Depressed women report more symptoms, especially changes in appetite and weight, disturbed sleep, feelings of worthlessness and guilt and health worries. Men are more likely to be disappointed in themselves, be self-critical, have to force themselves to work, be unable to cry, withdraw socially.
Depression tends to be associated with other disorders, especially anxiety and substance abuse. Men tend to have higher rates of substance abuse, women higher rates of anxiety disorders.
Men and women have different responses to treatment.
Joyce’s research group is trying to understand why treatment for depression may work for one person but not for another. It’s their fourth inquiry into the treatment of depression in the last decade, work described by the Health Research Council as “groundbreaking”.
The group has carried out random trials comparing fluoxetine and nortriptyline. Fluoxetine, or Prozac, is in the class of medications called selective serotonin reuptake inhibitors, or SSRIs, which work by increasing the amount of serotonin, a substance in the brain that helps maintain mental balance. The older antidepressant nortriptyline elevates mood by raising the level of neurotransmitters in brain tissue.
“For people under 25, the new antidepressants are much better than the old ones. That is, fluoxetine is better than nortriptyline,” says Joyce. “Probably, what is happening in practice is that people are routinely being given one of the new SSRIs first.
“But we found a gender difference with side-effects. Older men, over 40, were more likely to get side-effects from fluoxetine-like drugs than women. But women were more likely to get side-effects with nortriptyline types than men.”
Joyce also discovered that many people suffering from depression fell into a daytime pattern.
“The classic pattern was that they were really slow to start, then got better as the day went on. But within our sample there was a group with the reverse: their day would start not so bad, then during the afternoon their mood would dip and they’d feel worse and worse. That second group did better with nortriptyline than with fluoxetine.
“So, doctors should recognise gender, ask whether there was a pattern during the day, and conclude maybe they shouldn’t be using one of the SSRIs even though on balance they have some advantages and they’re safer.”
The leading psychotherapies for depression are cognitive behaviour therapy (CBT) and interpersonal therapy (IPT).
Carter notes two different arguments here. The first says IPT is more effective for women because it focuses on interpersonal problems, thought to be central to women’s sense of self. And CBT is more effective for men because it is more rational; and analytical methods suit men’s self-image.
The second reverses the order. It suggests that the optimal therapy for both sexes will be the one that makes them think and act in ways that are opposite to their “nature”. So CBT may be better for women because of its analytical perspective and focus on mastery and action. And IPT might do the same for men because, for example, it emphasises unrestricted emotion.
Even emerging therapies may favour one sex or the other.
There has been a shift to a third way that Carter believes may be good for women.
Traditional cognitive theory helps someone get over depression by challenging them to get a realistic perspective. But, says Carter, the third way is called meta-cognitive therapy, and it is all about taking a step back from depression and not engaging with it.