Social Stigmatization and Societal Expectations as Factors of Health Inequalities Illustrated by

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1 Social Stigmatization and Societal Expectations as Factors of Health Inequalities Illustrated by the Example of Depression Psychotherapists report their experiences Lena Hünefeld, M.A. Health Inequalities V: Verhältnisse für Gesundheit 11./12. Juni Bielefeld

2 Index 1 Depression Definition and Forms 2 Prevalence Rate of Depression 3 Causes of Depression 4 Research Question 5 Methods 6 Results 7 Conclusion

3 Depression - Definition (Müller-Rörich 2007) The word depression covers a broad spectrum of behavior and mood states, from normal mood swings to severe impairments requiring treatment Depressive moods can be defined as disease 1. when they last longer than average more than two weeks 2. when these causes and effects are disproportionate 3. when they are of strong intensity impairment of daily routine

4 Depression Types and Symptoms (ICD-10) Types: 1. Depressive episode 2. Recurrent depressive disorder 3. Persistent mood disorders a) Dysthymia b) Cyclothymia Severity: 1. Mild 2. Moderate 3. Severe a) without psychotic symptoms b) with psychotic symptoms Core Symptoms: a) depressed mood b) loss of interest and enjoyment c) reduced energy d) increased fatiguability e) marked tiredness after only slight efforts f) reduced self-esteem and selfconfidence g) somatic disorders (e.g. disturbed sleep, diminished appetite) h) ideas or acts of self-harm or suicide

5 Prevalence Rate of Depression (Culbertson 1997, WHO 2010) Current situation: million people are affected by depression worldwide - 4 millions are affected by depression in Germany Lifetime prevalence: - Women: 20-25% - Men: 7-12% Ratio of women to men in industrial societies: 2:1

6 Causes of Depression Biological / Genetic Approach - Neurotransmitters: Male organisms produce more serotonin, men have less serotonin receptors (Schäfer 2007) - Hormones: e.g. premenstrual syndrome, pregnancy, menopause (e.g. Dinner 2005) Social Psychological Approach - Family status (Hautzinger 1984/85, Hecht 1990) - Limited role repertoire vs. role plurality (e.g. Gove 1972, Hecht 1990) - Lower social status and discrimination against women (ILO 2003)

7 Causes of Depression Artefact Approach: Different vulnerability of depression is an artefact and women and men are affected by depression to a similar extent males show different symptoms than women (male depression) (Rutz 1997, Real 1999, Dinner 2005, Kogler & Kaiser-Kaplaner 2007) males show less symptoms or describe more somatic symptoms (Ernst & Angst 1992, Kessler et al. 1993, Wittchen 2000) sex differences in perception of symptoms (Gijsbers van Wijk & Kolk 1997, Wolfersdorf 2006) males seek help in a different manner (Briscoe 1987, Rickwood & Braithwaite 1994, Möller-Leimkühler 2000)

8 Research Question How do social expectations influence the health behavior and the therapy of depressive men?

9 Qualitative Study Recruiting psychotherapists (n=6) Interviewing experts with structured interviews (October February 2009) Transcription with regards to content Analyzing of Data (Interpretative Analysis-Strategy, Meuser & Nagel 2005) Development of a theory across different categories

10 Results Handling of Depression Sex vs. Gender Men and Depression Symptoms of Depression Medical Treatment of Depression Social expectations as parameter

11 Results Gender specific handling of depression 5 of 6 psychotherapist reported a male specific handling of depression: Men externalize the reasons of the depression Men show a lower acceptance of depression than women Men disclaim the depression Men try to treat the depression themselves Women came more often to the therapist for themselves Men describe their complaints rather briefly while women elucidate their descriptions more. And they are more accessible. Men are more emotionally reserved. (No.2/w)

12 Results Gender specific (reporting of) symptoms of depression All psychotherapists reported gender specific symptoms: Men report more somatic symptoms Women report more about emotions and sadness Men disclaim the symptoms or trivialize the symptoms Men have more severe symptoms than women So, for men it is difficult to speak about themselves as a depressed patient. So, I think it is consistent with the stereotype that a man speaks more about physical symptoms rather than about classic depressive symptoms. (No. 4/m)

13 Results Social expectations as parameter 3 of 6 psychotherapist specify the social expectations as one parameter why the proportion of women in the statistics of depression is higher: Men have to be strong Men are more afraid of disadvantages at the workplace Women are allowed to show their suffering 2009) Men need to last longer, they compare themselves with their own sex and men must be strong. While women are free to show their suffering (No.2/w

14 Results Gender specific treatment of depression 5 of 6 psychotherapist reported that gender influences the therapy of depression: The access to female patients and their emotions is easier than it is to men Implementation of different therapy approaches for male and female patients (men: Progressive muscle relaxation, pragmatic approach, women: Interoceptive exercises, imaginary journey) With women it is easier to get to the core of the matter. (No. 6/m)

15 Results Sex vs. Gender 4 of 6 psychotherapist report that sex is not a reason for the higher proportion of depressed women Men do not allow the diagnosis of depression Women and men are equally affected by depression That's a social requirement for men. Depression fits more in the self-concept of women. (No.4/m)

16 Conclusion Women are twice as likely as men to be affected by depression Previous studies and the expert interviews show evidence that the depression statistics are an artefact Men and women deal differently with symptoms and depression Gender influences the therapy of patients with depression

17 Questions How can we inform and sensitize society about depression? How can we help men to handle depression in a healthier way? Do we need a gender sensitive training about diseases in general and depression in particular? How can we develop diagnosis criteria without gender bias?

18 Sociology with the Specialty Gender and Life Course Research Lena Hünefeld, M.A. Phone Thank you for your attention!

19 Appendix Method: Semi-structured expert interviews with psychotherapists (2009) - 15 Questions: 1. Diagnosis of depression 2. Experiences with male and female patients 3. Explanations of gender differences - Psychotherapists: 3 women, 3 men (6) years old at least 4 years of experience with depressive patients

20 Appendix Analysis: 1. Transcription 2. Paraphrasing Processing of 3. Categorize Data 4. Thematic comparison 5. Sociological conceptualization 6. Theoretical conceptualization Meuser & Nagel 2005

21 Appendix Categories: Handling of Depression Handling of Emotions Society as Parameter Symptoms of Depression Medical Treatment of Depressions Gender as Parameter Unreported Cases of Depression

22 Appendix noticing symptoms (interpretation, looking for information) denial minimization trivialization etc. E1 self-medication E2 disclosure to significant others (re-interpretation, making a consensus, social pressure) self-initiated E3 E4 referral to lay system referral to professional care system self-initiated externally initiated

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