Psychological Bulletin Copyright 1987 by the American Psychological Association, Inc.

1981. Vol. 101. No. 2, 259-282 0033-2909/87/J00.75

Sex Differences in Unipolar Depression: Evidence and Theory

Susan Nolen-Hoeksema
University of Pennsylvania

A large body of evidence indicates that women are more likely than men to show unipolar depression.
Five classes of explanations for these sex differences are examined and the evidence for each class is
reviewed. Not one of these explanations adequately accounts for the magnitude of the sex differences
in depression. Finally, a response set explanation for the sex differences in depression is proposed.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

According to this explanation, men are more likely to engage in distracting behaviors that dampen
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their mood when depressed, but women are more likely to amplify their moods by ruminating about
their depressed states and the possible causes of these states. Regardless of the initial source of a
depressive episode (i.e., biological or psychological) men's more active responses to their negative
moods may be more adaptive on average than women's less active, more ruminative responses.

The epidemiology of a disorder can provide important clues Background on the Affective Disorders
to its etiology. When a disorder only strikes persons from one
geographical region, one social class, or one gender, we can ask According to the third edition of the Diagnostic and Statisti-
what characteristics of the vulnerable group might be making cal Manual of Mental Disorders (DSM-IIJ; American Psychiat-
its members vulnerable. ric Association, 1980), the common symptoms of depression
A frequent finding in epidemiological studies of mental disor- include loss of motivation, sadness, anhedonia, low self-esteem,
ders is that women are more prone to unipolar affective disor- somatic complaints, and difficulty in concentrating. The oppo-
ders than are men (Boyd & Weissman, 1981; Weissman & KJer- site of depression is mania. Manic symptoms include greatly
man, 1977). A number of different explanations have been pro- increased energy, racing thoughts, pressured speech, wild and
posed to account for women's greater vulnerability to extravagant behaviors, and grandiosity. Persons who suffer
depression. Previous reviews of these explanations (e.g., Weiss- manic episodes typically also suffer episodes of depression,
man & Klerman, 1977) have been quite brief and uncritical. whereas the majority of persons who suffer depressive episodes
In this article, the evidence for sex differences in unipolar never experience mania. Thus in DSM-III, the affective disor-
depression first is summarized, then the most prominent expla- ders are broken down into bipolar affective disorder, which is
nations proposed for these sex differences are discussed in de- characterized by alternating episodes of mania and depression,
tail. These explanations include those attributing the differ- and unipolar depression.
ences to the response biases of subjects, as well as biological, To date, almost all of the discussion of sex differences in de-
psychoanalytic, sex role, and learned helplessness explanations. pression has been concerned with sex differences in unipolar
Although most of the proposed explanations for sex differ- depression. It has been generally assumed that there are no sex
ences in depression have received some empirical support, not differences in bipolar disorder (e.g., Boyd & Weissman, 1981;
one of them has been definitively supported and not one as yet Weissman & Klerman, 1977). Yet in a review of the literature
accounts for the magnitude of sex differences in depression. In on bipolar disorder, Clayton (1981) showed that women pre-
the final section of this article it is suggested that differences in dominate among persons given the diagnosis of bipolar disorder,
the ways that men and women respond to their own depressive as well as among those with unipolar depression. The only ex-
episodes, whatever the origin of these episodes, may be an im- planation that has been offered for sex differences in bipolar
portant source of the sex differences observed in depression. disorder is the suggestion of Winokur and others (see Gershon
& Bunney, 1976; Winokur & Tanna, 1969) that both bipolar
and unipolar affective disorder are associated with genetic ab-
This work was supported by a National Science Foundation Graduate normalities linked to the female chromosomes. (This explana-
Fellowship to Susan Nolen-Hoeksema, U.S. Public Health Service tion is reviewed in the section on Biological Explanations.) Be-
Grant MH-19604 to Martin E.P. Seligman, and U.S. Public Health Ser- cause each of the other explanations of sex differences in depres-
vice Grant MH-40142 to Martin E.P. Seligman, Joan S. Girgus, and sion reviewed here refers only to sex differences in unipolar
Susan Nolen-Hoeksema.
depression, the data review focuses on studies of unipolar de-
The author thanks Martin E.P. Seligman, Jonathon Baron, Christo-
pression.
pher Peterson, and three anonymous reviewers for their very helpful
comments on earlier drafts of this article. The DSM-III divides unipolar depression into major depres-
Correspondence concerning this article should be addressed to Susan sive disorder (MDD) and dysthymic disorder (DD). The diag-
Nolen-Hoeksema, who is now at the Department of Psychology, Stan- nosis of MDD is given to patients who have the acute experience
ford University, Jordan Hall, Building 420, Stanford, California 94305. of severe depressive symptoms for a period of 2 weeks or more.

259
 260 SUSAN NOLEN-HOEKSEMA

Table 1
DSM-III Categories for Unipolar Depression and the Corresponding DSM-II and ICD-9 Labels

Major depressive disorder subtypes

With Without Dysthymic

Labels Unspecified melancholia melancholia With psychotic features disorder

DSM-II Manic-depressive Involutional Depressive Involutional melancholia; Depressive

illness, depressed melancholia neurosis psychotic depressive neurosis
type reaction
ICD-9 Manic-depressive Endogenous Reactive Depressive psychosis; Neurotic
reaction, depressed depression; depression psychotic depression; depression
type involutional reactive depressive
melancholia psychosis; psychogenic
depressive psychosis
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Note. DSM-II and DSM-III: Diagnostic and Statistical Manual of Mental Disorders (2nd ed., 3rd ed; American Psychiatric Association, 1968,
1980). ICD-9: The International Classification of Diseases (9th ed.; World Health Organization, 1980).

There are two subtypes of MDD. Major depressive disorder portant to look at both treated cases of depression and surveys
with melancholia is characterized by marked anhedonia, the so- of untreated depressive symptoms in any investigation of the
matic symptoms of depression (e.g., early morning wakening, epidemiology of depression. With regard to the explanations for
psychomotor retardation), and extreme guilt. The subclass sex differences in depression reviewed here, some of the expla-
"MDD with psychotic features" is used when the patient shows nations are more applicable either to severe depressions or to
gross impairment in reality testing. The diagnosis of DD is moderate levels of depression. Thus, in the present review, stud-
given to a person who chronically experiences moderate-to-se- ies of treated cases of depression and community studies of de-
vere depressive symptoms for at least a 2-year period. The pression are reviewed separately.
DSM-III classification of depressive disorders departed in a Very few of the studies described in this article were designed
number of ways from its predecessor, the DSM-II, and from the specifically to measure sex differences in depression. Most of
classification system used outside the United States, the Inter- the studies were general surveys of psychopathology in particu-
national Classification of Diseases (/CD; World Health Organi- lar geographical areas. One goal of this review was to produce
zation, 1980). So that studies using different classification sys- summary statistics describing the magnitude of the sex differ-
tems can be more easily compared, Table 1 lists the types of ences in depression across studies (after M.L. Smith & Glass,
depression identified by DSM-III and matches these labels with 1977). Rachman and Wilson (1980) have raised objections to
the most closely corresponding categories in the DSM-II and such meta-analyses, because differences in the quality of meth-
ICD systems. odologies vary greatly across studies. Thus, the conclusions re-
garding sex differences in depression drawn here are based only
Evidence for Sex Differences in Unipolar Depression on studies that meet the following criteria for adequate method-
ology: (a) Standardized assessment procedures and/or stan-
There are two sources of data on rates of depression in men dardized diagnostic systems are used to identify depression in
and women: records of persons treated for diagnosed affective a sample, (b) sample sizes are reasonably large (i.e., over 50), (c)
disorders and surveys of the general population in which re- the selection of the sample was reasonably random, and (d) data
spondents are asked about symptoms of depression they are ex- on unipolar depression are presented separately from data on
periencing. Many clinicians and researchers argue that clini- bipolar depression. Some studies that did not meet these cri-
cally severe levels of depression and subclinical levels of depres- teria are reviewed separately, because they provide the only
sive symptoms are two distinct types of depression, with available data on depression in certain countries outside the
different characteristics, causes, and courses (cf. Depue & Mon- United States.1
roe, 1978). From this viewpoint, studies in which self-report
questionnaires are used to detect depression in a community
Treated Cases of Depression
sample tell us nothing about the epidemiology or etiology of
true depressive disorders. Others argue that clinical depression Table 2 summarizes the data from the methodologically
and subclinical depression are simply two points along a contin- strong studies of treated cases of depression in the United
uum of severity in depressive symptoms. In support of this ar- States. Whenever possible, the rates of depression in women and
gument, Hirschfeld and Cross (1982) found that clinical and men in each study were adjusted for the number of women and
subclinical depressions shared many of the same psychosocial men who participated in the study. All but three of the ratios
risk factors, such as a high number of bad life events. Hirschfeld listed in Table 2 indicate that significantly more women than
and Cross (1982) and Boyd and Weissman (1981) point out, men were given a diagnosis of depression. The mean female-to-
however, that factors such as socioeconomic status, geographic
setting (rural vs. urban residence), and sex role stereotypes can
affect help-seeking behavior. From this viewpoint, then, it is im- 'The reader may obtain a list of omitted studies from the author.
 SEX DIFFERENCES IN DEPRESSION 261

Table 2
Studies of Treated Cases a/Depression in the United States

Study Diagnosis F:M Comments

Williams &Spitzer( 1983) Major depression 2.3" Diagnoses given in the field trials for the DSM-1II
Dysthymic disorder 1.9"
Faden(1977) Depressive neurosis 1.4** All admissions to inpatient psychiatric services in
Psychotic depression 0.8'* the United States, 1974-1975
Involutional meloncholia 1.5**
All affective disorders 1.3**
Rosen, Bahn, & Kramer ( 1 964) Depressive reaction 1.6** All admissions to outpatient psychiatric services
Psychotic depression 1.4** in the United States, 1961-1962
Pederson, Barry, & Babigian Psychotic depression 1.8** All admissions to inpatient and outpatient
(1972) psychiatric services in Monroe County, NY,
1961-1962
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Lemkau, Tietze, & Cooper Depressive reaction 2.2 Admissions to a Baltimore hospital, 1936. Only
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(1942) 1 1 women and 5 men were given this diagnosis

S. [Link](1966) Depressive reaction 4.6" Admissions to a Massachusetts Mental Health
Center, 1965
Weissman, Sholomskas, Current or former depression 4.0** Outpatients who had a Raskin Scale score of 7 or
Pottenger, Prusoff, & Locke above. Sample excludes patients also given the
(1977) diagnosis of alchoholism
Slangier & Printz ( 1 980) Major depression 0.8 Students at the University of Washington
Dysthymic disorder 1.7*

Note. F:M is the ratio of females to males, corrected for the number of females and males in the sample, if possible. Chi-squares were calculated to
test for sex differences in the rates of disorder.
a
The chi-square could not be calculated because of insufficient data.

male ratio across all studies in Table 2 was 1.95:1. Thus, across because of the low numbers of men and women given the diag-
all studies of treated depression in the United States reviewed nosis.
here, nearly twice as many women as men have been diagnosed The only other study in which women did not outnumber
as depressed. A (test (R. Rosenthal, 1978) performed to test men among depressives was that reported by Slangier and
the null hypothesis that the average female-to-male ratio across Printz (1980). Slangier and Printz's (1980) data are from diag-
studies would be 1:1 yielded a tf 14) = 3.26 (p < .01), indicating noses given to University of Washington students seen in the
that the observed sex differences in rates of depression were sta- university's psychology clinic. Nineteen of the 320 women in
tistically significant. this sample and 14 of the 180 men were diagnosed as having
Williams and Spitzer (1983) report the only large study to MDD (Ihe difference was nonsignificant). As we shall see later,
date of the rates of treated depressive disorders according to the studies of depressive symptoms reported by college students on
DSM-III classification system. In the field trials for the DSM- questionnaires also have found no sex differences in the level of
III, clinicians in many different treatment settings across the symptoms. However, note thai in Slangier and Prinlz's study
United States used DSM-III criteria to diagnose their patients. significantly more women than men were given the diagnosis of
The female-to-male ratios of 2.1 and 1.9 for MOD and DD, DD(p<.05).
respectively, indicate a clear and significant preponderance of The methodologically stronger studies of trealed cases of de-
women among depressives (chi-square statistics for both ratios pression outside Ihe United Slates are summarized in Table 3.
were significant at p < .01). The mean female-to-male ratio in these studies was 2.39,
There are three studies in Table 2 in which women do not t( 14) = 7.03, p < .01, with all bul one (Halevi, Naor, & Cocha-
significantly preponderate among depressives. In Faden's vy's [ 1969] sludy of depressive reactions in Israel) reporting sig-
(1977) report of all diagnoses of depression given to psychiatric nificantly more women than men diagnosed as depressed.
inpatients in the United States in 1974-1975, significantly Several of these studies report dala from psychialric registers,
more men than women were diagnosed as psychotically de- which are comprehensive records of all persons treated in psy-
pressed. Yet in both Rosen, Bahn, and Kramer's (1964) and chiatric institutions and private practice in a large geographical
Pederson, Barry, and Babigian's (1972) reports of psychiatric area. All bul one sludy (Gershon & Liebowitz, 1975) used the
diagnoses in large samples, significantly more women than men ICD criteria for diagnoses. Comparisons of the ICD and DSM-
were diagnosed as psychotically depressed. III systems are shown in Table 1. In Table 3, we see evidence
Lemkau, Tietze, and Cooper (1942) reported that 11 women thai women significanlly outnumber men among unipolar de-
and 5 men out of 3,337 psychiatric patients in a Baltimore hos- pressives in Denmark, Scolland, England, Wales, Australia,
pital in 1936 were given the diagnosis of depressive reaction. Canada, Iceland, and Israel.
This yielded a female-to-male ratio for the diagnosis of 2.2, Table 4 presents data from studies thai only provided sum-
which appears substantial but was not statistically significant mary dala on all affeclive disorders or lhal used eilher idiosyn-
 262 SUSAN NOLEN-HOEKSEMA

Table 3
Studies of Treated Cases of Depression Outsidethe United States

Nation Study Diagnosis F:M Comments

Denmark Weeke, Bille, Videbech, Dupont, & Depressive reaction 3.8* Psychiatric register, 1 960- 1 964
Juel-Nielsen(1975) Neurotic depression 3.0*
Scotland Baldwin (1971) Neurotic depression 2.4* Scottish mental hospital admissions, 1977
England and Wales Martin, Brotherson, & Chave (1957) Neurotic depression 1.7' Psychiatric register, 1949-1954
England Dean, Walsh, Downing, & Shelley Psychotic depression 1.8* Psychiatric register, 1976
(1981)
Australia Berah(1983) Neurotic depression 1.8* State and general hospital patients, 1978-198 1
Krupinski & Stoller ( 1 962) Psychotic depression 3.0* Admissions to a Victoria hospital, 1 95 1 - 1 952
Canada Canadian Bureau of Statistics (1970) Neurotic depression 2.2* First admissions to psychiatric services, 1967
Iceland Helgason(l977) Psychotic depression 2.9* Psychiatric register, 1966-1967
Israel Halevi, Naor, & Cochavy (1969) Reactive depression 1.3 Census of 41 psychiatric institutions, 1964
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Psychotic depression 1.8*

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Involutional melancholia 3.5*

All affective disorders 2.3*
Gershon & Liebowitz (1975) Unipolar depression 2.0* Inpatients at psychiatric hospitals
(Feigner criteria)

Note. F:M is the ratio of females to males, corrected for the number of females and males in the sample, if possible. Chi-squares were calculated to
test for sex differences in the rates of disorder.
* The chi-square could not be calculated because of insufficient data.
•[Link].

cratic criteria for diagnoses or small samples. The mean female- ing structured interviews or self-report questionnaires. Reviews
to-male ratio across these studies was 1.5, t(24) = 6.26, p < .01. of these studies follow.
Note that a number of the studies conducted in less modern
cultures did not find significant sex differences in depression. Community Studies of Depression
Some of these studies had serious flaws, however. The two stud-
Several questionnaires and interviews have been used in stud-
ies from India (Mohan, 1972; Rao, 1970) and the study of Nige-
ies of depression in U.S. samples. These include the Beck De-
ria (Ezeilo & Onyeama, 1980) were conducted in hospitals built
pression Inventory (BDI; Beck & Beck, 1972), the Center for
to accomodate 3-4 times more men than women. The data
Epidemiological Studies Depression Scale (CES-D; Radloff,
from Egypt (El-Islam, 1969), Iraq (Bazzoui, 1970), and Rhode-
1977), and the Zung Self-Report Depression Scale (SDS; Zung,
sia (Buchan, 1969) were based on the impressions of one or two
1965), all of which are self-report questionnaires. The origina-
psychiatrists, without the use of conventional diagnostic cri-
tors of each of these questionnaires have designated cutoff
teria. In addition, Bazzoui (1970) and Rao (1970) point out that
scores, and persons scoring above these cutoffs are considered
access to psychiatric treatment is more restricted for women
to be seriously depressed. In addition, there are structured in-
than for men in many nonmodern countries. So it is not clear
terviews, such as the Schedule for Affective Disorders and
that the rates of depression in men and women in these studies
Schizophrenia (SADS; Endicott & Spitzer, 1978) and the Diag-
illustrate a true absence of sex differences in depression in these
nostic Interview Schedule (DIS; Robbins, Helzer, Croughan, &
countries.
Ratcliff, 1981). Information gathered in these interviews is used
As mentioned earlier, the ratio of female to male depressives
to make diagnoses according to DSM-HI criteria or the similar
varies greatly from country to country. Mazer (1967) demon-
Research Diagnostic Criteria (Spitzer, Endicott, & Robins,
strated that in different cultures, criteria for diagnoses are 1978).
differentially weighted, and certain diagnoses are more fre- Studies that have used any of these instruments to measure
quently applied than others. Even so, there is a consistent ten- depression in the United States are summarized in Table 5.
dency for women to preponderate among depressives across a Most of the studies carried out in large, heterogeneous samples
wide variety of nations. show a significantly greater degree of depression among women.
The number of treated cases of a disorder does not represent The mean female-to-male ratio in the studies in Table 5 was
the true rate of a disorder in a population, because often only 1.62,«(17) = 6.82,p<.01.
the most severe cases of the disorder, or those persons most dis- Much higher rates of moderate-to-severe symptoms of de-
ruptive to society, or those in the upper socioeconomic classes pression in both men and women are found when self-report
are treated (Wing, 1976). Further, when psychiatric diagnoses inventories are used to detect depression than when structured
are relied on, idiosyncracies in the application of diagnostic cri- interviews are used to diagnose depressive disorders. Yet both
teria from psychiatrist to psychiatrist (or country to country) methods reveal large sex differences in depression. For example,
can confound the data. Myers et al. (1984) report a study in which a structured inter-
To avoid these problems and others, researchers have sought view, the DIS, was used to diagnose MDD and DD in a general
to measure the rate of depression in the general population, us- community sample. Myers et al. report that 4% of the women
 SEX DIFFERENCES IN DEPRESSION 263

Table 4
Weak Studies of Treated Cases of Depression Outside the United States

Nation Study Diagnosis F:M Comments

Canada Weissman&Klerman(1977) All affective disorders 1.7' Data from the World Health
Czechoslovakia All affective disorders 2. 1 " Organization Collaborative Study; rates
Denmark All affective disorders 1.8" of females and males with sub-types of
Finland All affective disorders 1.3" affective disorder were unavailable
France All affective disorders 1.6'
Norway All affective disorders 1.5"
Poland All affective disorders 1.4'
Sweden All affective disorders 1.8"
Switzerland All affective disorders 1.4"
England and Wales All affective disorders 1.8"
New Zealand All affective disorders 1.8'
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England Cooper, Kendell, Gurland, All affective disorders 1 .4 Admissions to a London hospital, n = 1 45
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Sartorius, & Farkas (1969)

New Zealand Christie (1968) All affective disorders 2.1* Patients given diagnosis of "affective
disorder"; n = 50; the diagnostic
criteria were unclear
The Netherlands Saenger(1968) Psychiatric ratings of 1.3 Persons admitted to a psychiatric hospital
severe depression and rated by psychiatrist, n = 289
Hong Kong Yap(1965) Affective disorder 1.1 Diagnoses given to 130 patients admitted
initial episode to a hospital
recurrent episodes 1.7* One-year follow-up of 62 patients
India Rao(1970) Endogenous depression 0.6* Patients treated by the author for
depression, n = 62
Mohan (1972) Affective psychosis 1.4 Patients institutionalized in a hospital
that primarily accommodates males,
n = 140
Egypt El-Islam (1969) Nonpsychotic depression 1.0 Patients seen by the author, n = 157; the
diagnostic criteria were unclear
Iraq Bazzoui(1970) Depression 1.2 Hospitalized patients (n = 42) and private
practice patients (n = 16); the
diagnostic criteria were unclear
Rhodesia Buchan(l969) Depression 1.1 Patients seen by the author, n = 77; the
diagnostic criteria and method of
patient selection were unclear
Nigeria Ezeilo & Onyeama (1980) Psychotic depression 0.8 Discharge diagnosis for 969 patients; "no
Neurotic depression 1.6* conventional diagnostic inventories
available for use."
Kenya Vadher&Ndetei(1980) Nonpsychotic depression 2.3* Patients being treated with chemotherapy
for depression,« = 30

Note. F:M is the ratio of females to males, corrected for the number of females and males in the sample, if possible. Chi-squares were calculated to
test for sex differences in the rates of disorder.
' The chi-square could not be calculated because of insufficient data.
*p<.05. **p<.01.

interviewed were diagnosed as having had an MDD at some diagnosed depressive disorders in men and women in Myers et
time during the previous 6-month period, whereas 1.7% of the al's study, the female-to-male ratios in the two studies are nearly
men interviewed were given the same diagnosis (ratio = 2.4, identical.
p < .01). Women also significantly outnumbered men among The last four studies listed in Table 5 show no significant sex
adults, with a 6-month prevalence of DD in all age groups and differences in depression. The samples in these studies repre-
cities. The average percentage of women given this diagnosis sent subgroups of the American population, specifically, the Old
was 4%, whereas the average for men was 2% (ratio = 2.0, Order Amish (Egeland & Hosteller, 1983), university sludenls
p<.01). (Hammen & Padesky, 1977), bereaved adults (Bornslein, Clay-
Contrast these data with data from a study by Eaton and Ion, Halikas, Maurice, & Robins, 1973), and elderly adulls
Kessler (1981), in which a self-report inventory of depressive (Blazer & Williams, 1980). One of the most interesting of these
symptoms called the CES-D scale was completed by a nation- studies is Egeland and Hosteller's 6-year epidemiological study
wide sample of 2,867 adults. Eaton and Kessler report that 11% of affective disorders among Ihe Old Order Amish in Pennsylva-
of the men in this study and 21% of the women scored in the nia. The Old Order Amish are an ullraconservalive Proleslanl
severe range of the CES-D (i.e., 15 or above). This is a female- religious seel, whose members maintain a closed society sepa-
to-male ratio of 1.9 (p < .01). Thus, even though the rates of rated from Ihe modern world. Egeland and Hosletter eslab-
severe depressive symptoms in this study are five times those of lished conlacts within the Amish community who would in-
 264 SUSAN NOLEN-HOEKSEMA

Table 5
Community Studies of Depressive Symptoms in the United States

Study Criteria for "depressed" F:M Comments

Myers etal.( 1984) Major depression, diagnosed with the DIS 2.4*' DIS administered to 9,000 adults in St. Louis, MO;
Dysthymic disorder, diagnosed wilh Ihe DIS 2.0*' Baltimore, MD; and New Haven, CT.
Eaton&Kessler(198l) Scores > 15 on the CES-D 1.9" Nationwide sample of 2,867 adults
Frerichs, Aneshensel, & Clark Scores >15 on theCES-D 1.8* Los Angeles County adults, n = 1,003
(1981)
Radloff(1975) Scores > 15 on the CES-D 1.3* Kansas City blacks, n = 283
1.4** Kansas City whites, n = 876
1.8** Maryland whites, n - 1,638
Amenson & Lewinsohn (1981) SADS Sample of 998 adults living in Oregon
Current unipolar depression 2.3**
Past depressive episodes 1.3"
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Weissman & Myers (1978) SADS SADS administered lo 511 adults in New Haven, CT
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Current major depression 1.6

Current minor depression 1.2
Lifetime risk, major depression 2.1"
Lifetime risk, minor depression 2.0*
Blumen thai (1975) Scores in the severe range on the Zung SDS 1.8" Sample of 320 married adults
Egeland & Hosteller (1983) SADS: major depression 1.0 Community of 8,186 Old Order Amish
Hammen & Padesky (1977) Scores in the severe range on the BDI 1.1 University students, n = 2,272
Bornstein, Clayton, Halikas, Feighner criteria 1.1 Sample of 92 bereaved adults
Maurice, & Robins (1973)
Blazer & Williams (1980) DSM-III criteria for major depression 1.2 Structured interview given to 997 elderly persons

Note. F:M is the ratio of females to males, corrected for the number of females and males in the sample, if possible. Chi-squares were calculated to
test for sex differences in the rates of disorder. BDI = Beck Depression Inventory (Beck & Beck, 1972). CES-D = Center for Epidemiological Studies
Depression Scale (Radloff, 1977). DIS = Diagnostic Interview Schedule (Robbins, Helzer, Croughan, & Ratcliff, 1981). DSM-III = Diagnostic and
Statistical Manual of Mental Disorders (3rd ed.; American Psychialric Association, 1980). SADS = Schedule for Affective Disorders and Schizophre-
nia (Endicolt & Spitzer, 1978). SDS = Self-Report Depression Scale (Zung, 1965).
*p<.05. **/><.OI.

form them when a member of the community appeared "dis- sex differences among students treated for depression. One pos-
turbed." This individual would then receive a SADS interview sible explanation for the sex differences in young adults is that
conducted by Egeland or her colleagues, with diagnoses as- depression has an earlier onset in men. That is, it may be that
signed when indicated. Over a 5-year period, 21 women and 20 those men who in their lifetimes will become depressed usually
men were given the diagnosis of major depression, indicating do so in young adulthood. After the early 20s, however, the inci-
no sex differences in the rates of unipolar depression in this dence of male depression may decline. Women, on the other
culture. hand, may be as vulnerable as men to depression in young
The methods Egeland and her colleagues used to ascertain adulthood but never show the decrease in vulnerability to de-
cases of mental disorder may have lead to the underdetection of pression with age that men show. Data from several studies do
some disorders, however. Because the criterion for being given not support this explanation. For example, Winokur, Tsuang,
a SADS interview by the researchers was that an individual and Crowe (1982) found no significant differences between men
showed clear disruption in his or her role functioning, disorders and women in the median age of onset of unipolar depression
in which the individual quietly suffers, such as depression, may in a sample of 225 hospitalized depressives. In addition, Spicer,
have gone unnoticed. This hypothesis is supported by the fact Hare, and Slater (1973) found that first admissions for depres-
that Egeland found rates of affective disorder that were one-half sion in England and Wales peaked at an earlier age for women
those found in other studies. In addition, Egeland found equal than for men. Thus, it does not appear that the absence of sex
rates of bipolar and unipolar depression among the Amish, differences in depression among college students can be ex-
whereas most studies find the rates of unipolar depression to be plained by a tendency toward earlier onset of depression
10 times the rates of bipolar depression (Clayton, 1981). The in men.
symptoms of mania would be more likely to disrupt role func- Another possible explanation for the absence of sex differ-
tioning than the symptoms of depression. In general, the dis- ences in depression in college students is that only women with
crepancies between Egeland's data and data from other studies exceptionally good mental health (e.g., who are not depressed)
suggest that unipolar depression may have been underdiag- go to college. On the other hand, men who go to college may
nosed. In particular, because Amish women spend most of their be more representative of the mental health of men in general,
time in the home, detection of moderate-to-severe levels of de- perhaps because men are expected to go to college more than
pression in women may have been very difficult. women are, so even depressed men go to college. This hypothe-
The survey study of university students by Hammen and sis is supported by data from Radloff's (1975) study on levels
Padesky (1977), which found no sex differences in depression, of depression in a group of 18- to 25-year-olds that included
is in line with Slangier and Printz's (1980) data indicating no persons not attending college as well as persons attending col-
 SEX DIFFERENCES IN DEPRESSION 265

lege. Radloff found that the mean depression scores of women Note that two of the studies in Table 6 in which there clearly
in this group were significantly higher than men's scores. Sim- are no sex differences in depression, that is, Leighton et al.'s
ilarly, Faden (1977) found that among a group of 18- to 24- (1963) study of a tribe in Nigeria and Bash and Bash-Liechti's
year-olds that included both college students and people not in (1969) study of rural Iran, were conducted in nonmodern cul-
college, significantly more women than men were treated for tures. Further, the rate of depression in these nonmodern areas
depression in inpatient psychiatric units in the United States. was much lower than the rate in urban areas of Iran or in the
Thus, it appears that the absence of sex differences in depres- other African studies, which were conducted near cities. This
sion in college students does not generalize to the rest of that age trend might reflect a self-selection among depressives to move
group not in college. This supports the hypothesis that college into the city, where they could obtain treatment. On the other
women are self-selected for positive mental health. hand, it could reflect negative influences of urbanization and
Another subgroup of the American population in which no modernization on mental health. Recall that the rate of affective
sex differences in rates of depressive symptoms often are found disorder in Egeland and Hostetter's (1983) study of the Old Or-
is the bereaved. For example, Bornstein et si. (1973) used the der Amish, a strictly nonmodern culture, also was much lower
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Feighner criteria (Feighner et al., 1972) to diagnose depression than the rate of depression in the general U.S. population.
This document is copyrighted by the American Psychological Association or one of its allied publishers.

in a sample of 65 women and 27 men recently bereaved. One Summary. Women are diagnosed as having a depressive dis-
month after their spouse's death, 33% of the men and 36% of order significantly more frequently than are men and, with a
the women met the criteria for depression. One year later, 19% few exceptions, report more depressive symptoms than do men
of the men and 17% of the women continued to be depressed. in most geographical areas of the world. If the ratios for all the
In a review of the literature on the physical and mental health stronger studies of depression (i.e., those in Tables 2, 3, 5, and
of bereaved men and women, Stroebe and Stroebe (1983) con- 6) are averaged, the mean female-to-male ratio is 2.02, ((57) =
cluded that women do not show as much of a decline in physical 8.88, p < .01. The populations in which sex differences in de-
and mental health after the death of a spouse as men. Stroebe pression have not been consistently found include university
and Stroebe suggest that women are trained to expect the death students, the bereaved, the elderly, the Old Order Amish, and
of their spouse, especially in old age, more than men are. Thus, residents of some rural, nonmodern cultures.
bereavement may not be as much of a shock for women as for
men. In addition, men are not accustomed to having to cope
Explanations for the Sex Differences in Depression
with the daily chores of life, so when they lose their spouses,
their daily lives are more disrupted. Several biological and psychosocial explanations have been
Finally, some studies find no sex differences in depression proposed to account for the sex differences in depression. Weiss-
among older Americans. For example, Blazer and Williams man and Klerman (1977) briefly discussed many of these expla-
(1980) administered a structured interview to 997 elderly per- nations. In this review, the evidence for and against each expla-
sons and found that the rates of MOD in men and women were nation for the sex differences in depression is evaluated, and
not significantly different. Similarly, Ensel (1982) found no sex conclusions are reached about the level of support for each ex-
differences in mean scores on the CES-D scale for persons over planation. First, however, we must examine the possibility that
the age of 50. However, Radloff (1975) did find that women over the sex differences in depression are artifacts of differences in
the age of 65 had higher mean CES-D scores than men over 65. the socioeconomic status of men and women, or differences in
Thus these data on sex differences in depression in the elderly the willingness of men and women to show the common symp-
are mixed. In those studies that did not find sex differences, it toms of depression.
appears that rates of depression in men increase substantially
with age, whereas rates of depression in women remain the
Artifact Explanations
same with age or decline slightly. Similarly, in the studies of be-
reaved adults (described previously), the absence of sex differ- Artifact Explanation 1: It is an income effect, not a gender
ences in depression appears because the levels of depression in effect. By most indicators, women's economic status is lower
men rise with bereavement to match those of women. than men's (U.S. Department of Commerce, Bureau of the
In sum, seven of the studies in Table 5 indicated that women Census, 1985). Women also do not attain the same levels of
are depressed significantly more often than men, but four stud- education as men. It could be that the differences observed in
ies showed no sex differences in depression. These studies, how- rates of depression in men and women are the result of differ-
ever, were conducted in nonrepresentative samples of the Amer- ences in socioeconomic status instead of gender differences.
ican population, specifically: the Amish, university students, the Radloff (1975) and Ensel (1982) tested for this possibility by
elderly, and the bereaved. Excluding these studies, the female- comparing men's and women's mean scores on the CES-D, con-
to-male ratio for depressive symptoms in the general U.S. popu- trolling for income level, education level, and occupation. In
lation is 1.8:1. both of these studies, women still had more depressed mean
In Table 6, studies of depression in the general populations of CES-D scores than men after all these socioeconomic indicators
nations outside the United States that used standardized mea- were taken into account. These results suggest that observed sex
sures and diagnostic criteria are summarized. Again, although differences in depression are not simply the result of differences
the female-to-male ratio varied considerably from one study to in income.
the next, the average ratio of 2.08 (excluding Vadher & Ndetei's Artifact Explanation 2: Reporting biases. Some researchers
[1981] study) indicated that significantly more women than have been concerned that the sex differences in depression re-
men are depressed, ((12) = 4.15,p< .01. sult from men's unwillingness to admit to and seek help for
 266 SUSAN NOLEN-HOEKSEMA

Table 6
Community Studies of Depressive Symptoms in Countries Outside the United States

Nation Study Criteria for "depressed" F:M Comments

Sweden Essen-Moeller(1956) ICD: affective disorder 1.8* Structured interviews, n = 2,550

Essen-Moeller & Hagnell (1961) 1CD: affective disorder 3.0** Interviewed subjects from Essen-Moeller et
al. (1956) 10 years later
Denmark Sorenson & Stromgren ( 1 96 1 ) ICD: psychogenic depression and 3.5** Information taken from public records and
depressive neurosis interviews, n = 4,876
T. Fremming (1961; cited in ICD: affective disorder 2.0** Structured interviews, n = 4, 1 30
Helgason, 1961)
Iceland Helgason(1961) ICD: current affective disorder, 1.8*» Structured interviews, n = 3,843
lifetime risk of affective disorder 1.8**
Australia Henderson, Duncan-Jones, Byrne, ICD: current depression 2.6 Structured interviews (PSE), n = 1 57
Scott, &Adcock( 1979)
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Byrne (1980) Scores in the depressed range on the 1.4* Same sample as Henderson et al. ( 1 979)
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Zung Self-Report Depression

Scale
Uganda Orley&Wing(1979) ICD: affective disorder 1.6 Structured interviews (PSE), n = 206
Kenya Vadher&Ndetei(1980) ICD: affective disorder 18:0 Structured interviews (PSE), n = 56
Nigeria Leightonetal. (1963) DSM-II: neurotic depression 0.9 Structured interviews with 262 members
of the Yoruba tribe
Iran
Urban Bash &Bash-Liechti( 1974) ICD: affective disorder 3.6" Structured interviews, n = 928
Rural Bash & Bash-Liechti ( 1 969) ICD: affective disorder 1.0 Structured interviews, n - 482

Note. F:M is the ratio of females to males, corrected for the number of females and males in the sample, if possible. Chi-squares were calculated to
test for sex differences in the rates of disorder. DSM-II = Diagnostic and Statislical Manual of Mental Disorders (2nd ed.; American Psychiatric
Association, 1980). ICD = The International Classification of Diseases (World Health Organization, 1980). PSE = Present State Examination
(Wing, 1976).
*p<.05. **p<.01.

depressive symptoms (Padesky & Hammen, 1977; Phillips & relations between the three response bias variables and the mental
Segal, 1969). This hypothesis holds that men and women expe- health scores were controlled for, the sex differences in mental
rience depressive symptoms equally frequently, and to the same health scores were even larger. These studies were replicated in sim-
degree, but because depressive symptoms are perceived as femi- ilar studies by Gove and Geerken (1976) and Gove, McCorkel, Fain,
nine (Chevron, Quinlan, & Blatt, 1978), men are less likely to and Hughes (1976).
admit to them. The claim that women are more willing to seek psychother-
A number of studies have failed to support this hypothesis. apy for depression has also not been consistently supported in
For example, King and Buchwald (1982) predicted that if this the literature. Women do go to medical professionals more of-
artifact hypothesis was true, men should be less willing than ten than men (Faden, 1977). In addition, Padesky and Hammen
women to disclose symptoms in a public disclosure condition (1977) report a study of college students in which the level of
(e.g., an interview with the researcher), whereas fewer sex depressive symptoms at which women said they would seek psy-
differences should be found in a private (anonymous) disclosure chotherapy was lower than the level at which men said they
condition. Instead, King and Buchwald found men no less will- would seek help. However, two studies of actual help-seeking
ing to disclose in the public condition than women, and neither behavior have found that men and women with similar levels of
sex was less willing to disclose symptoms in a public disclosure self-reported depressive symptoms were equally likely to seek
situation than in private. Bryson and Pilon (1984) have repli- psychiatric help or go to a general practitioner (Amenson &
cated these results. Both of these studies, however, used college Lewinsohn, 1981; Phillips & Segal, 1969). In addition, Amen-
students for subjects. Recall that there is no tendency toward son and Lewinsohn (1981) found that men and women with
sex differences in depressive phenomena in this population. equal levels of self-reported symptoms were equally likely to be
Clancy and Gove (1974) investigated the influence of three types diagnosed as depressed in a clinical interview.
of response bias on the endorsement of items on the Langner Mental In summary, the hypothesis that the lower rates of depression
Health Scale, which consists of 22 items representing psychological observed in men are due to men's unwillingness to admit to
and physiological symptoms of distress (Langner, 1962). These their depressive symptoms has not been consistently supported.
three variables were "perceived desirability" of the items, "need for Men appear to be just as likely to admit to and seek help for
social approval," and the tendency to "yea-say" or "nay-say." In their a given level of depression. Still, women appear to experience
random sample of 404 adults (not college students), Clancy and depression more commonly than men.
Gove found no significant sex differences in ratings of the undesir- Artifact Explanation 3: Kinds of symptoms. According to
ability of the mental health items or in need for social approval. this hypothesis, men and women are equally susceptible to de-
Women, however, were more likely than men to nay-say. Women pression, but depression in men often takes the form of "acting-
also had significantly higher scores on the Langner scale. When the out" behaviors instead of sadness, passivity, and crying, which
 SEX DIFFERENCES IN DEPRESSION 267

are symptoms commonly included in self-report inventories sion may be the result of biological characteristics unique to
(Hammen & Peters, 1977). In particular, it has been suggested women. Two general types of biological explanations for the sex
that the male equivalent of depression is alcoholism (Winokur differences in depression have been proposed. The first group of
& Clayton, 1967). Proponents of this argument point to statis- explanations arises from evidence that women are particularly
tics showing that twice as many men as women are diagnosed prone to depression during periods in which they experience
as alcoholics (e.g., Williams & Spitzer, 1983), and suggest that significant changes in hormone levels. Several investigators have
the rates of alcoholism in men make up for the absence of de- suggested that depression in women is brought about by
pression in men. This argument is boosted by evidence that in changes in the levels of estrogen, progesterone, or other hor-
cultures in which alcohol consumption is strictly prohibited, mones.
such as among the Amish, no sex differences in depression are The second group of biological explanations of the sex
found (Egeland & Hostetter, 1983). In addition, many studies differences in depression attributes the differences to a greater
find high rates of depressive symptoms among alcoholic men genetic predisposition to depression in women. According to
(cf. Petty & Nasrallah, 1981). these explanations, women are more likely to inherit the disor-
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Winokur and his colleagues (Cadoret & Winokur, 1974; Win- der, because the genetic abnormality that leads to depression is
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okur & Clayton, 1967; Winokur, Rimmer & Reich, 1971) ar- somehow linked to the chromosomes that determine gender.
gued that depression and alcoholism are genetically linked to Hormones and moods. It is widely believed that hormonal
each other, with depressive features linked to female chromo- fluctuations strongly affect moods in women. Women are be-
somes and alcoholic features linked to male chromosomes. Evi- lieved to be more prone to depression during the premenstrual
dence for a genetic link between depression and alcoholism period, the postpartum period, and menopause, each of which
comes from family history studies that show much higher rates is characterized by changes in the levels of a number of hor-
of depression in the families of alcoholics and of alcoholism in mones. Specifically, after the onset of puberty, levels of estrogen
the families of depressives than in comparison groups (Cadoret and progesterone rise and fall sharply during the menstrual cy-
& Winokur, 1974; Cotton, 1979). cle (Ganong, 1984). During the first 2 weeks of the cycle, arbi-
Yet there is evidence that depression is as likely a conse- trarily defined as the first 2 weeks after the onset of blood flow,
quence as a cause of alcoholism in men. Petty and Nasrallah levels of progesterone and estrogen remain quite low. Around
(1981), in a critical review of the literature on depression and the end of the first 2 weeks, the level of estrogen rises and peaks,
alcoholism, found a much greater tendency for depression to then declines again. Near the 21st day of the cycle, the level of
follow alcoholism, especially in men, than for alcoholism to fol- estrogen peaks again and the level of progesterone peaks for the
low the onset of depressive symptoms. Cadoret and Winokur first time. Then, during the last few days before the onset of the
(1974) report that in patients suffering from both depression next menstrual flow, the levels of both hormones drop precipi-
and alcoholism, most of the men reported becoming depressed tously, and remain low until after the menstrual flow.
at least 10 years after the onset of alcoholism. The alcoholics Levels of estrogen and progesterone also change dramatically
who did not become depressed tended to be periodic bingers during pregnancy, the postpartum period, and menopause.
rather than constant heavy drinkers. Cadoret and Winokur sug- During pregnancy, both estrogen and progesterone are pro-
gest that depression in male alcoholics is often due to the toxic duced in large amounts. Then, shortly after a woman gives birth
effects of chronic alcoholism.
(the postpartum period), her estrogen and progesterone levels
Even so, there is clearly some evidence that alcoholism and
drop sharply. Similarly, during menopause estrogen and proges-
depression often covary within families and within individuals,
terone production decline to very low levels and remain there
and that men tend to show more alcoholism whereas women
the rest of a woman's life.
tend to show more depression. This is not, however, evidence
If women commonly experience depression during these pe-
that alcoholism and depression are the same disorder or that
riods of hormonal change, this suggests that their greater vul-
alcoholism is a symptom of depression. Instead, these two dis-
nerability to depression in general may be the result of the nega-
orders can be considered two different maladaptive responses to
tive effects of changes or imbalances in female hormones on
difficult life circumstances. Societal restrictions against women
moods. The notion that depressions during periods of hor-
drinking excessively may protect women who are vulnerable
monal fluctuation are common is not well supported, however.
to alcoholism from developing the disorder. In the same vein,
Menopausal depression was once thought common, and early
certain societal demands on men may protect them against de-
DSM editions (Z>SM-/and DSM-II) called this type of depres-
pression. This is very different from saying that alcoholism is a
sion involutional melancholia. However, in the DSM-III, the
symptom of depression. Rather, one should say that both de-
category of involutional melancholia was excluded from the
pression and alcoholism could arise given environmental trou-
classification of affective disorders in response to the absence
bles, but societal demands result in sex differences in vulnera-
of evidence for a unique, endogenous type of depression that
bilities to each disorder.
typically arose in women during middle-to-late adulthood
In summary, there apparently is little justification for dis-
(Weissman, 1979; Winokur, 1973). Indeed, levels of self-re-
missing the observed sex differences in depression as simply due
to differences in men's and women's willingness to show the ported depressive symptoms seem to drop in women as they
common symptoms of depression. pass through menopause (Frieze, Parsons, Johnson, Ruble, &
Zellman, 1978).
Biological Explanations Estimates of the incidence of postpartum symptoms are high,
The pervasiveness of the sex differences in depression across ranging from 30% to 60% (Sherman, 1971). Yet the great major-
cultures suggests that women's greater vulnerability to depres- ity of women experiencing postpartum depressive symptoms
 268 SUSAN NOLEN-HOEKSEMA

recover fully from them within 1 day (Pitt, 1973). O'Hara, of women scoring as depressed (i.e., an additional 10% of the
Rehm, and Campbell (1982) and Atkinson and Rickel (1984) female sample, compared to the male sample), half (50%) of all
found that most women who remain depressed several weeks women would have to experience moderate-to-severe depressive
postpartum were already depressed before giving birth. Be- symptoms during the premenstrual period. That is, 20% (the
cause hormone levels are quite different during pregnancy and average percentage of women scoring as depressed) = 10% (the
postpartum, such data contradict the hormonal explanation for assumed base rate of depression) + (20% [the percentage of
many postpartum depressions. Thus, the data on postpartum women that are premenstrual in any study] x 50%).
and menopausal depressions do not support the notion that Recall that a number of studies have reported that the per-
hormonal fluctuations often are related to depression in centage of women who reported experiencing moderate-to-se-
women. vere premenstrual emotional symptoms is at least 40% (Hal-
The rate of premenstrual depressions is estimated by some breich etal., 1983; Janowsky etal., 1967; Schuckit etal., 1975).
studies to be very high, perhaps as high as 90-100% (Janowsky, This is not quite 50%, but a 40% incidence of premenstrual
Gorney, & Mandell, 1967; see also Sherman, 1971). For exam- depressions would account for most of the excess depression in
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

ple, Schuckit, Daly, Herrman, and Hineman (1975) adminis- women.

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tered a structured interview to 105 college women, asking about However, the validity of questionnaires that ask subjects to
the regular occurrence of depression, anxiety, irritability, and retrospectively rate their mood levels during different phases of
crying during different periods of the menstrual cycle. Sixty- the menstrual cycle has been seriously questioned (Parlee,
three percent of the students reported that they have at least one 1973). Studies using retrospective questionnaires apparently
of these symptoms regularly during the premenstrual period; greatly overestimate the number of women who actually experi-
33% of the students said they were often depressed during the ence significant depressive symptoms during the premenstrual
premenstrual period. period. For example, Abplanap, Haskett, and Rose (1979)
Recently, research diagnostic criteria for premenstrual de- asked 33 women to complete a daily mood checklist, and once
pression have been developed by Halbreich, Endicott, and Nee per month to complete the Moos Menstrual Distress Question-
(1983) and Steiner, Haskett, and Carroll (1980). Halbreich et naire (Moos, 1968). The Moos questionnaire asks subjects to
al. introduced the Premenstrual Assessment Form (PAF), a 95- rate the degree to which they experienced a number of premen-
item inventory of psychological and physiological symptoms. strual symptoms during different phases of their last menstrual
Respondents are asked to indicate, retrospectively, the severity cycle. On the retrospective Moos questionnaire, subjects re-
with which they experience each symptom during the premen- ported having experienced significantly more symptoms during
strual period. Answers to the PAF can be compared to criteria their last premenstrual period than at any other period in their
for diagnosing a premenstrual major depressive syndrome; cycle. However, Abplanap et al. found no relation between cycle
these criteria are quite similar to the DSM-III criteria for phase and daily mood ratings (for similar results, see Persky,
MOD. Halbreich et al. administered the PAF to 335 women, O'Brien, & Kahn, 1976). Similarly, Schuckit et al. (1975) found
and found that 43% met the criteria for a premenstrual major that of the 63% of their sample who claimed that they regularly
depressive syndrome. experienced premenstrual increases in negative affect, only 7%
From the studies just cited, premenstrual depression appears (i.e., 4% of their overall sample) actually showed significant in-
to be quite common. Indeed, if 43% of the premenstrual women creases in depression during the premenstrual period. In sum,
in any given sample, such as the sample in a questionnaire study the evidence from daily mood ratings suggests that the sex
of depression, were experiencing major depression as a result differences in depression observed in community studies are
of being premenstrual, these premenstrual depressions could probably not accounted for by the number of women reporting
account for the greater rate of depression in women than men premenstrual depressive symptoms on depression question-
observed in such studies. We can examine this possibility with naires.
some simple calculations. Let us first consider the studies that Yet if daily diaries indicate that most women do not experi-
use self-report inventories for depression. Many questionnaire ence significant premenstrual mood changes, why do women
studies that find significant sex differences in rates of depression report on retrospective questionnaires that they feel more de-
report that approximately 20% of the female subjects and 10% pressed during their premenstrual period than during other
of the male subjects score in the moderate-to-severe ranges of times? As Paige (1971) and Ruble and Frieze (1978) point out,
the depression questionnaires (DSM-III, American Psychiatric even in westernized countries, societal attitudes toward men-
Association, 1980; Eaton AKessler, 1981;Frerichsetal., 1981; struation are still very negative. Menstruating women are ex-
Radloff, 1975). Imagine that in the absence of premenstrual pected to hide all signs of blood flow, and the taboos against sex
influences, the true rate of depression among women would be during menstruation are still commonly observed. It is possible
10%, just as it is in men. Could premenstrual depressive symp- that women's negative expectations about their emotional state
toms account for the additional 10% of the female subjects who during the premenstrual and menstrual phases represent their
score as depressed on the questionnaires? The premenstrual pe- dread of the social inconvenience of these phases. Similarly, the
riod lasts approximately 5 days in each 28-day cycle (Ganong, actual increases in anxiety and depression in some women dur-
1984). Thus, if we assume that the menstrual cycles of women ing the premenstrual and menstrual phases may be psychologi-
in any given group are randomly distributed over the month, cal reactions to the negative social consequences of menstrua-
we can estimate that approximately 20% (5/28) of women par- tion and to the physical discomfort of menstruation (e.g., bloat-
ticipating in any given questionnaire study are premenstrual. ing and cramping), and not the direct result of biochemical
In order for premenstrual depression to account for the excess fluctuations.
 SEX DIFFERENCES IN DEPRESSION 269

One way to test the notion that hormonal changes during the 1977). Decreased serotonin uptake has been associated with de-
menstrual cycle affect women's moods and that these hormon- pression in some cases (Baldessarini, 1986); thus it has been
ally based mood changes contribute to the sex differences in suggested that women experience depression during estrogen
depression would be to conduct a study in which depressive or progesterone withdrawal because serotonin uptake decreases
symptoms and cycle phase are measured repeatedly in a large with the withdrawal (Hackman, Wirz-Justice, & Lichtsteiner,
sample. The incidence of premenstrual depression could then 1972).
be established and the presence of premenstrual depression Declines in estrogen and progesterone levels also have been
could be controlled for in comparisons of the rates of depres- associated in some studies with increases in the activity of
sion in men and women. monoamine oxidase (MAO; Grant & Pryse-Davies, 1968; Ja-
Although we do not yet have evidence that depressions nowsky et al., 1971). Monoamine oxidase facilitates the break-
caused by regular hormonal fluctuations in women contribute down of norepinephrine, and norepinephrine depletion is asso-
to the sex differences in community surveys of depression, it ciated with depression (J. W. Maas, 1975).
is still possible that abnormalities in hormonal functioning in Thus there appears to be considerable evidence that hor-
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women account for their higher rate of clinically severe depres- monal abnormalities are related to depression in women. Yet
This document is copyrighted by the American Psychological Association or one of its allied publishers.

sions. Many hypotheses have been proposed for exactly how there are as many studies that do not support the hormonal
hormonal abnormalities would affect mood in women (see re- theories of female depressions as there are that do (see Janow-
views by Janowsky & Rausch, 1985, and Rubinow & Roy- sky&Rausch, 1985; Rubinow & Roy-Byrne, 1984). For exam-
Byrne, 1984). Most of the theories of the effects of hormones ple, the premenstrual decline in estrogen is not the only de-
on psychopathology have focused on the two ovarian hormones, crease in estrogen that occurs during the menstrual cycle. Just
estrogen and progesterone. Many of the studies of these hypoth- after a midcycle peak, estrogen levels fall sharply, and this de-
eses have used samples of women who sought treatment for se- cline is not associated with depressive symptoms (Dalton,
vere premenstrual syndrome (PMS). 1964). Premenstrual symptoms are also uncommon during
Because each of the periods during which women have been that part of the menstrual cycle when estrogen/progesterone ra-
thought to be more vulnerable to depression (e.g., menopause, tios are at their highest. In addition, Backstrom, Sanders, and
the premenstrual period, and the puerperium) are character- Leask (1983) found no differences in estrogen levels between
ized by decreased estrogen levels, it has been proposed that es- PMS sufferers and controls.
trogen withdrawal triggers depression and other premenstrual A number of studies have found that progesterone levels in
symptoms (Backstrom & Mattsson, 1975; Klaiber, Broverman, women who suffer severe premenstrual tension are no different
Vogel, & Kobayshi, 1979). The evidence for this hypothesis is from levels in women who do not (Andersch, Hahn, Andersson,
indirect. Klaiber et al. (1979) report reductions of depressive & Isaksson, 1978; Andersen, Larsen, Steenstrup, Svendstrup, &
symptoms in depressed women given estrogen therapy. In addi- Nielson, 1977). Munday et al. (1981) found that premenstrual
tion, some women ingesting estrogen in oral contraceptives also symptoms emerged in PMS sufferers before declines in proges-
show decreases in depression (Bardwick, 1971; Moos, 1968). terone occurred in the menstrual cycle. Several studies have
Another estrogen-related hypothesis holds that high levels of found that progesterone therapy is no more effective than pla-
estrogen in conjunction with low levels of progesterone are what cebo in alleviating dysphoria and other symptoms of the pre-
lead to tension and dysphoria. One study found that women menstrual syndrome (Copen, Milne, & Outram, 1969; Jord-
suffering from PMS had higher estrogen/progesterone ratios heim, 1972; Sampson, 1979; S.L. Smith, 1976). After reviewing
than women not suffering from PMS (Backstrom & Cartensen, studies of progesterone therapy and other therapies for premen-
1974), and two other studies found elevated levels of estrogen in strual depression, Rubinow and Roy-Byrne (1984) concluded
women suffering from PMS (Abraham, Eisner, & Lucas, 1978; that "the bulk of the evidence in support of current popular
Munday, Brush, & Taylor, 1981). treatments is derived from uncontrolled trials, and, as is true
Others have argued that declines in levels of progesterone, with studies of etiology, the lack of comparability across studies
not estrogen, trigger depressive symptoms. Increases and de- at even the most fundamental levels of population definition
creases in levels of progesterone are correlated with increases and symptom measurement makes the uniform demonstration
and decreases in depressive symptoms (Janowsky, Fann, & of any result highly unlikely" (p. 168).
Davis, 1971). Some studies have found correlations between the Other researchers have argued that fluctuations in the miner-
degree of depression in some women and the amount of proges- alocorticoids during the premenstrual phase may shift the salt
tin in the oral contraceptives they were using (Culberg, 1972; and water balance in the central nervous system, causing emo-
Grant & Pryse-Davies, 1968; Kutner & Brown, 1972). In addi- tional symptoms (Dalton, 1964; Janowsky et al., 1967). There
tion, several studies have found lower levels of progesterone just is evidence that aldosterone, a mineralocorticoid, may fluctuate
prior to menstruation in PMS sufferers compared to controls in parallel with depressive symptoms during the menstrual cy-
(Abraham et al., 1978; Backstrom & Cartensen, 1974; Munday cle (Demarchi & Tong, 1972; Janowsky, Berens, & Davis, 1973).
etal., 1981;S.L. Smith, 1976). Other studies, however, have found no differences in aldosterone
By what mechanism would estrogen or progesterone with- levels in patients exhibiting PMS and normal controls (e.g.,
drawal lead to depression? Levels of estrogen and progesterone Munday etal., 1981).
in women have been correlated with levels of certain neuro- Other researchers have suggested that depressive symptoms
transmitters implicated in depression. For example, in women in the premenstrual, postpartum, and menopause phases may
given estrogen and progesterone therapy, increased serotonin result from excess prolactin levels (see Rubinow & Roy-Byrne,
uptake has been noted (Cone, Davis, & Coy, 1981; Ladisich, 1984) or from fluctuations in the adrenocortical hormones,
 270 SUSAN NOLEN-HOEKSEMA

such as androgens and glucocorticoids (Vermeulen & Verdonck, ber of studies (reviewed by Gershon & Bunney, 1976) have indi-
1976; M.S. Walker & McGilp, 1978). Yet, again, there is as cated that the loci for color blindness and the Xg blood group
much evidence against these hypotheses as there is for them (see are not near each other.
Janowsky & Rausch, 1985; Rubinow& Roy-Byrne, 1984). Another way to test the X-linkage hypothesis is to examine
In sum, hypotheses that abnormalities in fluctuations of hor- the transmission of affective disorder from parents to children.
mones or other biochemicals in women are associated with se- Specifically, if a father carries the mutant gene on his X chromo-
vere depression have not been consistently supported. The evi- some (and therefore manifests affective disorder), all of his
dence suggesting that biochemical fluctuations lead to mood daughters will carry the mutant gene, because the father always
changes is indirect, open to multiple interpretations, and con- gives his daughters an X chromosome. Yet none of an affected
tradicted by an equal amount of negative evidence. father's sons will carry the mutation, because the father always
Yet it is premature to conclude that hormonal fluctuations gives his sons a Y chromosome. If a mother carries the mutant
have no effects on mood in women, because many studies of gene on one of her two X chromosomes, then her daughters and
hormones and moods have serious methodological flaws. In ad- sons have equal chances of carrying the mutant gene. In short,
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dition, it must still be explained why sex differences in depres- if affective disorder is linked to the X chromosome, we should
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sion do not emerge until after puberty, when cyclic changes in observe father-daughter pairs of affected individuals, but no fa-
hormones and other biochemicals begin in women. ther-son pairs (except for sons suffering from reactive depres-
One other biological explanation of the sex differences in de- sions). We should observe equal numbers of mother-daughter
pression has been proposed. According to this explanation, and mother-son pairs.
women's greater vulnerability to both severe and mild depres- However, most family history studies of the X-linkage hy-
sion can be attributed to a genetic predisposition toward de- pothesis have discovered more father-son pairs of affective dis-
pression. A review of the evidence for this explanation follows. order individuals than is compatible with transmission via the
Genetic factors in the sex differences in depression, X chromosome (e.g., Fieve, Go, Dunner, & Elston, 1984;
Affective disorder runs in families (Gershon, 1983; Weissman, Green, Goetze, Whybrow, & Jackson, 1973). Gershon and Bun-
Kidd, & Prusoff, 1982). This aggregation of affective disorders ney (1976) compiled data from these and several other studies
within families could be due to either genetic or environmental and found that for 106 father-son pairs in which the father had
factors shared by family members. Yet in a review of twin stud- an affective disorder, 10 sons (roughly 10%) showed affective dis-
ies of affective illness, Allen (1976) found that in dizygotic order. This prevalence is higher than that in the general popula-
twins, the average concordance rate for unipolar depression was tion. If the X-linkage hypothesis were true, the prevalence of
11%, but in monozygotic twins the average concordance rate depression in the sons of fathers with affective disorder should
for unipolar depression was 40%. The substantially higher con- be considerably lower than that in the general population.
cordance rate for monozygotic twins indicates some sort of ge- More recently, Cloninger, Christiansen, Reich, and Gottes-
netic transmission of the disorder. man (1978; see also Kidd & Spence, 1976) argued that most
Could it be that the sex differences in depression are due to a common psychiatric disorders are unlikely to result from major
greater genetic predisposition to depression in women? A num- chromosomal abnormalities or individual abnormal genes. In-
ber of investigators have argued that serious affective illness is stead, such disorders are more likely the result of an aggregation
the result of a mutant gene on the X chromosome (Ferris, 1966; of minor genetic abnormalities that interact with environmen-
Winokur & Tanna, 1969). Because females have 2 X chromo- tal variables to make an individual vulnerable to disorder. Clon-
somes, they should be more at risk for depression than men. inger et al. group all the genetic and other familial factors that
One way investigators have tested the X-linkage hypothesis of influence risk for a particular disorder under the label "liabil-
affective disorder is to examine the correlation between affective ity," and argue that only individuals whose liability is above a
disorders and two abnormalities known to result from muta- certain threshold will manifest the disorder. If one sex manifests
tions on the X chromosome, red-green color blindness and the a disorder less frequently than another, this may be because that
Xg blood group. If affective disorder is caused by mutations on sex has a higher threshold for the disorder. For example, men
the X chromosome that are in close proximity to the X-chro- may manifest depression less frequently because they have a
mosome mutations believed to cause color blindness or the Xg higher threshold for developing the disorder. However, the rela-
blood group, then we should see significant, high correlations tive invulnerability to depression of men also may be due to
between the presence of affective disorder and the presence of nonfamilial environmental factors that protect them. Cloninger
either color blindness or the Xg blood group. A number of stud- et al. argue that we can determine whether observed sex differ-
ies have examined the family pedigrees of persons suffering ences in a disorder are probably due to genetic/familial factors
from affective disorder and have found that relatives who show or to environmental factors by examining the rates of the disor-
affective disorder also tend to have the Xg blood group or color der in the parents and siblings of affected persons. Specifically,
blindness (e.g., Mendelwicz, Fleiss, & Fieve, 1972; Reich, Clay- if less depression in men is due to a lesser genetic loading (i.e.,
ton, & Winokur, 1969; Winokur & Tanna, 1969). higher liability threshold), then we would expect to see more
However, Gershon and Bunney (1976) note that the family depression in the relatives of depressed men than in the relatives
pedigrees used in these studies have often been incomplete and of depressed women. This is because depressed men are more
the statistical significance of the relations observed is often mar- genetically deviant than depressed women, and thus are more
ginal. In addition, these linkage studies assume that the loci for likely to transmit their depression to relatives (and to have had
affective disorder, color blindness, and Xg blood group occur in their depression transmitted from their parents). However, if the
close proximity on the X chromosome. However, a large num- sex differences in depression are due primarily to nonfamilial
 SEX DIFFERENCES IN DEPRESSION 271

environmental factors, we should expect no differences in the (Lee & Hertzberg, 1978; Sherman, 1971). For example, there is
rates of depression among the relatives of depressed men and no support for the Oedipal shift in girls from attachment to the
women. mother to attachment to the father (Sherman, 1971). Similarly,
Merikangas, Weissman, and Pauls (1985) applied these analy- there is little evidence of either castration anxiety in boys or
ses to family history data from 133 diagnosed unipolar depres- penis envy in girls, although many women acknowledge an envy
sives. Complete pedigrees were obtained from all probands, and of men's social power.
diagnostic assessments were made of all living relatives of the Later psychodynamic theorists (e.g., Homey, 1967; Menaker,
probands on the basis of SADS interviews (Endicott & Spitzer, 1979) downplayed notions of biological determinism in person-
1978), medical records, and family history information. Meri- ality development, emphasizing instead the interactions be-
kangas et al. found that the relatives of male and female depres- tween biological roles and cultural restrictions on women's be-
sives were equally likely to be diagnosed as depressed. These haviors. These and many more contemporary psychoanalytic
data indicate that the sex differences in depression are not due writers point to the restrictions placed on female sexual expres-
to genetic factors, but to environmental factors. sion, power, and personal freedom by patriarchal cultures as
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Summary of the biological explanations. There is no con- sources of frustration for women. Further, women's roles as
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sistent evidence that the observed sex differences in serious child-bearers and child-rearers conflict with their needs for self-
affective disorders are due to a greater genetic predisposition to development and independence. To the extent that a woman re-
the disorder in women. The evidence for the influence of fluc- nounces her role as mother, she suffers the disapproval of others,
tuations in female hormones and other biochemicals on mood and, according to most of the neo-Freudians, she denies the pri-
was more mixed. Some studies provided indirect support for mary component of female self-definition. These restrictions on
relations between levels of particular biochemicals and moods, female expression, the inferior status of the female role, and the
but many others did not. The more general notion that depres- conflicts between the innate desire to bear children and needs
sion is common during the premenstrual, postpartum, and for independence all contribute to a greater tendency toward
menopause periods has not been supported. masochism in women (Horney, 1967).
Finally, the biological explanations of sex differences in de- The neo-Freudian accounts of female psychology are rich in
pression, as a class of explanations, do not explain the absence their discussions of the interactions between social pressures
of sex differences in certain subgroups, such as the Amish, uni- and biological pressures. Such explanations might do well in
versity students, and bereaved persons. Psychosocial factors, accounting for the prevalence of sex differences in depression
such as the supportiveness of the Amish culture or the greater across many cultures. Characteristically, the theoretical rich-
impact of a spouse's death on men than on women, more con- ness of the psychodynamic explanations is counterbalanced by
vincingly explain the variations across groups in sex differences the absence of empirical support for these explanations.
in depression. However, a number of the suggestions offered by the neo-
Freudians on how women's roles as passive wives and mothers
affect mental health have been incorporated in contemporary
Psychoanalytic Explanations
sex role explanations of female psychopathology. These sex role
According to classic psychoanalytic theory, women are more explanations have been empirically tested, and reviews of these
susceptible to the depressive process than men because of the tests follow.
personality structure that results from women's psychosexual
development (Mitchell, 1974). During the Oedipal stage, while
Sex Role Explanations
castration anxiety is motivating a boy to develop a superego, a
girl "realizes" she and all other females have been deprived of a One sex role theory of depression, proposed by Miller (1976)
penis and all the power and status that accompany being male. and Scarf(1980), draws heavily on the work of Karen Horney, a
The girl's realization leads to hostility toward her mother for neo-Freudian. Horney (1967) argued that many women greatly
this deprivation, a great decline in her own self-worth, and the overvalue love relationships as a result of perceived rejection by
growth of envy of her father and all males. their fathers. This overvaluation of love leads to obsessive quests
A girl's fixation on her father, which is the model for later love for self-affirmation through involvement in intimate relation-
relationships with men, is a weak one, based on narcissistic love, ships, as well as internalized rage at all competitors (other
rather than an object attachment, because it is motivated by a women) for lovers and at the lovers themselves.
desire to get back a part of herself she feels she has lost. It is this Similarly, Miller (1976) and Scarf (1980) (see also Gilligan,
tendency toward narcissistic love relationships, driven by penis 1982) have argued that a central element of women's roles in
envy, that puts women at greater risk for melancholia, accord- society is the nurturance of relationships. Women's greater con-
ing to psychoanalytic theory (Mitchell, 1974). The woman cern with relationships has been viewed by traditional psycho-
looks to men to make up for her losses, but she is inevitably analytic theory and moral development theory as an indication
and frequently disappointed. After such disappointment, she is that women do not advance to as high a stage of moral develop-
prone to turning her libidinal energy back in on herself rather ment as do men, who are more concerned with issues of justice
that reattaching it to new objects. Her already injured ego is and rationality. Instead, Miller (1976) and Gilligan (1982) ar-
confronted by the hostility she feels against the object just lost, gue, women's concern with relationships simply represents a
and melancholia is likely to result. different, equally valid approach to moral issues compared to
The psychoanalytic description of the development of female men's approach.
personality has received almost no solid experimental support Yet, these theorists suggest, women's concern with relation-
 272 SUSAN NOLEN-HOEKSEMA

ships makes them more vulnerable to despair and depression. nonworking wives reported more depression than working men.
Scarf writes, "It is in terms of highly vested and extraordinarily In addition, Radloff found that nonworking wives were more
important loving attachments that most women's secret self- depressed than working wives. Rosenfield (1980) and Ensel
assessments and interior appraisals of self-worth are made" (p. (1982) report similar patterns of results from data from depres-
95). When a love relationship fails, a woman loses her self-defi- sion questionnaires. These data do not support the role-conflict
nition. hypothesis described previously.
What is the evidence that women are more concerned with Gove and Tudor (1973) suggested that having two sets of du-
relationships than are men? Gilligan (1982) has reported a se- ties or roles in one's life actually protects one against depres-
ries of studies of men's and women's ways of reasoning about sion. What is wrong (in part) with the traditional female role,
moral issues. Gilligan presents largely anecdotal evidence indi- according to Gove and Tudor, is that it allows only one source
cating that women are most likely to worry about how the prob- of gratification, the family. Men may be protected against de-
lem presented to them would affect relationships between the pression because when one source of gratification is taken away,
persons involved, whereas men were more likely to invoke rules either the family or work, men have that second source to fall
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of justice in solving problems. Gilligan's work has been criti- back on. Data such as Radloff's (1975), Rosenfield's (1980),
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cized by L.J. Walker (1984), however, for the far-reaching con- and Ensel's (1982), in which women who had both a family and
clusions she makes on the basis of data from unstructured inter- a job were less depressed than nonworking wives, lend partial
views conducted with small samples. support to this hypothesis.
In an extensive review of studies of sex differences in social Other sex role theories focus on the subjective value of a
behaviors and self-concept, Maccoby and Jacklin (1974) found woman's role in society compared to the value of a man's role.
that, although women and girls describe themselves as more so- At a very young age, girls are more likely to say they wish they
cially oriented than men, their actual behaviors do not show were boys than boys are to say they wish they were girls (Abel
more concern with social relationships than men's behav- ASahinkaya, 1962;Hartup&Zook, 1960; Parsons, 1978). This
iors do. undervaluing of the female sex role relative to the male sex role
In addition, it is not clear why investing one's self-worth in has been attributed to the greater prestige, power, competence,
interpersonal relationships should be more likely to lead to de- size, and strength associated with men (Kohlberg, 1966).
pression than investing it in material and professional success, Gove and Tudor (1973) argue that the traditional female role
as men are said to do. Are failed love relationships more fre- as homemaker is becoming increasingly boring and underval-
quent events over the life span than failures at work? Why would ued as more modern conveniences are introduced. They suggest
not men's lack of investment in interpersonal relationships that the sex differences in depression (and other neurotic disor-
make them more vulnerable to feelings of loneliness and loss? ders) can be attributed to the lesser value put on the female
Horney (1967), Miller (1976), and Scarf (1980) suggest that, role, and the resulting lesser gratification women receive from
because the desire for relationships is an inherent aspect of fe- fulfilling that role. The data cited in the present article indicat-
male personality, women who attempt to succeed in jobs will ing no sex differences in the Old Order Amish and in university
be continually faced with disturbing conflicts between their nat- students seem to support this explanation of the sex differences
ural propensity toward relationships and demands to be inde- in depression. The male and female roles in Amish society, al-
pendent and competitive in the job. A number of other sex role though different, are both seen as essential to the family and
theorists have been concerned with the incompatible expecta- community (Egeland & Hosteller, 1983). In college students,
tions put on a woman when she enters the marketplace (Frieze the goals and life-styles of men and women are more similar
et al., 1978; Kohn, Wolfe, Quinn, & Snoek, 1965). That is, a than they are in noncollege populations (Hammen & Padesky,
woman may be expected to be both passive, unselfish, and sup- 1977). Thus, the equality in value given to the male and female
portive in line with her feminine role, and assertive, self-suffi- roles in these two subcultures might result in the absence of sex
cient, and demanding if she is to achieve in her work. These dual differences observed.
sets of expectations are difficult because the woman may feel Even if a woman accepts the traditional female role gladly at
forced to violate one set, ignore one set, or perhaps live up to one point in her life, chances are her role will change dramati-
both sets of expectations at the same time (Katz, 1975). Devi- cally several limes in her life (Ginzberg, 1966; H. S. Maas &
ance from sex role expectations may result in social rejection. Kuypers, 1974). This role discontinuity is due to the different
For example, Costrich, Feinstein, Kidder, Marecek, & Pascale demands put on a woman when she becomes a wife and men a
(1975) found that assertive women were rated as more unattrac- mother, when her children leave home, and when she becomes
tive and in need of psychotherapy than were assertive men. a widow. Each of these new phases in life demand major reorga-
Some support for the role conflict hypothesis comes from epi- nizations and reorientalions of lime, effort, and values. Coupled
demiological studies of depressive symptoms in the general pop- wilh the stress of adjusting to new roles may be the loss of a
ulation. Aneshensel, Frerichs, and Clark (1981) administered particular gratification from the previous role (e.g., when chil-
the CES-D to 1,000 residents of Los Angeles County. They dren leave home; LeMaslers, 1957).
found that among persons who were married and employed, These patterns of change in role obligations are said to have
women reported significantly more depressive symptoms than no parallel in a man's life cycle (H. S. Maas & Kuypers, 1974).
men; this was not true among unmarried, employed persons, Yet it certainly cannot be said that the roles of men do not make
however. This pattern of results is in line with the assertion that demands that induce stress. Indeed, when men and women are
having dual roles can be a risk factor for depression in women. asked to indicate ihe number of slressful evenls in Iheir lives, no
However, Radloff (1975) found that both working wives and sex differences are found (Uhlenhuth, Lipman, Baiter, & Stern,
 SEX DIFFERENCES IN DEPRESSION 273

1974). It is not so much the number of demands put on women Radloff and Monroe (1978) asserted that the epidemiological
because of their sex role that makes them more vulnerable to trends in the incidence of depression in different groups may be
low self-esteem or despair, but the conflicts or radical changes best explained by the learned helplessness model. High rates
in the expectations for women and the society's devaluation of of depression are found among the poor, the undereducated,
the stereotypical female role. nonwhites, the unemployed, the ill, and of course, women. In
The biggest problem with sex role accounts of sex differences each of these groups other than women, it is easy to see how
in mental health is the frequent absence in these accounts of a one might expect his or her actions to be ineffectual in bringing
well-described process by which role conflict or undervaluation about good events and avoiding bad events. How does learned
might lead to depression or other disorders. It is particularly helplessness explain the preponderance of women among de-
difficult to explain why sex role pressures would lead some pressives?
women and not others into depressions so severe they must be First, women may receive more "helplessness training" over
hospitalized. Some theorists draw on psychoanalytic notions their lifetimes than men (LeUnes, Nation, & Turley, 1980). In
about the need to express aggression outwardly to explain why an extensive review of childrearing practices, Maccoby and
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

the female sex role would predispose to depression (Bardwick, Jacklin (1974) found that one of the few practices in which par-
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1971; Chester, 1972; Chodorow, 1974). That is, women are so- ents consistently treated girls and boys differently was in their
cialized to control aggressive feelings, which possibly leads to a attention to girls* and boys' actions. Whereas boys' behaviors
greater tendency to introject anger. This description of a mecha- and misbehaviors were praised or criticized accordingly, girls'
nism by which sex roles predispose to depression suffers from behaviors were largely ignored. Similarly, when boys and girls
the lack of research for the psychoanalytic introjected hostility misbehave in class, teachers are more likely to respond to the
theory of depression (Sherman, 1971). misbehavior of boys than that of girls (Dweck, Davidson, Nel-
Other psychologists and sociologists suggest that the female son, & Enna, 1978; Serbin, O'Leary, Kent, & Tonick, 1973).
sex role contributes to greater feelings of lack of control and Girls seem to have many opportunities to learn that their re-
helplessness, thereby leading to depression (see Radloff, 1975, sponses do not control outcomes. Cross-cultural studies indi-
for a review). This helplessness hypothesis is described in the cate that in many cultures, boys are trained to be more self-
next section. reliant and active, whereas girls are encouraged to be dependent
on others (Maccoby & Masters, 1970; Whiting & Whiting,
1975).
Learned Helplessness Explanation
As adults, women can also expect that their actions will be
Learned helplessness has been denned as a set of motiva- less successful at generating desired outcomes than men's. In
tional, cognitive, and affective deficits that occur when uncon- several experimental studies, men's performances at laboratory
trollable negative events are experienced. In humans these tasks were rated higher than equally good female performances
deficits include lowered response initiation, an inability to learn (Deaux & Taynor, 1973; Pheterson, Kiesler,& Goldberg, 1971).
new response-outcome contingencies, sadness, and lowered Successful women are often rated as less acceptable and likable
self-esteem. According to the original learned helplessness the- than unsuccessful women or successful men (Feather & Simon,
ory (Maier, Seligman, & Solomon, 1969; Seligman, 1975), these 1975; Horner, 1968). Goldberg (1968; see also Lavach & Lainer,
deficits are the result of the expectation that outcomes will be 1975) found that the achievements of women were rated as less
uncontrollable, because no response can be found to control valuable than the achievements of men. Outside of the labora-
them. In the best-known application of learned helplessness tory, women are less likely to be promoted than men given sim-
theory, Seligman (1975) pointed out the similarities between ilar job performances (Rosen & Jerdee, 1974).
depressive symptoms and helplessness deficits, and suggested On another level, women have more difficulty having their
that some depressions may be due to the expectation that one ideas taken seriously by groups than do men (Unger, 1978;
has no control over important events. Wahrman & Pugh, 1974). In addition, when a women attempts
A reformulation of the original helplessness model was pro- to gain power over a situation by asserting that she has greater
posed by Abramson, Seligman, and Teasdale (1978) to account expertise, greater information, greater authority, or a greater
for inadequacies in the original model in explaining the general- right to make a decision than a man, she is often seen as being
ity, chronicity, self-esteem loss, and individual differences in hu- "out of place" (Johnson, 1976).
man helplessness. The focus of the reformulated model was on Besides experiencing more events that could give them a
the explanations people make for events. People who tend to sense of helplessness, women may also be more prone to the
explain bad events by causes that influence many areas of their maladaptive explanatory style the reformulated helplessness
lives (global causes), instead of causes that influence only one theory identifies as a risk factor for depression. A number of
area (specific causes), will expect to be helpless in many areas studies of children and college students have found that women
of their lives. People who explain bad events by causes that are are more likely to attribute success on academic tasks and other
stable rather than unstable in time will expect to be helpless in positive events to luck or the favors of others, and to attribute
the future. People who blame themselves instead of others for failures to a lack of ability and other stable, global factors
bad events will experience a loss of self-esteem. Thus, according (Breen, Vulcano, & Dyck, 1979; Dweck, 1975; Dweck & Re-
to Abramson et al., people who habitually tend to explain bad pucci, 1973; Nicholls, 1975; Wiegers& Frieze, 1977). Such at-
events by internal, stable, and global causes (and explain good tribution patterns are associated with a greater tendency to be-
events by external, unstable, and specific causes) will be more come helpless after failing at tasks.
vulnerable to depression than people with the opposite style. Although a wide range of studies have supported the hypothe-
 274 SUSAN NOLEN-HOEKSEMA

sis that a maladaptive explanatory style is a risk factor for de- Response Sets for Depressive Episodes
pression (for a review see Peterson & Seligman, 1984), most of
the studies of the reformulated model have used populations in Most people occasionally experience mild-to-moderate epi-
which sex differences in levels of depression are usually not sodes of depressive symptoms. For some of us, these episodes
found (e,g., university students, children, and hospitalized de- last only a few hours or days. Yet we somehow bring ourselves
pressives). There have been no studies using a nonstudent adult out of such episodes before we reach the point where we would
sample to test whether sex differences in explanatory style ac- say we are depressed on a questionnaire or would seek profes-
count for sex differences in depression. sional help. For others, however, initially mild depressive symp-
Of course, it is neither necessary nor sufficient under the help- toms often become more severe, until they are moved to ac-
lessness theory to have a maladaptive explanatory' style in order knowledge it to those who ask or even to seek therapy.
to become depressed. It is sufficient that one expects to be help- There is reason to believe that the ways we respond to or cope
less in controlling the environment. As discussed previously, with our moods affect the severity and chronicity of those
there is considerable evidence that women in many areas of the moods (Rippere, 1977). In particular, persons who tend to re-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

world are trained to have this expectation. Thus, learned help- spond to their own episodes of depression by engaging in activi-
This document is copyrighted by the American Psychological Association or one of its allied publishers.

lessness theory could explain the preponderance of women ties designed to distract them from their mood appear to re-
among depressives across cultures. Direct tests of the helpless- cover faster from depressive episodes than those who tend to be
ness theory account of sex differences in depression have not inactive and to ruminate about the causes and implications of
been done, however. their depressed moods (cf. Beck, Rush, Shaw, & Emery, 1979;
One test of this explanation of sex differences in depression Teasdale, 1985; Zullow, 1984).
would include measuring the number of uncontrollable events Evidence is emerging from a number of studies that men and
in the lives of a sample of {nonstudent) women and men, and women show different patterns of responding to their own feel-
assessing their explanatory styles and their levels of depression. ings of depression. The general results of these studies, which
The learned helplessness explanation of sex differences in de- are described in more detail in the following sections, are that
pression would be supported if it was shown that a greater de- men, when depressed, tend to engage in activities designed to
gree of uncontrollability and a more maladaptive explanatory distract themselves from their mood. Women, when depressed,
style in women account for any sex differences observed in de- tend to be less active and to ruminate more about the possible
pression in the sample. A more important study would be a causes of their mood and the implications of their depressive
longitudinal study in which explanatory style, uncontrollable episodes.
life events, and depression are first assessed in a large group of Some may want to argue that such differences reduce the sex
differences in depression to artifacts of response bias (cf. Funab-
children and then reassessed frequently as the children go
iki, Bologna, Pepping, & Fitzgerald, 1980). I propose, however,
through puberty, adolescence, young adulthood, and older
that women's response tendencies toward depression are actu-
adulthood. The learned helplessness theory would predict that
ally a cause of their greater tendency toward depression,
the emergence of sex differences in depression after puberty
whereas men's response tendencies actually lessen their rates of
should be preceded by a divergence in men's and women's ex-
depression. That is, the more ruminative response style of
planatory styles and uncontrollable life experiences, with
women amplifies and prolongs their depressive symptoms,
women developing more maladaptive explanatory styles and be-
whereas the more active response style of men dampens and
ginning to experience more uncontrollable events than men.
shortens their depressive symptoms. Indeed, men and women
Similarly, if women become less vulnerable to depression in
may not even need to have different vulnerabilities to the onset
older adulthood (cf. Frieze et al., 1978), then this change in vul-
of depression for the sex differences in rates of depression to
nerability should be preceded by improved explanatory style
emerge. The sex differences in response tendencies for de-
and a reduced number of uncontrollable events.
pressed moods and the effects of these differential responses on
the severity and chronicity of depressed moods in themselves
could account for the observed sex differences in rates of de-
Summary pression.
First, let us examine the evidence for sex differences in re-
Five different explanations of the sex differences observed in sponse tendencies for depressive episodes.
depression have been reviewed. From the evidence currently Sex differences in responses to depressive symptoms. In or-
available, not one of these explanations has been strongly sup- der to investigate the possible sex differences in responses to
ported. depressed moods, Nolen-Hoeksema (1986) presented college
In the final section of this article, a new explanation for the students with a "list of things people do when depressed" and
sex differences in depression is proposed. It is argued that, re- asked them to rate how likely they would be to engage in the
gardless of the initial source of a depressive episode, how an behaviors or thoughts described when depressed. The subjects
individual responds to his or her own depressed state may con- were instructed to be sure to "rate these items according to
tribute to the severity, chronicity, and recurrence of an episode. what you think you would do, not what you should do." The
Specifically, it is argued that the men's responses to their dys- men in the sample had significantly higher scores than women
phoria are more behavioral and dampen their depressive epi- on 4 of 37 items: "I avoid thinking of reasons why I'm de-
sodes, whereas women's responses to their depressive episodes pressed," "I do something physical," "I play a sport," and "I
are more ruminative and amplify them. take drugs." Each of these responses would tend to distract the
 SEX DIFFERENCES IN DEPRESSION 275

individual from his depressed mood. The women in the sample adults, the responses of males to stress and feelings of sadness
scored significantly higher than the men on "I try to determine tend to be active and often designed to distract them from their
why I'm depressed," "I talk to other people about my feelings," mood. The responses of females to their episodes of depression
and "I cry to relieve the tension." These responses tend to focus tend to be inactive and likely to focus their attention back on
and maintain the individual's attention on her mood. the mood and the self. These sex differences in responses to
Quite similar sex differences in responses to depressed mood one's own affective state contribute to the sex differences ob-
have been found in other studies (Chino & Funabiki, 1984; Fu- served in rates of depression. That is, men's active response
nabiki et al., 1980; Kleinke, Staneski, & Mason, 1982). For ex- style toward depression dampens the severity of their depressed
ample, Kleinke et al. (1982) found that male college students mood and shortens the episodes of depression. Yet women's ru-
were more likely than female students to say they coped with minative, inactive response style amplifies and prolongs their
depression by thinking about other things, ignoring their prob- episodes of depression.
lem, or engaging in physical activity. Female students were more Effects of response style on depressed moods. There are at
likely to say they would cut down on responsibilities and activi- least three mechanisms by which a ruminative, inactive re-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

ties when depressed, confront their feelings, and blame them- sponse set for depression should amplify and prolong an epi-
This document is copyrighted by the American Psychological Association or one of its allied publishers.

selves for being depressed. Again, the men's responses to their sode, whereas an active response set for depression should
mood tended to be active and designed to relieve the mood by dampen and shorten an episode. First, rumination interferes
distraction, whereas the women's responses tended to be less with attention, concentration, and the initiation of instrumen-
active and more likely to focus attention on their mood. tal behaviors (Diener & Dweck, 1978; Heckhausen, 1980;
These sex differences in activity levels during depression may Kuhl, 1981; Sarason, 1975). Kuhl (1981) has argued that these
emerge during childhood. In a study of self-reported depressive difficulties lead to increased failures and a greater sense of help-
symptoms in 168 children from 8 to 11 years old, Nolen-Hoek- lessness in controlling one's environment, and thereby contrib-
sema, Girgus, and Seligman (1986) found that the depressive ute to depression. On the other hand, engaging in active behav-
symptoms distinguishing depressed girls from nondepressed iors when depressed increases the individual's chances for con-
girls were different from those distinguishing depressed boys trolling the environment and obtaining positive reinforcers,
from nondepressed boys. Discriminant function analyses of the thereby dampening an existing depressed mood.
children's answers to the Children's Depression Inventory Support for this argument comes from a study by Kuhl
(GDI; Kovacs, 1980) revealed that depressed boys more often (1981). He classified subjects as either "state oriented" or "ac-
endorsed items indicating misbehavior, such as "I never do what tion oriented" on the basis of their responses to a questionnaire
I am told," "I do bad things," and "I get into fights all the time." asking what they would do in response to a variety of bad
Depressed girls did not tend to have high scores on these misbe- events. Then he exposed these subjects to uncontrollable fail-
havior items. Instead, the depressed girls endorsed items indi- ures at cognitive tasks (i.e., the standard learned helplessness
cating negative self-evaluation, self-preoccupation, and loneli- training). The state-oriented subjects showed more helpless be-
ness, such as "I hate myself," "I'll never be as good as other haviors on subsequent tasks than did the action-oriented sub-
kids," and "I feel alone." (Both boys and girls scoring in the jects. Kuhl found that the state-oriented subjects did not appear
depressed range on the GDI had high scores on items indicating to become helpless during training because they came into the
sadness, pessimism, and indecision.) These sex differences in training with a generalized belief that they could not succeed at
most prominent depressive symptoms do not translate directly the tasks. Rather the state-oriented subjects' excessive rumina-
into sex differences in responses to depressed affect. Yet they do tion about their failures during the helplessness training ap-
indicate that even in childhood, depressed boys tend to be ac- peared to interfere with learning in subsequent tasks, thereby
tive, whereas depressed girls tend to be more contemplative or leading to poor performance on these tasks, compared to the
self-focused. action-oriented subjects. With regard to depression, Kuhl ar-
Dweck and Gilliard (1975) provide observational evidence to gues that state-oriented persons may be more likely to focus on
support the more general notion that when stressed, men re- their mood state when depressed and that this focus interferes
spond actively but women are more contemplative, even in with instrumental behavior. The individual then experiences in-
childhood. They gave boys and girls experiences with unsolv- creased failure and loss of control, which act as helplessness
able tasks and asked the children to state their expectancies for training.
future success after each trial or only after the first and last tri- A second mechanism by which a tendency to become rumi-
als. Their results indicate that asking for expectancy statements native when depressed would amplify depression, whereas a
after each trial of failure was associated with decreases in persis- tendency to become active would dampen it, is suggested by
tence at later trials and in expectations for success at future tri- Bower (1981) and Teasdale (1983, 1985). Bower, Teasdale, and
als in both boys and girls. When the experimenter asked for others have demonstrated that mood state has a powerful effect
expectancy statements only after the first trial, the boys did not on an individual's recall of past events, social perceptions, and
show decreased persistence on later trials. However, the girls ability to learn new material. Persons who are depressed or who
showed decreases in persistence that were as large as those in have been made sad by affect induction procedures (cf. Velten,
the condition in which expectancy statements were asked for 1968) show greater access to negative memories and easier
after every trial. That is, the girls appeared to engage naturally learning of negatively toned new material. For example, Teas-
in self-evaluation and rumination about the future, regardless dale and Fogarty (1979) induced a happy or sad mood in college
of whether or not they were asked to, whereas boys did not. students by having the subjects read a series of self-referent
In summary, there is evidence that in both children and statements appropriate in tone and content to the mood to be
 276 SUSAN NOLEN-HOEKSEMA

induced. Self-reports of mood by subjects confirmed that the Dweck argued that the more frequent invocation of depressing
procedures did induce the intended affect. Then the subjects explanations by the ruminating children led to the greater help-
were given a series of positively toned or negatively toned stimu- lessness deficits seen in them. Additional evidence for this argu-
lus words and were asked to tell the experimenter what past ment comes from a study by Zullow (1984), who found that
experience each stimulus word brought to mind as quickly as college students who showed both a ruminative style and a ten-
the experience was recalled. The latency of retrieval for pleasant dency to explain events in pessimistic terms (cf. Abramson et
and unpleasant memories was measured. The time required to al., 1978) were more prone to depression than were students
retrieve pleasant memories, relative to that needed to retrieve who only showed rumination or a tendency toward pessimistic
unpleasant memories, was significantly longer for the subjects explanations.
with induced depression than for the subjects with induced hap- In sum, I have argued that a ruminative response set for de-
piness. Teasdale and Fogarty argued that these results indicate pression may amplify depressive episodes, relative to an active
that mood state affects the accessibility of pleasant and unpleas- response set for depression, by (a) interfering with instrumental
ant memories, with depressed mood enhancing the accessibility behavior, thereby increasing failures and a sense of helplessness;
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

of unpleasant memories and impairing the accessibility of (b) increasing the accessibility of negative memories; and (c)
This document is copyrighted by the American Psychological Association or one of its allied publishers.

pleasant memories. increasing the chances that an individual will consider depress-
Bower (1981) and Teasdale (1985) describe a vicious cycle ing explanations for his or her depression. Women appear to
between mood and memory that would maintain and deepen a engage in more rumination and less distracting activity than
depressed mood. The depressed mood activates a storehouse of men during depressive episodes. The sex differences in rates of
negative memories, which amplify the current depressed mood depression arise because women's ruminative response styles
and lead one to interpret current events in light of memories of amplify and prolong their depressive episodes by the mecha-
past failures and losses. The depressed mood is thereby exacer- nisms described previously, whereas men's active response
bated and extended. styles dampen their depressive episodes.
An individual who tends to be inactive and ruminative in re- Origins of response styles. Why would women be more ru-
sponse to a depressed mood should be more likely to become minative and men more active in their responses to depressed
caught in the vicious cycle between mood and memory de- moods? Being active and ignoring one's moods are part of the
scribed by Teasdale and Bower, This cycle would both amplify masculine stereotype- Being emotional and inactive are part of
and maintain the depressed mood. An individual who tends to the feminine stereotype. From a very young age, children de-
respond to a depressed mood by becoming active should be scribe themselves and others in terms of sex role stereotypes,
more likely to distract him- or herself from the mood and nega- even before their actual behavior conforms to the stereotype
tive cognitions, thereby breaking the cycle and dampening the (Brown, 1956;Nadelman, 1974;Schell&Silber, 1968). Parents
depressive episode. reinforce behaviors consistent with these stereotypes; parents
Finally, ruminative response sets during depressive episodes seem particularly concerned that boys not show feminine or
may increase the likelihood that an individual will consider de- sissy behaviors (Maccoby & Jacklin, 1974). Thus, the active re-
pressogenic explanations for current negative events (Diener & sponse style of men toward their depressed moods may result
Dweck, 1981; Kuhl, 1981; Zullow, 1984), thereby increasing simply from conformity to the sanctions against emotionality
expectations of helplessness and hopelessness. That is, ruminat- in men. Rumination in women may not be encouraged directly
ing about one's current state generates depressing explanations by parents or others; parents and teachers do not appear to re-
that increase depression (e.g., "I am depressed because I really ward girls for passivity and contemplation—they simply do not
blew it at the meeting today"). Such explanations, according to reward them as much for activity as they do boys (Dweck et al.,
the reformulated helplessness theory (Abramson et al., 1978), 1978; Serbin et al., 1973). In addition, because women are told
increase the individual's expectations that he or she will con- that they are naturally emotional, they may come to believe that
tinue to have problems in the future. Another type of vicious depressed moods are unavoidable and cannot be easily dis-
circle is set up, in which the individual's expectations of uncon- missed when present. Such an attitude would decrease the prob-
trollability lead to decreases in positive, goal-oriented behavior, ability of women taking simple actions to distract themselves
and the resulting failures enhance the individual's sense of help- from their moods.
lessness and depression (Radloff&Rae, 1979). Implications for interventions and the prevention of depres-
Support for this mechanism comes from Diener and Dweck's sion in women. If a ruminative response style amplifies
(1978) study with children. They gave children solvable or un- women's vulnerability to depression, then the recommended in-
solvable puzzles and asked them to vocalize whatever they were terventions for depressed women should be ones that help to
thinking while working on the puzzles and after each puzzle. distract them from their mood and increase activity. In addi-
Diener and Dweck found that some children had many tion, it would be important to educate the depressed client
thoughts about their past and future performances and others about the distorting effects of mood on thinking and memory
did not seem to think much at all about explanations and expec- so that she realizes the difficulties involved in thinking clearly
tations. Both the ruminating and the nonrummating children about problems and situations while depressed. Several of the
expressed some depressive explanations for their failures. Yet interventions suggested by cognitive-behavioral therapies for
the ruminating children invoked these depressing explanations depression (i.e., Beck etal., 1979; Teasdale, 1985) would be par-
more frequently than the nonruminators. In addition, after tri- ticularly appropriate for the treatment of depression in women.
als with unsolvable puzzles, the rummators showed more help- These interventions provide the client with exercises to disen-
lessness on future tasks than did the nonruminators. Diener and tangle herself from the effects of mood on thinking as well as a
 SEX DIFFERENCES IN DEPRESSION 277

structured approach to problem solving that helps her deal with to conduct a longitudinal field study in which the response sets
existing problems in the most rational way possible. A ruminat- for depression and depressive symptoms are measured repeat-
ing depressive would be encouraged to engage in some activity edly over an extended period of time in a nonstudent sample.
when depressed in order to distract herself from the mood. She The response set explanation would predict that women should
could also be discouraged from allowing herself to worry con- show more rumination during depression and that this style
stantly. Beck, Emery, and Greenberg (1985) and others have rec- would be related to more frequent, more chronic, and more
ommended setting aside a half-hour at the end of the day to do severe depressive episodes in women as compared to men.
one's worrying. The rummator often finds her worries dimin- One large study could be done that would simultaneously test
ished in size and number by the time the "worry hour" arrives. several of the proposed explanations of sex differences in de-
In addition, the depressive should be encouraged never to make pression. This study would be longitudinal, beginning with a
a decision or try to solve a problem when she is depressed, be- large sample of prepubescent children. The response sets for
cause she has particular access to negative memories and de- depression, explanatory style, uncontrollable life events, and
pressing attributions for events. Instead, she should do some- depressive symptoms would be measured repeatedly (perhaps
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

thing to distract herself to relieve the mood state, then go back semiannually) and information concerning the onset of menses
This document is copyrighted by the American Psychological Association or one of its allied publishers.

to the decision or problem to think about it. and the menstrual cycle phase would be gathered from the girls
To help prevent depression when grown, girls should be en- once they reached puberty. These variables then could be com-
couraged to be as active in response to their moods as boys are pared for their ability to predict the depressive episodes that
encouraged to be. This does not imply that women should be women and men experience over their life spans and the emer-
encouraged to become cold or unfeeling, or that they should fill gence of sex differences in depression.
their lives with distractions to avoid thinking about their real
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