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Depression, gender, and the treatment gap in Mexico

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Journal of Affective Disorders 138 (2012) 165–169

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Brief report

Depression, gender, and the treatment gap in Mexico

Claudia Rafful, María Elena Medina-Mora ⁎, Guilherme Borges, Corina Benjet, Ricardo Orozco
National Institute of Psychiatry, Calzada México Xochimilco No 101-Col. San Lorenzo Huipulco, México D.F., C.P. 14370, Mexico City, Mexico

a r t i c l e i n f o a b s t r a c t

Article history: Background: Gender is associated to lifetime risk of mood disorders, women having the high-
Received 5 October 2011 est lifetime and 12-month prevalence. In Mexico one out of five individuals with any mood dis-
Received in revised form 18 November 2011 order receives treatment during the first year. We evaluate the ages at which women and men
Accepted 14 December 2011 are more vulnerable for the first onset of a major depressive episode, the longest duration and
Available online 14 February 2012
greatest number of episodes, the areas of daily functioning most affected, and which variables
predict whether or not a person receives any kind of treatment.
Keywords: Methods: The Mexican National Comorbidity Survey, as part of the World Mental Health Sur-
Depression veys Initiative, is based on a stratified, multistage area probability Mexican urban household
Gender
sample aged 18 to 65 (n = 5782). Wald X2 tests were performed to evaluate gender and cohort
Treatment gap
differences; logistic regression models were performed to evaluate gender and cohort as treat-
CIDI
ment predictors.
Results: The most vulnerable group is the cohort of 45–54 year-old women. Once a first episode
occurs, there are no sex differences in terms of number or length of episodes. There is a gap in
service use, especially among 18–29 year-old women; the oldest women are the most im-
paired.
Limitations: Individuals from rural communities are not represented and there may have been
recall bias due to the retrospective design.
Conclusions: Efforts should focus on factors related to the first onset episode and on early treat-
ment programs to reduce the risk of subsequent episodes. Research and health resources
should attend to the most vulnerable group, and the youngest women, who are in the repro-
ductive age and have the largest treatment gap.
© 2011 Elsevier B.V. All rights reserved.

1. Introduction unemployment, the need of medicines, and other medical

Mood disorders are the most prevalent mental disorders;
between 3.3% and 21.4% of the world population suffer from
them (Kessler et al., 2007). In Mexico, the reported lifetime
prevalence of any mood disorder is 9.2% (Medina-Mora et
al., 2007) and in the last 12 months 4.8% (Medina-Mora et
al., 2005a). According to the World Health Organization
(WHO, 2008), approximately 56% of the people suffering
from depression worldwide do not receive any treatment.
Lack of treatment for mood disorders is especially critical
given the impairment associated with these disorders.
Mood disorders are a major contribution to the total burden
of disease and economic burden, which includes
⁎ Corresponding author. Tel.: + 52 55 56 55 01 85.
E-mail address: medinam@imp.edu.mx (M.E. Medina-Mora).
and social services (WHO, 2008).
In Mexico, 70% of those with any mood disorder have re-
ceived any kind of treatment (Wang et al., 2007); and only
16% received services in the same year that the symptoms
started (Medina-Mora et al., 2009; Wang et al., 2007). The
duration of delay in treatment has been estimated to be
14 years (Wang et al., 2007). In order to close the treatment
gap that exists among the Mexican population, it is important
to identify the population groups that are most vulnerable to
depression and least likely to seek services.
To date, there has not been a detailed analysis of how the
prevalence of major depressive episode (MDE) is distributed
among the Mexican population, the disability associated with
the disorder, or the treatment needs. Since it is already
known that women have a higher prevalence of mood disor-
ders than men (Caraveo-Anduaga et al., 1996; Medina-Mora

0165-0327/$ – see front matter © 2011 Elsevier B.V. All rights reserved.
doi:10.1016/j.jad.2011.12.040
 Author's personal copy
166 C. Rafful et al. / Journal of Affective Disorders 138 (2012) 165–169
et al., 2005a, 2007), we specifically aim to identify the ages at
which women and men are most vulnerable for the first
onset of MDE, longer duration of episodes and greater num-
ber of episodes. In addition, we also want to identify the
areas of daily life (such as household or work activities)
that are most affected by MDE, and which variables may pre-
dict whether or not a person gets any kind of treatment.
2. Methods
2.1. Sample and procedure
The Mexican National Comorbidity Survey was based on a
stratified, multistage area probability sample of persons aged
18–65 in the non-institutionalized population living in urban
areas (population ≥ 2500) of Mexico, which represents 75% of
the Mexican population. All recruitment and consent proce-
dures were approved by the Internal Review Board of the Na-
tional Institute of Psychiatry. The response rate was 76.6%
(n = 5826) of eligible respondents and within the scope of
other surveys from the World Mental Health Initiative
(45.9–87.7% response rate range) (Kessler et al., 2007). De-
tails of the survey and procedure are provided elsewhere
(Medina-Mora et al., 2007).
2.2. Instruments
MDE was assessed with the WHO World Mental Health
Survey Initiative version of the CIDI (WMH-CIDI) (Kessler
and Üstün, 2004). For this paper, we report on the lifetime
and 12-month prevalence of MDE and treatment for MDE.
Participants were screened for the presence of MDE symp-
toms; those that answered positive to any of the 3 screening
questions were asked the CIDI Depression section. MDE was
assessed according to DSM-IV criteria. Participants were
also asked whether they had ever in their life talked to or
consulted a medical doctor or other professional about their
emotional problems. Respondents who reported that they
had talked to a professional were then asked how old they
were the first time they did so. Responses to this question
were used to define ages of first treatment contact.
The Sheehan Disability Scales (SDS; (Sheehan et al.,
1996)) were used to assess functional impairment due to
major depressive episode. The self-report Likert scales mea-
sure impairment in close relations, home, work, and social
life on a scale ranging from 0 (no impairment) to 10 (severe
impairment). Respondents were also asked to estimate the
total number of days in the past 12 months when they were
unable to work or to carry out any of the normal daily activ-
ities because of the MDE.
2.3. Data analysis
As a result of a complex sample design and weighting
explained elsewhere (Kessler et al., 2007; Medina-Mora et
al., 2005a), multivariate significance tests were based on
Wald X 2 tests computed from design-based coefficient vari-
ance–covariance matrices and the estimates of standard er-
rors for proportions were obtained by the Taylor series
linearization method using the SUDAAN software (Research
Triangle Institute, 2002). Age of onset was estimated using
a two-part actuarial method implemented in SAS 8.2 (SAS
Institute, 2001). Treatment predictors were examined using
logistic regression models. Significance tests were all evaluat-
ed at the 0.05 level with two-sided tests.
3. Results
3.1. Prevalence and course
Women had a higher lifetime prevalence of MDE than men
(Table 1). The highest estimates for women were for those
aged 45 to 54 while for men the highest estimates were for
those over 55. The lowest prevalence among women was for
those aged 18 to 29 and among men, though not significant,
was for those aged 30 to 44. Among individuals that reported
lifetime prevalence, close to 10% also reported a MDE in the
previous year. For the 12-month conditional prevalence, the
difference between men and women was only significant for
the 30 to 44 year old cohort and the total population. The high-
est conditional 12-month prevalence among men and women
was for those over 55 and the lowest for the youngest
women and for men aged 30 to 44 (not significant).
The mean age of onset of MDE was close to 27 years of age
with no gender differences. Women in the oldest cohort had
a longer duration of episodes than the young ones. The mean
length of episode was 4.5 years for females and 3.9 years for
males. With regards to the number of lifetime episodes,
there was a significant sex difference for the 45 to 54 year
old cohort, women having had more episodes than men.
Among women, there was a significant cohort difference,
such that women over 55 years of age had a greater number
of episodes than the younger.
3.2. Functional impairment
Household and work activities, and days out of role, were
the only impairment indicators that showed significant re-
sults. For household activities, women aged 30 to 44 were
significantly more impaired than men of the same age
(X 21 = 4.2; p b 0.05). Though not significant, 45 to 54 year
old men and women were the most impaired of the whole
sample. In the work domain, there was a significant cohort
difference among women, the 45 to 54 year olds being the
most impaired (X 23 = 8.9; p b 0.05). For men, significant dif-
ferences between cohorts were found for the number of
days out of role due to a MDE; once again, the oldest men
were the most impaired (X 23 = 8.0; p b 0.05) (data not
shown on tables but available upon request).
3.3. Treatment
We also analyzed the predictors of any treatment for de-
pression in the last 12 months among the respondents with
12-month MDE (Table 2). Only 28.85% of women and 36.7%
of men had received treatment. The biggest treatment differ-
ence between sexes was found in the youngest cohort (18 to
29 years old); a significantly less proportion of women re-
ceived treatment in the last 12 months (OR = 0.3; CI = 0.1–
0.9; X 21 = 4.9; p b 0.05). In addition, we found a significant
difference across the age groups in women with the youngest
women less likely to receive treatment (X 23 = 8.2; p b 0.05).
 Author's personal copy

C. Rafful et al. / Journal of Affective Disorders 138 (2012) 165–169 167

Table 1
Lifetime, 12-month prevalence and course of major depressive episode by sex and cohort. Mexican National Comorbidity Survey, 2002.

Cohorts Total Women Men X²

(df = 1)
N %/mean (SE) N %/mean (SE) N %/ mean (SE)

Lifetime prevalence
18–29 2060 7.1 (0.8) 1218 8.6 (1.0) 842 5.4 (1.0) 7.4⁎
30–44 2236 7.8 (0.7) 1384 10.6 (1.0) 852 4.7 (0.8) 30.6⁎
45–54 840 9.8 (1.2) 489 13.1 (1.6) 351 6.0 (1.6) 11.3⁎
55 + 646 9.7 (1.4) 406 12.4 (2.3) 240 6.6 (1.7) 4.1⁎
All ages 5782 8.0 (0.5) 3497 10.4 (0.7) 2285 5.4 (0.6) 50.8⁎
X2 (df = 3) 8.4⁎ 10.5⁎ 2.2
12-month prevalence among lifetime
18–29 166 9.0 (1.1) 118 10.1 (1.5) 48 7.4 (1.6) 1.7
30–44 201 9.5 (1.0) 160 11.6 (1.3) 41 6.6 (1.7) 5.9⁎
45–54 91 11.1 (2.0) 73 12.9 (2.6) 18 8.0 (3.3) 1.3
55 + 73 12.4 (2.0) 58 13.3 (2.8) 15 11.2 (3.8) 0.2
All ages 531 9.8 (0.8) 409 11.4 (0.9) 122 7.6 (1.1) 9.5⁎
X2 (df = 3) 4.1 1.8 1.6
Mean age of onset
18–29 166 18.1 (0.5) 118 17.9 (0.6) 48 18.5 (0.8) 0.3
30–44 201 26.2 (0.7) 160 26.1 (0.9) 41 26.2 (1.8) b0.01
45–54 91 33.9 (1.7) 73 32.9 (2.0) 18 36.3 (3.0) 0.8
55 + 73 41.8 (2.8) 58 41.1 (2.6) 15 43.2 (4.3) 0.4
All ages 531 26.6 (0.6) 409 26.4 (0.8) 122 26.8 (1.2) 0.1
3 df 212.8⁎ 153.9⁎ 73.3⁎
Mean number of years in episode
18–29 166 3.0 (0.3) 118 3.1 (0.3) 48 2.6 (0.5) 0.8
30–44 201 3.9 (0.4) 160 4.1 (0.6) 41 3.5 (0.7) 0.3
45–54 91 5.4 (1.1) 73 6.2 (1.4) 18 3.4 (1.0) 2.7
55 + 73 7.6 (1.6) 58 6.8 (1.4) 15 9.3 (4.6) 0.3
All ages 531 4.3 (0.3) 409 4.5 (0.4) 122 3.9 (0.7) 0.5
3 df 14.1⁎ 14.7⁎ 3.1
Mean number of lifetime episodes
18–29 166 4.9 (0.8) 118 4.7 (0.9) 48 5.3 (1.6) 0.1
30–44 201 12.4 (3.3) 160 12.3 (4.0) 41 12.6 (6.1) b0.01
45–54 91 8.9 (2.3) 73 10.5 (2.4) 18 4.9 (2.5) 7.3⁎
55 + 73 21.3 (6.7) 58 18.3 (7.2) 15 27.4 (12.5) 0.4
All ages 531 10.2 (1.7) 409 10.2 (1.9) 122 10.3 (3.2) b0.01
3 df 9.2⁎ 9.3⁎ 3.3

Frequencies non-weighted; percentages weighted. Mexican National Comorbidity Survey, 2002.

⁎ Significance at p b 0.05.

4. Discussion
Consistent with previous publications (Caraveo-Anduaga
et al., 1996; Hopcroft, 2007; Medina-Mora et al., 2007), we
found that women had a higher lifetime prevalence of MDE
than men in all age groups. However, our findings differ
from international surveys that have reported gender differ-
ences to be more evident in the older than younger popula-
tion (Seedat et al., 2009); we found that in the Mexican
population the older men and women have more similar

Table 2
Predictors of 12-month treatment among 12-month MDE. Mexican National Comorbidity Survey, 2002.

Cohorts Women Men X2

%a ORb (CI) %a ORb (CI) (df = 1)

18–29 15.7 0.3 (0.1–0.9)⁎ 37.8 1.0 (1.0–1.0) 4.9⁎

30–44 31.4 0.9 (0.2–3.2) 34.4 1.0 (1.0–1.0) b0.01
45–54 26.6 0.6 (0.1–2.8) 37.6 1.0 (1.0–1.0) 0.4
55 + 29.7 0.8 (0.1–5.8) 33.3 1.0 (1.0–1.0) b0.01
All ages 24.7 0.6 (0.3–1.2) 36.0 1.0 (1.0–1.0) 2.2
Difference in treatment prevalencec 8.2⁎ 0.1
Difference in ORs 9.5

Percentages weighted. Mexican National Comorbidity Survey, 2002. Crude logistic regressions.
a
% of people with 12-month treatment among cases with MDE in each predictor category.
b
OR are estimating the likelihood of 12-month treatment with each gender and age as predictors; OR are not presented for cells where the count of respon-
dents within the demographic category is less than 15, or the count respondents with treatment is less than 5.
c
Significance test across cohorts with corresponding predictor categories for difference in prevalence, controlling for the same demographics. No N restriction
for test across cohorts; results for rows with multiple small cells may be unstable or not able to converge.
⁎ X2 significant at p b 0.05.
 Author's personal copy
168 C. Rafful et al. / Journal of Affective Disorders 138 (2012) 165–169
prevalences than the younger. This older age group had the
highest prevalence of MDE in men, the most reported work
impairment, and the most days out of role.
Among those with MDE, only one cohort showed sex dif-
ferences in the course of the disorder or age of onset. The
only impairment difference was among the 30 to 44 cohort;
women in this group reported significantly more impairment
than men for household activities. This difference may be
explained by differential gender role duties and the unequal
division of labor. This is the age at which women are most
likely to be burdened with the double shift of caring for
young children, household chores and outside employment
(Instituto Nacional de las Mujeres, 2006). Adult Mexican
women dedicate 38 h per week to domestic chores whereas
men only engage approximately 8 h per week. It is therefore
not surprising that men with fewer household duties are less
impaired in this area at the same stage of life when women
are particularly burdened relative to men. However, this
was not the group with the highest proportion of impair-
ment; older women reported more impairment perhaps sug-
gestive of more severe episodes or less social support at this
age. Hence, the main gender difference is the risk of first
onset, which is consistent with the literature (Kessler et al.,
1993).
The gender difference in the prevalence of depression has
been explained by a variety of factors which include social
roles, negative family experiences during childhood, cultural
norms (Piccinelli and Wilkinson, 2000), sex-related violence
(Medina-Mora et al., 2005b), and other kinds of violence
inflicted by the partner or other family members (Ludermir
et al., 2008; Natera et al., 2007). All these factors may also
contribute to the lack of service use in females. Even though
MDE is more prevalent among women than men, and
women of a certain age are more impaired in their daily
household activities, there is a trend of lower treatment seek-
ing relative to men (only significant among the youngest).
This finding contradicts previous reports of gender differ-
ences in treatment seeking for any mental disorder
(Medina-Mora et al., 2005a) and for any mood disorder
(Wang et al., 2007).
4.1. Limitations
This study had several limitations. First, the information
was collected among the urban population, which may not
necessarily represent rural communities. Second, although
the method was designed to minimize recall bias, memory
failure may still alternatively explain the differences in age
of onset among the cohorts. However, this bias was consid-
ered in the analysis. Third, participants were asked about
treatment seeking for any mental disorder and not only de-
pression, which implies that the treatment gap may be
wider than what we report.
5. Conclusions
Even when women are more likely than men to experi-
ence a depressive episode, the course and consequences do
not differ between them. Men, however, are more likely to
use services for treatment of MDE in Mexico. For preventive
purposes, in Mexico, as elsewhere, it may be most efficient
to focus specifically on the factors related to the first episode
onset. Once a first episode has developed, the risk of multiple
episodes throughout the lifetime is higher (Judd et al., 2000);
which makes it imperative to develop early treatment pro-
grams accessible in order to reduce the risk of subsequent ep-
isodes (Benjet et al., 2004).
Role of funding source
The Mexican National Comorbidity Survey was supported by the Nation-
al Institute of Psychiatry Ramon de la Fuente (grant INPRFM-DIES 4280) and
by the National Council on Science and Technology (grant CONACyT-
G30544-h), with supplemental support from the Pan American Health
Organization.
Conflict of interest
All the authors report no conflicts of interest.
Acknowledgments
We thank the World Mental Health staff for assistance with instrumen-
tation, fieldwork, and data analysis.
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