Gender differences in adolescent depression - Journal of Affective ...

Journal of Affective Disorders 89 (2005) 35 – 44 www.elsevier.com/locate/jad

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Gender differences in adolescent depression: Do symptoms differ for boys and girls? David S. Bennett a, Paul J. Ambrosini a,*, Diana Kudes b, Claudia Metzc, Harris Rabinovich d b

a Drexel University College of Medicine, United States University of Rochester/Golisano Children’s Hospital, United States c Case Western Reserve University, United States d Thomas Jefferson Medical College, United States

Received 26 June 2004; accepted 31 May 2005 Available online 10 October 2005

Abstract Background: Limited prior research suggests that depressed women are more likely to experience certain symptoms of depression than are depressed men. The purpose of this study was to examine whether such gender differences in depressive symptoms are present during adolescence. Methods: The Childhood Version of the Schedule for Affective Disorders and Schizophrenia and the Beck Depression Inventory were administered to adolescents presenting for evaluation at an outpatient clinic (n = 383; ages 11.9 to 20.0). Results: Depressed girls and boys had similar symptom prevalence and severity ratings for most depressive symptoms. However, depressed girls had more guilt, body image dissatisfaction, self-blame, self-disappointment, feelings of failure, concentration problems, difficulty working, sadness/depressed mood, sleep problems, fatigue, and health worries than depressed boys on some comparisons. In contrast, depressed boys had higher clinician ratings of anhedonia, depressed morning mood, and morning fatigue. Limitations: Longitudinal research is needed to test whether such relatively gender-specific symptoms play different roles in the onset, maintenance, or remittance of depression for boys and girls. Conclusions: These findings indicate that, in general, the experience of depression is highly similar for adolescent girls and boys. However, some gender differences previously found among depressed adults appear to be present by adolescence, possibly suggesting somewhat distinct etiologies for depression among males and females. D 2005 Elsevier B.V. All rights reserved. Keywords: Depression; Symptoms; Gender differences; Adolescence

* Corresponding author. Division of Child and Adolescent Psychiatry, Friends Hospital, 4641 Roosevelt Blvd., Philadelphia, PA 19124-2399, United States. Tel.: +1 215 831 1560; fax: +1 215 831 6382. E-mail address: [email protected] (P.J. Ambrosini). 0165-0327/$ - see front matter D 2005 Elsevier B.V. All rights reserved. doi:10.1016/j.jad.2005.05.020

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D.S. Bennett et al. / Journal of Affective Disorders 89 (2005) 35–44

1. Background Lifetime prevalence of affective disorders is twice as high in women as men (Kessler et al., 1994; NolenHoeksema, 1987; Weissman et al., 1996). This difference appears to emerge in early adolescence between the ages of 12 and 14 (Hankin and Abramson, 2001; Wade et al., 2002; Twenge and Nolen-Hoeksema, 2002). Reasons for gender differences in unipolar depression are not yet well understood. One model suggests that adolescent girls and young women are more prone to exhibit a cognitive style characterized by negative self-evaluation and rumination, which in turn may predispose them to depression (Garber and Martin, 2002; Gilligan and Attanucci, 1988; Hankin and Abramson, 2001; Nolen-Hoeksema et al., 1999; Siegel et al., 1999). The presence of gender-based differences in cognitive symptoms is documented among both psychiatric patients and normal controls. For example, females endorse higher overall scores than males on the Beck Depression Inventory (BDI; Beck et al., 1961), which emphasizes cognitive symptoms of depression. This is reported among both adults (Oliver and Simmons, 1985) and adolescents (Ambrosini et al., 1991; Roberts et al., 1991). Gender differences also are found in brain functioning, as women with histories of childhood depression exhibit greater right midfrontal alpha wave suppression (Miller et al., 2002). Furthermore, depressed women, but not men, who respond to medication had lower purine–metabolite ratios than nonresponders (Renshaw et al., 2001). Collectively, such differences suggest that the characteristics of depression may differ for males and females. Studies comparing the individual symptoms of depressed men and women also have found gender differences. Specifically, depressed women report more somatic symptoms such as appetite and weight increases, sleep problems, psychomotor retardation, and somatization (Angst and Dobler-Mikola, 1984; Carter et al., 2000; Frank et al., 1988; Kornstein et al., 2000; Silverstein, 2002; Young et al., 1990) and also more crying, guilt, and body image dissatisfaction than depressed men (Angst and Dobler-Mikola, 1984; Carter et al., 2000; Vredenburg et al., 1986; Wilhelm et al., 2002). In contrast, depressed men have reported more work inhibition and health concerns (Vredenburg et al., 1986). However, it is unclear

how replicable these findings are and how early such gender specific depressive symptom patterns emerge. It has been hypothesized that depressed girls exhibit more mood symptoms (e.g., feeling sad) and cognitive symptoms (e.g., self-deprecation), whereas depressed boys exhibit more irritability (Kovacs, 2001). Yet, gender differences in depressive symptoms have not been found among children or adolescents meeting criteria for major depression (Kovacs, 2001; Roberts et al., 1995; Sorensen et al., 2005) or dysthymic disorder (Masi et al., 2001). A major limitation of these studies, however, is their use of modest samples of depressed children or adolescents (i.e., between 42 and 92 subjects), limiting their ability to detect moderate but theoretically important symptom differences between girls and boys. A fourth study used cutoff scores on the BDI to designate a group of depressed adolescents and did find differences as body image distortion, loss of appetite, and weight loss were more common among depressed girls, and work inhibition, insomnia, and social withdrawal among depressed boys (Baron and Joly, 1988). The goal of the present study was to examine gender differences in the prevalence and severity of depressive symptoms among depressed adolescents. Based on the adult findings, we hypothesized that depressed girls would report more guilt, appetite, sleep, and cognitive symptoms of depression than depressed boys.

2. Methods 2.1. Sample The sample consisted of 416 adolescents referred to a pediatric depression clinic at two university medical centers. Subjects were consecutive referrals who completed the study procedures as part of the clinics’ standard evaluation process. Potential subjects were excluded if they were physically ill, mentally retarded, or had symptoms clearly suggestive of anorexia/bulimia nervosa, autism, or primarily disruptive behavior disorders. An additional 33 subjects were excluded from the study because they exhibited symptoms of birritable depression.Q This may be a unique depressive subtype characterized by the lack of a depressed mood or pervasive anhedonia, but only having irritability as


the predominant affective state (Ambrosini, 1997). The final sample consisted of 383 adolescents (218 girls, 165 boys) between the ages of 11.9 and 20.0 years (M = 15.8, S.D. = 1.6), most of whom were evaluated as outpatients (360 outpatient; 23 inpatient). The largest group of subjects met criteria for major depressive disorder (MDD; n = 183), while 59 met criteria for minor depressive disorder/dysthymic disorder (MD/ DD). The remaining 141 subjects were classified as non-depressed psychiatric controls (PC). The most common diagnoses given to controls were oppositional defiant disorder (n = 23), ADHD (n = 13), and overanxious disorder (n = 13), with 24 not meeting criteria for any diagnosis. One hundred and four subjects were seen in Cleveland and 279 in Philadelphia. The Philadelphia clinic predominantly recruited depressed youth while the Cleveland clinic recruited both depressed and anxious youth. The two samples were similarly matched on age, gender, socioeconomic status (SES), and depression severity ratings. 2.2. Procedures All subjects were initially screened for signs and symptoms of depressive or anxiety disorders during their first phone contact. Subjects were then scheduled for an extensive history gathering session with their parents at the clinic. Following this intake, two sessions were scheduled (one with the adolescent and one with the parent(s)) within 3 days of each other. A diagnostic interview, the Childhood Version of the Schedule for Affective Disorders and Schizophrenia (K-SADS-IIIR, IV; Ambrosini, 2000; Ambrosini et al., 1989) was administered to assess adolescents’ depressive symptoms. The K-SADS generates summary diagnoses based on the adolescents’ and parents’ interviews for two time frames, the last 12 months and the last week. The summary diagnoses for the last week were used in the present study, implying that subjects were in an active phase of their disorder. Forty-nine subjects were not administered a full KSADS interview due to time constraints and instead completed a Mini-SADS. This abbreviated interview only covers the affective disorder symptoms from the full K-SADS. Diagnoses were made using DSM-III (American Psychiatric Association, 1980), DSM-IIIR (American Psychiatric Association, 1987) and/or Research Diag-

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nostic Criteria (RDC; Spitzer et al., 1978). All diagnoses were based preferentially on RDC; DSM criteria were used for those disorders not included in the RDC domain. The transition from DSM-III to -IV diagnoses had little impact on affective disorder diagnoses as the criteria for MDD and MD/DD did not change from DSM-III to -IV. To assess symptom severity, the 17-Item Depression Rating Scale was extracted from the clinician administered K-SADS (Ambrosini et al., 1989). It includes all of the RDC for a major depressive disorder. The 17-Item Depression Rating Scale is a valid measure of depression severity and is sensitive to pharmacological change (Ambrosini et al., 1991, 1994). Scores range from 17 to 86. A second measure of symptom severity, the 21item Beck Depression Inventory (BDI; Beck et al., 1961), was completed by the adolescent prior to the K-SADS. The BDI has satisfactory concurrent and discriminant validity with adolescents (Ambrosini et al., 1991; Bennett et al., 1997). The total BDI score ranges from 0 to 63. 2.3. Statistical methods Demographic characteristics (race, age, SES) were examined using v 2 tests and Analyses of Variance (ANOVAs). Gender differences in the prevalence of individual depressive symptoms were examined using v 2 tests with Yate’s correction for continuity; differences in symptom severity were examined using a series of 2 (gender) 3 (diagnostic group) MANOVAs. Post-hoc univariate analyses using Tukey tests were conducted when significant multivariate gender effects were found. This large sample size provided power to detect moderate differences between boys’ and girls’ scores. Although there was a 92% chance of identifying a mean difference of 0.5 (with a standard deviation of 1.0; p b .05) between boys’ and girls’ scores on any given symptom in the MDD group, power falls to 63% once a Bonferroni correction (groupwise type I error rate = 0.05) for all 21 BDI items is used. In addition, past research suggests that gender differences in particular depressive symptoms are more likely to be modest than large. While we had specific hypotheses regarding several symptoms, we also wanted to consider gender differences among all

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symptoms. Hence, we report findings that were significant both prior to and following Bonferroni correction. Finally, logistic regressions with simultaneous entry of individual symptoms were conducted to identify which symptoms best discriminate depressed boys from girls when controlling for the effects of the other symptoms.

3. Results The demographic characteristics of the three diagnostic groups are shown in Table 1. As would be expected, there was a greater proportion of girls in the depression (MDD and MD/DD) groups than in the PC group (v 2 (2 df) = 8.67, p b .05). Gender, however, was unrelated to race, age, SES (Hollingshead, 1975), duration of depression, and age of onset of the current depressive episode. Gender also was unrelated to comorbid disorders (ADHD; conduct disorder; generalized anxiety disorder; obsessive–compulsive disorder; oppositional defiant disorder; overanxious disorder; separation anxiety disorder; simple phobia; social phobia), examined separately within the MDD and MD/DD groups.

3.1. Symptom prevalence: 17-Item Depression Rating Scale Chi-square tests with Yate’s correction were used to examine gender differences in the prevalence of depressive symptoms for each diagnostic group (see Table 2). A symptom was considered to be present if rated as 3 or higher, indicative of at least mild severity. For most symptoms, the prevalence was similar between boys and girls within the same diagnostic group. However, girls with MDD were more likely to be rated as having excessive guilt (v 2 (1 df) = 4.21, p b .05), and girls with MD/DD were more likely to be rated as having concentration problems (v 2 (1 df) = 4.91, p b .05). In contrast, boys with MDD were more likely to have morning fatigue (v 2 (1 df) = .21, p b .05) and psychomotor retardation (v 2 (1 df) = 4.07, p b .05). Each of the above gender differences became non-significant after Bonferroni correction ( p significant at b.003). 3.2. Symptom severity: 17-item depression scale To examine whether the pattern of gender differences found for symptom prevalence was present for

Table 1 Demographic characteristics of subjects by gender and diagnostic group MDDa (n = 183) Gender Male Female Race Male European-American African-American Other Female European-American African-American Other Age Male Female SES category Male Female

MD/DDb (59)

PCc (141)

Total (383) v 2(2) = 8.67*

74 109

18 41

73 68

165 218 n. s.

58 12 4

15 3 0

55 12 5

128 27 9

85 16 7

33 5 3

43 21 4

161 42 14

16.1 (1.7) 16.1 (1.6)

15.8 (1.6) 16.0 (1.5)

15.4 (1.7) 15.3 (1.6)

165 218

2.1 (1.1) 2.2 (1.5)

2.1 (1.2) 2.0 (1.1)

2.1 (1.2) 2.1 (1.3)

143 186

n. s.

n.s.

*p b .05, n.s. = not significant. a Major Depressive Disorder. b Minor Depression/Dysthymic Disorder. c Psychiatric Control.


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Table 2 Depressive symptom prevalence (%) among depressed adolescents and psychiatric controls Major depressive disorder

Depressed mood Depressed mood worse in a.m. Irritable mood Excessive guilt Anhedonia Fatigue Fatigue worse in a.m. Concentration problems Psychomotor agitation Psychomotor retardation Insomnia Hypersomnia Loss of appetite/anorexia Increased appetite Hopelessness Suicidal Social avoidance

MD/DDa

Psychiatric controls

Boys (n = 74)

Girls (109)

Boys (18)

Girls (41)

Boys (73)

Girls (68)

100.0 17.6# 68.9 52.7 89.2 87.8 18.9* 94.6 27.0 50.0* 70.3 18.9 44.6 13.5 79.7 54.1 36.5

98.2 7.3 61.5 68.8* 79.8 87.2 6.4 92.7 35.8 33.9 70.6 14.7 52.3 21.1 71.6 63.3 32.1

100.0 11.1 50.0 11.1 38.9 11.1 5.6 33.3 0.0 11.1 27.8 0.0 22.2 5.6 22.2 16.7 11.1

100.0 4.9 29.3 26.8 29.3 39.0# 2.4 68.3* 7.3 4.9 29.3 2.4 19.5 4.9 36.6 12.2 22.0

4.1 0.0 6.8 2.7 6.8 19.2 4.1 42.5# 5.5 2.7 16.4 4.1 4.1 5.5 9.6 1.4 0.0

2.9 0.0 1.5 11.8# 11.8 20.6 1.5 26.5 13.2 1.5 19.1 5.9 5.9 2.9 10.3 4.4 1.5

*p b .05, #p b .10, for gender differences within each diagnostic group. a Minor Depression/Dysthymic Disorder.

severity ratings, mean scores were analyzed (see Table 3). A 2 (gender) 3 (diagnostic group) betweensubjects MANOVA was performed on the 17 items. Significant effects were found on the multivariate tests

for gender (Wilks Lambda = 0.91, F (17,361) = .09, p b .01), diagnostic group (Wilks Lambda = 0.16, F (34,722) = 31.30, p b .001), and for the gender by diagnostic group interaction (Wilks Lambda = 0.86,

Table 3 Mean 17-Item Depression Rating Scale item scores

Depressed mood Depressed mood worse in a.m. Irritable mood Excessive guilt Anhedonia Fatigue Fatigue worse in a.m. Concentration problems Psychomotor agitation Psychomotor retardation Insomnia Hypersomnia Loss of appetite/anorexia Increased appetite Hopelessness Suicidal Social avoidance

Major depressive disorder

MD/DDa

Boys (n = 74)

Girls (109)

Boys (18)

Girls (41)

Boys (73)

Girls (68)

5.2 1.5* 3.7 2.8 4.2** 4.1 1.6* 4.1 2.3 2.6# 3.2 1.7 2.4 1.5 3.6 2.9 1.4

4.9 1.2 3.5 3.2# 3.6 4.0 1.2 4.1 2.4 2.4 3.4 1.6 2.7 1.7 3.3 3.1 1.3

3.5 1.3 2.8 1.4 2.2 1.5 1.2 2.1 1.7 1.8 2.3 1.1 1.8 1.3 1.7 1.8 1.1

4.0* 1.1 2.3 2.2** 2.4 2.6** 1.1 3.0* 1.8 1.9 2.4 1.4* 1.7 1.1 2.1 1.6 1.2

1.5 1.0 1.6 1.2 1.4 1.7 1.2 2.3** 1.7 1.5* 1.8 1.3 1.2 1.3 1.4 1.1 1.0

1.5 1.0 1.6 1.4# 1.5 1.8 1.1 1.8 1.8 1.3 1.9 1.3 1.2 1.2 1.3 1.2 1.0

(1.2) (1.0) (1.7) (1.6) (1.3) (1.2) (1.0) (1.0) (0.8) (1.0) (1.2) (1.1) (1.6) (1.1) (1.4) (1.7) (0.5)

(1.3) (0.7) (1.6) (1.4) (1.3) (1.3) (0.7) (1.1) (0.8) (0.7) (1.3) (1.0) (1.6) (1.3) (1.4) (1.6) (0.5)

**p b .01, *p b .01, #p b .10, for gender differences within each diagnostic group. a Minor Depression/Dysthymic Disorder.

(0.6) (0.8) (1.4) (0.7) (0.9) (0.9) (0.5) (1.1) (0.5) (0.6) (1.2) (0.3) (1.4) (0.8) (1.1) (1.4) (0.3)


(0.9) (0.5) (1.2) (1.2) (1.2) (1.7) (0.3) (1.4) (0.6) (0.6) (1.2) (0.5) (1.1) (0.5) (1.0) (1.3) (0.4)

(0.7) (0.2) (0.7) (0.5) (0.8) (1.0) (0.5) (1.2) (0.6) (0.6) (1.1) (0.6) (0.5) (0.8) (0.7) (0.5) (0.1)

(0.6) (0.2) (0.7) (0.7) (0.8) (1.2) (0.4) (1.0) (0.7) (0.5) (1.1) (0.6) (0.7) (0.7) (0.7) (0.7) (0.1)

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F (34,722) = 1.72, p b .01). Consistent with hypothesis, girls had higher severity ratings. The diagnostic group effect, as expected, indicated that subjects with MDD generally had higher severity ratings than subjects with MD/DD, who in turn had higher ratings than subjects in the PC group. Given the significant gender by diagnostic group interaction, gender differences were examined separately within each diagnostic group. Within the MDD group, the only symptom for which girls were rated higher was excessive guilt, and this was only a trend (t (141 df) = 1.73, p b .10). Girls with MD/DD, though, were rated as experiencing more depressed mood (t (57) = 2.05, p b .05), guilt (t (57) = 2.64, p b .05), fatigue (t (55) = 3.44, p = .001), concentration problems (t (57) = 2.32, p b .05), and hypersomnia (t (51) = 2.25, p b .05). In contrast, boys in the MDD group were rated higher on anhedonia (t (181 df) = 2.95, p b .01), morning fatigue (t (181) = 2.53, p b .05), and a depressed mood that was worse in the morning (t (120 df) = 2.06, p b .05). Examining the PC group, the only significant differences were that boys had more concentration problems (t (139) = 3.00, p b .01) and psychomotor retardation (t (139) = 2.04, p b .05). When a Bonferroni groupwise correction was applied ( p significant at b.003) the only finding to remain significant was that girls in the MD/DD group were rated as experiencing more fatigue. Summing all 17 items into a total score, gender ( F (1) = 4.83, p b .05), diagnostic group ( F (2) = 183.05, p b .001), and gender by diagnostic group interaction ( F (2) = 4.00, p b .05) effects were found. The gender by diagnostic group interaction indicated that girls in the MD/DD group experienced more overall depressive symptoms (t (29) = 3.53, p b .001).

symptoms than those in the PC group. The gender by diagnostic group interaction was not significant. However, gender differences were again examined within the context of each diagnostic group to provide parallel analyses to those for the 17-Item Depression Rating Scale data (see Table 4). Girls with MDD endorsed feeling sad (t (171) = 2.10, p b .05), self-blame (t (171) = 2.02, p b .05), feeling ugly (t (171) = 2.00, p b .05), not being able to work or to do anything (t (171) = 2.68, p b .01), and having sleep problems (t (171) = 2.41, p b .05) more than did boys with MDD. Girls in the MD/DD group reported a higher severity of feeling like a failure (t (56) = 2.17, p b .05), feeling guilty (t (54) = 3.30, p b .01), being disappointed in themselves (t (52) = 2.32, p b .05), having lost interest in people (t (54) = 2.70, p = .01), feeling ugly (t (55) = 4.44, p b .001), and having health worries (t (56) = 2.25, p b .05). Boys did not report greater severity for any BDI symptom in either depressed group. Examining the PC group, girls reported more suicidality (t (123) = 2.78, p b .01), crying (t (120) = 2.03, p b .05), and feeling ugly (t (80) = 3.96, p b .001). Boys did not report more BDI symptoms in any group. After Bonferroni correction ( p b .0024), the findings that girls in the MD/DD group reported more guilt and feeling ugly remained significant, as did the finding that girls in the PC group felt ugly more than did boys. Summing all BDI items into a total score, gender ( F (1) = 13.96, p b .001) and diagnostic group ( F (2) = 123.50, p b .001) effects were significant. For each diagnostic group, BDI total scores were higher for girls (MDD: t (171) = 2.11, p b .05; MD/DD: t (56) = 2.69, p b .01; PC: t (128) = 2.40, p b .05). There was no gender by diagnostic group interaction for the total score.

3.3. Symptom severity: Beck Depression Inventory A similar 2 (gender) 3 (diagnostic group) between-subjects MANOVA was performed on the 21 BDI items. As for the clinician ratings on the 17Item Depression Rating Scale, girls reported more depressive symptoms (Wilks Lambda = 0.89, F (21,335) = 1.96, p b .01). A diagnostic group effect also was found (Wilks Lambda = 0.48, F (42,670) = 7.03, p b .001) and was again due to the tendency of the MDD group to report more symptoms than those in the MD/DD group, who in turn tended to report more

3.4. Which depressive symptoms are most closely associated with child gender? Logistic regressions were conducted for the combined depressed groups (n = 242). These analyses examined which symptoms, controlling for the effects of the other symptoms, best distinguished depressed girls from depressed boys. In the first analysis, all 17 items of the Depression Rating Scale were entered simultaneously to predict gender. The overall logistic regression model indicated a satisfactory fit to the data


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Table 4 Mean Beck Depression Inventory item scores MD/DDa

Major depressive disorder

1. Feels sad 2. Discouraged about future 3. Feels like a failure 4. Lacks enjoyment (anhedonia) 5. Feels guilty 6. Feels punished 7. Disappointed in self 8. Blames self 9. Suicidal 10. Crying 11. Irritated 12. Lost interest in people 13. Indecisive 14. Looks ugly 15. Can’t work/do anything 16. Sleep problems 17. Tired 18. Poor appetite 19. Weight loss 20. Health worries 21. Decreased interest in sex Total BDI score


Boys (n = 74)

Girls (109)

Boys (18)

Girls (41)

Boys (73)

Girls (68)

1.5 1.6 1.4 1.7 1.1 1.3 1.4 1.4 1.0 1.5 1.3 0.9 1.2 1.0 1.5 1.0 1.4 0.8 0.4 0.6 0.7 24.7

1.8* 1.6 1.3 1.7 1.3 1.3 1.6 1.7* 1.3 1.7 1.3 1.1 1.5# 1.4* 1.8** 1.4* 1.6# 1.1# 0.6 0.6 0.6 28.2*

0.9 1.0 0.7 1.0 0.2 0.9 0.7 0.6 0.8 1.4 1.3 0.2 1.0 0.2 1.0 0.9 0.7 0.5 0.5 0.3 0.1 15.0

1.1 1.0 1.2* 1.0 0.8* 1.0 1.2* 1.2 0.7 1.4 1.0 0.7* 1.2 1.3** 1.2 1.2 1.1# 0.7 0.7 0.7* 0.4 20.8**

0.3 0.5 0.5 0.5 0.2 0.5 0.4 0.4 0.3 0.3 0.7 0.3 0.6 0.2 0.6 0.6 0.6 0.3 0.3 0.3 0.1 8.4

0.3 (0.6) 0.4 (0.7) 0.6 (0.7) 0.8# (1.0) 0.4 (0.5) 0.5 (0.9) 0.6 (0.8) 0.6 (0.7) 0.6**(0.7) 0.7* (1.1) 0.9 (0.9) 0.4 (0.7) 0.8 (0.9) 0.8** (1.2) 0.8 (0.9) 0.6 (0.9) 0.8 (0.8) 0.5 (0.8) 0.3 (0.6) 0.2 (0.5) 0.2 (0.6) 11.5* (7.9)

(1.0) (1.0) (1.1) (1.0) (1.0) (1.3) (1.0) (1.0) (0.9) (1.2) (0.8) (1.0) (1.0) (1.3) (0.9) (0.9) (0.9) (0.9) (0.9) (0.8) (0.9) (11.5)

(0.9) (1.0) (0.9) (0.9) (1.1) (1.3) (1.0) (0.9) (0.9) (1.0) (0.7) (0.9) (1.0) (1.3) (0.8) (0.9) (0.9) (1.1) (0.9) (0.9) (0.9) (9.6)

(1.0) (1.0) (0.9) (1.0) (0.4) (1.4) (0.6) (0.7) (1.1) (1.5) (0.5) (0.4) (0.8) (0.6) (0.8) (1.1) (0.8) (0.6) (0.9) (0.5) (0.5) (5.6)

(0.8) (0.9) (0.9) (1.0) (0.9) (1.1) (1.1) (1.0) (0.7) (1.0) (0.7) (0.9) (1.0) (1.3) (0.8) (1.0) (0.9) (0.9) (0.9) (0.7) (0.9) (8.1)

(0.6) (0.8) (0.7) (0.7) (0.5) (0.9) (0.7) (0.8) (0.6) (0.8) (0.8) (0.5) (0.8) (0.4) (0.7) (0.8) (0.7) (0.6) (0.5) (0.6) (0.6) (6.9)

**p b .01, *p b .01, #p b .10, for gender differences within each diagnostic group. a Minor Depression/Dysthymic Disorder.

(Hosmer–Lemeshow test; v 2 (8) = 9.37, p N .10). Four items were significant predictors of gender as depressed girls were more likely to exhibit excessive guilt (odds ratio (OR) = 1.36, Wald statistic = 6.51, p = .01) and increased appetite (OR = 1.36, Wald = 3.90, p b .05), but less likely to exhibit anhedonia (OR = 0.69, Wald = 9.18, p b .01) and morning fatigue (OR = 0.63, Wald = 4.54, p b .05) than were boys. The overall model correctly identified 81.3% of the girls, but only 40.2% of the boys. In a second regression, all 21 BDI items were simultaneously entered to predict gender. The overall model also indicated a satisfactory fit to the data (Hosmer–Lemeshow test; v 2 (8) = 9.68, p N .10). Three BDI items were significant predictors of gender as depressed girls were more likely to report feeling that they looked ugly (OR = 1.44, Wald = 5.25, p b .05), but were less likely to exhibit anhedonia (OR = 0.65, Wald = 4.72, p b .05) and irritability (OR = 0.63, Wald = 4.68, p b .05) than were boys. As for the 17Item Rating Scale, the overall model was better at identifying girls than boys (84.4% vs. 41.7%).

4. Discussion Depressed girls and boys generally experience similar prevalence and severity ratings of depressive symptoms, consistent with prior studies of youth (Kovacs, 2001; Masi et al., 2001; Roberts et al., 1995) and adults (Young et al., 1990). Yet, several potentially important differences emerged. Consistent with studies of depressed adults, depressed girls appear to experience more guilt and body image dissatisfaction than depressed boys. Furthermore, depressed girls reported or were rated as having more sadness/depressed mood, self-disappointment, self-blame, feelings of failure, concentration problems, difficulty working, fatigue, and health worries than depressed boys. In contrast, depressed boys with MDD had higher clinician ratings of anhedonia, morning depressed mood, and morning fatigue. In addition, anhedonia on the BDI, though not greater among boys than girls, was more predictive of depression for boys than girls in the logistic regression.

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Gender differences in guilt were fairly consistent across depression diagnoses and measures in the present study. Similarly, Breslau and Davis (1985) found guilt to be the most important predictor in discriminating MDD from generalized anxiety disorder vs. no diagnosis in their sample of women. The emergence of gender differences in guilt may play an important role in the onset of depression for females. Given that girls are more likely to be socialized from an early age to be caring and sensitive, to express emotions that minimize disagreements, and to be concerned about what others think of them (Ferguson et al., 1999), such socialization differences may lead to greater guilt and related cognitive symptoms of depression when social rules are violated. Longitudinal research is needed to examine whether guilt symptoms are antecedents, and not merely concomitants, of other depressive symptoms. The poor body image item (bI believe that I look uglyQ) on the BDI also was more prevalent among depressed girls, consistent with prior research finding a relation between body image dissatisfaction and depressive symptoms among girls (Allgood-Merten et al., 1990; Siegel et al., 1999; Seiffge-Krenke and Stemmler, 2002). Given that increased appetite also was somewhat specific to depressed girls in the logistic regression, these findings suggest a model in which stress may lead to increased eating and depressive symptoms, particularly for girls. Restrained eaters, who are more commonly girls than boys (Fox et al., 1994), tend to increase their eating following stressful events, whereas unrestrained eaters decrease their eating when stressed (Greeno and Wing, 1994). Furthermore, restrained eating has been related to increased depressive symptoms (Rotenberg and Flood, 1999). Thus, girls may be more likely to respond to stress by eating, which may lead to increased body dissatisfaction and depression. Of course, other girls (and boys) experience loss of appetite when depressed, suggesting the presence of different eating patterns associated with depression. Furthermore, as for guilt it is unclear whether body image dissatisfaction and increased appetite are best conceptualized as symptoms, correlates, or as causal or maintaining factors of depression. One of the largest gender differences was found for concentration problems on the 17-Item Depression

Rating Scale, but only for the MD/DD group. Breslau and Davis (1985) found btrouble concentratingQ to be an important discriminator of depression in their sample of women. A potential gender difference in concentration problems is not surprising given that rumination is more common among females, is related to increased depression (Nolen-Hoeksema et al., 1999), and has been related to increased concentration problems (Lyubomirsky et al., 2003). A study finding more girls to endorse high levels of depressive symptoms also found concentration problems to be the best discriminator of those with high scores (Sund et al., 2001), further suggesting a gender difference related to concentration. Unexpectedly, anhedonia and early morning difficulties with mood and fatigue were relatively specific to boys’ experience of depression. The present study appears to be the first to indicate that depressed males may have higher levels of these symptoms. Given that the K-SADS rating of anhedonia includes several probes about bboredomQ, which has been more frequently reported by men than women in community samples when gender differences are observed (Watt and Vodanovich, 1999), it is possible that elevated boredom among boys is, at least in part, responsible for the gender difference in anhedonia. Finally, the present findings highlight the potential importance of informant and the specific wording of questions when examining gender differences. For some symptoms, there was consistent evidence of either a gender difference (e.g., guilt) or no gender difference (e.g., suicidality) across both the K-SADS and the BDI. For other symptoms, however, inconsistencies were found across measures (e.g., sleep problems; concentration problems). It is unclear whether the use of different informants (i.e., adolescent vs. combining adolescent and parent report), ratings (i.e., clinician vs. self), or item wording may have produced such discrepancies. A limitation of the present study is its use of a predominantly European-American sample. Given that gender differences in depressive symptoms may be greater among European-American than African-American and Latino adolescents (Hayward et al., 1999), the present findings may not generalize across ethnic groups. In addition, this study assessed depressive symptoms at one point in time. Longitudinal research is needed to see if relatively gen-


der-specific symptoms play differing roles for boys and girls in the onset or maintenance of depression, and whether they remit at the same rate as other symptoms over the course of a depressive episode. In summary, the evidence for gender differences among a sample of depressed adolescents suggests that depressed girls are more prone to exhibit some cognitive and somatic symptoms of depression than are depressed boys. An awareness of these potential differences may be helpful to clinicians in treatment planning. For example, if guilt and body image dissatisfaction are more prominent factors in depression for girls than boys, cognitive interventions aimed at alleviating excessive guilt (Kubany and Manke, 1995) and enhancing body image (e.g., Strachan and Cash, 2002) may be particularly helpful for some depressed girls.

References Allgood-Merten, B., Lewinsohn, P.M., Hops, H., 1990. Sex differences and adolescent depression. J. Abnorm. Psychology 99, 55 – 63. Ambrosini, P.J., 1997. Irritable and depressed moods: are they synonymous? American Psychiatric Association annual meeting, San Diego, May.. Ambrosini, P.J., 2000. Historical development and present status of the schedule for affective disorders and schizophrenia for school-age children (K-SADS). J. Am. Acad. Child Adolesc. Psych. 39, 49 – 58. Ambrosini, P.J., Metz, C., Prabucki, K., Lee, J.C., 1989. Videotape reliability of the third revised edition of the K-SADS. J. Am. Acad. Child Adolesc. Psych. 28, 723 – 728. Ambrosini, P.J., Metz, C., Bianchi, M., Rabinovich, H., Undie, A., 1991. Concurrent validity and psychometric properties of the Beck Depression Inventory in outpatient adolescents. J. Am. Acad. Child Adolesc. Psych. 30, 51 – 57. Ambrosini, P.J., Bianchi, M., Metz, C., Rabinovich, H., 1994. Evaluating clinical response to open nortriptyline pharmacotherapy in adolescent major depression. J. Child Adolesc. Psychopharmacol. 4, 233 – 244. American Psychiatric Association, 1980. Diagnostic and Statistical Manual (DSM-III). American Psychiatric Press, Washington, DC. American Psychiatric Association, 1987. Diagnostic and Statistical Manual (DSM-III-R). American Psychiatric Press, Washington, DC. Angst, J., Dobler-Mikola, A., 1984. Do the diagnostic criteria determine the sex ratio in depression? J. Affect. Disord. 7, 189 – 198. Baron, P., Joly, E., 1988. Sex differences in the expression of depression in adolescents. Sex Roles 18, 1 – 7.

43

Beck, A.T., Ward, C.H., Mendelson, M., Mock, J., Erbaugh, J., 1961. An inventory for measuring depression. Arch. Gen. Psychiatry 4, 561 – 571. Bennett, D.S., Ambrosini, P.J., Bianchi, M., Barnett, D., Metz, C., Rabinovich, H., 1997. Relationship of Beck Depression Inventory factors to depression among adolescents. J. Affect. Disord. 45, 127 – 134. Breslau, N., Davis, G.C., 1985. Refining DSM-III Criteria in major depression. J. Affect. Disord. 9, 199 – 206. Carter, J.D., Joyce, P.R., Mulder, R.T., Luty, S.E., McKenzie, J., 2000. Gender differences in the presentation of depressed outpatients: a comparison of descriptive variables. J. Affect. Disord. 61, 59 – 67. Ferguson, T.J., Stegge, H., Miller, E.R., Olsen, M.E., 1999. Guilt, shame, and symptoms in children. Dev. Psychol. 35, 347 – 357. Fox, K.R., Page, A., Armstrong, N., Kirby, B., 1994. Dietary restraint and self-perceptions in early adolescence. Pers. Individ. Differ. 17, 87 – 96. Frank, E., Carpenter, L.L., Kupfer, D.J., 1988. Sex differences in recurrent depression: are there any that are significant? Am. J. Psychiatry 145, 41 – 45. Garber, J., Martin, N.C., 2002. Negative cognitions in offspring of depressed parents: mechanisms of risk. In: Goodman, S.H., Gotlib, I.H. (Eds.), Children of Depressed Parents: Mechanisms of Risk and Implications for Treatment. American Psychological Association, Washington, DC, pp. 121 – 153. Gilligan, C., Attanucci, J., 1988. Two moral orientations. In: Gilligan, C., Ward, J.V., Taylor, J.M., Bardige, B. (Eds.), Mapping the Moral Domain: A Contribution of Women’s Thinking to Psychological Theory and Education. Harvard University Press, Cambridge, MA, pp. 73 – 86. Greeno, C.G., Wing, R.R., 1994. Stress-induced eating. Psychol. Bull. 115, 344 – 364. Hankin, B.L., Abramson, L.Y., 2001. Development of gender differences in depression: an elaborated cognitive vulnerabilitytransactional stress theory. Psychol. Bull. 127, 773 – 796. Hayward, C., Gotlib, I.H., Schraedley, P.K., Litt, I.F., 1999. Ethnic differences in the association between pubertal status and symptoms of depression in adolescent girls. J. Adolesc. Health 25, 143 – 149. Hollingshead, A.B., 1975. Four-factor Index of Social Status. Yale University Press, New Haven. Kessler, R.C., McGonagle, K.A., Zhao, S., Nelson, C.B., Hughes, M., Eshleman, S., et al., 1994. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Results from the National Comorbidity Survey. Arch. Gen. Psychiatry 51, 8 – 19. Kornstein, S.G., Schatzberg, A.F., Thase, M.E., Yonkers, K.A., McCullough, J.P., Keitner, G.I., et al., 2000. Gender differences in chronic major and double depression. J. Affect. Disord. 60, 1 – 11. Kovacs, M., 2001. Gender and the course of major depressive disorder through adolescence in clinically referred youngsters. J. Am. Acad. Child Adolesc. Psych. 40, 1079 – 1085. Kubany, E.S., Manke, F.P., 1995. Cognitive therapy for traumarelated guilt: conceptual bases and treatment outlines. Cogn. Behav. Pract. 2, 27 – 61.

44


Lyubomirsky, S., Kasri, F., Zehm, K., 2003. Dysphoric rumination impairs concentration on academic tasks. Cogn. Ther. Res. 27, 309 – 330. Masi, G., Favilla, L., Mucci, M., Poli, P., Romano, R., 2001. Depressive symptoms in children and adolescents with dysthymic disorder. Psychopathology 34, 29 – 35. Miller, A., Fox, N.A., Cohn, J.F., Forbes, E.E., Sherrill, J.T., Kovacs, M., 2002. Regional patterns of brain activity in adults with a history of childhood-onset depression: gender differences and clinical variability. Am. J. Psychiatry 159, 934 – 940. Nolen-Hoeksema, S., 1987. Sex differences in unipolar depression: evidence and theory. Psychol. Bull. 101, 259 – 282. Nolen-Hoeksema, S., Larson, J., Grayson, C., 1999. Explaining the gender difference in depressive symptoms. J. Pers. Soc. Psychol. 77, 1061 – 1072. Oliver, J.M., Simmons, M.E., 1985. Affective disorders and depression as measured by the Diagnostic Interview Schedule and the Beck Depression Inventory in an unselected adult population. J. Clin. Psychol. 41, 469 – 477. Renshaw, P.F., Parow, A.M., Hirashima, F., Ke, Y., Moore, C.M., Frederick, B.D., et al., 2001. Multinuclear magnetic resonance spectroscopy studies of brain purines in major depression. Am. J. Psychiatry 12, 2048 – 2055. Roberts, R.E., Lewinsohn, P.M., Seeley, J.R., 1991. Screening for adolescent depression: a comparison of depression scales. J. Am. Acad. Child Adolesc. Psych. 30, 58 – 66. Roberts, R.E., Lewinsohn, P.M., Seeley, J.R., 1995. Symptoms of DSM-III-R major depression in adolescence: evidence from the epidemiological survey. J. Am. Acad. Child Adolesc. Psych. 34, 1608 – 1617. Rotenberg, K.J., Flood, D., 1999. Loneliness, dysphoria, dietary restraint, and eating behavior. Int. J. Eat. Disord. 25, 55 – 64. Seiffge-Krenke, I., Stemmler, M., 2002. Factors contributing to gender differences in depressive symptoms: a test of three developmental models. J. Youth Adolesc. 31, 405 – 417. Siegel, J.M., Yancey, A.K., Aneshensel, C.S., Schuler, R., 1999. Body image, perceived pubertal timing, and adolescent mental health. J. Adolesc. Health 25, 155 – 165.

Silverstein, B., 2002. Gender differences in the prevalence of somatic versus pure depression: a replication. Am. J. Psychiatry 159, 1051 – 1052. Sorensen, M.J., Nissen, J.B., Mors, O., Thomsen, P.H., 2005. Age and gender differences in depressive symptomatology and comorbidity: an incident sample of psychiatrically admitted children. J. Affect. Disord. 84, 85 – 91. Spitzer, R.L., Endicott, J., Robins, E., 1978. Research diagnostic criteria: rationale and reliability. Arch. Gen. Psychiatry 35, 773 – 782. Strachan, M.D., Cash, T.F., 2002. Self-help for a negative body image: a comparison of components of a cognitive–behavioral program. Behav. Ther. 33, 235 – 251. Sund, A.M., Larsson, B., Wichstrom, L., 2001. Depressive symptoms among young Norwegian adolescents as measured by The Mood and Feelings Questionnaire (MFQ). Eur. Child Adolesc. Psychiatry 10, 222 – 229. Twenge, J.M., Nolen-Hoeksema, S., 2002. Age, gender, race, socioeconomic status, and birth cohort differences on the Children’s Depression Inventory. J. Abnorm. Psychology 111, 578 – 588. Vredenburg, K., Krames, L., Flett, G.L., 1986. Sex differences in the clinical expression of depression. Sex Roles 14, 37 – 49. Wade, T.J., Cairney, J., Pevalin, D.J., 2002. Emergence of gender differences in depression during adolescence: national panel results from three countries. J. Am. Acad. Child Adolesc. Psych. 41, 190 – 198. Watt, J.D., Vodanovich, S.J., 1999. Boredom proneness and psychosocial development. J. Psychol. 133, 303 – 314. Weissman, M.M., Bland, R.C., Canino, G.J., Faravelli, C., Greenwald, S., Hwu, H.G., et al., 1996. Cross-national epidemiology of major depression and bipolar disorder. JAMA 276, 293 – 299. Wilhelm, K., Roy, K., Mitchell, P., Brownhill, S., Parker, G., 2002. Gender differences in depression risk and coping factors in a clinical sample. Acta Psychiatr. Scand. 106, 45 – 53. Young, M.A., Scheftner, W.A., Fawcett, J., Klerman, G.L., 1990. Gender differences in the clinical features of unipolar major depressive disorder. J. Nerv. Ment. Dis. 178, 200 – 203.