تفاوت های جنسیتی در افسردگی در 23 کشور اروپایی؛ تنوع بین الملل در شکاف جنسیتی در افسردگی

One of the most consistent findings in the social epidemiology of mental health is the gender gap in depression. Depression is approximately twice as prevalent among women as it is among men. However, the absence of comparable data hampers cross-national comparisons of the prevalence of depression in general populations. Using information about the frequency and severity of depressive symptoms from the third wave of the European Social Survey (ESS-3), we are able to fill the gap the absence of comparable data leaves. In the ESS-3, depression is measured with an eight-item version of the Center for Epidemiological Studies–Depression Scale. In the current study, we examine depression among men and women aged 18–75 in 23 European countries. Our results indicate that women report higher levels of depression than men do in all countries, but there is significant cross-national variation in this gender gap. Gender differences in depression are largest in some of the Eastern and Southern European countries and smallest in Ireland, Slovakia and some Nordic countries. Hierarchical linear models show that socioeconomic as well as family-related factors moderate the relationship between gender and depression. Lower risk of depression is associated in both genders with marriage and cohabiting with a partner as well as with having a generally good socioeconomic position. In a majority of countries, socioeconomic factors have the strongest association with depression in both men and women. This research contributes new findings, expanding the small existing body of literature that presents highly comparable data on the prevalence of depression in women and men in Europe.

Cross-national research on gender differences in depression In the Western world, depression is approximately twice as prevalent in women as it is in men (Piccinelli & Wilkinson, 2000). This pattern appears in both clinical and general population samples and is virtually independent of location, method of assessment and diagnostic system (Kessler, Mcgonagle, Swartz, Blazer, & Nelson, 1993). While the average gender difference points to more universal genetic, neurohormonal, or psychobiological gender-linked antecedents of depression (Kuehner, 2003), cross-national variation in the gender ratio of depression suggests that social conditions also have a strong association with depression (Weissman et al., 1996). Hence, most current research accepts that gender differences in depression are the result of a variable interplay among biological, psychological and social factors (Hopcroft and Bradley, 2007 and Kuehner, 2003). The available research on cross-national variation in the gender ratio of depression should be considered cautiously since it is limited in several ways. The main limitation is the absence of comparable data that is representative of the general population. Usually, cross-national differences are estimated using meta-analyses of data from a diverse set of studies using different depression inventories, sampling designs and sampling populations. Moreover, the few multi-country epidemiological studies that do use a comparable design have several shortcomings. A recent study based on the World Values Study (Hopcroft & Bradley, 2007) had only one item available as a factor of depression/unhappiness. Other studies are limited to samples of students (Fischer & Manstead, 2000) or couples aged 50 and older (Börsch-Supan et al., 2005). Some are based on patient samples only (Angst et al., 2002, Ayuso-Mateos et al., 2001 and Maier et al., 1999) or contain only a small set of countries (Alonso et al., 2004). In these studies, it is not the number of countries involved that hampers the usefulness of these data so much as it is that they are convenience samples, which hinders the generalizability of the findings. In addition, the aforementioned studies present mixed results concerning cross-national variation in gender differences in depression. In certain studies, countries can be grouped by the size of the gender gap in depression. For example, based on the ODIN data, one study reported that the largest gender differences in depression were found in Anglo-Saxon countries, and lower levels of depression were reported in Nordic countries (Ayuso-Mateos et al., 2001). Other data however did not confirm this clustering, but found that among Eastern European countries the smallest and the largest gender gap in depression could be established in two separate countries; the same held for some of the Northern and Southern European countries (Hopcroft and Bradley, 2007 and Immerman and Mackey, 2003). Other studies found a smaller variation in gender differences in depression across countries (Börsch-Supan et al., 2005 and Maier et al., 1999). Using information from the third wave of the European Social Survey (ESS-3) we are able to fill this gap in the literature. The ESS-3 is representative of the general population in almost all European countries and has gathered information on depression using a shortened version of the internationally validated and reliable inventory, the Center for Epidemiologic Depression Scale (CES-D). The ESS-3 data thus allow us to analyze to what extent gender differences in depression vary across Europe. A high degree of cross-national variability would indicate that the consideration of social sources of stress is important for understanding the gender gap in depression. Explaining the gender gap in depression The stress and vulnerability model, which describes the relationship between stressors the individual is exposed to and the individual’s reaction to those stressors, is often used to predict the causes of depression (Pearlin, 1989). In addition to biological and psychological risk factors (for an overview see Kuehner, 2003), the literature addressing the gender gap in depression identifies a large variety of gender-specific social risk factors. Theories on depression often address the gendered pattern of social roles and social positions within different domains of private and social life. Female roles seem more prone to role limitations associated with lack of choice, to role overload, to competing social roles and to a tendency for females to be under-valued (Piccinelli and Wilkinson, 2000 and Stoppard, 2000); female social positions are therefore more characterized by powerlessness and lower status levels (Collins et al., 1993 and Connell, 1985). When studying these roles and positions, depression researchers usually focus on the gender-specific demands that marriage, childcare and employment often make. These demands and role expectations show increasing differentiation according to gender because of structural and cultural changes that have taken place, particularly in the last two decades. For example, mothers who stay at home and are unemployed are increasingly less valued. Additionally, women continue to join the workforce in larger numbers, becoming economically independent and increasingly share childcare responsibilities with men. However, filling the role of homemaker and childcare provider continues to decrease the likelihood of paid employment for women; it can also result in additional responsibilities for those women who fill those roles and are employed (Bebbington, 1996 and Piccinelli and Wilkinson, 2000). Women entering the job market face a higher risk of economic discrimination and job inequality than men do, and when employed, they may face an increased risk of depression due to role overload and role conflict because of the combination of responsibilities associated with employment and the household and care giving (Piccinelli & Wilkinson, 2000). For men, structural changes in family arrangements and the labor market are often accompanied by a significant challenge to the traditional definition of masculinity, which includes an inhibition against help-seeking and specific ideas about fatherhood, about male emotional expression, and about the role of men as sole breadwinners (Courtenay, 2000 and Garfield et al., 2006). The effect of these social changes on male depression and male risk and vulnerability factors has not been sufficiently studied and remains unclear (Addis, 2008 and Garfield et al., 2006), but there is evidence that divorced fathers — even as non-custodial parents — experience many parenting-related strains; this partly explains why they are more depressed than married men (Umberson & Williams, 1993). One related finding is that, after marital dissolution, fathers are as equally prone to depression as mothers when there are preschool-aged children in the home (Williams & Dunne-Bryant, 2006). Recent research has shown however that despite the emergence of new male risk groups for depression and the decline of the stereotypical, traditional family—a wage-earning father and a stay-at-home mother, in most European countries housekeeping and care giving is still mainly a woman’s responsibility (Lewis, Campbell, & Huerta, 2008). Related research on the social determinants of the female preponderance of depression focuses on stressful life events, like marital disruption and employment problems. Some models show that the gender gap in depression is due to a higher exposure of women to such events; other models point to gender differences in vulnerability as well (Kendler, Thornton, & Prescott, 2001). The empirical evidence for gendered patterns in depressive reactions to both marital disruption (see e.g., Kalmijn and Monden, 2006 and Simon and Marcussen, 1999 vs. Lucas, 2005 and Marks, 1996) and employment problems (see e.g., Leeflang, Kleinhesselink, & Spruit, 1992 vs. Artazcoz et al., 2004 and Vanroelen et al., in press) is mixed. One recurrent finding is that females are more dependent on emotional support and on personal relationships in which emotional intimacy, trust and solidarity are exchanged than men are (Pearlin et al., 1981 and Rosenfield et al., 2000). Women seem to bear “the cost of caring” (Bracke et al., 2008 and Kendler et al., 2001), meaning that they are more exposed to and more sensitive to social network events, leading to increased levels of depression when interpersonal stress or interpersonal loss is experienced. For men, there is a large body of evidence that suggest they are more prone to depression due to work-related stressful events (Kendler et al., 2001). However, empirical studies often report conflicting findings, suggesting that the association of the risk ratio of depression with negative life events and chronic strains needs further consideration (Kuehner, 2003). Explaining cross-national variation in the gender gap in depression Social models that explain gender differences in depression have emphasized the activities and circumstances of the everyday lives of women and men as sources of stress that may have an adverse effect on mental health. These models relate both socioeconomic- and family-related factors to stress. General gender stratification theories, for example, focus on the link between the differences in privilege and power in society and gender-based inequality (Collins et al., 1993). Blumberg (1984) argues that women’s economic power is the strongest predictor of their overall status. A disadvantaged socioeconomic position, therefore, may be the primary explanation for higher levels of depression in women (Chonody & Siebert, 2008). However, the question that remains is to what extent does this hypothesis hold across different European countries. Women’s economic power is directly related to the extent to which a welfare state enables women to survive as independent workers and decreases women’s economic dependence on the family (Bambra, 2007). While high levels of de-familialization are typical of Nordic countries, in Southern European countries women are strongly dependent on family (Zunzunegui et al., 2007). The Anglo-Saxon countries offer women the right to gender equality at work, but offer limited public assistance for the cost of childcare, creating problems regarding income and time, and resulting in gender inequality, questionable childcare arrangements and poor outcomes for children (Gornick & Meyers, 2003). Similarly, Eastern European countries publicly advocate a dual-earner model. However, in the private sphere, gender roles have remained rather traditional (Pascall & Lewis, 2004). It is reasonable to assume that, in addition to structural restrictions, stressors that occur in life domains that are highly valued also trigger depression. Research indicates that gender ideology is still relatively traditional in Eastern and Southern Europe and is more egalitarian in Nordic and Anglo-Saxon countries (Stickney & Konrad, 2007). Research has not yet tested empirically whether women suffer more from family-related stress in countries with a more traditional gender ideology. The aim of the current study is threefold. First, we will determine cross-national variation in the gender gap in depression in 23 European countries. Second, we will examine to what extent socioeconomic factors and family-related factors explain the gender difference. Last, we will study how social risk factors associated with depression vary across countries and between genders.