Feminism & Psychology

Feminism & Psychology http://fap.sagepub.com

Are We Medicalizing Women’s Misery? A Critical Review of Women’s Higher Rates of Reported Depression Jane M. Ussher Feminism Psychology 2010; 20; 9 DOI: 10.1177/0959353509350213 The online version of this article can be found at: http://fap.sagepub.com/cgi/content/abstract/20/1/9

Published by: http://www.sagepublications.com

Additional services and information for Feminism & Psychology can be found at: Email Alerts: http://fap.sagepub.com/cgi/alerts Subscriptions: http://fap.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.co.uk/journalsPermissions.nav Citations http://fap.sagepub.com/cgi/content/refs/20/1/9

Downloaded from http://fap.sagepub.com at University of Western Sydney on February 15, 2010

Jane M. USSHER

Are We Medicalizing Women’s Misery? A Critical Review of Women’s Higher Rates of Reported Depression

Epidemiological research consistently reports that women experience higher rates of depression than men. Competing biomedical, psychological and sociocultural models adopt a realist epistemology and a discourse of medical naturalism to position depression as a naturally occurring pathology within the woman, caused by biology, cognitions or life stress. Feminist critics argue that this medicalizes women’s misery, legitimizes expert intervention, and negates the political, economic and discursive aspects of experience. However, the alternative model of social constructionism may appear to dismiss the ‘real’ of women’s distress, and deny its material and intrapsychic concomitants, as well as negate relevant research findings. A critical review of sociocultural and psychological research on women’s depression is conducted. It is argued that a critical-realist epistemology allows us to acknowledge the material-discursive-intrapsychic concomitants of experiences constructed as depression, without privileging one level of analysis above the other, in order to understand women’s higher rates of reported depression. Key Words: critical-realism, critical review, material-discursive-intrapsychic, medicalization, women’s depression

Medicalizing misery as ‘Depression’

We are consistently told that women are more ‘mad’ than men, manifested in the current era of psychiatric nosology as higher levels of the psychiatric disorder ‘depression’. Epidemiological researchers have reported that women outnumber men in lifetime prevalence of depression at a ratio that ranges from 2:1 (Bebbington, 1996; Kessler et al., 1994; Maier et al., 1999; Weissman et al., 1996) to 4:1 (Perugi et al., 1990). At the same time, studies examining incidence in the previous 12 months report that women are between 1.2 and 2.7 times Feminism & Psychology © 2010 SAGE (Los Angeles, London, New Delhi, Singapore and Washington DC) http://fap.sagepub.com, Vol. 20(1): 9–35; 0959-3535 DOI: 10.1177/0959353509350213


10

Feminism & Psychology 20(1)

more likely to have experienced depression than men, and women significantly outnumber men in first admission rates for hospital treatment and on register studies where incidence is calculated by contact with services (see Bebbington, 1996). Women are also estimated to be twice as likely as men to be prescribed psychotropic medication for depression (Ashton, 1997; Hamilton et al., 1996), in particular Serotonin Re-uptake Inhibitors (SSRIs) (Currie, 2005). Within a discourse of ‘medical naturalism’ (Pilgrim, 2007: 539), these statistics imply that depression is a naturally occurring pathology existing within the sufferer, which can be objectively defined and measured. Within a realist epistemological framework, standardized diagnostic criteria, such as those as laid out in the Diagnostic and Statistical Manual of Mental Disorders, Edition IV (DSM-IV; APA, 2000), are used to ensure uniformity across research, with assessment of individual symptoms conducted through standardized questionnaires or clinical interviews. However, as Paula Treichler has argued, statistics can be seen as simply ‘bad science infected by rumor and fantasy’ (1992: 391), which give the impression that diseases, such as depression, are an ‘unmediated epidemiological phenomenon’ (Gardner, 2003: 109). Indeed, depression has been conceptualized as a social category created by a process of expert definition that medicalizes the whole continuum of mild to severe misery as a unitary psychiatric disorder (Kirk and Kutchins, 1992; Littlewood and Lipsedge, 1982; Stoppard, 2000). Described as a ‘disjunctive concept’, which is deemed applicable to individuals with no symptoms in common, and thus a ‘professional reification about human misery, not a fact’ (Pilgrim and Bentall, 1999: 271), this raises questions about the higher reported rates of 'depression' in women. The framework of medical naturalism that led to the establishment of depression as a real entity that exists independent of perception, language or culture has its origins in psychiatric nosology first promoted by Kraeplin in the late 19th century. Three now defunct separate diagnoses – melencholia, neuresthenia and mopishness – stand as the precursors of ‘mental depression’, a diagnosis that first appeared in the mid-19th century (Pilgrim and Bentall, 1999). ‘Depression’ only became a widely used term at the beginning of the 20th century, translated into ‘major depressive disorder’, and positioned as scientific truth, in the DSM (Kirk and Kutchins, 1992). However, this is very much a western cultural concept, as there is no word for ‘depression’ in many non-western cultures (Marsella, 1981). Indeed, many so called ‘symptoms’ of western depression are not expressed, or positioned as signs of distress, in non-western contexts (Jadhav, 1996). Rather, suffering is signified by bodily or psychological complaints as varied as chest pains (China), burning on the soles of the feet (Sri Lanka), semen loss (India), ants crawling inside the head (Nigeria) or soul-loss (Hmong) (Marecek, 2006: 289). The influence of western psychiatry in establishing and maintaining the legitimacy of the concept of depression, and at the same time reinforcing a bio-determinist perspective, cannot be underestimated (Kutchins and Kirk, 1997; McPherson and Armstrong, 2006). Since the mid-19th century, psychiatry has claimed authority over the


USSHER: Are We Medicalizing Women’s Misery

11

mad and melancholic, subjecting ‘patients’ to myriad physical ‘treatments’ which included isolation, restraint, enforced bed rest and immersion in freezing water whilst shrouded in wet sheets (Geller and Harris, 1994). The first half of the 20th century saw the emergence of psycho-surgery and electro-convulsive therapy, as well as psycho-tropic medication. However, at the same time, between the 1940s and mid 1960s, psychiatric theory was dominated by psychoanalysis, with hysteria, and ‘neurotic disorders’ being diagnoses applied to women, and oedipal notions of gender development underlying explanations of distress. This was reflected in the diagnostic classifications outlined in the first version of the DSM, published in 1954, where ‘mental disorders’ were considered to result from early experiences with parents that become internalized as adults through unconscious processes (Metzl, 2003: 39). In the early 1970s, a backlash against psychoanalytic thinking occurred in psychiatry, with proponents of ‘evidenced based treatment’ and a biological model of madness taking control of the discipline, resulting in depression being firmly positioned as an illness within the brain, to be primarily managed by psycho-tropic medication (Gardner, 2003). Governments are also active in promoting depression literacy in everyday life (Gattuso et al., 2005), resulting in a continual widening of the boundaries of mental illness categories (Busfield, 2002). At the same time, the pharmaceutical industry, and its allies, have been accused of ‘disease mongering’ in their active encouragement of the medicalization of ‘ordinary ailments’ (Moynihan et al., 2002: 324). They are deemed to act in conjunction with psychiatry to legitimate medical intervention for ‘common personal and social problems’ (Double, 2002: 900), through direct-to-consumer advertising, promotion of self-diagnosis (Currie, 2005) and the funding of national education campaigns on how to ‘Beat Depression’ (Pilgrim and Rogers, 2005). Japan is a case in point, where there wasn’t even a term for mild depression before SSRIs were promoted by a pharmaceutical company in 1999. Experiences such as melancholia, sensitivity and fragility were accepted as part of life, not deemed to be pathological conditions to be alleviated. However, after vigorous ‘public education campaigns’ promoted by the drug company, a new ‘disease’, kokoro no kaze, was established, with a message that it ‘can be cured by medicine’. As a result, sales of SSRIs in Japan quintupled between 1998 and 2003 (Currie, 2005: 11).1 This creation and expansion of a market for drugs through extending the boundaries of diagnosis to encapsulate all forms of sadness, misery or dysphoria is not confined to Japan. As Shorter (1997) has argued, the boundaries of depression have been extending relentlessly outward since the 1960s, now encompassing mild levels of mood change, as well as major intractable depression, with the result that diagnoses of depression have increased exponentially (Healy, 2003). This ‘diagnostic bracket creep’ is applauded by proponents of SSRIs, who want the boundaries of mental illness to be continuously expanded to match the drugs that are developed to treat ‘conditions’ (e.g. Kramer, 1993). Prescriptions for psychotropic medication, primarily SSRIs, have also dramatically increased, because they are viewed as ‘chemical cures’ (Moncrieff, 2009:


12


301), that treat a ‘deficiency disease’ (Currie, 2005: 4). However, there is no evidence of specific imbalances in serotonin in individuals reporting depression (Moncrieff, 2009), and no evidence that making serotonin nerves more active, the aim of SSRIs, can help people over come emotional problems (Breggin and Breggin, 1991). Scientists themselves readily admit they are unsure how antidepressants work (Gardner, 2003), and the efficacy of placebos in comparison to SSRIs is so strong that the pharmacological rationale for the treatment is undermined (Moncrieff and Kirsch, 2005). Diet and exercise can be as effective as SSRIs in treating depression (Dunn et al., 2005), as can psychological therapy such as cognitive-behaviour therapy (CBT) (Williams, 1992). As SSRIs have also been associated with serious side effects, including suicide, aggression, harm to relationships, akathisia and ‘out of character’ behaviour (Gunnell et al., 2005; Liebert and Gavey, 2008), their widespread use raises many serious concerns.

MEDICALIZING WOMEN’S MISERY – FEMINIST CRITIQUES

Feminist critics have a long history of critiquing the medicalization of women’s misery and of seeing psychiatry as a profession that acts to regulate women (Penfold and Walker, 1984; Stoppard, 2000; Ussher, 1991). As Phyllis Chesler commented, in her oft-quoted book Women and Madness: Most twentieth century women who are psychiatrically labelled, privately treated and publically hospitalised are not mad . . . they may be deeply unhappy, self-destructive, economically powerless, and sexually impotent – but as women they’re supposed to be. (Chesler, 1972: 25)

More recently, Jeanne Marecek (2006) argued ‘depression is not something people have, but a set of practices authorized by the culture through which people express to others that they are suffering’ (2006: 303). Biomedical theories of women’s depression have come under particular feminist scrutiny (Sayers, 1982; Ussher, 1989). From a biomedical perspective, the primary explanation put forward for reports of women’s higher rates of depression is reproductive hormones, in particular oestrogen (Seaman, 1997), linked to premenstrual, post-natal and menopausal stages of the reproductive lifecycle (Studd, 1997). Justification for this ‘raging hormones’ approach is deemed to be found in reports that women’s greater propensity to report depression emerges at puberty (Angold et al., 1998; Peterson et al., 1991), and is no longer present post-menopause (Bebbington et al., 1998; Kessler et al., 1993). However, whilst gender differences in the reporting of depression may appear at puberty, this cannot be explained by the ‘turning on’ of the endocrine system, as has been claimed (e.g. Kuehner, 2003: 167). For example, in one study that examined adolescent girls’ depression, only 4 percent of the variance was accounted for by oestrogen levels, with life events, and the interaction of oestrogen levels and life events, accounting for 17 percent (Brooks-Gunn and Warren,



13

1989). The evidence for ‘times of great hormonal fluctuation’ across the life-span (Studd, 1997: 977) being causally linked to women’s distress is equally weak. Premenstrual distress has been found to be strongly associated with women’s social and relationship context (Ussher and Perz, 2010), in particular with overresponsibility, relationship dissatisfaction and communication problems (Ussher, 2003a, 2004b). Depression in the post-natal period has been conceptualized as an understandable reaction to the strains of early motherhood (Nicolson, 1998), linked to high and unrealistic expectations (Mauthner, 1999), combined with low social support (Bifulco et al., 1998). Finally, community studies report that the majority of peri-menopausal and menopausal women are happy and satisfied with their lives, rather than depressed (e.g. Avis et al., 1994; Dennerstein, 1996). Social and relational context, and women’s negotiation of midlife change, have been reported to be factors associated with distress (or happiness) at midlife – rather than hormonal changes in the menopausal body (McQuaide, 1998; Perz and Ussher, 2008). Constructing Women’s Misery as Depression In contrast to this the realist biomedical viewpoint, many feminists have adopted a social constructionist standpoint, arguing that psychiatric diagnosis is a gendered practice that pathologizes femininity (Chesler, 1972; Stoppard, 2000; Ussher, 1991). Gender role stereotypes used by medical practitioners (see Sherman, 1980) and gender bias in psychometric instruments that categorize normative aspects of feminine behaviour (such as crying or loss of interest in sex) as ‘symptoms’ (Salokangas et al., 2002) have been deemed to result in medical practitioners diagnosing depression in women at higher rates than men (Potts et al., 1991). It has also been argued that many women only label their unhappiness as ‘depression’, and as a result take up a biomedical model to explain their ‘symptoms’, after receiving medical diagnosis and treatment (Gammell and Stoppard, 1999; Lafrance, 2007). The discursive construction of women’s unhappiness as depression in health policy (Gattuso et al., 2005), medical journals (Ussher, 2003b), self-help books (Gardner, 2003; Rittenhouse, 1991), drug company literature (Metzl and Angel, 2004; Munce et al., 2004), women’s magazines (Gattuso et al., 2005) and other mass circulated literature (Blum and Stracuzzi, 2004) also plays a significant role in women increasingly positioning their distress as an illness, ‘depression’. Premenstrual dysphoric disorder (PMDD) is an obvious example of this process. Whilst premenstrual change is a normal part of women’s experience, feminists have argued that these changes are only positioned as ‘PMDD’ because of hegemonic cultural constructions of the premenstrual phase of the cycle as negative and debilitating (e.g. Chrisler and Levy, 1990; Rittenhouse, 1991), which impact upon women’s appraisal and negotiation of premenstrual changes in mood or behaviour (Ussher, 2006, 2008). In cultures where PMDD does not circulate as a discursive category, women do not attribute psychological distress


14


to the premenstrual body, and do not position premenstrual change as pathology (Chrisler, 2002). It is the regimes of truth within western medicine that position premenstrual change as pathology that provide the discursive context for women to take up the subject position of ‘premenstrual stress [PMS] sufferer’, through a process of subjectification (Ussher, 2004a). The very existence of PMDD as a legitimate psychiatric diagnosis can thus be questioned (Chrisler and Caplan, 2002), as can the recommendation that SSRIs should be the primary cure (see Steiner and Born, 2000). The gendered nature of this medicalization results in an insidious creeping of pathologization into women’s lives. For example, in a study that examined advertisements for SSRI anti-depressants over the period 1985–2000, Metzl and Angel (2004) reported that there was a clear shift towards positioning women’s normative reactions to life events associated with marriage, motherhood, menstruation or menopause as psychiatric illnesses that warrant SSRI medication, resulting in emotional experiences such as ‘being overwhelmed with sadness’, or ‘never feeling happy’ being positioned as depression. This stands in contrast to the biomedical positioning of men’s depression as ‘an illness with bio-chemical roots’ (Metzl and Angel, 2004: 580), suggesting that normal reactions to life’s vicissitudes are less likely to be pathologized in men. Anti-depressant advertisements also reinforce a script of hetero-normativity, with the pre-medicated woman2 often depicted as unable to find a man, or unhappy with her husband, whilst the post-medicated woman is ‘dating’, or declares, ‘I got my marriage back’ (Metzl, 2003, p155). At the same time, SSRIs have been promoted as a ‘feminist’ drug that turn mildly depressed, anhedonic, and rejection sensitive women into occupationally and romantically successful ‘hyperthymic’ personalities (e.g. Kramer, 1993). These representations function to extend the boundaries of ‘depression’ to include dissatisfaction with heterosexual relationships or lack of achievement at work, with the solution being a chemical cure. Feminist Critiques of Psychological Theories of Women’s Depression Psychology offers an alternative perspective to biomedicine in relation to the aetiology and treatment of depression, but has not escaped feminist scrutiny. In recent years, cognitive-behavioural approaches (e.g. Beck, 1987), in particular, have made some inroad into medical dominance of intervention, with CBT now being recommended by many governments (including those of Australia and the UK) as a first-line treatment for depression (Holmes, 2009). However, feminist critics have argued that there is little evidence of gender differences in the majority of cognitive ‘deficits’ deemed to underlie depression from a cognitive-behavioural perspective, which undermines the utility of such theories for explaining women’s higher rate of depression (Miller and Kirsch, 1987; Stoppard, 1989). Psychological theories of depression have been dismissed for being overgeneralized and over-simplified (Marecek, 2006: 298), or for being based on a positivist epistemology that positions women’s distress as symptoms of an under-



15

lying disorder (Stoppard, 1999: 83). Indeed, feminist critics have argued that both biomedical and psychological theories of depression decontextualize what is often a social problem, simply acting to legitimize expert intervention, whilst negating the political, economic and discursive aspects of women’s experience (Lafrance, 2009; Stoppard, 2000; Ussher, 1991). Psychological treatment has also been the subject of criticism by some feminists. This is because the solution to depression is still positioned within the individual, with women entreated to engage in therapy that is seen to ignore social context (Perkins, 1991), or to engage in self-management strategies (Gattuso et al., 2005). This has been seen to simply maintain the status quo and produce more productive citizens (Lafrance, 2007), as well as ensure that social and political inequalities that lead to distress in the first place remain unchallenged.

REJECTING PATHOLOGIZATION WHILST ACKNOWLEDGING WOMEN’S DISTRESS

There are limitations, however, to adopting a social constructionist analysis of women’s depression, as many feminists have done (e.g. Gammell and Stoppard, 1999; Lafrance, 2007; Mauthner, 1999). Social constructionism has been criticized for negating the ‘real’ (see Nightingale and Cromby, 1999) and in its denial of realism, leading to an ‘abyss of relativism . . . in a world where ‘truth’ is all but abandoned’ (Williams, 2003: 50). The act of positioning depression as a discursive construct could also appear to negate the existence or magnitude of the misery experienced by many women. It has been reported that over the last 35 years, women’s levels of subjective well-being have fallen, both absolutely and relative to those of men (Blanchflower and Oswald, 2004), and many women do undoubtedly experience extreme and debilitating misery. We need to understand why this is so, even if we are critical of the diagnostic category ‘depression’. Feminists who dismiss medicalization are also left with the dilemma that at an individual level, the diagnosis of depression can serve to validate to women that there is a ‘real’ problem, isolating prolonged misery from ‘the character of the sufferer’ (Lafrance, 2007: 130). In a similar vein, many women will embrace a diagnosis of PMS, PMDD (Ussher, 2003a) or post-natal depression (Mauthner, 1999) in order to assure themselves (and others) that they are not ‘going crazy’. A social-constructionist approach can also appear to negate the material and intrapsychic concomitants of the experiences that are constructed as ‘depression’. The development of ‘material-discursive’ approaches (Lafrance and Stoppard, 2007; Stoppard, 2000; Ussher, 1997) that acknowledge the interaction of discourse and materiality, in particular the sociocultural context, go some way to addressing this criticism. This can be seen as part of a broader tradition of feminist psychologists drawing on sociocultural theories that locate the causes of depression in a woman’s social environment (e.g. Doyle, 1995; Mauthner, 1999; Nicolson, 1998; Stoppard and McMullen, 2003). Ironically, these feminist critics


16


are in many ways in agreement with oft-quoted reviewers in the field of psychiatry, who argue that attention should be paid to ‘physical and social environment’ (Bebbington, 1998: 5) or the effects of ‘environmental provoking influences’ (Kessler, 2003: 5), when attempting to explain the higher rates of depression reported among women. There are problems in adopting sociocultural theories uncritically, however, as many share the realist epistemological framework of the much maligned psychological and biomedical approaches, where associations between environmental indices and levels of depression are assumed to reflect causal pathways, and the indices under examination are assumed to exist independently of perception or culture. At the same time, the dismissal of positivist research and the focus on a qualitative approach (e.g. see Stoppard, 1999) could also function to negate substantial bodies of research that may be useful in understanding women’s experience of ‘depression’. In order to illustrate this point, I will now undertake a critical review of current psychological and sociocultural research that sets out to explain women’s higher rates of reported depression.3 I will follow this with an exploration of a critical-realist-epistemological perspective that allows us to address the ‘real’ of women’s unhappiness and misery, as well as its psychological, social and biological concomitants, at the same time as acknowledging the sociocultural context within which women’s misery is constructed and experienced as ‘depression’. STRESS, SOCIAL DEPRIVATION AND COGNITIONS: A REVIEW OF SOCIOCULTURAL AND PSYCHOLOGICAL RESEARCH ON WOMEN’S HIGHER RATES OF REPORTED DEPRESSION

Inequality, Discrimination and Violence The social context of women’s lives has been put forward by many as the primary reason for women’s higher rates of reported depression. Gendered inequalities in society, leading to the discriminatory treatment of women, have been reported to be a significant factor (Cabral and Astbury, 2000). For example, in a World Mental Health Report (Desjarlais et al., 1996), the social roots of women’s mental health problems in low-income countries were identified as under-nourishment, low-paid work and domestic violence, leading to a plea for coordinated efforts to economically empower women and reduce violence in all of its forms. In the USA, whilst differences in rates of depression have been reported across AsianAmerican, African-American and Latino women (Brown et al., 2003), these differences have been said to disappear when socioeconomic differences are controlled (Alegria et al., 2008; Jackson-Triche et al., 2000). Women who live in US states that are high on the economic autonomy index, and where women have better reproductive rights, are also reported to be significantly less likely to experience depression (Chen et al., 2005). Similarly, in European countries, women’s life satisfaction was reported to have increased after the introduction of abor-



17

tion rights and birth control (Pezzini, 2005). This has led to the conclusion that depression can be reduced by increasing women’s access to economic resources and employment, as well as facilitating autonomy over reproductive decisions. Discrimination operating at an individual level is also deemed to be an influential factor in women’s depression. Researchers have reported that women who experience frequent sexism (Klonoff et al., 2000), or who perceive themselves to be subjected to personal discrimination (Dambrun, 2007), report higher levels of depression than those who experience little sexism or low levels of discrimination (Belle and Doucet, 2003). The experience of physical and sexual violence has been linked to a range of women’s mental health problems, including depression, anxiety, substance abuse and post traumatic stress syndrome (Cabral and Astbury, 2000; Cortina and Kubiak, 2006; Kendler et al., 2000; Molnar et al., 2001), as well as physical health problems (Kendall-Tackett, 2007). Indeed, women’s higher rates of having experienced child sexual abuse (Molnar et al., 2001) or adult sexual violence (Koss et al., 2003) has been described as going ‘a considerable way to explaining the adult sex difference in depressive disorders’ (Bebbington, 1998: 4). In one study, it was estimated that 35 percent of the differences in rates of depression between women and men could be accounted for by sexual abuse occurring before the age of 18 (Cutler and Nolen-Hoeksema, 1991). This is an issue for a significant proportion of women, as violence against women is so prevalent across cultures it is now recognized as a primary health and human rights issue by the World Health Organization (2000). Gender Roles and Life Events The construction and experience of gendered roles has also been classified as a significant factor in the development of women’s depression. It has been posited that ‘gender intensification’ occurs at puberty, characterized by parental and peer expectation of girls’ conformity to ‘restrictive social roles’ (Nolen-Hoeksema and Girgus, 1994: 436). Girls who resist feminine gender-typed activities, assert their intelligence or pursue ‘masculine type activities’, have been reported to risk rejection by boys, acting to ‘contribute to their propensity to depression’ (Nolen-Hoeksema and Girgus, 1994: 436). Mothers have also been reported to engage their daughters in discussion of sadness and fear, whilst encouraging suppression of such emotions in their sons, which has been linked to a greater focus on depressive emotions in girls (Nolen-Hoeksema and Jackson, 2001). Adolescent body dissatisfaction, resulting from the objectification of women’s bodies in western culture (Fredrickson and Roberts, 1997), is another issue of concern. Over 80 percent of girls compared to 40 percent of boys aged 12–18 report dissatisfaction with their body image (Kostanski and Gullone, 1998), leading Nolen-Hoeksema and Girgins (1994) to argue that body dissatisfaction ‘may account for a substantial part of the gender difference in depressive symptoms in adolescence, but not all of it’ (1994: 435). Indeed, one explanation put forward for the lower rates of depression reported by African-American girls is the low rate of


18


body dissatisfaction compared to white girls (Hayward et al., 1999: 148). Gender roles have also been linked to the negotiation and experience of life events. It has been reported that depression is associated with both severe life events (Bifulco et al., 1998; Brown and Harris, 1989b) and cumulative adversity (Turner and Lloyd, 1995), for women and men. Indeed, one explanation for higher rates of depression reported by adolescent girls, when compared to boys, is the higher levels of social and relational challenges (Nolen-Hoeksema and Girgus, 1994), life events (Gore et al., 1992), or life stress (Jose and Brown, 2008) girls experience at this time. Certain groups of women, particularly those caring for young children (Brown and Harris, 1978), those experiencing poverty (Belle and Doucet, 2003) and those with negative close relationships (Bifulco et al., 1998), have been reported to have a greater susceptibility to life events, and to experience depression as a result. It has also been suggested that women and men respond differentially to certain life events, those involving children, housing and reproduction, because of the greater salience of these events to women’s role identity (Nazroo et al., 1998). Described as ‘network events’ this is interpreted as being the result of women’s greater involvement in the lives of those around them (Kessler and Mcleod, 1984: 620), with women’s responsiveness representing a ‘cost of caring’ (Kessler et al., 1985: 492) that leads to elevated levels of depression. Indeed, whilst men and women have been observed to be equally likely to remember their own life events, men have been found to be less likely than women to remember life events affecting significant others, leading to the suggestion that men may avoid depression through ‘blocking out’, or not attending to, network events (Turner and Avison, 1989). Cognitive Appraisal and Rumination A range of psychological explanations have also been put forward to explain women’s higher rates of reported depression. It has been argued that there are gender differences in some aspects of cognitive appraisal and coping style (Miller and Kirsch, 1987). Meta-analytic research has been used to argue that, in the face of stress, women are more likely to use coping strategies that involve verbal expression to others or the self – seeking emotional support, rumination, and posi tive self-talk – whereas, in contrast, men are said to engage in avoidance in the face of stressors that involve relationships or other people (Tamres et al., 2002). It has also been argued that rumination, rather than taking distracting action or changing the situation, is associated with depression in both men and women, with adolescent girls and adult women being more likely to show ruminative tendencies than adolescent boys or men (Nolen-Hoeksema and Girgus, 1994; Nolen-Hoeksema, Larson, and Grayson, 1999), a gender difference that has been reported to emerge by age 13 (Jose and Brown, 2008). In a similar vein, Hankin and Abramson (2001) argue that adolescent girls’ greater tendency for rumination is a key aspect of their ‘depressogenic attributional style’ (2001: 785). Drawing on a general cognitive-vulnerability theory



19

of depression (Abramson et al., 1989; Beck, 1987), the emergence of gender differences in depression post puberty is deemed to result from an interaction of pre-existing vulnerabilities, negative life events and cognitive vulnerabilities. These are described as: genetic risk for depression, girls’ greater tendency to report neuroticism (Goodwin and Gotlib, 2004), and maltreatment (primarily sexual abuse), which is deemed to interact with negative body image and ‘depressiogenic inferential style’ (Hankin and Abramson, 2001: 785), manifested by rumination. Within this model, the likelihood of depression is said to be increased by parental socialization, involving high levels of control, which lead to girls’ negative self-evaluations and greater tendency to take responsibility for failure, compared to boys (Pomerantz and Ruble, 1998). In apparent support for this view, beliefs about having no control of emotions, having responsibility for the tone of relationships, and feelings of lack of mastery over negative events have been reported to mediate gender differences in rumination (Nolen-Hoeksema and Jackson, 2001). Affiliation, Attachment Style and Self-silencing An alternative multi-factorial model, with a psycho-biological slant to it, has been presented by Cyranowski and colleagues (2000), who explain adolescent onset of depression in terms of girls’ heightened affiliative needs, interacting with adolescent transition difficulties and negative life events, particularly those with interpersonal consequences. They draw on meta-analytic research that claims that women are more concerned with affiliation, whilst men are more likely to be concerned with personal autonomy, instrumentality and agency (Fengold, 1994), to argue that heightened affiliative needs have an evolutionary basis. This is deemed to be located in ‘women’s historically greater investment in offspring care and their relatively greater use of long-term sexual mate selection strategies’ (1994: 22), linked to the ‘mammalian neuropeptide oxytocin’ (Cyranowski et al., 2000: 23). Absence of a secure parental base, leading to an insecure attachment style has also been posited as a potential contributory factor in Cyranowski et al’s (2000) model, as insecure attachments are said to be linked to lower self-esteem, lower social support, and greater symptoms of psychological distress (Cooper et al., 1998). Similarly, in her work on self-silencing, a pattern of behaviour involving a focus on others at the expense of the self, accompanied by repression of a woman’s own needs and concerns, Jack (1991) has associated insecure attachment style with high levels of self-silencing and, as a consequence, with women’s depression (Duarte and Thompson, 1999). Drawing on self-in-relation theory (Kaplan, 1986), women are deemed to self-silence because they believe that they are not loved for who they are, but for how well they meet the needs of others (Jack and Dill, 1992), with the resultant silencing of needs and anger, and the use of external standards to judge the self, leading to feelings of worthlessness and hopelessness. There are other psychoanalytic theories of women’s depression


20


that focus on object relations, unconscious motivations and defence mechanisms (Gyler, 2010). However, these theories have not been used to date as the basis for empirical research evaluating causes for women’s higher rates of reported depression.

‘WOMAN AS PROBLEM’: THE NEGATION OF THE POLITICAL CONTEXT OF WOMEN’S DEPRESSION

We cannot simply accept these sociocultural and psychological explanations for women’s higher rates of reported depression uncritically. The majority of the accounts reviewed above provide us with, at best, partial and, at worst, deeply flawed analyses, as they still position depression within the woman. As is also the case with biomedical models, they de-politicize the roots of women’s distress, and neutralize the causal pathways under scrutiny, and indeed, depression itself, as objective entities that can be simply measured or monitored. As Pilgrim and Bentall (1999) argue, whilst ‘it is possible to talk about the ‘diagnosis of child sexual abuse’ and the ‘diagnosis of depression’ in its survivors, it is less mystifying to think about the enduring misery created by the sexual oppression of children by adults’ (1999: 270). Constructs such as ‘neuroticism’, ‘stressful life events’ or ‘depressogenic attributional style’ are stripped of their gendered context (Stoppard, 1999: 81) and accepted as unquestioned causal mechanisms. Equally, whilst we may correlate social inequalities, gender roles or adult sexual violence with women’s depression, the majority of sociocultural accounts provide no analysis of the hetero-patriarchal political context and structural conditions that maintain deeply entrenched gender divisions in reproductive labour and economic activity, to the disadvantage of women. We need to question ‘who benefits from the restriction of women’s reproductive rights?’ ‘Why is it that domestic and sexual violence is so endemic, and that so few cases are prosecuted?’ (see Gavey, 2005). ‘Why are women still taking on the greater burden of childcare, resulting in their greater vulnerability to adverse life events?’ ‘Why do women earn less then men, even they are as well qualified?’ and ‘Why are women in a minority in positions of power in society?’ To take just one example, whilst women may suffer on an individual basis from the ‘cost of caring’, if they did eschew this traditional feminine role, the expenditure placed on the state would blow national budgets – estimated as 739 billion pounds a year in the UK (Vine and Kindersley, 2009). It would also mean greater demands would be made on men, who currently do far less unpaid caring, or housework, than women (Sirianni and Negrey, 2000). Stripping accounts of women’s misery of any acknowledgement of the historical or political context of women’s lives, whilst paying lip service to sociocultural or psychological influences, thus serves to shore up the very structural factors that lead to distress in the first place, through making gender inequality an invisible issue.



21

Marriage and Depression A case in point is analysis of the relationship of marriage and depression. For many years marriage has been put forward as a risk factor for women’s depression (Bebbington et al., 1991; Gove, 1972; Gove and Tudor, 1973), with young married women with small children deemed to be at particularly high risk (Brown and Harris, 1978). Conversely, marriage has been said to act as a protective factor for men (Weissman et al., 1984), with one study reporting that wives experience over five times the rate of depression as husbands (Bebbington et al., 1981). However, a number of studies report that marriage is a protective factor for both men and women, as it acts to buffer psychological distress (e.g. Sachs-Ericsson and Ciarlo, 2000), with divorced or separated individuals at high risk of depression (Bebbington et al., 1988). It has also been reported that single mothers are at higher risk for depression than married mothers, because of the difficulties of child care and multiple role responsibilities in what are often disadvantaged circumstances (Bifulco et al., 1998; Meltzer et al., 1995; Sachs-Ericsson and Ciarlo, 2000), whilst women who have no children at home have a lower risk for depression (with the presence of children having no impact on depression in men) (Bebbington et al., 1998). In reporting research on ‘marriage’ and depression, I am not taking a naive hetero-normative position, for it is ‘marriage’ between a man and a woman that has been the focus of research in this area. And whilst the importance of gender roles within marriage is often implicitly acknowledged by researchers (e.g. Brown and Harris, 1989a: 381), there is rarely, if ever, any critique of the underlying tenets of hetero-patriarchy that may be instrumental in creating the particular conditions associated with ‘marriage’ or ‘childrearing’ and women’s depression. Specific factors in heterosexual relationships that have been linked to women’s depression include relationship distress and dissatisfaction (Whisman and Bruce, 1999), self-silencing (Whiffen and Foot, 2007), humiliation (Brown et al., 1995), partner violence towards the woman (Koss et al., 2003), dissatisfaction with decision making, financial issues and child-care (Byrne et al., 2004), inequality in relation to domestic responsibilities (Doyle, 1995), absence of partner support (Brown et al., 1986), the presence of demand-withdrawal interactions (Byrne and Carr, 2000), communication problems (Byrne et al., 2004), and feelings of disempowerment (Price, 1991). Whilst Brown and colleagues (1995) describe these relational patterns as creating ‘depressogenic effects’, as Pilgrim and Bentall argue, ‘this could be reframed by simply stating that miserable women live with oppressive men’ (1999: 270). The very use of the medicalized term ‘depression’ therefore acts to depoliticize women’s distress. If we look outside of a heterosexual matrix, where roles within relationships are not taken for granted and divided on gendered terms, these oppressive patterns of relating are less common, suggesting that it is not ‘marriage’ or child-rearing per se that is a risk factor for women’s depression, but particular aspects of relationships that are more common in a hetero-patriarchal context. For researchers


22


have reported that in comparison to heterosexual relationships, lesbian relationships are experienced as more satisfying (Green et al., 1996; Kurdek, 2003; Metz et al., 1994) and communication is more likely to include open exploration of feelings, empathic attunement to non-verbals, negotiation and the absence of contempt (Connolly and Sicola, 2006). Conflict is resolved more effectively (Kurdek, 2004b; Metz et al., 1994), with less likelihood of a demand-withdrawal style of conflict resolution (Kurdek, 2004a). There is also greater egalitarianism, in dealing with household responsibilities (Green et al., 1996: 197), including child-care (Koepke et al., 1992), accompanied by adaptability in dealing with relational needs and domestic tasks (Connolly, 2005: 270). Higher levels of cohesion or connectedness are also reported (Green et al., 1996), linked to mutual empathy, empowerment and relational authenticity (Mencher, 1990). This has implications for mental health. For example, in a recent study on women’s premenstrual distress, conducted with women who self defined as ‘PMS sufferers’, women in lesbian relationships reported lower levels of depression and anxiety and higher levels of premenstrual coping than women in heterosexual relationships. Lesbians also reported higher levels of empathy, support and positive communication with their woman partner, compared to rejection, absence of communication and lack of empathy on the part of many male partners, particularly when the woman was premenstrual (Perz and Ussher, 2009; Ussher and Perz, 2008). This suggests that it should be hetero-patriarchy that is the focus of critical attention, not decontextualized ‘marital’ factors, as is so often the case in analyses of the relational context of women’s depression. Psychological Theories Acknowledging Hetero-patriarchal Context There are examples of attempts by psychological researchers to demystify, and position the blame for misery outside of the women, and to acknowledge the hetero-patriarchal context of distress, even when psychological mechanisms, such as rumination or self-silencing, are the focus of attention. For example, in Nolen-Hoeksema et al.’s research, women’s propensity to ruminate is deemed to be tied to the chronic strain they experience, ‘the grinding annoyances and burdens that come with women’s social power (including) . . . a greater load of the housework and child care and more of the strain of parenting than men’ as well as absence of affirmation by their male partners (Nolen-Hoeksema et al., 1999: 1068). This is deemed to be combined with women’s lower social status, their unequal power and status in relationships, as well as greater life-time prevalence of sexual and physical assault, leading to feelings of chronic lack of control, low self-mastery and learned helplessness, and as a consequence, depression. The solution put forward by Nolen-Hoeksema and colleagues is to help women to gain more mastery over their lives, but also to change their social circumstances so they ‘don’t have so much to ruminate about’ (1999: 1068). Similarly, Dana Jack’s self-silencing theory locates women’s propensity to self-silence in gender-specific schema and culturally constructed relationship



23

norms, which lead women to internalize anger and engage in self-sacrifice as part of the role of being a good wife and mother (Jack, 1991). Indeed, whilst a number of studies have reported that men self-silence as much as, or more than, women (Cowan et al., 1995; Duarte and Thompson, 1999; Thompson, 1995; Whiffen and Foot, 2007), men’s self-silencing appears to be motivated by intentions to prioritize their own needs and to maintain a feeling of self-sufficiency (Remen et al., 2002), tied to cultural norms of masculinity, which does not result in depression, anger and a loss of self (Duarte and Thompson, 1999).

A MATERIAL-DISCURSIVE-INTRAPSYCHIC ANALYSIS OF WOMEN’S DEPRESSION

So where does this leave us? Reconciling competing theories and research findings on the subject of women’s depression has previously been described as ‘impossible,’ because ‘the premises behind the stories and the disciplinary commitments they entail are incommensurate’ (Marecek, 2006: 304). However, if we take a critical-realist epistemological standpoint, we can acknowledge feminist critiques of the medicalization of women’s misery, as well as the findings of a range of research studies, without having to accept, or reconcile, competing disciplinary commitments. Critical realism is an epistemological standpoint that lies between the two apparently oppositional positions of positivism/realism and constructionism (see Pilgrim and Bentall, 1999). Critical realism recognizes the materiality of somatic, psychological and social experience, but conceptualizes this materiality as mediated by culture, language and politics (Bhaskar, 1989). The legitimacy of subjective experience is acknowledged, yet the constructionist focus on theoretical debate at the expense of empirical research (Speer, 2000), or the focus on discursive practices alone (Pilgrim, 2007), is rejected. The utilization of a variety of methodologies is also accepted, both qualitative and quantitative, without one being privileged above the other (Sayer, 2000). This allows us to incorporate the findings of research conducted from a range of theoretical perspectives (biomedical, psychological, sociocultural or discursive) into one framework, without having to reconcile competing epistemological assumptions (Williams, 2003). A critical-realist analysis allows us to acknowledge the ‘real’ of women’s psychological and somatic distress, whether this distress is mild or severe, yet to conceptualize it as a complex phenomenon that is only discursively constructed as ‘depression’ within a specific historical and cultural context. Equally, we can acknowledge that an individual woman, living in a particular historical and cultural context, with a particular set of life circumstances, and a particular set of beliefs and coping strategies, may come to experience psychological distress, to label it as depression and then seek treatment, because of the complex interaction of these different factors within her life. We can also acknowledge the materiality of embodied distress, and biological concomitants of the phenomenon positioned


24


as ‘depression’. However, within a critical-realist framework, none of these material, discursive or intrapsyhic levels of analysis is privileged above the other. This material-discursive-intrapsychic model (Ussher, 2000) stands in contrast to a biopsychosocial approach (Engel, 1977) which is at essence a medical model that privileges biology. It also stands as a further development of material-discursive approaches that privilege discourse, and negate the intrapsychic concomitants of ‘depression’.4 Within a critical-realist approach, both qualitative and quantitative research, ranging from large-scale epidemiological studies to single case designs, can be used to provide insight into women’s experiences that come to be positioned as ‘depression’ – without seeking universal answers, or universal solutions, that deny the experiences of women across different social, cultural or relational contexts. This allows us to develop programmes of prevention and intervention at a political, social, familial and individual level. Interventions that focus on one level alone – whether this is biomedical, sociocultural, psychological or discursive – will not address the totality of the experiences of women that come to be categorized as depression. We do need to question the increasing medicalization of misery in the West, in particular the way in which women who experience mild distress or understandable problems with everyday life are defined as having a mental disorder ‘depression’ and told that the optimum treatment is medication, most frequently an SSRI. The term ‘depression’ may function to communicate the extent of a woman’s distress, and validate her subjective experience; however, it needs to be conceptualized outside of a medical model that positions it as pathology within the woman. As feminists we also need to be wary of reinforcing medical naturalism through discursively positioning our research focus, or our participant’s experiences, as ‘depression’. In the same way that feminist psychologists have used the term ‘premenstrual change’ or ‘premenstrual distress’ in order to avoid the medicalized connotations of the diagnostic categories of PMS or PMDD (Ussher, 2006), we may need to deliberately subvert taken for granted assumptions by using terms such as ‘severe distress’, ‘prolonged misery’ or ‘continuum of depressive experiences’, to make the point that depression is not a unitary, global, trans-historical pathology. Yet we also need social and political change so that women are not living in a context of inequality, violence and abuse. We need to critically examine the gendered socialization of girls and women, which may act to increase their likelihood of rumination, self-silencing, self-objectification and the internal attribution of problems. However, this does not mean that the distress of individual women is ignored. It is possible to offer therapeutic support that acknowledges women’s individual life experience, as well as the cultural context within which their distress is constructed and lived, as feminist therapists who adopt a narrative therapy model, often alongside cognitive-behavioural or psycho-dynamic techniques, have demonstrated (e.g. Gremillion, 2004; Lee, 1997; McQuaide, 1999; Ussher et al., 2002). Psychotropic medication, particularly when used alongside



25

therapy, may be beneficial for alleviating some cases of ‘extreme mental turmoil’ (Moncrieff, 2009: 308); however, it is not necessary or appropriate for the ‘problems in everyday living’ (Currie, 2005: 19) that are positioned as depression in pharmaceutical advertising. Finally, it is important to acknowledge that depressed mood or misery is not solely a ‘woman’s problem’, as ‘depression’ is reported by both women and men. The ways in which this phenomenon is manifested and experienced differently across gender is deserving of further investigation. At the same time, unravelling the phenomenon of women’s higher rates of reported depression may provide insights into the nature and aetiology of ‘depression’ per se, as has been previously suggested (Bebbington, 1996; Rutter et al., 2003). However, it also provides insights into the gendered nature of social and familial life, the consequences of inequality and discrimination for women, and gendered patterns in certain aspects of psychological processing that occur within a relational and cultural context. Examining the construction and treatment of depression also provides insights into the cultural construction of what it means to be ‘woman’, where diagnosis with pathology is an ever present spectre, whether we accept or reject archetypal feminine roles.

ACKNOWLEDGEMENTS Thanks are offered to Dave Pilgrim and to three anonymous reviewers for comments on an earlier version of this manuscript, as well as to Nicola Gavey and Janette Perz for comments and ongoing suggestions.

NOTES 1. Thanks are offered to Nicola Gavey for suggesting that I read Currie’s paper. 2. Women outnumber men as examples of ‘patients’ in anti-depressant advertisements at ratios of 5:1–10:0 (Hansen and Osborne, 1995), a gender imbalance that has been implicated in the greater likelihood of physicians providing a formal diagnosis of depression for women’s problems (Munce et al., 2004). 3. I am not examining biomedical theories, as there is no consistent evidence for a simple biological substrate which explains gender differences in depression (Blehar, 2006). 4. Many feminist accounts do, however acknowledge women’s subjective experiences of distress (Lafrance, 2007; Stoppard, 2000).

REFERENCES Abramson, L.Y., Metalsky, G.I. and Alloy, L.B. (1989) ‘Hopelessness Depression: A Theory Based Sub-type of Depression’, Psychological Review 96: 358–72. Alegria, M., Casino, G., Shrout, P.E., Woo, M., Duan, N., Vila, D., Torres, M., Chih-nan, C.


26


and Xiao-Li, M. (2008) ‘Prevalence of Mental Illness in Immigrant and Non-immigrant US’, The American Journal of Psychiatry 165(3): 359–69. Angold, A., Costello, E.J. and Worthman, C.M. (1998) ‘Puberty and Depression: The Roles of Age, Pubertal Status and Pubertal Timing’, Psychological Medicine 28: 51–61. APA (2000) Diagnostic and Statistical Manual of Mental Disorders, Edition IV. Washington, DC: American Psychiatric Association. Ashton, H. (1997) ‘Psychotropic Drug Prescription for Women’, British Journal of Psychiatry 158(suppl. 10): 30–35. Avis, N., Brambilla, D., McKinlay, S.M. and Vass, K. (1994) ‘A Longitudinal Analysis of the Association between Menopause and Depression: Results from the Massachutes Women’s Health Study’, Annals of Epidemiology 4(3): 214–20. Bebbington, P.E. (1996) ‘The Origins of Sex Differences in Depressive Disorder: Bridging the Gap’, International Review of Psychiatry 8(4): 295–332. Bebbington, P.E. (1998) ‘Sex and Depression’, Psychological Medicine 28(1): 1–8. Bebbington, P.E., Dean, C., Der, G., Hurry, J. and Tennant, C. (1991) ‘Gender, Parity and the Prevalence of Minor Affective Disorder’, British Journal of Psychiatry 158: 33–40. Bebbington, P.E., Hurry, J., Tennant, C., Sturt, E. and Wing, J.K. (1981) ‘The Epidemology of Mental Disorders in Camberwell’, Psychological Medicine 11: 561–66. Bebbington, P.E., Brugha, T., Maccarthy, B., Potter, J., Sturt, E. and Wykes, T. (1988) ‘The Camberwell Collaborative Depression Study. I. Depressed Probands: Adversity and the Form of Depression’, British Journal of Psychiatry 152: 754–65. Bebbington, P.E., Dunn, G., Jenkins, R., Lewis, G., Brugha, T., Farrell, M. and Meltzer, H. (1998) ‘The Influence of Age and Sex on the Prevalence of Depression Conditions: Report from the National Survey of Psychiatric Morbidity’, Psychological Medicine 28(1): 9–19. Beck, A.T. (1987) ‘Cognitive Models of Depression’, Journal of Cognitive Psychotherapy: An International Quarterly 1: 5–37. Belle, D. and Doucet, J. (2003) ‘Poverty, Inequality, and Discrimination as Sources of Depression among US Women’, Psychology of Women Quarterly 27: 101–13. Bhaskar, R. (1989) Reclaiming Reality: A Critical Introduction to Contemporary Philosophy. London: Verso. Bifulco, A., Brown, G.W., Moran, P., Ball, C. and Campbell, C. (1998) ‘Predicting Depression in Women: The Role of Past and Present Vulnerability’, Psychological Medicine 28: 39–50. Blanchflower, D. and Oswald, A. (2004) ‘Well-being over Time in Britain and the USA’, Journal of Public Economics 88(7–8): 1359–86. Blehar, M.C. (2006) ‘Women’s Mental Health Research: The Emergence of a Biomedical Field’, Annual Review of Clinical Psychology 2: 135–60. Blum, L.M. and Stracuzzi, N.F. (2004) ‘Gender in the Prozac Nation: Popular Discourse and Productive Femininity’, Gender and Society 18(3): 269–86. Breggin, P.B. and Breggin, G.R. (1991) Toxic Psychiatry: Why Therapy, Empathy and Love must Replace the Drugs, Electroshock and Biochemical Theories of the ‘New Psychiatry’. New York: St. Martins Press. Brooks-Gunn, J. and Warren, M.P. (1989) ‘Biological and Social Contributions to Negative Affect in Young Adolescent Girls’, Child Development 60: 40–55. Brown, C., Abe-Kim, J. and Barrio, C. (2003) ‘Depression in Ethnically Diverse Women: Implications for Treatment in Primary Care Settings’, Professional Psychology: Research and Practice 34(1): 10–19.



27

Brown, G.W. and Harris, T.O. (1978) Social Origins of Depression: A Study of Psychiatric Disorders in Women. London: Tavistock. Brown, G.W. and Harris, T.O. (1989a) ‘Depression’, in G.W. Brown and T.O. Harris (eds) Life Events and Illness, pp. 49–93. New York, NY, US: Guilford Press. Brown, G.W. and Harris, T.O. (eds) (1989b) Life Events and Illness. New York: The Guilford Press. Brown, G.W., Harris, T. O. and Hepworth, C. (1995) ‘Loss, Humiliation and Entrapment among Women Developing Depression: A Patient and Non-patient Comparison’, Psychological Medicine 25: 7–21. Brown, G.W., Andrews, B., Harris, T.O. and Adler, Z. (1986) ‘Social Support, Self-esteem and Depression’, Psychological Medicine 16(4): 813–31. Busfield, J. (2002) Rethinking the Sociology of Mental Illness. London: Blackwell. Byrne, M. and Carr, A. (2000) ‘Depression and Power in Marriage’, Journal of Family Therapy 22: 408–27. Byrne, M., Carr, A. and Clark, M. (2004) ‘Power in Relationships of Women with Depression’, Journal of Family Therapy 26: 407–29. Cabral, M. and Astbury, J. (2000) Women’s Mental Health: An Evidence Based Review. Geneva: World Health Organization. Chen, Y., Subramanian, S.V., Acevedo-Garcia, D. and Kawachi, I. (2005) ‘Women’s Status and Depressive Symptoms: A Mulitlevel Analysis’, Social Science and Medicine 60: 49–60. Chesler, P. (1972) Women and Madness. New York: Doubleday. Chrisler, J.C. (2002) ‘Hormone Hostages: The Cultural Legacy of PMS as a Legal Defence’, in L.H. Collins and M.R. Dunlap (eds) Charting a New Course for Feminist Psychology, pp. 238–252. Westport: Praeger Publishers. Chrisler, J.C. and Caplan, P. (2002) ‘The Strange Case of Dr. Jekyll and Ms. Hyde: How PMS Became a Cultural Phenomenon and a Psychiatric Disorder’, Annual Review of Sex Research 13: 274–306. Chrisler, J.C. and Levy, K.B. (1990) ‘The Media Construct a Menstrual Monster: A Content Analysis of PMS Articles in the Popular Press’, Women and Health 16(2): 89–104. Connolly, C.M. (2005) ‘A Qualitative Exploration of Resilience in Long-term Lesbian Couples’, The Family Journal: Counseling and Therapy for Couples and Families 13(3): 266–80. Connolly, C.M. and Sicola, M.K. (2006) ‘Listening to Lesbian Couples: Communication Competence in Long Term Relationships’, in J.J. Bigner (ed.) An Introduction to GLBT Family Studies, pp. 271–96. New York: Howarth Press. Cooper, M.L., Shaver, P.R. and Collins, N.L. (1998) ‘Attachment Styles, Emotion Regulation and Adjustment in Adolescence’, Journal of Personality and Social Psychology 74: 1380–97. Cortina, L.M. and Kubiak, S.P. (2006) ‘Gender and Post-traumatic Stress: Sexual Violence as an Explanation for Women’s Increased Risk’, Journal of Abnormal Psychology 115(4): 753–9. Cowan, G., Bommersbach, M. and Curtis, S. (1995) ‘Codependency, Loss of Self and Power’, Psychology of Women Quarterly 19: 221–36. Currie, J. (2005) ‘The Marketization of Depression: The Prescribing of SSRI Antidepressants to Women’, Women and Health Protection, accessed 15 July 2009. Available: http:// www.whp-apsf.ca/pdf/SSRIs.pdf Cutler, S.E. and Nolen-Hoeksema, S. (1991) ‘Accounting for Sex Differences in Depression


28


through Female Victimisation: Childhood Sexual Abuse’, Sex Roles 24: 425–38. Cyranowski, J.M., Frank, E., Young, E. and Shear, M.K. (2000) ‘Adolescent Onset of the Gender Difference in Lifetime Rates of Major Depression’, Archives of General Psychiatry 57: 21–7. Dambrun, M. (2007) ‘Gender Differences in Mental Health: The Mediating Role of Perceived Personal Discrimination’, Journal of Applied Social Psychology 37(5): 1118– 29. Dennerstein, L. (1996) ‘Well-being, Symptoms and the Menopausal Transition’, Maturitas 23: 147–57. Desjarlais, R., Eisenberg, L., Good, B. and Kleinman, A. (1996) World Mental Health: Problems and Priorities in Low Income Countries. Oxford: Oxford University Press. Double, D. (2002) ‘The Limits of Psychiatry’, British Medical Journal 324: 900–4. Doyle, L. (1995) What Makes Women Sick? Gender and the Political Economy of Health. New Brunswick: Rutgers University Press. Duarte, L.M. and Thompson, J.M. (1999) ‘Sex-differences in Self-silencing’, Psychological Reports 85: 145–61. Dunn, A., Trivedi, M., Kampers, J. and Clark, C. (2005) ‘Exercise Treatment for Depression Efficacy and Dose Response’, American Journal of Preventative Medicine 28(11): 1–8. Engel, G. (1977) ‘The Need for a New Medical Model: A Challenge for Bio-medicine’, Science 196: 129–36. Fengold, A. (1994) ‘Gender Differences in Personality: A Meta-analysis’, Psychological Bulletin 116: 429–56. Fredrickson, B.L. and Roberts, T.A. (1997) ‘Objectification Theory: Toward Understanding Women’s Lived Experiences and Mental Health Risks’, Psychology of Women Quarterly 21(2): 173–206. Gammell, D.J. and Stoppard, J.M. (1999)’ Women’s Experience of Treatment of Depression: Medicalization or Empowerment?’, Canadian Psychology 40(2): 112–28. Gardner, P. (2003) Distorted Packaging: Marketing Depression as Illness, Drugs as Cure. Journal of Medical Humanities, 24(1/2): 105–30. Gattuso, S., Fullagar, S. and Young, I. (2005) ‘Speaking of Women’s “Nameless Misery”: The Everyday Construction of Depression in Australian women’s magazines’, Social Science and Medicine 61: 1640–8. Gavey, N. (2005) Just Sex? The Cultural Scaffolding of Rape. London: Routledge. Geller, J.L. and Harris, M. (1994) Women of the Asylum. Voices from Behind the Walls 1840–1945. New York: Anchor Books. Goodwin, R. D. and Gotlib, I.H. (2004) ‘Gender Differences in Depression: the Role of Personality Factors’. Psychiatry Research 126: 135–42. Gore, S., Aseltine, R.H. and Colton, M.E. (1992) ‘Social Structure, Life Stress and Depressive Symptoms in a High School Aged Population’, Journal of Health and Social Behaviour 33: 97–113. Gove, W. (1972) ‘Sex, Marital Status, and Mental Illness’, Social Forces 51: 34–55. Gove, W. and Tudor, J. (1973) ‘Adult Sex Roles and Mental Illness’, American Journal of Sociology 78: 812–35. Green, R.J., Bettinger, M. and Zacks, E. (1996) ‘Are Lesbian Couples Fused and Gay Male Couples Disengaged? Questioning Gender Straightjackets’, in J. Laird and R.-J. Green (eds) Lesbians and Gays in Couples and Families: A Handbook for Therapists, pp. 185–230. San Francisco, CA: Jossey Bass. Gremillion, H. (2004) ‘Unpacking Essentialisms in Therapy: Lessons for Feminist



29

Approaches from Narrative Work’. Journal of Constructivist Psychology 17(3): 173– 88. Gunnell, D., Saperia, J. and Ashby, D. (2005) ‘Selective Serotonin Reuptake Inhibitors (SSRIs) and Suicide in Adults: Meta-analysis of Drug Company Data from Placebo Controlled Randomized Controlled Tirals Submitted to MHRA’s Safety Review’, British Medical Journal 330: 385. Gyler, L. (2010) The Gendered Unconscious. London: Routledge. Hamilton, J.A., Grant, M. and Jensvold, M.F. (1996) ‘Sex and Treatment of Depressions: When Does it Matter?’, in J.A. Hamilton, M. Jensvold, E. Rothblum and E. Cole (eds) Psychopharmacology of Women: Sex, Gender and Hormonal Considerations, pp. 241– 60. Washington, DC American Psychiatric Press. Hankin, B.J. and Abramson, L.Y. (2001) ‘Development of Gender Differences in Depression: An Elaborated Cognitive Vulnerability-transactional Stress Theory’, Psychological Bulletin 127(6): 773–96. Hansen, F.J. and Osborne, D. (1995) ‘Portrayal of Women and Elderly Patients in Psychotropic Drug Advertisements’, Women and Therapy 16: 129–41. Hayward, C., Gotlib, I.H., Schraedley, M. A. and Litt, I.F. (1999) ‘Ethnic Differences in the Association between Pubertal Status and Symptoms of Depression in Adolescent Girls’, Journal of Adolescent Health 25: 143–9. Healy, D. (2003) Let Them Eat Prozac. Toronto: James Lorimer. Holmes, J. (2009) ‘All You Need is Cognitive Behaviour Therapy?’, in J. Reynolds, R. Muston, T. Heller, J. Leach, M. McCormick, J. Wallcraft and M. Walsh (eds) Mental Health Still Matters, pp. 311–15. London: Palgrave Macmillan. Jack, D.C. (1991) Silencing the Self: Women and Depression. Cambridge, MA: Harvard University Press. Jack, D.C. and Dill, D. (1992) ‘The Silencing the Self Scale: Schemas of Intimacy with Depression in Women’, Psychology of Women Quarterly 16: 97–106. Jackson-Triche, M.E., Sullivan, J.G., Wells, K.B., Rogers, W., Camp, P. and Mazel, R. (2000) ‘Depression and Health-related Quality of Life in Ethnic Minorities Seeking Care in General Medical Settings’, Journal of Affective Disorders 58: 89–97. Jadhav, S. (1996) ‘The Cultural Origins of Western Depression’, International Journal of Social Psychiatry 42: 269–86. Jose, P.E. and Brown, I. (2008) ‘When Does Gender Difference in Rumination Begin? Gender and Age Differences in the Use of Rumination by Adolescents’, Journal of Youth and Adolescence 37: 180–92. Kaplan, A. (1986) ‘The “Self-in-relation”: Implications for Depression in Women’, Psychotherapy 23: 234–42. Kendall-Tackett, K.A. (2007) ‘Inflammation, Cardiovascular Disease, and Metabolic Syndrome as Sequelae of Violence against Women: The Role of Depression, Hostility and Sleep Disturbance’, Trauma, Violence and Abuse 8(2): 117–26. Kendler, K.S., Bulik, C.M., Silberg, J., Hettema, J.M., Myers, J. K. and Prescott, C.A. (2000) ‘Childhood Sexual Abuse and Adult Psychiatric and Substance Use Disorders in Women’, Archives of General Psychiatry 57: 953–9. Kessler, R.C. (2003) ‘Epidemiology of Women and Depression’, Journal of Affective Disorders 74: 5–13. Kessler, R.C. and Mcleod, J.D. (1984) ‘Sex Differences in Vulnerability to Undesirable Life Events’, American Sociological Review 49: 620–31. Kessler, R.C., McLeod, J.D. and Wethington, E. (1985) ‘The Costs of Caring: A Perspective


30


on the Relationship between Sex and Psychological Distress’, in I.G. Sarason and B. Sarason (eds) Social Support: Theory, Research and Applications, pp. 491–506. Boston, MA: Martinus Nijhoff. Kessler, R.C., McGonagle, K.A., Swartz, M., Blazer, D.G. and Nelson, C.B. (1993) ‘Sex and Depression in the National Comorbidity Survey I: Lifetime Prevalence, Chronicity and Recurrence’, Journal of Affective Disorders 29: 85–96. Kessler, R.C., McGonagle, K.A., Zhao, S., Nelson, C.B., Hughes, M. and Eshleman, S. (1994) ‘Lifetime and 12-month Prevalence of DSM-II-R Psychiatric Disorders in the United States: Results from the National Co-morbidity Survey’, Archives of General Psychiatry 5(1): 8–19. Kirk, S. and Kutchins, H. (1992) The Selling of DSM: The Rhetoric of Science in Psychiatry. New York: A. de Gruyter. Klonoff, E.A., Landrine, H. and Campbell, R. (2000) ‘Sexist Discrimination may Account for Well-known Gender Differences in Psychiatric Symptoms’, Psychology of Women Quarterly 24: 93–9. Koepke, L., Hare, J. and Moran, P. (1992) ‘Relationship Quality in a Sample of Lesbian Couples with Children and Child-free Couples’, Family Relations 41: 224–29. Koss, M.P., Bailey, J.A., Yuan, N.P., Herrera, V.M. and Lichter, E.L. (2003) ‘Depression and PTSD in Survivors of Male Violence: Research and Training Initiatives to Facilitate Recovery’, Psychology of Women Quarterly 27: 130–42. Kostanski, M. and Gullone, E. (1998) ‘Adolescent Body Image Dissatisfaction: Relationships with Self-esteem, Anxiety, and Depression Controlling for Body Mass’, Journal of Child Psychology and Psychiatry 39: 255–62. Kramer, P. (1993) Listening to Prozac: A Psychiatrist Explores Antidepressant Drugs and the Remaking of the Self. New York: Viking Penguin. Kuehner, C. (2003) ‘Gender Differences in Unipolar Depression: An Update of Epidemiological Findings and Possible Explanations’, Acta Psychiatr Scand 108: 163– 74. Kurdek, L.A. (2003) ‘Differences between Gay and Lesbian Cohabiting Couples’, Journal of Social and Personal Relationships 20: 411–36. Kurdek, L.A. (2004a) ‘Are Gay and Lesbian Cohabiting Couples Really Different from Heterosexual Married Couples?’, Journal of Marriage and Family 66: 880–900. Kurdek, L.A. (2004b) ‘Gay Men and Lesbians: The Family Context’, in M. Coleman and L.H. Ganong (eds) Handbook of Contemporary Families: Considering the Past, Contemplating the Future, pp. 96–105. Thousand Oaks, CA: Sage. Kutchins, H. and Kirk, S. (1997) Making Us Crazy: DSM: The Psychiatric Bible and the Creation of Mental Disorders. New York Free Press. Lafrance, M.N. (2007) ‘A bitter pill: A discursive analysis of Women’s Medicalized Accounts of Depression’, Journal of Health Psychology, 12(1): 127–40. Lafrance, M.N. (2009) Women and Depression: Recovery and Resistance. London/New York: Routledge. Lafrance, M.N. and Stoppard, J.M. (2007) ‘Re-storying Women’s Depression: A Materialdiscursive Approach’, in C. Brown and T. Augusta-Scott (eds) Narrative Therapy: Making Meaning, Making Lives, pp. 23–37. Thousand Oaks, CA: Sage. Lee, J. (1997) ‘Women Re-authoring their Lives through Feminist Narrative Therapy’, Women and Therapy 20(3): 1–22. Liebert, R. and Gavey, N. (2008) ‘“I Didn’t Just Cross a Line I Tripped over an Edge”: Experiences of Serious Adverse Side Effects with Selective Serotonin Reuptake Inhibitor



31

Use’, New Zealand Journal of Psychiatry 37(1): 38–48. Littlewood, R. and Lipsedge, M. (1982) Aliens and Alienists: Ethnic Minorities and Psychiatry. Harmondsworth: Penguin. Maier, W., Gansicke, M., Gater, R., Rezaki, M., Tiemens, B. and Urzula, R.F. (1999) ‘Gender Differences in the Prevalence of Depression: A Survey in Primary Care’, Journal of Affective Disorders 53: 241–52. Marecek, J. (2006)’ Social Suffering, Gender, and Women’s Depression’, in C.L. Keyes and S.H. Goodman (eds) Women and Depression: A Handbook for the Social, Behavioral and Biomedical Sciences, pp. 283–308. Cambridge: Cambridge University Press. Marsella, A. (1981) ‘Depressive Experience and Disorder across Cultures’, in H. Triadis and J. Draguns (eds) Handbook of Cross Cultural Psychiatry, pp. 237–89. Boston, MA: Allyn and Bacon. Mauthner, N. (1999) ‘Feeling Low and Feeling Really Bad about Feeling Low: Women’s Experience of Motherhood and Post-partum Depression’, Canadian Psychology 40(2): 143–61. McPherson, S. and Armstrong, D. (2006) ‘Social Determinants of Diagnostic Labels in Depression’, Social Science & Medicine 62(1): 50–8. McQuaide, S. (1998) ‘Women at Midlife’, Social Work, 43(1): 21–31. McQuaide, S. (1999) ‘Using Psychodynamic, Cognitive-behavioral, and Solution-focused Questioning to Co-construct a New Narrative’, Clinical Social Work Journal 27(4): 339–53. Meltzer, H., Gill, B., Petticrew, M. and Hinds, K. (1995) The Prevalence of Psychiatric Morbidity among Adults Living in Private Households, OPCS survey of psychiatric morbidity in Great Britain, Report 1. London: HMSO. Mencher, J. (1990) Intimacy in Lesbian Relationships: A Critical Re-examination of Fusion, Work in Progress No 42. Wellesley, MA: Wellesley College, Stone Center for Women’s Development. Metz, M.E., Rosser, B.R.R. and Strapko, N. (1994) ‘Differences in Conflict-resolution Styles among Heterosexual, Gay, and Lesbian Couples’, The Journal of Sex Research 31(4): 293–308. Metzl, J.M. (2003) Prozac on the Couch: Prescribing Gender in the Era of Wonder Drugs. Durham, NC: Duke University Press. Metzl, J.M. and Angel, J. (2004) ‘Assessing the Impact of SSRI Antidepressants on Popular Notions of Women’s Depressive Illness’, Social Science and Medicine 58: 577–84. Miller, S.M. and Kirsch, N. (1987) ‘Sex Differences in Cognitive Coping with Stress’, in R.C. Barnett, L. Biener and G.K. Baruch (eds) Gender and Stress, pp. 278–307. New York: Free Press. Molnar, B.E., Buka, S.L. and Kessler, R.C. (2001) ‘Child Sexual Abuse and Subsequent Pathology: Results from the National Comorbidity Survey’, American Journal of Public Health 91(5): 753–60. Moncrieff, J. (2009) ‘Deconstructing Psychiatric Treatment’, in J. Reynolds, R. Muston, T. Heller, J. Leach, M. McCormick, J. Wallcraft and M. Walsh (eds) Mental Health Still Matters, pp. 301 –309. London: Palgrave Macmillan. Moncrieff, J. and Kirsch, I. (2005) ‘Efficacy of Anti-depressants in Adults’, British Medical Journal 331: 155–7. Moynihan, R., Heath, I. and Henry, D. (2002) ‘Selling Sickness: The Pharmaceutical Industry and Disease Mongering’, British Medical Journal, 324: 886–90. Munce, S., Robertson, E.P., Sansom, E.K. and Stewart, D.E. (2004) ‘Who is Portrayed in


32


Psychotropic Drug Advertisements?’, Journal of Nervous and Mental Disease, 192(4): 284–8. Nazroo, J.Y., Edwards, A.C. and Brown, G.W. (1998) ‘Gender Differences in the Prevalence of Depression: Artefact, Alternative Disorders, Biology or Roles?’, Sociology of Health and Illness 20(3): 312–30. Nicolson, P. (1998) ‘Post-natal Depression: Psychology, Science and the Transition to Motherhood. London: Routledge. Nightingale, D.J. and Cromby, J. (1999) Social Constructionist Psychology: A Critical Analysis of Theory and Practice. Buckingham: Open University Press. Nolen-Hoeksema, S. and Girgus, J.S. (1994) ‘The Emergence of Gender Differences in Depression during Adolescence’, Psychological Bulletin 115: 424–43. Nolen-Hoeksema, S. and Jackson, B. (2001) ‘Mediators of the Gender Difference in Rumination’, Psychology of Women Quarterly 25: 37–47. Nolen-Hoeksema, S., Larson, J. and Grayson, C. (1999) ‘Explaining the Gender Difference in Depressive Symptoms’, Journal of Personality and Social Psychology 77(5): 1061– 72. Penfold, S. and Walker, G. (1984) Women and the Psychiatric Paradox. Milton Keynes: Open University Press. Perkins, R. (1991) ‘Therapy for Lesbians? The Case Against’, Feminism and Psychology 1(3): 325–38. Perugi, G., Musetti, L., Simonini, E., Piagentini, F., Cassano, G. B. and Akiskal, H.S. (1990) ‘Gender Mediated Clinical Features of Depressive Illness: The Importance of Temperamental Differences’, British Journal of Psychiatry 157: 435–41. Perz, J. and Ussher, J.M. (2008) ‘The Horror of this Living Decay: Women’s Negotiation and Resistance of Medical Discourses around Menopause and Midlife’, Women’s Studies International Forum 31: 293–9. Perz, J. and Ussher, J.M. (2009) ‘Connectedness, Communication and Reciprocity in Lesbian Relationships: Implications for Women’s Construction and Experience of PMS’, in P. Hammock and B.J. Cohler (eds) Life Course and Sexual identity: Narrative Perspectives on Gay and Lesbian Identity, pp. 223–50. Oxford: Oxford University Press. Peterson, A.C., Sarigiani, P. A. and Kennedy, R.E. (1991) ‘Adolescent Depression: Why More Girls?’, Journal of Youth and Adolescence 20: 247–71. Pezzini, S. (2005) ‘The Effect of Women’s Rights on Women’s Welfare: Evidence From a Natural Experiment’, The Economic Journal 115: C208–27. Pilgrim, D. (2007) ‘The Survival of Psychiatric Diagnosis’, Social Science & Medicine 65: 536–47. Pilgrim, D. and Bentall, R.P. (1999) ‘The Medicatisation of Misery: A Critical Realist Analysis of the Concept of Depression’, Journal of Mental Health 8(3): 261–74. Pilgrim, D. and Rogers, A. (2005) ‘The Troubled Relationship between Psychiatry and Sociology’, International Journal of Social Psychiatry 51(3): 228–41. Pomerantz, E.M. and Ruble, D.N. (1998) ‘The Role of Maternal Control in the Development of Sex Differences in Child-self-evaluative Factors’, Child Development 69: 458–78. Potts, M.K., Burnam, M.A. and Wells, K.B. (1991) ‘Gender Differences in Depression Detection: A Comparison of Clinician Diagnosis and Standardized Assessment’, Psychological Assessment: A Journal of Consulting and Clinical Psychology 3(4): 609– 15. Price, J.S. (1991) ‘Change or Homeostatsis? A Systems Theory Approach to Depression’,



33

British Journal of Medical Psychology 64: 3331–44. Remen, A.L., Chambless, D.L. and Rodebaugh, T.L. (2002) ‘Gender Differences in the Construct Validity of the Silencing the Self Scale’, Psychology of Women Quarterly 26: 151–9. Rittenhouse, C.A. (1991) ‘The Emergence of Premenstrual Syndrome as a Social Problem’, Social Problems 38(3): 412–25. Rutter, M., Caspi, A. and Moffit, T.E. (2003) ‘Using Sex Differences in Psycho-pathology to Study Causal Mechanisms: Unifying Issues and Research Strategies’, Journal of Child Psychology and Psychiatry 44: 1092–115. Sachs-Ericsson, N. and Ciarlo, J.A. (2000) ‘Gender, Social Roles and Mental Health: An Epidemiological Perspective’, Sex Roles 43(9/10): 605–28. Salokangas, R.K. R., Vaahtera, K., Pacriev, S., Sohlman, B. and Lehtinen, V. (2002) ‘Gender Differences in Depressive Symptoms: An Artefact Caused by Measurement Instruments’, Journal of Affective Disorders 68: 215–20. Sayer, A. (2000) Realism and Social Science. London: Sage. Sayers, J. (1982) Biological Politics: Feminist and Anti-Feminist Perspectives. London: Tavistock. Seaman, M.V. (1997) ‘Psychopathology in Women and Men: Focus on Female Hormones’, American Journal of Psychiatry 154(12): 1641–7. Sherman, J.A. (1980) ‘Therapist Attitudes and Sex Role Stereotyping’, in A.M. Brodsky and R.T. Hare-Mustin (eds) Women and Psycho-therapy¸ pp. 35–66. New York: Guilford. Shorter, E. (1997) A History of Psychiatry. New York: Wiley. Sirianni, C. and Negrey, C. (2000) ‘Working Time as Gendered Time’, Feminist Economics 6(1): 59–76. Speer, S. (2000) ‘Let’s Get Real? Feminism, Constructivism and the Realism/Relativism Debate’, Feminism and Psychology 10(4): 519–30. Steiner, M. and Born, L. (2000) ‘Diagnosis and Treatment of Premenstrual Dysphoric Disorder: An Update’, International Clinical Psychopharmacology15(suppl. 3): 5–17. Stoppard, J.M. (1989) ‘An Evaluation of the Adequacy of Cognitive/Behavioural Theories for the Understanding of Depression in Women’, Canadian Psychology 30(1): 39–47. Stoppard, J.M (1999) ‘Why New Perspectives are Needed for Understanding Depression in Women’, Canadian Psychology, 40(2): 79–90. Stoppard, J.M. (2000) Understanding Depression: Feminist Social Constructionist Approaches. London: Routledge. Stoppard, J.M. and McMullen, L.M. (2003) Situating Sadness: Women and Depression in Social Context. New York: New York University Press. Studd, J. (1997) ‘Depression and the Menopause’, British Medical Journal 314: 977. Tamres, L.K., Janicki, D. and Helgeson, V.S. (2002) ‘Sex Differences in Coping Behavior: A Meta-analytic Review and an Examination of Relative Coping’, Personality and Social Psychology Review 6(1): 2–30. Thompson, J.M. (1995) ‘Silencing the Self: Depressive Symptomatology in Close Relationships’, Psychology of Women Quarterly 19: 337–53. Treichler, P. (1992) ‘AIDS, HIV and the Cultural Construction of reality’, in G. Herdt and S. Linderman (eds) The Time of AIDS: Social Analysis, Theory and Method, pp. 65–98. Newbury Park, CA: Sage. Turner, R.J. and Avison, W.R. (1989) ‘Gender and Depression: Assessing Exposure and Vulnerability to Life Events in a Chronically Strained Population’, The Journal of Nervous and Mental Disease 177(8): 443–5.


34


Turner, R.J. and Lloyd, D.A. (1995) ‘Lifetime Tramuas and Mental Health: The Significance of Cumulative Adversity’, Journal of Health and Social Behaviour 36(4): 360–76. Ussher, J.M. (1989) The Psychology of the Female Body. London/New York: Taylor and Francis/Routledge. Ussher, J.M. (1991) Women’s Madness: Misogyny or Mental Illness? Amherst, MA: University of Massachusetts Press. Ussher, J.M. (1997) Body Talk: The Material and Discursive Regulation of Sexuality, Madness and Reproduction. London: Routledge. Ussher, J.M. (2000) ‘Women’s Madness: A Material-Discursive-Intra psychic Approach’, in D. Fee (ed.) Psychology and the Postmodern: Mental Illness as Discourse and Experience, pp. 207–30. London: Sage. Ussher, J.M. (2003a) ‘The Ongoing Silencing of Women in Families: An Analysis and Rethinking of Premenstrual Syndrome and Therapy’, Journal of Family Therapy 25: 388–405. Ussher, J.M. (2003b) ‘The Role of Premenstrual Dysphoric Disorder in the Subjectification of Women’, Journal of Medical Humanities 24(1/2): 131–46. Ussher, J.M. (2004a) ‘Blaming the Body for Distress: Premenstrual Dysphoric Disorder and the Subjectification of Women’, in A. Potts, N. Gavey and A. Wetherall (eds) Sex and The Body, pp. 183–202. Palmerstone North, NZ: Dunmore Press. Ussher, J.M. (2004b) ‘Premenstrual Syndrome and Self-policing: Ruptures in SelfSilencing Leading to Increased Self-Surveillance and Blaming of the Body’, Social Theory & Health 2(3): 254–72. Ussher, J.M. (2006) Managing the Monstrous Feminine: Regulating the Reproductive Body. London: Routledge. Ussher, J.M. (2008) ‘Challenging the Positioning of Premenstrual Change as PMS: The Impact of a Psychological Intervention on Women’s Self-Policing’, Qualitative Research in Psychology 5(1): 33–44. Ussher, J.M. and Perz, J. (2008) ‘Empathy, Egalitarianism and Emotion Work in the Relational Negotiation of PMS: The Experience of Lesbian Couples’, Feminism and Psychology 18(1): 87–111. Ussher, J.M. and Perz, J. (2010) ‘Disruption of the Silenced-Self: The Case of Pre-Menstrual Syndrome’, in D.C. Jack and A. Ali (eds) The Depression Epidemic: International Perspectives on Women’s Self-silencing and Psychological Distress. Oxford: Oxford University Press. Ussher, J.M., Hunter, M. and Cariss, M. (2002) ‘A Woman-centred Psychological Intervention for Premenstrual Symptoms, Drawing on Cognitive-behavioural and Narrative Therapy’, Clinical Psychology and Psychotherapy 9: 319–31. Vine, S. and Kindersley, T. (2009) Backwards in High Heels: The Impossible Art of Being Female. London: Fourth Estate. Weissman, M.M., Bland, R.C. and Canino, G.J. (1996) ‘Cross National Epidemiology of Major Depression and Bipolar Disorder’, JAMA 276: 293–29. Weissman, M.M., Leaf, P.J., Holzer, C.E., Myers, J.K. and Tischler, G.L. (1984) ‘The Epidemiology of Depression: An Update on Sex Differences in Rates’, Journal of Affective Disorders 7: 179–88. Whiffen, V.E. and Foot, M.L. (2007) ‘Self-silencing Mediates the Link between Marital Conflict and Depression’, Journal of Social and Personal Relationships 24(6): 993– 1006. Whisman, M.A. and Bruce, M.L. (1999) ‘Marital Distress and Incidence of Major



35

Depressive Episode in a Community Sample’, Journal of Abnormal Psychology 108: 674–8. Williams, J.M.G. (1992) The Psychological Treatment of Depression. London: Routledge. Williams, S. (2003) ‘Beyond Meaning, Discourse and the Empirical World: Critical Realist Reflections on Health’, Social Theory & Health 1: 42–7. World Health Organization (2000) Women’s Mental Health: An Evidence Based Review. Geneva: World Health Organization.

Jane M. USSHER is Professor of Women’s Health Psychology, and Director of the Gender Culture and Health Research Unit: PsyHealth, at the University of Western Sydney, Australia. Her current research focuses on women’s sexual and reproductive health, with particular emphasis on premenstrual experiences, sexuality and cancer, and gendered issues in caring. She is author of a number of books, including The Psychology of the Female Body (Routledge, 1980), Women’s Madness: Misogyny or Mental Illness? (Harvester Wheatsheaf, 1991), Fantasies of Femininity: Reframing the Boundaries of Sex’ (Penguin, 1997), and Managing the Monstrous Feminine: Regulating the Reproductive Body (Routledge, 2006). A further development of the arguments in this paper will appear in her book The Madness of Women: Myth and Experience, to be published by Routledge next year. ADDRESS: School of Psychology, University of Western Sydney, Locked Bag 1797, Penrith South DC, NSW 1797, Australia. [email: [email protected]]
