The Demographic Correlates of Mental Depression 

Depression is the flaw in love.  To be creatures who love, we must be creatures who can despair at what we lose, and depression is the mechanism of that despair.  --- Andrew Solomon

Depression is a disorder of mood, characterized by sadness and loss of interest in usually satisfying activities, a negative view of the self and hopelessness, passivity, indecisiveness, suicidal intentions, loss of appetite, weight loss, sleep disturbances, and other physical symptoms. Some or all of these symptoms may be present in people suffering from depression.  To be more precise, DSM-IV (the Diagnostic and Statistical Manual of Mental Disorders 4th edition, published by the American Psychiatric Association, 1994) offers this diagnostic scheme:

For a diagnosis of a major depression:
    1. At least 5 of the following symptoms.
    2. These symptoms must be present during the same 2 week period.
    3. These symptoms must represent a change from a previous level of functioning.
    • Depressed mood, nearly every day during most of the day.
    • Marked diminished interest or pleasure in almost all activities.
    • Significant weight loss (when not dieting), weight gain, or a change in appetite.
    • Insomnia or hypersomnia (excess sleep).
    • Psychomotor agitation or psychomotor retardation.
    • Fatigue or loss of energy.
    • Feelings of worthlessness or inappropriate guilt.
    • Impaired ability to concentrate or indecisiveness
    • Recurrent thoughts of death, recurrent suicidal

Depression affects millions of people in the USA, and costs the U.S. economy billions and billions of dollars in medical expenses and lost productivity.  In turn, the treatment of depression is also a multi-billion dollar industry.  We will now cite some survey data taken from the MARS OTC/DTC Pharmaceutical Study.  This is a mail survey of 22,079 USA adults conducted during the first quarter of 2002.  According to this study, 10.6% of adults in the USA said that they have experienced depression in the last 12 months, either professionally diagnosed or self-diagnosed.  Based upon a projected total poplation of 205 million adults, about 23 million people experience depression over the course of a year.

Like many other afflictions, depression does not wreck havoc uniformly across the population.  Rather, some segments of the population are more susceptible than others.  The causes of depression are not known with any certainty, but it is believed that stresses in life (such as deaths of beloved ones, job losses, financial setbacks, etc) can trigger episodes of depression in those who are predisposed genetically or pro-socially.  These external stresses will differ according to life cycle.  The following description of the connections between depression and life cycle was given by the Moods Disorder Unit in Sydney, Australia

Depression in childhood

Depression in infancy is uncommon, and usually in response to extreme deprivation (for example, lack of care in an orphanage in a war-torn country). A syndrome of withdrawal, listlessness and apathy can arise if the mother/infant bond is disrupted. This is really a normal separation response rather than ‘depression’. Debate is continuing about the effect of stress during pregnancy and its effect on foetal, and subsequent, development.

Depression in the years up to puberty is much more common, and often expressed in behavior (e.g. stealing, bullying, withdrawal, not eating) rather than symptoms. The distinction between different types of depression (0) is unclear as the condition is still evolving. Neuroendocrine changes similar to those seen in adult depression have been reported, and treatment with antidepressant medication is useful in some cases. The signs at this age may be hidden by other symptoms: a prolonged sad mood; a loss of interest in normal activities such as playing and games; withdrawal both at home and school; and tiredness, particularly in the afternoon. Other symptoms include sleep disturbance and bed wetting.

Depression at this stage may be linked, for example, to family difficulties (marital or family conflict, change in economic status), birth of a sibling, or an impact on the child’s social ties such as a move to a new house or school. Both family and school perspectives are necessary to get a clear picture of the child and its environment.

Many of these children go on to have further episodes of depression, although those with mild depression related to a significant stress have a good rate of recovery.

Depression in adolescence

Depression in this age group should be taken seriously. Youth suicide is the third most common cause of death in this age group. Both biological and developmental factors contribute to depression in adolescence and it may be difficult to tease them apart, though it is necessary to try if there is suspected manic depressive disorder or psychosis. There are dramatic endocrine and physical changes, and both sexual development and social identity are evolving. It can be hard to distinguish adolescent turmoil from depressive illness, especially as the child is also forging new roles within the family and struggling with independence, and academic and career decisions. Consider a review of the family and school environment, their friendships and peer group and any ‘biological’ symptoms. As in the younger child, obvious depression may not be the presenting problem. An adolescent may display social withdrawal, falling school performance, risk-taking behavior (e.g. reckless driving, inappropriate sexual involvements) and drug and alcohol abuse. This can be distinguished from more intractable problems by a history of ‘unremarkable’ behavior up until that point. A minor physical problem is sometimes used as a disguised appeal for help.

It can help in tracking down difficulties by considering some of the areas that the adolescent is dealing with: school, family, peer group and intimate and/or sexual relationships. Bipolar disorder could also be considered in this age group. A genetic predisposition plus indicative behaviors may support this diagnosis.

Depression in younger adults

The changes in this group center around the progress from single to spouse to parent. Bipolar disorder also presents for the first time before the age of 30: so whenever a ‘biological’ depression presents, bipolar disorder should also be considered. Women are vulnerable in this age bracket. They may experience considerable role conflict and a loss of autonomy. Young mothers are particularly at risk, especially if they lack supportive relationships.

A high proportion of women suffer from depression after childbirth. Fathers may also be at risk if their partner is caught up in the demands of caring for the baby. Men express their distress differently from women, maybe acting out, and/or drinking or working to excess.

Consider causes of stress and how some might be alleviated. Some relief can be found for Isolation, lack of support, lack of a confiding relationship, the demands of work and financial strain when these are recognized and assistance is required.

Depression in mid-life

The ‘business’ that occupies people at this stage of life can lead to a reassessment of goals. Children are leaving home, and there is a renewed focus on one’s partner, if such exists. Mortality becomes less abstract and bodily niggles can signal that youthfulness is further away than it once was. Missed and diminished opportunities may cause a kind of grief, particularly if either family or career has been neglected in earlier years. Attempts to combat depression may involve anything from taking up jogging, to beginning a new relationship. Depression is eminently treatable and should be taken seriously: middle-aged single males with a depression are the most at risk for suicide.

Depression in older age

Depression in the elderly is common but not inevitable. Such depression can be a consequence of both social and biological factors. However, many affective illnesses in this age group are reversible. Sometimes the presentation can be confusing: for instance some elderly people can become so depressed that they develop a ‘pseudo-dementia’, when in fact their condition is very treatable. Others complain about physical symptoms and after many investigations fail to indicate a physical disorder, treatment for depression may quickly resolve such distress. Indicators of depression include a previous history of depression, a depressed mood, and the ability to perform more complex tasks than you would expect from the way they present. Isolation, lack of stimulation and curtailed independence all contribute to problems for this age group. It is worth considering, due to the fact that this age group takes multiple medications, whether the depression is a side-effect or an interaction with one of these medications.

In the following chart, we show the incidences of depression by age/sex groups in the MARS study.  The patterns are certainly different among the groups, with the most obvious difference being the gender gap.  This may have to do with women’s unequal status compared to men -- the fact that they get less pay and authority at work, for example, and face a greater burden of housework and childcare at home.  We should emphasize that these types of survey data cannot be used to determine causal effects.  For example, other lines of research would point to non-social/non-psychological factors such as hormones and estrogen.

(source:  Multimedia Audience Research Systems 2002)

In the next chart, we show the incidence of depression by the presence of children in the household and annual household income.  For women, the belief is that the childbearing years, particularly the first few weeks after childbirth, are the peak period for onset of depression because of a mother’s fears and depressive concerns about the well-being of her baby or her sense of inadequacy as a parent.  According to this chart, the incidence of depression is somewhat higher in households where infants and children are present.  When the child is between the 2 to 11 years old, the incidence is higher than when an infant is present, even though the conventional wisdom is that depression is most likely during the post-natal period (that is, up to six months after birth).   

On one hand, there is the image of psychoanalysis being the domain of the rich and famous who can afford to pay those exorbitant rates over many years to sort out their imaginary problems.  Or, to put it unkindly, only the rich can afford to be depressed.  On the other hand, depression is often induced by external stresses and poor people are more likely to face stressful situations such as economic difficulty, discrimination and other challenges to self-esteem.  In this chart, we see a monotonically decreasing trend for depression incidence with respect to annual household income.

(source:  Multimedia Audience Research Systems 2002)

There also exists a strong belief that depression is related to beliefs and situations.  Within the USA, it is an urban legend that members of the Church of Jesus Christ of Latter Day Saints (colloquially known as the Mormons) are more likely to be using anti-depression drugs.  Here is a sample news item:

More Utahns take Prozac-style drugs than in any other state, according to a study conducted in June of 2001 by Express Scripts, a pharmacy benefit management firm.  The study indicated that Utah residents average 1.1 prescriptions per person per year of medications such as Prozac, Zoloft, and Paxil. The national average is 0.7.  "Oregon and Maine also had above average anti-depressant usage, but those states' percentage of overcast days and average length of winter could  explain the increased number of depressed residents," said Jim Jorgenson, director of pharmacy services for the University of Utah.  No such weather explanations exist in Utah, which has a high percentage of sunny days and average winter duration, he said.  Jorgenson said Utah women, the group accounting for the largest percentage of anti-depressant use, are under larger amounts of stress than their counterparts in other states because of large family size in Utah.  He also said some experts believe pressures on time and emotions could explain the high Prozac usage among Latter-day Saints.  Judd offered an additional hypothesis after stressing that Utah's usage of anti-depressants does not indicate there is a higher lever of depression in the state.  "Utahns are more educated per capita than residents of other states," he said. "So instead of trying to ignore mental problems or medicate it on our own with alcohol or something else, we tend to seek professional help. We try to address our problems through legal legitimate ways."

In the next chart, we show the distribution of depression incidences by geographical territory and county size (A counties are those in the large metropolitan areas, while D counties are in rural or small metropolitan areas and have small populations).  Mormons are concentrated in the smaller areas of Southwest (the states of Arizona and New Mexico) and Pacific (the state of Utah), but these data cannot be taken to show that they are more likely to be depressed.   At most, it may be hypothesized that population density and geographical location (and therefore weather conditions) are correlated to depression.

(source:  Multimedia Audience Research Systems 2002)

When confronted with depression, there are many ways to cope.  Taking medication or seeking psychotherapy are some obvious solutions.  If it is depressing to contemplate the problems of one's personal life, one might decide simply not to deal with them.  Taking recreational drugs or getting totally immersed in work are some other solutions.  Or, one may retreat into a 'depression' and spend all one's time watching television.  According to Mark  Singer, a professor of social work at Case Western Reserve University, "Television is a great way to numb out, to escape. Kids who have pre-existing depression or anxiety can literally numb themselves and make problems go away temporarily by watching large amounts of television." 

According to the MARS study, the average American adult claims to watch 4.5 hours of television every day.  Among those who experience depression, the amount goes up to 5.4 hours per day.  In the following chart, we have ranked the amount of television viewing and then classified people into deciles (the lowest 10%, the next 10%, ... , to the heaviest 10%).  The incidence of depression is a monotonic increasing function of television viewing.  At the top decile (90%-100%), the average amount of television viewing is 11 hours per day and the incidence is 17.2%.  Watching television is not necessarily an effective coping strategy, as Mark Singer noted: "When you watch hours and hours of television, it doesn't lift your depression. It makes it even worse."

(source:  Multimedia Audience Research Systems 2002)


(posted by Roland Soong, 10/20/2002)

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