consider the importance of affordable access to care and trained primary care providers who can recognize symptoms and offer appropriate antidepressant medication along with referrals to mental health providers. For women with serious depression, rehabilitation services must be enhanced that include residential care and independent living supports.

Lastly, according to the report, public education campaigns are an invaluable source for improving recognition and understanding of major diseases. The contributors recommend different strategies to educate the public about depression in women, which could ultimately increase the number of women who seek treatment. Professional organizations, the media, federal agencies, foundations, private industries, labor unions and health care organizations can play a role in educating the public on depression.

Copyright 2002 The American Psychological Association. All rights reserved.