What’s Behind the “Depression Gap” Impacting Women?

The list of gender gaps is sufficiently long and distressing. Disparities in pay, employment, and housework are well-documented — but did you know that women are twice as likely as men to suffer from depression?

According to the CDC, Major Depressive Disorder (MDD) affects 11% of women as opposed to 6% of men. This significant and persistent disparity has been called the “depression gap,” and experts know that rectifying it begins with understanding its causes.

“Women get depressed much more frequently than men do,” explained William Dodson, M.D., LF-APA, in his ADDitude webinar titled “Managing Mood Disorders and Depression in ADHD Adults and Kids.” “At first, it was thought that women just went to see psychiatrists more easily than men. Now, thanks to very large population studies, we know that women really do have depression more often and they also seem to have bipolar disorder more often.”

Increased rates of depression in women may be of particular concern to the ADHD community, where depression is far more common. For example, a recent ADDitude survey of 1,500 readers revealed that 70% of adults with ADHD also have depression; in the general population, this number is 8%.

Depression in Women: A Closer Look

A recent study published in the American Journal of Epidemiology, using a sample of 813,189 respondents, found a persistent gender gap in depression that has remained steady for the past 35 years.¹ The study uncovered that the biggest difference in rates of depression in girls versus boys happened between the ages of 13–15. Among teens, the depression gap has only grown larger since 1982.

[Read: 6 Unexpected Signs of Depression]

These findings are echoed in the 2021 CDC Youth Risk Behavior Survey, which revealed that three in five teenage girls felt persistent sadness. Not only was this double the rate of sadness experienced by teen boys; it was almost double the rate of depression found in teen girls 10 years ago. By contrast, the incidence of depression in teen boys rose just 8% over the last decade. The percentage of boys who seriously considered suicide remained largely unchanged from 10 years before, while the rate of suicidal thinking and impulses among girls jumped from 19% to 30%.

For girls with ADHD, the dangers of depression are even greater. In an APSARD presentation titled, “Girls and Women with ADHD,” Stephen Hinshaw, Ph.D., explained that girls with combined type ADHD are three to four times more likely to attempt suicide than are their neurotypical peers, and they are more than twice as likely to engage in non-suicidal self-injuring behavior.

These studies, and others like them, make clear that a “depression gap” does indeed exist, but why it exists is far less clear. Experts believe the explanation is likely a combination of biological and sociological factors that uniquely impact women.

Biological Causes of Depression in Women

Several types of mood disorders are caused by fluctuations in estrogen and progesterone. These span the lifetime, often beginning in puberty and persisting through menopause. These also disproportionately affect women with ADHD. According to a study published in the Journal of Psychiatric Research, women with ADHD are more likely to experience hormone-related mood disorders and their symptoms tend to be more severe than those experienced by their neurotypical counterparts.²

[Download: Free Guide to Hormones & ADHD in Women]

PMDD (Premenstrual Dysphoric Disorder)

Premenstrual dysphoric disorder (PMDD) is a hormonal health condition in which changes in estrogen cause mood shifts, impaired functioning, and even some suicidality in the week or two leading up to a woman’s period. Women who suffer from PMDD may experience irritability, hopelessness, and anxiety, as well as fatigue, difficulty concentrating, and sleep disturbances. Though PMDD shares symptoms with PMS, the manifestation of these symptoms is far more severe in PMDD and significantly interferes with a woman’s functioning, requiring treatment.

In a recent survey of 1,856 women with ADHD, 68% said they experienced PMS and 14% said they also experienced PMDD — nearly double the national average. The most debilitating symptoms, they said, are irritability, mood swings, cramps or discomfort, and tension or anxiety. Most began experiencing symptoms of PMDD by age 13 or 14 and continued to feel its effects for 25 years or more. “If PMDD occurred in men,” Dodson said, “we’d have a cure by now.”

An ADDitude reader, Ine, describes her experience with PMDD in this way: “Around a week before my period starts, I feel heavy, unmotivated, depressed. Hanging up the laundry and other household tasks are like climbing a mountain and 99% end with me in tears.”

“It’s horrible,” agrees Kristi, an ADDitude reader from Michigan. “We get two weeks of mental anguish before our periods, one week of feeling physically bad on our periods, and one week a month to feel normal. PMDD sucks.”

PPD (Postpartum Depression)

Postpartum depression (PPD) occurs in 12.5% of women, according to the CDC. For women with an ADHD diagnosis, the number jumps to 17% for postpartum depression and 25% for postpartum anxiety, according to recent research published in the Journal of Affective Disorders.³ Though symptoms of PPD typically emerge in the first six weeks after childbirth, some women experience symptoms during pregnancy and others report them up to a year after birth.

In a recent ADDitude survey of 1,152 women who have experienced pregnancy, an astounding 56% said they suffered PPD; more than half of them said their symptoms lasted 10 months or longer.

Symptoms of postpartum depression include many hallmark symptoms of depression such as irritability, crying spells, loss of interest in preferred activities, and suicidal thoughts. Other symptoms include:

• Difficulty bonding with your baby
• Fear that you’re not a good mother
• Thoughts of harming your baby

PPD is a serious condition that, if left untreated, can persist for months or years, and can have harmful effects on both mother and baby. Thankfully, it responds well to treatment, which generally comprises a combination of medication and therapy.

Sara, an ADDitude reader from New Hampshire, recalls her experience of postpartum depression: “I felt disconnected emotionally from my daughter, like I was going through the motions of being a parent but could not feel the joy of parenting. I had a really hard time controlling my temper and got overwhelmed easily.”

“My hormones and postpartum depression and anxiety were so bad,” explains Jenny, an ADDitude reader from Nevada. “Instead of being able to enjoy my baby. I remember that time as very dark and challenging. It makes me so sad; I want to cry every time I think about it.”

Perimenopause and Menopause

In the years leading up to menopause, called perimenopause, decreasing levels of estrogen and progesterone can usher in a host of emotional issues including anxiety, mood swings, and possibly depression.

Research has revealed that the likelihood of depression in perimenopause is up to three times greater than it is before perimenopause begins.⁴ Women with a history of depression are nearly five times more likely to develop depression during perimenopause, and for women with ADHD, the risk of depression is elevated as well. Hope exists in the finding that within two to four years after menopause, the risk for depression decreases significantly.⁵ Effective treatment can include antidepressants in combination with therapy; in some cases, doctors may suggest hormone therapy.

In an ADDitude survey of 826 women with ADHD aged 50 and older, half of respondents said their ADHD symptoms had a ‘life-altering’ impact during their 50s. By contrast, only a third of women said the same about their ADHD symptoms from ages 10 to 19. Though recency bias may color self-reported symptom severity, women routinely and unequivocally tell us that ADHD symptoms spike in menopause.

One ADDitude reader describes the way in which her hormone-related mood disorders spanned decades of her life: “I was diagnosed with premenstrual dysphoric disorder in my early 30s. Then perimenopause hit around age 40, which started the 10-year emotional roller coaster from hell.”

Sociological Causes of Depression in Women

While biological causes create unique risk factors for women, the “depression gap” is also influenced by life events and circumstances that tend to impact women more often than men.

Sexual Assault

One in six women experience sexual assault, according to the Rape, Abuse & Incest National Network (RAINN), and it’s likely that the widespread prevalence of sexual violence is a contributing factor to the elevated rates of depression in women. A study published in JAMA Internal Medicine ⁶ found a strong association between depression and a history of sexual assault; women who had experienced sexual assault were three times more likely to develop depressive symptoms than were women who hadn’t.

Intimate Partner Violence

While intimate partner violence affects all genders, four in five victims are female, according to the National Domestic Violence Hotline. The connection between depressive symptoms and exposure to intimate partner violence is well-established. Recent research in BMC Public Health⁷ revealed that:

• Women who experience controlling behavior by their partner are 2.5 times more likely to report symptoms of depression
• Women who experience physical violence are 3 times more likely to suffer from depression
• Women who experience sexual violence are 4.5 times more likely to suffer from depression

Overwhelm and Role Strain

Work-life imbalance and the heavy burden of impossible societal expectations also contribute to poor mental health in women. The Lancet Public Health published a review of 19 studies examining the connection between unpaid labor (such as childcare responsibilities and housework) and mental health challenges including anxiety and depression. The authors of the study concluded: “The combination of a high unpaid workload with paid working commitments can lead to both role strain and time poverty, both of which can negatively affect mental health and wellbeing.”⁸ In the United States, women do an average 4.5 hours of this unpaid work each day compared with 2.8 hours for men; this strain and the ensuing stress likely play a role in the increased rates of depression in women.

Depression in Women Is Treatable

These research studies are helpful in clarifying risk factors as well as underlying associations, and they offer a broad view of how depression is impacting women today. However, Dodson is quick to emphasize that every person is unique, and not everyone’s experience is represented by these statistics. “We deal with individuals,” he explained. “And if it’s happening to you, then it’s 100% prevalent.”

If you are experiencing symptoms of depression, know that it is highly treatable. You should speak with your doctor to figure out an optimal treatment plan; in general, a combination of antidepressants and therapy is shown to be the most effective course of action.

If you are experiencing thoughts of suicide, you can reach the 988 Suicide & Crisis Lifeline by calling or texting 988. The hotline is open 24 hours a day, 7 days a week and is free and confidential.

Depression in Women: Next Steps

• Self Test: Depression in Adults
• Read: The ADHD–Depression Link – Symptom Parallels and Distinctions
• Read: What Does Depression Look Like in Adults?
• Watch: New Insights Into and Treatments for Comorbid Depression

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