Research Article: Stresses and Disability in Depression Across Gender

Research Article
Stresses and Disability in Depression across Gender

Sharmishtha S. Deshpande,
1
Bhalchandra Kalmegh,
1
Poonam N. Patil,
1
Madhav R. Ghate,
1
Sanjeev Sarmukaddam,
2
and Vasudeo P. Paralikar
3
1
Department of Psychiatry, Smt. Kashibai Navale Medical College and General Hospital, Narhe, Pune, Maharashtra 411041, India
2
Maharashtra Institute of Mental Health, Pune 411001, India
3
Psychiatry Unit, KEM Hospital, Pune 411011, India
Correspondence should be addressed to Sharmishtha S. Deshpande; sharod@redifmail.com
Received 31 July 2013; Revised 12 October 2013; Accepted 27 October 2013; Published 21 January 2014
Academic Editor: Yvonne Forsell
Copyright 2014 Sharmishtha S. Deshpande et al. Tis is an open access article distributed under the Creative Commons
Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.
Depression, though generally episodic, results in lasting disability, distress, and burden. Rising prevalence of depression and
suicide in the context of epidemiological transition demands more attention to social dimensions like gender related stresses,
dysfunction, and their role in outcome of depression. Cross-sectional and follow-up assessment of men and women with depression
at a psychiatric tertiary centre was undertaken to compare their illness characteristics including suicidal ideation, stresses, and
functioning on GAF, SOFAS, and GARF scales ( = 107). We reassessed the patients on HDRS-17 afer 6 weeks of treatment. Paired
t-test and chi-square test of signifcance were used to compare the two groups, both before and afer treatment. Interpersonal and
marital stresses were reported more commonly by women ( < 0.001) and fnancial stresses by men ( < 0.001) though relational
functioning was equally impaired in both. Women had sufered stresses for signifcantly longer duration ( = 0.0038). Men had
more impairment in social and occupational functioning compared to females ( = 0.0062). History of suicide attempts was
signifcantly associated with more severe depression and lower levels of functioning in case of females with untreated depression.
Signifcant cross-gender diferences in stresses, their duration, and types of dysfunction mandate focusing on these aspects over
and above the criterion-based diagnosis.
1. Introduction
Major depressive disorder (MDD) is a common and treatable
psychiatric disorder with high morbidity and mortality.
Complex interplay between mind, body, society, and cul-
ture has been implicated in the incompletely understood
pathophysiology of depression [1]. Antecedent stresses and
resulting disabilities interact with each other to worsen the
depression, whichinitself becomes additional stress. Patients
reports of stresses and adjustment problems frequently do
not get due importance in understanding and managing
depression, which may explain partial or delayed treatment
response and frequent relapses.
Very few diferences in the course of depression have
been detected across gender. Factors like time taken for
recovery, time for frst occurrence, and number and severity
of recurrences did not difer [2]. Background social contexts
and support systems are important for understanding the
contributing determinants of disease and for planning of
treatment [3].
Depression has been identifed as signifcant cause of
morbidity and mortality [4]. Ferreira et al. (2013) [5] showed
how rural India may be topping the list for depression and
disability following organic disorders like stroke. Bromet et al.
(2011) [6] in their exhaustive and impressive survey of cross-
national epidemiology of depression showed how social
conditions distinguish prevalence, disability, and burden of
depression across ranges of income. Seedat et al. (2009) [7]
showed the temporal narrowing of gender role traditionality
in case of MDD among cohorts across the globe, which
explains changing trends observed in Indian clinical practice
and popular newspapers. Epidemiological transition [8, 9],
globalization, and rapid urbanization [10] have contributed
to changing social and family structure and function. Nuclear
Hindawi Publishing Corporation
Depression Research and Treatment
Volume 2014, Article ID 735307, 8 pages
http://dx.doi.org/10.1155/2014/735307
2 Depression Research and Treatment
and small family norms have been responsible for changes in
role responsibilities. However, generally family is a source of
immense social support as well as of stress in Indian culture.
Stresses experienced by males and females difer in nature
and perception. Stress is known to precipitate or exacerbate
episodes of depression. Mitigating stress by efective stress
management has proved to be efective inpreventionof MDD
[11]. Te nature of these stresses needs scrupulous assessment
if preventive strategies have to be devised.
2. Subjects and Methods
Tis is a hospital-based study conducted at a tertiary hospital
of a medical college. Tis hospital caters free medical ser-
vices for the community. Patients predominantly from lower
socioeconomic strata fromin and around city, as well as from
out-station, beneft from this hospital. A signifcant minority
also comes from higher middle income social circles of the
hospital staf.
Outpatients in psychiatry department clinically diag-
nosed to have depression were screened for inclusion in this
study. Data collection was completed in a period of twelve
months fromJanuary 2011 onwards. Te study was completed
over a period of two years.
Prior permission of ethics committee of the institute
was obtained and informed written consent taken from
each patient. Consecutive patients with depression (current
major depressive episode, with or without dysthymic dis-
order and/or major depressive disorder) without signifcant
biomedical illness were informed about the study and those
willing to participate were included. A total of 107 such
patients, 66 females and 41 males, were interviewed by
authors (Sharmishtha S. Deshpande, Poonam N. Patil, and
Bhalchandra Kalmegh) in the stipulated period of time. Find-
ings about clinical characteristics of depression, presence of
atypical features and comorbid psychiatric disorders in major
depression fromthis study have been reported elsewhere [12].
Tis paper focuses on the gender diferences in these patients
stresses and in functioning in various spheres.
Afer initial screening, SCID-I (Structured Clinical Inter-
view for DSM IV axis I disorders) was administered to
confrmthe diagnosis of MDD[13]. HDRS (17 itemHamilton
Depression Rating Scale) [14] was administered to note the
severity of depression.
Te patients were asked if they were undergoing any kind
of stress in their life that may or may not be responsible
for their depressed mood. Stresses reported by these patients
were recorded verbatim(with duration) as perceived by these
patients, which were later classifed as per SCID-I axis IV
guidelines and analyzed.
Teir suicidal ideation was recorded using Paykels scale
[15]. Te patient was then asked about any attempt of self-
harm along with its details in the past. Any accidental
poisoning or injury was also probed to rule out possibility of
suicide attempt.
Te patients were asked to follow up at 3 and 6
weeks for review. Attrition was signifcant and the patients
ofen returned afer symptom exacerbation following drug
dropout. Te number of patients taking regular treatment for
six weeks or more ( = 40) was included in the second part
of study. HDRS (17 item Hamilton Depression Rating Scale)
was administered and level of functioning was also assessed
in these patients.
Level of functioning was assessed and recorded with
the help of GAF (Global Assessment of Functioning) scale,
SOFAS (Social and Occupational Functioning Assessment
Scale), and GARF (Global Assessment of Relational Func-
tioning) scale. Tese are the scales for assessment and rating
of axis V in DSM IV [16]. A semistructured questionnaire to
score on SOFAS and GARF has been prepared by the author
(Sharmishtha S. Deshpande) and used in an earlier study
[17]. Interrater reliability of these scores has been reported in
literature [18] and was also confrmed by the investigators in
this study.
Data obtained was entered in Microsof Excel sheets
and later imported in suitable format for analysis. Bio-
Medical Data Processor (BMDP 2.0) was used for statistical
analysis. Data were analyzed for gender-wise comparison
of various illness characteristics, namely, severity, stresses,
suicidal ideation and functioning using -test and chi-square
tests of signifcance.
3. Results
Tis study assessed 107 patients with depression who were
newly diagnosed to have depression or old patients who
were of treatment for at least a month and had developed
recurrence of symptoms. In addition, forty patients who had
received regular treatment with antidepressants for six weeks
or more were also reviewed for improvement in depressive
symptoms and functioning.
Initial sample included 66 females and 41 males rep-
resenting all age groups though mean age for females was
higher than for males (Table 1). More males were single than
females, whereas illiteracy and rural background in females
were much higher compared to males. Patients coming from
urban, semiurban, and rural areas were well represented in
the sample. Majority of patients were servants or lower class
workers and 40.9%women were homemakers, though we see
representation of all types of occupations.
In Table 2 we see the improvement in mean HDRS score
from 21 to 11.5. Mean HDRS score was comparable among
males and females before as well as afer treatment (Table 2).
Mean duration of ongoing stress reported was much higher in
women though duration of illness revealed from the history
was comparable. Te numbers of men and women with past
history of suicide attempt as well as extent of suicidal ideation
as measured by Paykels score were comparable.
However, mean duration of sufered stress was signif-
cantly higher in females. Tis is the duration of prominent
stress as reported by the patient during clinical interview
( = 0.0038). However, the nature of stresses perceived was
signifcantly diferent as mentioned in Table 3.
Women in this study had frequent problems with primary
support group than men (Table 3). Relationship problems
in the family, especially with husband, were commoner
Depression Research and Treatment 3
Table 1: Sociodemographic characteristics of the 107 patients with
MDD.
Demographic characteristic
Females
= 66 (%)
Males
= 41 (%)
Mean age (S.D.) 37.18 (11.69) 33.09 (10.09)
Residence
Urban 27 (40.9) 26 (63.4)
Semiurban 23 (34.8) 8 (19.5)
Rural 16 (24.3) 7 (17.1)
Education
Illiterate 19 (28.8) 1 (2.5)
Up to 10th 33 (50.0) 23 (56.1)
Up to college graduation 12 (18.2) 8 (19.5)
Graduate and above 2 (3.03) 9 (21.9)
Marital status
Married 53 (80.2) 22 (53.6)
Divorced/separated/widowed 8 (12.2) 3 (7.3)
Unmarried 5 (7.6) 16 (39.1)
Occupational status
Student 5 (7.6) 6 (14.6)
Maid/servant 16 (24.3) 6 (14.6)
Own business 15 (22.7) 17 (41.5)
Service/professional 3 (4.5) 8 (19.5)
Homemaker 27 (40.9) 0
Unemployed 0 4 (9.8)
( < 0.001). Conficts with in-laws and children were also
reported by many women. Males reported fnancial problems
as the commonest stress. Tis was not seen in case of women
( < 0.001). Problems related to social environment and
occupational problems, though not statistically signifcant,
were more among men. Also, other stresses and no stresses
were reported more by men. Other stresses reported were
academic failure, death of close relative, failure in romantic
relationship, social isolation, and so forth.
When we considered the married subgroup of the sample,
5 out of 22 men and 39 out of 53 women had reported
problems with primary support group (
2
= 14.5518, =
0.00013). Table 3 also refects on high number of women (31
out of 53 married women) and few men (4 out of 22 married
men) reporting problems with spouse as the source of stress
(
2
= 8.5942, = 0.00337). Te diference in the number of
married men (13/22) and women (13/53) reporting economic
problems was also statistically signifcant (
2
= 6.7448, =
0.0094).
Afer 6 weeks of treatment, 38.4% women and 42.8%
men patients were in remission (HDRS-17 score < 7).
Among women with persistent depression, 43.7% reported
interpersonal problems with spouse as predominant stressor
and additional 31.2% variety of problems with other family
members. Among women in remission, 70% had reported
stress due to problems with children or daughters-in-law.
Other sources of stress reported were own physical illness
or fnancial problems, proportionately much less in either
group. Half of the males in remission had not reported any
stress, whereas the other half had stress due to separation
from various family members. Among men with persistent
depressive features, no stress was reported by 25%, fnan-
cial stress by 37.5%, and some familial stress like dispute
with brother, infertility, and separation from parents by the
remaining 37.5%.
We have assessed social, occupational, and relational
functioning of these patients in detail. Functioning of an indi-
vidual in the sphere of household relationships is very impor-
tant but seldom assessed systematically. Global Assessment
of Relational Functioning scale (GARF) addresses issues like
problem solving, organization, and emotional climate in the
family which refect on the quality of relationships. Te
functioning as a family rated from daily routines, warmth,
and conficts is rated in the range from optimal functioning
to dysfunctionality, which are to be rated by psychiatrist in
1000 scale. Te scale has been used for a study in Brazil on
validity of GARF; cut of of 70 was found to have acceptable
validity coefcients [18].
Relational functioning (GARF score) was maximally
afected functioning in this disorder, equally in males and
females. It remained so even afer treatment (score < 70)
especially in case of females. Social and occupational func-
tioning was more impaired in men than women at the time
of presentation to psychiatrist. We see that 28 (42.4%) of
women in this sample were housewives; many were working
as maid, farmer, labourer, and so forth. Tey seem to have
continued to do their work despite distress caused by illness.
Global and mainly social and occupational functioning is
afected signifcantly to a greater extent in males. When we
compared GAF and GARF scores before and afer 6 weeks
of treatment by paired -test, improvement was signifcant
( < 0.001) in males as well as females, which refects on
comparable response to treatment in terms of improvement
in functioning in these spheres across gender. However,
improvement in social and occupational functioning score
(SOFAS) before and afer treatment was signifcant in females
( < 0.001) but not signifcant in males ( = 0.120).
Women but not men with past history of self-harm
had worse HDRS scores as well as worse functioning in
all the spheres. Tis indicates further suicide risk in these
patients and explains more frequency of suicide attempts
among females. Te time interval between suicide attempt
and interview was variable from 1 month up to 10 years.
However, it was comparable in males and females. Some
patients also had history of more than one attempt.
Afer treatment scores for females show signifcantly
higher HDRS score with past suicide attempt (16.85 +/ 8.21)
than those without past history of suicide attempt (8.94 +/
6.01). But the functioning scores were comparable to those
without history of suicide attempt in females as well as males.
4. Discussion
In routine psychiatry practice, we see depressed men and
women with varied stresses and diferential impact of illness
on their functioning. Tere seems to be intimate and complex
Table 2: Comparison of duration of stress and illness characteristics across gender.
Illness characteristic Females Males
by -test and statistical
signifcance
Mean duration of total illness (months) (S.D.)
Females ( = 66), males ( = 41)
29.36 (34.41) 37.07 (50.15)
0.348
Not signifcant
Mean duration of current episode (months) (S.D.)
12.83 (22.13) 10.73 (12.65)
0.581
Not signifcant
Mean duration of stress (months) (S.D.)
64.3 (85.35) 22.32 (40.12)
0.004
Highly signifcant
Mean of total number of episodes (S.D.)
1.37 (0.74) 1.40 (0.78)
0.840
Not signifcant
Mean Paykel suicidal ideation score (S.D.)
1.03 (0.91) 1.12 (0.90)
0.612
Not signifcant
Mean HDRS (S.D.)
21.07 (5.26) 20.93 (6.36)
0.896
Not signifcant
Mean HDRS (S.D.) [afer treatment] [ = 40]
11.4 (7.18) 11.86 (9.80)
0.173
Not signifcant
Past history of suicide attempt (before treatment group)
11 (16.7) 7 (17.0)
Chi-square = 0.0446
= 0.8327
Not signifcant
Past history of suicide attempt (afer treatment group) [ = 40]
7 (28) 4 (26.6)
Chi-square = 0.0752
= 0.7838
Not signifcant
interaction of these factors with suicidality in this disorder.
Tis study attempted to objectively assess this relationship.
In the last three decades suicide rate has increased by
43% in India and ratio of males to females is stable at 1.4 : 1
[19]. Major depressionis the commonest among contributors.
Importance of social and public health aspects of suicide
prevention in India has been emphasized in literature [20,
21]. Gender diferences in suicide attempters are succinctly
reported in a study fromSouth India [22]. Females were more
illiterate, rural and had less psychopathology. Signifcant
numbers of females in our study were also from rural
background and illiterate, but they reported sufering from
stresses for signifcantly longer time (Table 1). Tis sample
had patients with varied educational level and occupations
represented, which can be seen as a limitation of this study.
Comparable illness characteristics in males and females have
been confrmed (Table 2) as reported in previous studies [2,
2325]. However, females readily afrmed stresses, especially
in the family domain (Table 3). Duration of these stresses
was signifcantly prolonged in females as seen in Table 2. Tis
could be due to more sensitivity of women towards problems
in relationships as well as a function of dual importance of
home in their lifeas a work place and as an intimate group.
Social factors indepressionhave beenextensively studied.
Social variables are reported to difer across gender though
there is no diference in overall course or severity of depres-
sion [2, 2325]. Tis has been confrmed in the present study.
Long term follow-up studies in women have reported
persistent efect of depression on their social interactions and
relationships [25]. We see modest degree of improvement
in mean scores of social-occupational, relational, and global
functioning afer treatment of depression (Table 4). Tis
study assessed functioning using DSM-IV axis V scales.
SOFAS and GARF are diferent constructs but related to
GAF [14]. GARF has been correlated with clinician-assessed
axis II pathology [26]. Tese scales are useful in assessing
changes in personality psychopathology, social adjustments,
and relationship skills. All these are important in prognosis
and outcome of major depressive disorder.
Gender diferences in stress experiences and stress vul-
nerability have been elaborately discussed by Eisenberg [1], in
which fndings mainly indicate protective efect of marriage
against depression in males, but more negative efect on
females. In animal research the opposite efect of same stress
on male and female hippocampus has been documented
indicating probable biological aspect of these fndings [27].
Recent large systematic study Predict D has reported
that preventive measures will achieve a greater reduction
in the prevalence of depression than measures undertaken
to eliminate risk factors afer onset [7]. Our study has
highlighted perceived stresses of local Indianpopulations and
their diferential impact across genders and marital status.
In an Indian study, signifcantly more women with
features of neurasthenia spectrum disorder had identifed
marital problem as the most important perceived cause for
their sufering, while none of the men did so [28]. Similar
results from this study can be explained as patients are from
the similar cultural background (Table 3).
Tough depression is the third leading cause of disability,
it is seldomquantifed. We measured it clinically (HDRS) and
also indirectly interms of functional impairment (Table 4). In
a 10-year follow-up study of depression, impairment in social
functioning (housework, social interactions, and leisure)
was known to persist for years afer recovery though work
functioning improved signifcantly [29]. Functional disability
in females, especially housewives, is seldom noticed till it
Table 3: Various stresses reported by male and female patients with MDD categorized as per axis IV from SCID I.
Stress grouped as per axis IV categories in SCID I
Females
= 66 (%)
Males
= 41 (%)
Chi-square
Test statistic, , or Fishers exact
and statistical signifcance
Problems with primary support group 51 (77.3) 10 (24.4)
Chi-square = 28.868
< 0.001
Highly signifcant
Spouse 31 4
Children 12 2
Parents/sibs 3 3
In-laws/others 5 1
Problems related to social environment 12 (18.2) 10 (24.4)
Chi-square = 0.597
= 0.440
Not signifcant
Educational problems 1 (1.5) 0
Fishers exact = 0.999
Not signifcant
Occupational problems 1 (1.5) 3 (7.3)
Not signifcant
Housing problems 0 0
Fishers exact = 1.0
Not signifcant
Economic problems 12 (18.2) 27 (65.8)
Chi-square = 24.812
< 0.001
Highly signifcant
Problems with access to healthcare services 3 (4.5) 0
Not signifcant
Problems related to interaction with
legal services or crime
2 (3) 1 (2.4)
Fishers exact = 1.0
Not signifcant
Other psychosocial problems 3 (4.5) 3 (7.3)
Not signifcant
No stresses reported 7 (10.6) 7 (17.1)
Chi-square = 0.930
= 0.335
Not signifcant
Multiple stresses reported 23 (34.8) 14 (34.1)
Chi-square = 0.005
= 0.941
Not signifcant
Past history of suicide attempt (before treatment group) 11 (16.7) 7 (17.0)
Chi-square = 0.0446
= 0.8327
Not signifcant
Table 4: Scores of level of functioning in major depressive disorder across gender.
Scores on various
functioning scales
(axis V)
Before treatment Afer treatment
Mean score (SD)
Females ( = 66)
Mean score (SD)
Males ( = 41)
by -test and
stat. signifcance
Mean score (SD)
Females ( = 25)
Mean score (SD)
Males ( = 15)
by -test and
stat. signifcance
GAF 59.01 (9.37) 55.75 (8.97)
0.078
Marginally
signifcant
69.2 (9.43) 69 (12.28)
0.954
Not signifcant
SOFAS 59.24 (8.51) 54.63 (7.94)
0.006
Highly
signifcant
68.6 (10.66) 64.33 (13.21)
0.269
Not signifcant
GARF 52.50 (13.54) 52.80 (11.01)
0.904
Not signifcant
65.8 (17.54) 67.7 (14.49)
0.726
Not signifcant
reaches signifcant proportions. Tough they sufer great
distress, they continue to do household work and try their
best to conform to role expectations embodied by social
norms. Concern about conforming to social expectations in
females is also reported in other studies [30]. Difculties
in social and relational functioning are likely to lead to
secondary distress inwomenwhichcouldbe the perpetuating
factors for depression and suicidality.
Inour study 24 (60%) patients hadfailedto achieve remis-
sion afer treatment (HDRS scores > 7). Yet their functioning
Table 5: Association between suicide attempt and scores of psychopathology and functioning.
Axis V score
Women with history of
past suicide attempt
( = 11)
Mean (S.D.)
Comparison with women
without history of suicide attempt
( = 55)
(, , and statistical signifcance)
Men with history of past
suicide attempt ( = 7)
Mean (S.D.)
Comparison with men
without history of suicide
attempt ( = 34)
(, , and statistical
signifcance)
GAF 50.0000 (13.7840) 3.8474, 0.0002; highly signifcant 53.00 (6.30)
0.8905, 0.38
Not signifcant
SOFAS 51.8181 (9.5584) 3.4185, 0.0010; highly signifcant 54.28 (6.72)
0.1259, 0.9
Not signifcant
GARF 42.7273 (11.9087) 2.7522, 0.0076; highly signifcant 53.57 (4.76)
1.997, 0.84
Not signifcant
HDRS 25.7272 (4.9008) 3.4734, 0.0009; highly signifcant 21.00 (5.13)
0.0329, 0.97
Not signifcant
(axis V scores) had improved statistically signifcantly. Tis
may explain the observation that risk of self-harm persists
afer apparent clinical improvement.
As the concept of quality of life ofen difers across
various sociocultural groups, assessing their functioning in
various spheres seems to be more pertinent. Also, it is
hard to fnd indigenously validated quality of life scales for
depression suitable across heterogeneous patient groups in
diverse Indian culture. Most Indian women are also known
to equate their quality of life with their perceived adequacy
in rolefunctioning [19].
In an Indian study, the most common reasons for suicidal
attempts were marital and interpersonal problems followed
by psychiatric and physical illnesses in females [21]. 71% of
suicide attempters in India are below the age of 44 years
[21]. Assessment of relational functioning is thus crucial in
MDD patients. We see that this was the most afected sphere
of functioning and least to improve with routine outpatient
treatment for depression (Table 4). Tough very few males
reported stresses in the primary support group (Table 3),
their GARF score is comparable with females as depicted
in this table. Tis could also be due to underreporting of
relational stresses by men. Te relational functioning is likely
to have worsened due to depressed or irritable mood and
resultant depressive cognitions. It needs to be explored fur-
ther by undertaking a longitudinal study to see if enhancing
relational functioning helps in improving depressive features
in either gender.
Severity of depression and dysfunction in women with
history of suicide attempts are higher as depicted in our study
(Table 5) highlighting that establishing diagnosis on axis I is
not equivalent to full description of psychopathology. Role of
axis IV (stresses) and V (functioning) in perpetuating axis I
disorder needs to be understood individually in every patient
with depression.
Limited success in managing depression with sole phar-
macotherapy has beenmentionedinliterature [31] andso also
more favourable outcome with combined use of psychother-
apy with pharmacotherapy [32]. Review of contextual inter-
ventions for MDD has revealed signifcant success in 8 out of
dysfunction afects
social interactions,
relationships, and
work functioning in
a negative way
persistent and
becomes pervasive
Added to biological
MDD or dysthymic
Males: more of social,
fnancial stresses
Females: relationship
problems, failures, and losses
Axis V: resultant
diathesis and axis II
Distress worsening
of mood remains
disorder-axis I
Axis IV: stresses
Figure 1: Interactive model of axes I, IV, and V in depression.
13 studies reviewed recently [33]. Te interpersonal problems
especially in depressed patients living with a partner have
been reported to be successfully managed by group couples
therapy, with lesser number of dropouts in the London
Depression Intervention Trial [34]. Such management needs
to be a part of regular treatment of depression in Indian
setting. Considering interactions between axes I, IV, and V
for appropriate psychosocial intervention along with drug
treatment is necessary for comprehensive use of biopsychoso-
cial model in diagnosis and management. Figure 1 shows the
interaaactive model of axes I, IV, and V in depression.
Limitations of the Study. Patients across wide age range,
educational levels, diferent occupations, and marital status
are included in the sample reducing its homogeneity.
Limited duration of followup (6 weeks) and small size of
afer treatment group of patients ( = 40) limit generaliza-
tion of fndings.
5. Conclusion
Tere are qualitative and quantitative diferences in stresses
experienced by males and females that may have both cause
and efect relationship with depression via resultant dysfunc-
tion. One should consider causative role of functioning in the
complex etiopathology of depression in the context of body,
mind, society, and culture. Gender diferences in stresses
and various spheres of functioning should be addressed
in routine clinical practice. Relational functioning, being
the most afected domain, should be assessed regularly in
depressed patients.
Women have ofen sufered chronic stress commonly
due to problems with primary support group. Mental health
professionals should attend to these problems for neces-
sary intervention. More proactive approach by clinicians to
enhance social and relational functioning appears important
in suicide prevention.
Distinct diferences across gender in stresses and func-
tioning in depression warrant longitudinal studies to explain
the directionality between functioning, stress, and depres-
sion.
Conflict of Interests
Te authors declare that there is no confict of interests
regarding the publication of this paper.
Acknowledgment
Te study received funding from Maharashtra University of
Health Sciences, Nashik, under teachers research fellowship
grant to Dr. Sharmishtha S. Deshpande.
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