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Response Bias Because depression is diagnosed based on the information people provide about themselves, there may be a response bias on the part of women and men that contributes to the sex difference in depression. A common concern is that men are less likely than women to report depression because depression is inconsistent with the male gender role. The term depression has feminine connotations; it implies a lack of self-confidence, a lack of control, and passivity—all of which contradict the traditional male gender role. Sex differences in attitudes toward depression appear by early adolescence. A study of eighth graders showed that boys said that they would be less willing than girls to use mental health services for emotional problems and viewed people who sought mental health services as weird and weak (Chandra & Minkovitz, 2006). Attitudes toward the use of mental health services becomes more positive with age, but the sex difference remains (Gonzales, Alegria, & Prihoda, 2005; MacKenzie, Gekoski, & Knox, 2006). In a study of nearly 5,000 people in Israel, women were more likely than men to seek the help of a mental health care professional for mental health problems (Levinson & Ifrah, 2010). The sex difference among adults also seems to be limited to Whites; Hispanic and African American males and females have more similar attitudes to mental health problems.

One reason that men might be less willing than women to report depression is that they are concerned that others will view them negatively. This concern has some basis in fact. In a national survey, both women and men reported they were less willing to interact with a male than a female with mental health problems, including depression (Schnittker, 2000).

I have suggested a couple of reasons why men might want to deny being depressed. Is there evidence that men do, in fact, underreport depression? An older experimental study showed that men are leery of admitting depressive symptoms. As shown in Figure 13.3, men were more likely to endorse depressive items on an instrument labeled “hassles” than an instrument labeled “depression” (Page & Bennesch, 1993). The label did not affect women’s reports of depression.

A more subtle response bias on the part of men is that they may be less likely than women to realize they are depressed or to interpret their symptoms as depression. In other words, men may fall victim to the same kind of clinician bias just discussed. Men might perceive depression as a female problem and be unlikely to associate ambiguous symptoms with depression. I once interviewed a man following coronary bypass surgery who complained of a lack of energy, a loss of interest in leisure activities, and a desire to stay in bed all day. He was perplexed by these symptoms but completely denied any feelings of depression on a questionnaire I administered. Thus men may underreport their depression because they do not recognize depressive symptoms.

FIGURE 13.3Effects of questionnaire label on self-report of depression. Men were more likely to report symptoms of depression on a questionnaire that was labeled “hassles” rather than “depression.” The label attached to the questionnaire did not influence women’s reports of depressive symptoms. Source: Adapted from S. Page and Bennesch (1993).

Different Manifestations of Depression One difficulty in examining sex differences in depression, or any other disorder, is that symptoms of depression may differ for women and men. This is a general problem associated with the classification of many mental illnesses (Winstead & Sanchez, 2005). Most mental health problems seem to be more prevalent in one sex than

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the other, raising concerns about whether there is an actual sex difference in prevalence or if the disorder is described in ways that make it seem one sex is more likely to experience it than the other. If one eliminated disorders from the DSM-IV-TR for which there are sex differences in prevalence, the majority of the disorders would be removed. For example, histrionic personality disorder is more common among women than men. In an earlier version of the manual used to diagnosis this disorder (the DSM-III-R), a feature of the disorder was “overconcern with physical attractiveness.” There was some concern that this feature biased the disorder in favor of women. In the most recent version of the manual (DSM-IV-TR), this feature was changed to “physical appearance draws attention to the self.” Undoubtedly, this change in wording reduced the extent to which the disorder was linked to women. However, the change in wording also altered the actual feature of the disorder. If a feature of a disorder is linked to gender roles, should it be altered so it is equally endorsed by both sexes? We certainly would not change the features of medical illnesses such as prostate cancer or breast cancer so they are equally represented among both men and women. You may recall from Chapter 10 that heart disease is manifested differently among women and men. Men are more likely than women to experience classic chest pain, and women are more likely than men to experience shortness of breath. However, as Winstead and Sanchez (2005) point out, in this case, the underlying disease—heart disease—is the same among men and women. With psychiatric disorders there is no underlying disease (to date!) that can be objectively measured independently of symptom reports.

With respect to depression, some people argue that women and men are equally “distressed” but manifest it in different ways. A study of male and female twins showed differences in symptoms of depression (Khan et al., 2002). Females reported more fatigue, excessive sleepiness, and slowed speech and body movements, and males reported more insomnia and agitation. A study of depressed adolescents showed that females reported more guilt, body dissatisfaction, self-blame, feelings of failure, and difficulties concentrating compared to males (Bennett et al., 2005). The latter items could be linked to rumination (discussed later in the chapter), whereas the other items seem to reflect greater links to self-esteem difficulties in females. Find out if your peers perceive depression differently among women and men in Do Gender 13.2.

The idea that some items are more likely to be associated with a trait, such as depression, among men versus women is referred to as differential item functioning. For example, crying is a depression item that may be susceptible to differential item functioning. That is, crying is a symptom of depression that characterizes women more than men, even when women and men are equally depressed. This item could cause depression to be overdiagnosed in women. Recent research, however, argues against differential item functioning, noting that the items on depression inventories seem to be related to each other in similar ways for females and males (Leach, Christensen, & Mackinnon, 2008).