Research report
Al Ain community survey of psychiatric morbidity: II. Sex differences in the prevalence of depressive disorders

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Abstract

Aim: To examine sex differences in the prevalence of depressive disorders in an Arab community. Methods: One thousand three hundred and ninety-four subjects (n=1394) were systematically sampled from the general population in Al-Ain city, United Arab Emirates. All subjects were interviewed and assessed with the modified version of the Composite International Diagnostic Interview (CIDI) and a specially designed socio–demographic questionnaire. The lifetime male and female prevalence rates were estimated. Multivariate logistic regression of various socio–demographic variables was carried out to assess independent risk factors for depression. Statistical significance of sex differences in rates of depression by various socio–demographic groups were also assessed. Results: The lifetime rates in males and females were 2.8 and 10.3%, respectively. F:M ratio found in this study is highest reported ratio in the literature. Sex, life events, chronic difficulties and to a certain extent age were found to be risk factors for depression in the studied community. The prevalence rates of depression were higher in females in all above categories but such differences reached statistical significance in age category before 55, regardless of marital status, when the number of children is four or more and among those exposed to recent life events and chronic difficulties. Females were found to to be more exposed to chronic life difficulties but only depressed females were significantly more subjected to recent life events. Conclusion: Sex differences in depression is a robust finding but more studies are needed to explain the high F:M ratio found in this survey.

Introduction

Sex differences in the rates of depression have not been convincingly explained and this reflects a more general failure of research to provide a comprehensive aetiological account of depression (Bebbington, 1998). It is not even clear whether the determinants of this sex difference are predominantly biological or social. Although attractive, explanations in biological terms face a number of difficulties. If higher rates of depression in women are solely due to a biological vulnerability, the sex ratio ought to be unaffected by the socio–demographic status of the studied group. However, groups in which the social difference between men and women are minimised often show a reduced sex difference (Jenkins, 1985, Wilhelm and Parker, 1989). Marital status also affects the difference. It has been argued that being married brings more stress for women than for men (Weissman and Klerman, 1977, Paykel and Rowan, 1979, Weissman et al., 1984). In one Community Psychiatric Survey, single and divorced women had a lower prevalence of minor affective disorder than their male counterparts, while wives had over five times the prevalence of husbands (Bebbington et al., 1981a). However, marital status has different associations with affective disorder in different cultures. Married women at a low risk of disorder in Mediterranean countries (Mavreas et al., 1986, Va’zquez-Barquero et al., 1987), in rural New Zealand (Romans-Clarkson et al., 1988) and in British Orthodox Jews (Loewenthal et al., 1995). These societies all accord a high value to the home-making role. It is claimed that clinical depressive disorders are rare in childhood and show no female excess, perhaps even the reverse (Petersen et al., 1991, Angold and Rutter, 1992), although not all authors agree (Ruble et al., 1993). However, prevalence appears to rise sharply in late adolescence and early adulthood, particularly in females (Lewinsohn et al., 1994). Puberty may thus be linked to the emergence of the sex difference (Choquet and Menke, 1987, Cohen et al., 1993, Patton et al., 1996). In adulthood, the sex ratio tends to decline with age (Bebbington, 1998).

The interesting question is whether this can be related to the timing of the menopause. The recent British National Survey of Psychiatric Morbidity (Meltzer et al., 1995, Bebbington et al., 1998a) suggests that after age 55, the sex ratio changes, due mainly to a fall in female rates. Although, menopause was considered as a significant factor in the development of depression in women (Eagles and Whalley, 1985), there is very little epidemiological evidence of increased risk at this time (Der and Bebbington, 1987). Indeed, the recent large scale surveys using standardized instruments suggest the contrary. The ECCA surveys (Robins and Rigier, 1991) and the Edmonton DIS Survey (Bland et al., 1988) both suggest that only in younger subjects the F:M sex ratio is greater than unity. The purpose of this paper is to test the hypothesis as to whether sex ratio decline with age and whether also socio–demographic factors influence the sex differences in the rate of depression.

Section snippets

Materials and methods

The data stem from a community survey of adult population in Al-Ain city, United Arab Emirates. Subjects aged 18 years and over were systematically sampled from the general population in Al-Ain. One thousand three hundred and ninety-four subjects (n=1394) participated in this study. Only relevant information pertinent to this study will be included. Detailed methodology is reported in a paper that describes the prevalence of psychiatric disorders and their determinants (Abou-Saleh et al., 2001

Results

Eighty seven (19 males and 68 females) subjects were found to be suffering from various forms of depressive disorders. Their ages ranged from 18 to 70 years with a mean of 32.1±10.3 years. Approximately 19% were single, 61% married and the rest were either divorced, separated or widowed (postmaritals). Females accounted for 85 and 70% of the ICD-10 and minor depression groups, respectively, with no significant differences (χ2=2.07, df=1, P=0.08). Approximately 98% of subjects with ICD-10

Discussion

Sex differences in the prevalence rates of depression confirm the findings of previous community studies (Weissman and Myers, 1978, Robins et al., 1984, Bland et al., 1988, Wells et al., 1989, Canino et al., 1987). All those community studies may nevertheless have generated significant underestimates of life time prevalence, when the evidence of high rate of ‘forgetting’ earlier depressive episodes, particularly in community groups, is taken into account. Burke (1986) has reviewed the

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