Does gender play a role in treatment?

The World Health Organization reports that depression is the most common women’s mental health problem and, although more research is needed, this disorder may be more persistent in females than in men. Some psychologists do offer more gender-specific therapy, while others prefer to treat each client on an individual basis, regardless of sex.

Julie B. Wolter, Psy.D., president of the Center for Self Development, P.C., Nashua, N.H., said that depression often depends on how the individual identifies. For example, she finds men typically view themselves as the provider; job loss could shatter that notion and prompt depression.

“Men come in with anger, irritability and flat affect. Sometimes, there are behavioral or substance abuse issues. They are in productivity, fix-it modes and don’t pay attention to feelings,” she said. “They need to know depression can be just as debilitating for them as for women. It’s not about their character.”

Women, on the other hand, present with more dysphoria, low self-esteem and guilt. Wolter said, “Women are more connected to their emotions. Their depression may be related more to socialization.”

Wolter reported that more men are seeking help for depressive disorders. “They are willing to come in, but are sometimes surprised when I tell them they are depressed,”she said. “But men want to get better and are not hesitant about accepting help.”

However, when couples make an appointment, based on the woman’s request, men are more reluctant. “This is a bit trickier. They deny there is anything wrong. Men who come in on an individual basis have made a choice. They have awareness something is wrong,” Wolter explained.

From a clinical perspective, Wolter does see cycles that correlate with hormonal changes in women. Some clients also experience chronic versus situational depression, she noted. “It’s helpful to get a sense of when a person feels worse so the client can watch his or her own cycle,” she said.

Intervention for both genders typically involves cognitive behavioral therapy, combined with medication when appropriate, according to Wolter. Other options include the use of light boxes, acupuncture, transcranial magnetic stimulation or exercise. Treatment usually depends on presentation and personality, rather than on gender, according to Wolter.

Jill M. Goldstein, Ph.D., director of research at the Connors Center for Women’s Health and Gender Biology at Brigham and Women’s Hospital and professor of psychiatry and medicine at Harvard Medical School, has been studying the root causes of sex differences in depression. In a recent article for Frontiers in Neuroscience, she wrote that she and her colleagues are studying how prenatal exposures alter sex differences in the development of stress-related neural and endocrine circuitries, which lay the vulnerability for why we see sex differences later in life.

“We know that puberty potentiates what’s laid down in the brain during fetal development and therefore puberty is another key developmental period for understanding sex differences in the risk for depression,” Goldstein added. “Gonadal hormones are the primary drivers of the sexual differentiation of the brain, involving every level of neuronal growth and development.”

In fact, she believes that discoveries about how these hormones are disrupted during fetal development will lead to novel and more effective therapies. “We understand in this day and age of personalized medicine that one treatment does not fit all, and what can be more ‘personal’ than one’s sex,” Goldstein said.

According to Goldstein, it is important that neuroscience incorporate a “sex-specific” or “sex-dependent” lens when investigating the brain. This is particularly true for depression for which women have twice the risk. Depression is the number one cause of disability worldwide, and, therefore, increasing the efficacy of treatment is critical, particularly for women, she said.

But not all psychologists necessarily base treatment for depressive disorders based on gender. Michael Schaffer, Ph.D., private practitioner in Cranston, R.I., although aware of the literature suggesting differences between men and women when it comes to depression, prefers to treat every client as an individual.

“Theory and research can guide us, but we can’t assume, based on someone’s gender, how depression will manifest and how they will cope,” he added. For instance, although men are thought to indulge more in alcohol and drugs to deal with depression, Schaffer treats a number of both genders that misuse these substances.

Rather than focus on gender, Schaffer delves into personal and life history during the first few sessions, paying close attention to what the client is saying, how they are saying it, what they focus on and what they may be leaving out, as well as body language. “Listening gives you a road map during those first few sessions,” he said. “You have to listen for an association and then question the client. Bring up your hypothesis and see if it resonates with the person.”

Schaffer stated that the client with depression, whether male or female, has often made decisions throughout life that have interfered with goals. “An important part of therapy is helping patients recognize the reason they have made certain decisions and the power they have to change their decision-making process in the present and future to better achieve their goals.”

Moreover, establishing a strong client/therapist relationship is critical to the healing process. “The client has someone willing to try to understand all aspects of their life. Although the therapist is emotionally supportive, this doesn’t mean the relationship is without possible ups and downs,” Schaffer said. “Sometimes the client might be frustrated with the therapist, but ruptures and repairs are normal in any relationship. These moments of tension are often important signposts to the underlying dynamics that interfere with the patient’s ability to live a more fulfilling life. If the patient and therapist can discuss these moments openly and honestly, this often leads to underlying changes that help the patient move forward.”

Irrespective of the biology of sex and its implications for drug treatment, Goldstein is also a firm believer in the importance of psychotherapy for depression. She said, “Psychology brings a critical component for the treatment of depression in tandem with the development of more efficacious psychopharmacology that hopefully will begin to incorporate our knowledge of sex differences in the brain.”