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GENDER AND DEPRESSION:TYPICAL AND ATYPITCAL
SYMPTOMS AND SUICIDALIDEATION
Dissertation
Presented to the Faculty of the College of Health Sciencesof Touro University International
in Partial Fulfillment of the Requirements for the Degree ofDoctor of Philosophy in Health Sciences
By
Jed DiamondMarch 14, 2008
Dissertation Chair: Mihaela Tanasescu MD, ScDCommittee Member: Frank Gomez, PhD
Committee Member: Anne Maria Mller-Leimkhler, PhD
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Significance and Rationale For Study
Women seek helpmen die.
This conclusion was drawn from a study of suicide prevention by Angst & Ernst(1990). They found that 75% of those who sought professional help in an
institution for suicide prevention were female. Conversely 75% of those whocommitted suicide in the same year were male.
Since depression is a significant risk factor for suicide and men receive lesstreatment for depression than do women, it is vitally important that we have abetter understanding of the way depression manifests itself in males.
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Age
Socioeconomic status
Chronic disease (heart disease,
stroke, diabetes, cancer, other)
Marital status (and maritalhappiness)
Previous depression
Family history of depression
and suicide
Loss, trauma, life changes
Alcohol use, etc.
Suicidal
Ideation
Depression
(Typical
symptoms)
Gender
Atypical
symptomsof
depression
CONCEPTUAL MODELRisk Factors
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Research Hypotheses
There will be a significant positive relationship between typical
depression (CES-D) and atypical depression (DMDS).
Depressed men will score significantly higher for atypical symptoms(DMDS) than depressed women.
Non-depressed men will score significantly higher for atypical symptoms(DMDS) than non-depressed women.
There will be a significant relationship between known depressive riskfactors and atypical depression.
There will be a significant positive relationship between atypicalsymptoms (DMDS) and suicide risk.
Atypical symptoms of depression will be positively related to suicide riskwhen controlled for typical depression.
There will be a significant positive relationship between atypicalsymptoms (DMDS) and scores on the Gotland scale.
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Demographics of Study Population
323 females and 749 males (1072 total).
Age range 18-80, Mean 51, 58% over 50.
76% employed, 64% income > $50,000/year.
48% of the males and 40% of the females
depressed (CES-D 20).
53%, 1+ relatives have mood disorder.
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Factor Analysis of Diamond MaleDepression Scale (DMDS)
Factor 1: Emotional Acting-In Depression,Chronbachs alpha = .93
Negative, withdrawn, stressed, numb.
Factor 2: Emotional Acting-Out Depression,Chronbachs alpha = .89
Short-fuse, impatient, irritable, angry.
Factor 3: Physical Acting-Out DepressionChronbachs alpha = .73
Alcohol abuse, reckless, explosive, violent.
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Correlation of Typical Depression (CES-D 20)with DMDS Factors
Factor Pearson Correlation P-value
Factor 1, EmotionalActing-In
.700 < .001
Factor 2, EmotionalActing-Out
.474 < .001
Factor 3, Physical Acting-
Out
.319 < .001
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DMDS Factors in Depressed and Non-Depressed Men and Women
Predicting Factor 1 Emotional Acting-In UnstandardizedCoefficient P-value
Depressed Men vs. Women 1.15 .208
Non-depressed Men vs. Women .47 .510
Predicting Factor 2 Emotional Acting-Out
Depressed Men vs. Women 1.47 .002
Non-depressed Men vs. Women 1.19 .001
Predicting Factor 3 Physical Acting-Out
Depressed Men vs. Women 1.52 < .001
Non-depressed Men vs. Women .86 .003
The second and third hypotheses-- Depressed men will score significantly higherfor atypical symptoms (DMDS) than depressed women and non-depressed men will
score significantly higher for atypical symptoms (DMDS) than non-depressed womenwas answered affirmatively for Factor 2 and Factor 3.
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Atypical Symptoms of Depression and Known Depressive Risk Factors
There was a negativerelationship between atypical depression (DMDS) factorsand the following risk factors:
Age ( Factor 1, p = < .001, Factor 2, p = < .001, Factor 3, p = < .001) Gross family income ( Factor 1, p = .015, Factor 2, p = .001,
Factor 3, was not significant). Relationship happiness ( Factor 1, p = < .001, Factor 2, p = < .001,
Factor 3, p = < .001).
There was a positiverelationship between atypical depression (DMDS) factorsand the following risk factors:
Comorbid medical conditions ( Factor 1, p = < .001, Factor 2, p = .001,Factor 3, p =.006).
Having relatives who were depressed ( Factor 1, p = .034,Factor 2, p = .031, Factor 3, p =.002).
The forth hypothesis, There will be a significant relationship betweenknown depressive risk factors and atypical depression, was answeredaffirmatively for the risk factors previously noted.
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Logistic Regression for DMDS Factors and Beck Suicide Risk Adjustedfor Psychiatric Diagnoses, Age, Gender, and Gross Family Income
95.0% C.I. for Exp(B)
P-value Odds Ratio Lower Upper
Factor 1, Emotional Acting-In < .001 1.258 1.219 1.299
Factor 2, Emotional Acting-Out .221 .968 .919 1.020
Factor 3, Physical Acting-Out .560 .984 .933 1.038Psychiatric diagnoses .714 1.031 .959 1.306
Age .075 1.013 .861 1.235
Gender .035 1.497 1.029 1.178
Gross family income .004 .804 .692 .933
R Squared = .563The fifth hypothesis--There will be a significant positive relationship between atypical
symptoms (DMDS) and suicide risk--was answered affirmatively for Factor 1, EmotionalActing-In, but not for Factor 2, Emotional Acting-Out, or for Factor 3, Physical Acting-Out.
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Logistic Regression for DMDSFactors and Beck Suicide Risk Adjustedfor Psychiatric Diagnoses, Age, Gender, Gross Family Income, and
Typical Depression (CES-D 20)95.0% C.I. for Exp(B)
P-value Odds Ratio Lower Upper
Factor 1, Emotional Acting-In < .001 1.237 1.195 1.281
Factor 2, Emotional Acting-Out .316 .973 .924 1.026
Factor 3, Physical Acting-Out .506 .982 .931 1.036
Psychiatric diagnoses .917 1.010 .841 1.213
Age < .001 1.033 1.016 1.051
Gender .047 1.467 1.006 2.139
Gross family income .006 .809 .697 .940
CES-D 20 .027 1.547 1.050 2.281R Squared = .566
The six hypothesis--Atypical symptoms of depression will be positively related tosuicide risk when controlled for typical depression--was answered affirmatively for Factor1, Emotional Acting-In, but not for Factor 2, Emotional Acting-Out, or for Factor 3,Physical Acting-Out.
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Gotland Scale Correlations and
Factors 1, 2, and 3 of the DMDSFactor Pearson Correlation P-value
Factor 1, Emotional Acting-
In.794 < .001
Factor 2, Emotional Acting-
Out.584 < .001
Factor 3, Physical Acting-
Out.393 < .001
The seventh hypothesis--There will be a significant positive relationshipbetween atypical symptoms (DMDS) and scores on the Gotland scale--wasanswered affirmatively
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Implications for Theory
This study adds to the body of knowledge regardinggender and depression. By evaluating a larger set ofatypical depression symptoms (DMDS) than hadpreviously been used by Rutz (1999) with the GotlandScale for Assessing Male Depression, the study added toour understanding of male-type depression.
The study expands our understanding of therelationship between gender and atypical symptoms fordepression. It addressed a gap in the research literatureon gender and depression by clarifying three separatefactors or subscales that are associated with depressionand suicide risk.
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Potential Bias
There were selection biases since the study population was recruited throughwebsites that were focused on people with an interest in gender issues anddepression and thus not representative of the general population.
There were measurement biases since assessment of important variables such asdepression and suicide risk were based on respondents answers to an on-linequestionnaire. No outside, professional assessments were conducted.
Subjects were rated as being depressed or non-depressed based on their answersto a traditional depression scale (CES-D). Since one of the theoretical assumptions ofthe study was that depressed males might be missed using a traditional scale, this
may have introduced additional measurement bias.
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Recommendations for Future Research
Future research will be needed to validate the results of thestudy and to develop numerical scores for evaluatingdepression and suicide risk using the DMDS.
It would be helpful to conduct research with a generalpopulation to see if results were consistent in a populationrepresentative of the general community. Particular attentionshould be focused on including men and women from differentethnic groups, cultural backgrounds, economic levels, and agegroups.
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Recommendation for Clinical Practice
The belief that depression is a disease primarily affecting women has left toomany males undiagnosed and untreated.
Many clinicians believe that depressed males are undiagnosed because theevaluation scales being used do not address the symptoms of depression thatare more common in men.
Based on the results of the present study, it is recommended that cliniciansuse scales that include atypical symptoms such as those found on the DMDSand Gotland Scales.
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Surprises
Though the study was originally designed for U.S. clients, men andwomen from 44 other countries participated.
Based on clinical experience it was expected that it would bedifficult to recruit depressed males. This was not the case.
Only Factor 1, Emotionally-Acting In, was significantly related tosuicide risk when all three factors were used together.
There was actually a negative relationship between suicide risk andFactors 2 and 3, though the relationship was not significant.
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Thank You!
The three of you, each in your own way,
have made this study much better than itwould have been.