Cross-National Associations Between Gender and Mental Disorders in the World Health Organization World Mental Health Surveys

TLDR: In this article, the authors provide a more direct test of the gender roles hypothesis by analyzing community epidemiological data collected from respondents surveyed in 15 countries as part of the World Health Organization (WHO) World Mental Health (WMH) Survey Initiative.

Abstract: Epidemiological surveys have consistently documented significantly higher rates of anxiety and mood disorders among women than men1, 2 and significantly higher rates of externalizing and substance use disorders among men than women.3–5 Although a number of biological, psychosocial, and biopsychosocial hypotheses have been proposed to account for these patterns,6–8 evidence that gender differences in depression9, 10 and substance use11–13 have narrowed in a number of countries has led to a special interest in the “gender roles” hypothesis. The latter asserts that gender differences in the prevalence of mental disorders are due to differences in the typical stressors, coping resources, and opportunity structures for expressing psychological distress made available differentially to women and men in different countries at different points in history.14, 15 Consistent with this hypothesis, evidence of decreasing gender differences in depression and substance use has been found largely in countries where the roles of women have improved in terms of opportunities for employment, access to birth control, and other indicators of increasing gender role equality, while trend studies in countries where gender roles have been more static11, 16 or over periods of historical time when gender role changes have been small17 have failed to document a reduction in gender differences in depression or substance use. Most research aimed at investigating the gender roles hypothesis has focused on individual-level variation in roles in a single country at a single point in time.18–20 This approach is limited in three ways. First, selection bias into roles due to pre-existing mental illness (e.g., women with agoraphobia having a higher probability than other women of becoming homemakers rather than seeking employment outside the home) confounds attempts to evaluate the causal effects of gender roles. Second, gender differences are largely confined to differences in lifetime risk, with much less evidence for gender differences in recent prevalence among lifetime cases.21 This means that investigation of the determinants of gender difference should focus on lifetime first onset rather than on the recent prevalence that has been the focus of most studies. Third, as the gender roles hypothesis is a hypothesis about the effects of social context, a rigorous test of the hypothesis requires an analysis of societal-level time-space variation rather than analysis of the individual-level variation that has been the focus of most studies. A small number of cross-national comparative studies have examined spatial variation in gender differences in depression22 and alcohol abuse13 at a point in time or, more rarely, at two points in time.11 Although these studies raised the possibility that gender roles might be associated with variation in the magnitude of gender differences in these outcomes, they were unable to test this hypothesis due to the small number of cross-sectional country-level observations included in the analyses. The current report provides a more direct test of the gender roles hypothesis by analyzing community epidemiological data collected from respondents surveyed in 15 countries as part of the World Health Organization (WHO) World Mental Health (WMH) Survey Initiative.21 Previous cross-national comparisons of gender differences in mental illness focused on cross-sectional differences. We, in comparison, use retrospective reports obtained in the WMH surveys about lifetime occurrence and age-of-onset of mental disorders in different birth cohorts to study time-space variation in lifetime risk. Specifically, we examine both variation across cohorts within a single country (i.e., temporal variation) and variation across countries within a single cohort (i.e., special variation) in lifetime risk of mental disorders as a function of time-space variation in the traditionality of gender roles. Lifetime risk is the focus rather than recent prevalence even though accuracy of reporting is doubtlessly better for recent episodes than lifetime occurrence in order to address the fact that gender differences in lifetime risk are much more robust than gender differences in current prevalence among lifetime cases