The assessment of need for mental health services occurs at multiple and interacting levels of society. While debate continues about how best to define and measure that need for services for the purposes of resource allocation, the consensus seems to be that key dimensions are diagnosis of a mental illness; duration of the illness; disability and distress associated with the illness; and the risk of harm to self and others (1,2,3). Additional dimensions considered are the proportion of the population affected and likely to benefit (directly or indirectly) from treatment; the monetary costs of providing the treatment; and the risk of adverse outcomes from treatment (4).

This chapter focuses on major (unipolar) depression and mental health services for women. Depression is one of the most common mental disorders in the general population. About 10% of women annually suffer from major depression in what could be the most joyful and productive years of their lives. Depression is one of the most common hospital discharge diagnoses for women aged 18 to 44 years (obstetrical care being the most common discharge diagnosis). Because depression affects women during their childbearing and child-rearing years, untreated depression may also have health consequences for the offspring (5). The functional impairment of depression is comparable to or greater than that of a number of chronic medical conditions (6). It takes a sizable
economic toll in the workplace through reduced productivity and absenteeism (7,8). The Global Burden of Disease Study found that in established market economies, depression ranks second in terms of disability-adjusted life years. It is projected to displace ischemic heart disease as the leading source of disease burden over the next 20 years (9). Further studies echo these findings (10). Depression is associated with premature mortality from cardiovascular disease (11) and suicide. Among those diagnosed with depression, case fatality rates of suicide range between 2% and 6% (12), and depression is a factor in at least 60% of suicides (11).

By definition, a clinical diagnosis of a major depressive episode according to the DSM-IV system of classification of mental disorders implies that significant disability and distress are associated with the symptoms. Depending upon severity, an episode is defined as being mild, moderate, or severe (13). The DSM system, necessary for clinical practice, was not originally designed for the broad purpose of describing pathology in the general population. Depression is thought to be a dimensional construct that falls along a severity continuum that can lead to significant distress and disability. Conditions that do not meet diagnostic criteria are more prevalent in the general population than major depression and can be as disabling (14,15,16,17).

One of the most robust findings from surveys conducted internationally is the twofold higher prevalence of major depression in women compared to men. Although prevalence estimates vary widely between countries, the difference between women and men in these estimates does not. This gender difference emerges between the ages of 11 and 13 years. While hormonal factors may play a role, the link is not yet clear at this age, nor is it clear for the transition to menopause (18).

It has been postulated that the reason more women are identified as having depression than men is that women live longer, have longer episodes of depression, and have more frequent episodes than men. Therefore, when data are collected at one point in time, depression appears to be more common in women. Women are more likely to have a first onset of depression than men; however, there is less evidence to conclude whether the course of the depression varies significantly for men and women. In general, it has been difficult to draw firm conclusions about the etiology and natural history of depression due to problems with lifetime recall and the lack of longitudinal data in representive samples (18,19). As well, the course of illness may be affected by variations in the way men and women use mental health services over time.

A further complication is that depression tends to co-occur with other mental illnesses. Persons with depression are more likely to suffer from anxiety disorders, which, like depression, are more common in women than men (20). Indeed, the pathway for depression in women may be through anxiety disorders (18), although these disorders do not seem to account for the greater prevalence of depression in women (21). After anxiety disorders, substance abuse is the most common mental illness to co-occur with depression in women. While women may report that their depression antedates their substance abuse, depression may also be a result of the substance abuse (22).

A core symptom of depression is suicidal ideation. Suicidal ideation, plans, and behaviors may arise from depression or from other conditions (e.g., borderline personality disorder or eating disorder) or life contexts (e.g., a history of physical or sexual abuse) that co-occur with depression. In treatment settings, approximately one third of persons with depression are suicidal (23). Although men are more likely to die from suicide than women, women engage in more suicidal behaviors, putting themselves at risk for physical harm, associated disabilities, and premature mortality.

Clinical depression is quite treatable with antidepressants or some psychotherapies or a combination of antidepressants and psychotherapy (24,25,26). The average duration of a depressive episode is about three months (27). For antidepressants to be effective, they need to be taken a minimum of two months (28); therefore, some consistency or continuity of care with a primary care physician or a referral to a psychiatrist is desirable. A minimum of four counseling visits has been defined as appropriate for follow-up and medication monitoring (29,30,31). While the hormonal links with depression are not well understood, hormonal factors may play a role in treatment response. There is some research to suggest that men and women differ in their response to different classes of antidepressants. Women’s response may differ from men’s as well depending upon age-related or hormonal factors (32). Current evidence is insufficient to recommend estrogen therapy as a primary treatment for major depression in perimenopausal and menopausal women (33). Nonpharmacologic treatment of depression includes psychotherapy and, in special circumstances, electroconvulsive therapy. Psychotherapy generally requires multiple sessions with experts who have received specialized training. Combining or sequencing pharmacologic and psychotherapy may provide more long-term benefit than any one therapy alone. Combined therapies may be particularly worth pursuing in those who have a past history of depression (34). In women with a concurrent anxiety disorder, treatment for depression should be initiated as it may improve the symptoms of both disorders. Substance abuse is not a contraindication to treatment of depression. Aggressive treatment may reduce the use of these substances (35).

Until recently, there has been a lack of systematic evidence and guidelines about how to treat suicidal individuals, apart from or in addition to their mental illness (36,37,38,39). Controversy continues regarding the relative merits of prescribing the newer antidepressants to suicidal individuals. While they are less toxic if taken in overdose, use of these medications in persons under 18 years of age may be related to an increased risk of suicide-related adverse events (40). If that risk is true, young women may be of greatest concern given a greater likelihood of being prescribed these medications.