Struck by lightning or slowly suffocating : gendered expressions of depression in a primary health care context

Depression is a common mental health problem in primary health care. One third of the Swedish population is expected to experience depression at some point in their lives. The understanding of depression has expanded, both from a lay and primary health care perspective. The number of persons considering themselves as depressed, receiving the diagnosis, and getting treatment for it has increased steadily over the last decades. Unchanged, however, is that depression is diagnosed twice as often in women as in men, while twice as many men as women commit suicide. These gender differences appear in adolescence. In earlier research biomedical, psychological, and social-cultural explanations of gender differences have been discussed. Patient’s own perspectives have more seldom stood in focus, and men’s narratives in particular are still scarce. In this thesis, gender, i.e. how to be a woman or a man, is considered as a construct, formed and negotiated in social interaction. The aim of the study is to explore the gendered face of depression from a patient perspective: How is depression expressed and explained by patients in primary health care, by women and men, adults and adolescents? How are depressed women and men portrayed in the media? How do patient and media accounts of depression compare with the perspective offered in medical research articles? Method and material The analyses are based on data from three different sources: patient narratives, newspaper portrayals and scientific medical articles. – 37 in-depth interviews were undertaken with primary health care patients diagnosed with depression. Informants were chosen to include both men and women, grown-ups (Studies I + II) and young adults (Study V) of varying occupational and social class backgrounds. Data were analyzed according to grounded theory. – 26 articles portraying lay informants with depression (Study III) were drawn from three major Swedish daily newspapers by a search of database Mediearkivet 2002. The articles were analyzed by qualitative content analysis. –82 scientific articles concerning depression in relation to gender were identified in a PubMed search 2002. The understanding of depression in these articles was explored and compared with findings in the grown-up patient narratives and in the media portrayals by means of discourse analysis (Study IV). Findings Study I captured women’s and men’s formulations of their experiences of depression. To be marked with demands constituted a central experience for both women and men, but the outward manifestations differed in relation to gender as well as to class. Home and work had different priority. Men talked more about physical distress (often chest pain) than about emotions. Women readily verbalized emotional distress – shame and guilt – while physical symptoms were vague and secondary (often about the stomach). Men dealt with insecurity by aggrandizing their previous competence, women by self-effacement. Study II disclosed gendered trajectories into depression. Four symbolic illness narratives were identified: struck by lightning, nagging darkness, blackout and slowly suffocating. Most of the men considered their bodies suddenly “struck” by external circumstances beyond their control. The stories of women in the study were more diverse, reflecting all four illness narratives. However, the women had a tendency to blame their own personality and to describe depression as insidious and originating from the inside. The women expressed feelings of guilt and shame but also conveyed a personal responsibility and concern with relationships. Study III identified four themes in media portrayals of depression: displaying a successful facade, experiencing a cracking facade, losing and regaining control and explaining the illness. The mediated image of depression both upheld and challenged traditional gender stereotypes. The women’s stories were more detailed, relational, emotionally oriented and embodied. The portrayal of men was less emotional and expressive, and described a more dramatic onset of depression. Study IV revealed gaps in how depression in relation to gender is understood by the patients, the media, and the medical research establishment. There were differences in recognition, in understanding of the reasons, and in contextualization of depression. Although women and men described different symptoms and reasons for falling ill, in scientific articles these gendered differences were conceptualized mainly in terms of hormones and other biological markers. Study V elucidated the impact of gender on adolescent depression. The young women and men were all striving to be normal, influenced by demanding media images, confronted by identity trouble, and overwhelmed by feelings. They had dreams of an ordinary family and described normative expectations. Getting a safety net of friends and other adults was a way out. Both the young women and men were eager to communicate their distress when given the opportunity. This seemed especially important to some of the young men, who in talking about their emotional problems transgressed gender norms. Conclusions Patient perspectives enrich the understanding of gendered expressions of depression by making visible transgressions of and breaks with stereotype gender norms. Gender awareness is an important key in clinical consultation. To recognize gendered narratives of illness might have a salutary potential, making depression more visible among men, and relieving self-blame among women. By re-evaluating restrictive gender patterns, the clinician might encourage development of healthier practices of how to be a man or a woman, a development especially important for adolescents. An integrated model for understanding biological, gender and cultural aspects of depression has yet to be developed. As general practitioners we have a unique possibility to see and to study the whole individual in her social and cultural context