Gender and symptoms of depression and anxiety among Kikuyu secondary school students in Kenya

Sot. SC;. Med. Vol. 24, No. 4, pp. 303-3 16. 1987

Printed

in Great

0277-9536/87 $3.00 + 0.00 Copyright I? 1987 Pergamon Journals Ltd

Britain. All rights reserved

GENDER ANXIETY

AND SYMPTOMS OF DEPRESSION AND AMONG KIKUYU SECONDARY SCHOOL STUDENTS IN KENYA and

SHARON MITCHELL’ ‘University

of California,

Los Angeles, Kentucky,

SUSAN ABBOTT?

CA 90024 and ‘Department of Anthropology, Lexington. KY 40506, U.S.A.

University

of

Abstract-Numerous studies have confirmed that patterns of mental illness are influenced by sociocultural factors such as socioeconomic status and gender. This study describes the patterning of symptoms of depression and anxiety on a 20 item self-report questionnaire. the Health Opinion Survey, completed by 159 Kikuyu secondary school students in Kenya. Significant quantitative differences in the responses of males and females to seven of the questions were found, including females reporting more depression symptoms than males. These results are compared to an earlier study of I I6 Kikuyu adults in which the

differences between males and females were greater. This paper contributes to the literature on the relationship between gender and depression while adding to the sparse descriptive literature on symptoms of depression Key

and anxiety

words-affective

in normal

African

populations.

disorders, adolescence, gender, Africa

1NTRODUCTlON

This study examines the patterning of some common symptoms of affective distress in a sample of normal Kikuyu secondary school students of Kenya. The results are compared to the patterning of the same symptoms in a second sample of normal Kikuyu adults[l]. The paper attempts to answer two questions: (1) Are there differences in the kinds of symptoms acknowledged by females and males? and (2) What aspects of Kikuyu society and culture might have influenced the patterning of symptoms? The paper contributes to the discussion regarding the complex relationships among sociocultural factorsparticularly sex roles and status inequality and depression. It will also add one more account to the descriptive epidemiological literature on sparse psychiatric symptomatology in normal African populations. GENDER AND DEPRESSION

One of the most striking associations between mental illness and a sociocultural factor is that between gender and psychiatric disturbance. It is generally agreed that females have higher rates of depression, males have higher rates of personality disorder, and that rates of psychosis are approximately equal for each gender [2], although a very recent review of four longitudinal studies indicates that the epidemiology of depression and anxiety in one European (Sweden) and two European-derived societies (the United States and Canada) may have changed in the past 20 years so that women and men are becoming more similar in regard to their rates of depression and/or anxiety through a decline in the rate of depression among women in one study, an increasing rate among men in two studies, and a *Community

surveys are preferable to studies based on patient populations; factors such as differential access to and utilization of psychiatric services are eliminated. 303

combination of these changes in the remaining study [3]. While the rates given for disorders may vary widely from study to study, there are fairly consistent relationships between gender and psychopathology. See Goldman and Ravid [4] for a review of the data and discussion of these issues. The literature on the relationship between depression and gender is complex and burgeoning. Many investigators have devoted considerable attention to this issue yet little consensus has been achieved concerning both the validity of the findings and the explanations for the findings. For contrasting reviews see [5, 61. Our brief review of this literature will focus on community surveys of depression, excluding discussion of studies based on treated cases (cf. [7])*. The majority of both types of studies conclude that women predominate. Most community surveys of depression in the United States reveal that females have higher rates than males (cf. [8-171). Comstock and Helsing [18] found that white females had significantly higher rates than white males (N = 3540); the differences between rates for black females and black males (N = 295) was not significant. A recent five year survey of a community of 12,500 Old Order Amish in Pennsylvania is of great interest in that no significant differences for males and females in rates of either bipolar or unipolar depression were found [19]. Benfari et al. [20] found a mixed pattern, with females higher on what they termed anxietydepression and anxiety-vegetative disorders and no significant differences were found in the areas of low esteem, withdrawal, and cognitive depression. Amenson and Lewinsohn [21] found that the incidence of depression was comparable for males and females but that females had higher prevalence rates. Similarly, Weissman and Myers [22] found that the difference in current rates of diagnosis of depression was not significant but that females had no excess lifetime prevalence. Two non-random studies found gender differences to be not significant-a study of hospital employees and their spouses in Ohio [23] and a study

304

SHAKO& MITCHELL and SUSAN ABBOTT

of depression in the month following the death of a spouse in Missouri [24]. All community surveys of depression in other countries with which we are familiar conclude that female rates are higher. These include studies on Canada 191, England [25], Denmark [26-281, Australia [29], and Iran [30]. To our knowledge, no study has concluded that males suffer more depression than females. However, as we have seen. some have found the difference between the genders to be non-significant. Studies of college students provide another intriguing exception to the evidence for female preponderance of depression. It is by now well established that college students do not demonstrate the rate differential found in large random samples of the entire adult population. Every study of United States college students has found that the difference in rates of depression does not differ significantly for males and females (cf. [3 I --381). The only study we know of based on college students outside of the United States was in Australia. again finding no significant differences between male and female rates [39]*. Other exceptions to female preponderance occur in subgroups of large studies which have found significant overall gender differences. For example, Aneshensel et ~1.[8], in a random survey of 1000 Los Angeles residents, found that male and female rates were approximately equal in the subgroups without resident children. The greatest gender differences were in those with resident children. Ensel [41 J found that if the young married female subgroup was excluded. rates for married females and married males were comparable. It can be assumed that the young married group would be the most likely to have resident children. Kaplan [I I], in a sample of 500 adults in Texas. found one subgroup without a rate differential&those aged 40 and older. Again, we could imagine that this group would be the least likely to have resident children. As mentioned, the studies of college students reveal a lack of significant differences and this is another group unlikely to have resident children. Thus. an intriguing pattern begins to emerge as exceptions are examined. While the presence of children in the home certainly does not account entirely for the higher female rates. it does appear to be a contributing factor worthy of further study. This factor cannot be accounted for by work roles. assuming that women with resident children are less likely to work outside the home and therefore arc more vulnerable to depression (cf. [42]). Several studies have concluded that rates for married females do not differ significantly if the woman is a homemaker or employed outside the home [ 14. 15, 21,411. Many explanations have been offered for the

*In four of the U.S. studies male and female students were found to differ significantly on qualitative dimensions. Funabiki 01 N/. (341 found differences in the experience of depressron. with males evidencing more self-criticism and females evidencing more dependency. In two separate studies males and females in the most depressed subgroup selected different items [35.38]. Kashani and Prtesmeyer 1401 did not find gender differences in depression symptoms in their college student subjects.

higher rates nations.

of surveys

in Western.

industrialized

Phillips and Segal 1431 suggest that women report more symptoms than men due to cultural norms regarding appropriate behavior. Men are expected to be less expressive than women in their emotional behavior. A person’s gender affects both their recognition and expression of illness. ‘Sensitive or emotional behavior is more tolerated in women while self-assertive aggressive vigorous physical demonstrations are more tolerated in men” [43. p. 601. Beiscr [44] found this to be the case---“In Stirling County, cultural norms make it easier for a woman, as compared with a man, to admit feeling distressed .” (p. 944). Baumgart and Oliver 1231 suggest that in studies based in face-to-face interviews men are less likely tc admit symptoms than they arc on anonymous self-report questionnaires. Craig and Van Natta [45] observed that women admit to transitory symptoms of depression more, while the gender difference in symptoms persisting for fivje to seven days were more nearly equal. They attribute this IO reporting bias, although an explanation of thcsc differences as reflecting reali!y could also bc argued. Evidence has accumulated which detracts from the reporting bias explanation. Clancy and clove [46] found gender differences on two measures of reporting bias to be not significant and a significant difference on one measure of reporting bias indicating that females underreport symptoms. King and Buchwald [36] found that males reported their symptoms similarly whether in a situation of public or private disclosure. Padesky and Hammen [38] found that men were more reluctant to actually seek help for depression but that there was no gender difference in willingness to report symptoms. Weissman and Klcrman [S] concluded that the difference is real. that women experience more depression. They do not consider the rates to merely reflect reporting patterns. Instrument5

used ure

biased

Newman [ 131found significant gender Jiffercnces in depression scores yet in an item by item analysis concluded that the items which accounted for the female preponderance were largely ‘mild if not trivial.’ Parker [39] suggests that scales may be wjeighted to ‘feminine’ behaviors (e.g. crying). Padesky and Hammen [38] wonder if variables reflecting affect and self-esteem predominate in most studies. leading to higher rates for females.

The learned helplessness/hopelessness hypothesis originally formulated by Seligman and his colleagues [49] suggests that women have an expectation of powerlessness and an inability to control their lives which inhibits them from taking effective actions to change onerous situations. The stereotypical female role is characterized as passive; a lifetime of social experience predispose women to feelings of learned helplessness. When women encounter LL experiences which reinforce their feelings, (sic) of

Depression and anxiety among Kikuyu students in Kenya helplessness, they are likely to acquire depressive symptoms” [50, pp.79-801. Herman [Sl] discusses the common themes found in the literature on the psychology of women and the literature on theories of depression. Women’s

stutus

inequulit!~ contributes

to depression

Women’s status inequality is widely recognized, as is the social discrimination that results from women’s lower status ok-ci-tlis men. A chain of experiences beginning with low status result in “. . legal and economic helplessness. dependency on others, chronically low self-esteem, low aspirations, and ultimately, clinical depression” [50, p. 701. Klerman and Weissman [50] call this the social status hypothesis. See also Ref. [52]. Deriunt direc.tion.v ./or men and women difSer From this perspective, one gender cannot be said to suffer more in quantitative terms than the other. Rather, it is important to understand the differences and commonalities between the genders and to delineate which factors lead to various kinds of disturbances. Men have higher rates of violence, incarpersonality disorder, alcoholism, and ceration, suicide. Perhaps these conditions are alternative means of expressing and channeling distress, conditioned by a host of biological and social factors. Impressive support for this perspective has come from the recent Amish study in which no significant differences for males and females in rates of affective disorders were present [ 191. The authors suggest that this may be accounted for by the absence of alcoholism. drug abuse and sociopathy in this population. In this population. the expression of affective disorder among men is not masked, as it may be in other communities. At this time it is not possible to say if one or some of these explanations are better than others. It is important to point out that these hypotheses are not necessarily exclusive. It may be that a combination of these factors together result in increased depressive illness among women among some populations.

DEPRESSION

IN

AFRICA

Early reports from Africa indicated that depression was rare while later reports found it to be widespread. One cause for the dramatic shift may have been the variability symptoms of depression manifest in different cultural groups [53, 541. Depression when present does not assume a universal form, as a growing body of literature on this subject amply demonstrates. (See 1551 for a review of this literature as well as the recent volume edited by Kleinman and Good [56].) Several studies report how symptoms of depression in African subjects vary from those commonly found in Western subjects [53, 57-591. Prince [60] reviewed the literature on depression in Africa from 1890 to 1965. The picture of depression that emerged included less verbalization of affect, less self-blame and more projection of blame. Suicide seemed to be rare. Of particular interest is the

305

consensus among the studies he reviewed that somatic complaints dominate. See, for example, Lambo [6l] for Nigeria and Diop [62] for Senegal. More recent reviews continue to confirm the earlier descriptions [53, 57-591. Buchan [63] reported that depressive illness in African patients differs from the ‘usual pattern.’ His experience indicated that physical symptoms, anxiety symptoms and behavioral disturbances are often important presenting features. He concluded that “there are likely to be clinical differences in psychiatric illness which parallel cultural variations.” German [64] discussed intracultural variations in depression, reporting that acculturated African depressed patients presented similar manifestations of depression to Western peoples while unacculturated Africans did not. He reports that the symptoms of ‘unsophisticated’ patients are frequently expressed in somatic terms. Swift and Asuni [65] stated that the rural African does not complain of depression unrelated to somatic symptoms. The main complaints are often interference with normal sleep and eating patterns. Binitie [66] compared depressed patients at the Nervous Diseases Clinic in Benin, Nigeria, and a Hospital in London, England. Using Wing’s Present Mental State Examination, he determined that both groups exhibited depressed mood and a loss of interest in their work and the environment. However, the Nigerian patients reported more somatic symptoms than did British patients. The British group exhibited more guilt, suicidal ideas, and anxiety than did the Nigerian group. Guilt and suicidal ideas were rare in the African patients. Binitie concluded that these symptoms appear to be culturally determined, a position he continues to support [53]. More recently Binitie [67] concluded that one of the chief characteristics of depression in African patients is the somatization of symptoms. A depressed mood is usually not obvious. He has observed that classic Western depression is found only in those who affirm Christianity the most deeply. The preceding sections have emphasized the following points: (I) Depression is strongly influenced by sociocultural factors such as gender and cultural group. (2) These differences include epidemiologic differences and differences in the manifestations of symptoms. (3) Most random community surveys which compare males and females in rates of depression show that females tend to have higher rates than do males. (4) Few studies of depression and anxiety among normal African populations have been done. Most studies have been done in hospital settings. (5) Available data indicate that symptoms of depression in most Africans tend to be largely somatic. The next section establishes the economic, social, and cultural framework within which the subjects of this study, Kikuyu secondary school students, live. An understanding of this framework is essential to the interpretation of the results of the study. Particular emphasis is given to recent changes in Kikuyu life, youth as a stage of life in traditional and modern times, the importance of schooling to Kikuyu youth,

SHAKW MITCHELL

306

and the roles of females and males in Kikuyu society and culture. SETTING

Many changes have occurred in Kenya in a relatively short time span. One hundred years ago, the Kikuyu were a subsistence horticultural people. British control was established only 75 years ago. By 1936, Jomo Kenyatta noted that there existed “a welter of disturbing influences A Kikuyu does not know what he may or may not. ought or ought not. to do or believe“ [6X. p. 2511. In the same year, Kabetu wa Waweru. an elderly informant of L. S. B. Leakey. commented on the situation among the Kikuyu following the arrival of Europeans. “From that time the state of things began to change more and more rapidly. and ceased to be at all like it was in the olden days. The country became like a ncu country that was unknown to us” [69. p. 331. The changes arc pervasive. Formerly horticulturalists. the Kikuyu now have a diversitied economic base. They partlclpate m a money-based market economy with cash cropping and large scale male labor migration. In one Nycri District community, over 77% of the males over 21 worked for cash wage5 away from the community [70]. Because most adult men are gone from the rural areas. women nou routinely perform many formerly male horticultural tasks in addition to those they have always pcrformed. However. it has always been their responsibility to raise the bulk of the family’s food in their gardens. The emergence of constraint in land availability has also contributed to change. Other change5 include the introduction of Christianity and the adoption of formal schooling for children. Formerly. the status and role of each group in Kikuyu society was clearly defined [7l]. Traditionally, young people were active in the life of the family and the community. As we have seen. myriad changes have occurred and no clear-cut new-role has emerged for the young people [71]. Formerly. youth of the age of the subjects of this study were active in subsistence activities and the activities of their age group including initiations. warfare. dances. and work in their families’ gardens. Youth was truditionallv regarded by the Kikuyu ;I:, ;I relatively carefree pchod. It W;IS the period of greatest freedom. when the demands and restrictions of childhood ended and the greater responsibilities of married life had not yet begun. Younger children were expected to work diligently. Initiated youth. the age of the subjects of this study. were

allowed

more

and

SUSAN ABBOTT

leisure time for the pursuit of personal pleasure. The introduction of schooling has changed the roles 01 young people. Prior to the ers of intensive Western contact. the education of a Kikuvu child W;IS accomplished by the child’s family and gifted individuals in the community [6X, pp. 312~314: 72. p. Xi]. For example. children were instructed in the performance of household and agricultural tasks and gradually given rcsponsibilities in these areas. They also learned hq observing the interactions of adults and were told stories with moral lessons 1691. In this way, children gradually learned how to interpret the world around them and behave appropriately in their adult Kikuyu roles. E. B. Castle in (r‘ro~ri~~,qC;/) irl &sr .-l/r&r elucidates the aims of a traditional African education: “Its ;*1m~:LI to c0nsci-\e fhe cultur2ll hcrilagc 01‘lii~nrl!.cl;tfl and tribe. to adapt its children lo their physical environment and reach them how to use it. to explain to them that their own future and that of their community depended on the perpetuation and understanding of their tribal institutions. on the laws, language and values they had inherited from the past” 1731

Kenyans’ dcslrc for formal. Western-style cduarose when it became apparent that there was a connection between European wealth. technical superiority and prestige, and their formal system ol education [72]. Jomo Kcnyatta wrote that “education. especially reading and writing. was regarded as the white man’s magic” [6X. p. 2621. Kenyans still have an exceptionally high regard for education. Why is such great importance attached to cducation in Kenya‘? Kenyan parents generally want the best for their children [71], and school is a key mean> to that end in this setting. The mosr prestigious route to success is the achievement of a position in cithct the government and business bureaucracies. the professions. or the highly skilled specialties [70]. An education, essential for cntrancc into thcsc occupations. is primarily valued for the matcrlal gain5 and prestige it can afford to both an Individual and cation

the family to which he or she belongs. Education is begun as early IS possible [7l]. Parents arc willing 10

make

great

sacrifices

in order

that

their children In fact. parents stem willing to sacrifice whatelcr they hacc III this effort [72]. Homesteads lose much of the productive agricultural activitie\ of young pcoplc who must spend long hours engaged in attending school and studying in order to succeed. The economic burden to the family of school fees is often 3 considcrablc hardship. In addition. available space for all 01‘ the students who would like to pursue ;I sccondq school receive as much schooling as possihlc.

education does not exist in the schools. Gratiuatcs xc often absent from the comrnunit). seeking crnploment in cities. These factors increase the alread) considerable pressure on these students. The importance of an education to the attainment

of a

well-regarded and well-paying position in Kenya today cannot be o\cremphasized. Prior to Wcstcrnization. the status system V+;IS based largely on qc. sex. and wealth in fivestock and wlve\. Some mules and females were wealthier than others,. but there were limits to the amount of land. Mives, LIntI children that one man or woman could xcumulatc.* Persons

Depression

and anxiety

among

who had accumulated many sons and large land holdings would find their land divided among their many heirs in the next generation. The Kikuyu had no hereditary elite, although individual families could accumulate wealth. Another change which has occurred in Kikuyu life in this century is the emergence of greater social stratification. The primary access to coveted positions is the attainment of an education, hopefully a university degree. The objects of this study have succeeded in gaining entrance to secondary school. They will soon face the next layer of examinations, the O-level exams, which determine their opportunity to enter the next layer of schooling: Higher Secondary. which lasts for two years. Those that successfully complete Higher Secondary will then compete for a place at the University. In 1972, there were only 5000 students at the University of Nairobi, the only university in Kenya. The pressure is intense. In the words of one successful graduate. “The exams are really almost a matter of life and death. It is considered humiliating to fail an exam. A lot of students have mental breakdowns around exam time” [74]. The students included in this study have been more successful than most of their peers in securing a position at a secondary school. In 1972, there were 161,910 Kenyans enrolled in secondary school. Of these, 69% were males and 31% were females [75]. In 1979, 55.5% of all Kenyans aged 15-19 were attending some form of schooling, 65.9% of all Kenyan males aged 15-19 were attending school, and 45.5% of all Kenyan females aged 15-19 were attending school (761. As discussed, these students’ success does not mean that they are not subject to many stressors. Some of the sources of stress differ from those of their peers who are not in secondary school. They are expected to meet the demands of schooling by performing at a high level and this task becomes increasingly difficult as competition intensifies. As Binitie [67. p, 461 noted of African students ‘*. the student is under tremendous pressure to achieve academic success, irrespective of his ability to cope with the demands entailed. The strain of the expectations of others, coupled with those generally associated with academic achievement, causes a considerable number of students to suffer anxiety and mental breakdown.” The mental health of African students has also been discussed in several articles [77-951. Although the information available is not conclusive. the changed economic situation appears to be affecting Kikuyu values. The earlier ethnographic literature emphasized that the Kikuyu valued cooperation toward family and community goals over individual needs. The ideal was that a person establish right relations with and behavior toward other people rather than achicvc individual goals [68]. A person was said to be viewed in the context of his or her family. community. and tribe rather than as an isolated individual. The achievements of a family or an initiation group were shared by all members. In 1966, E. B. Castle noted a change-‘Communal identity individual ambigives place to tions.. steadily the young African moves into situation where hc treads with diminished confidence” [7x. p. 451. Beatrice Whiting has observed that

Kikuyu

students

in Kenya

307

Kenyan children are now receiving more training in competitiveness and individual achievement than they formerly did. Cleverness and curiosity appear to be valued more than generosity and goodheartedness [71]. The traditional Kikuyu value orientation may conflict with the individual ambition necessary to achieve success in the current economic system. For young people in particular, their success in school depends on individual achievement in highly competitive situations. We turn now to a discussion of the roles of males and females in Kikuyu society and culture. Traditionally. the division of labor between males and females was rigidly defined. Each gender had its own responsibilities [96]. “Custom prescribes the line between a man’s work and a woman’s work and this begins in the earliest years” [97. p. 1211. The division of labor by sex is only one way in which the differences between males and females in Kikuyu life are accentuated. For the Kikuyu, male and female are clearly distinct cultural categories. The differences between the sexes are considered to be many and significant. Adult members of this community hold the concerns of men and the concerns of women to be distinct [72]. The sexes are segregated in many spheres of life. “Men and women generally occupy separate social worlds, and their relationships with each other arc marked by patterns of deference and authority” [ 1, p. 1641. According to Kikuyu ideals, men are supposed to head their households. The reality of male absence often leaves actual decision making in the hands of their wives. Women actually control more decisions than indicated by ideal expectations alone 1701. Kikuyu society exhibits marked social inequality by sex. The sexes have unequal access to economic resources and prestige. Men have unquestionably greater political, legal, and economic power. Sources of power and satisfaction for women are real, but are less readily apparent. This situation is reflected in the ethnographic and popular literature in which the views of Kikuyu women are often contradictory. Women are sometimes depicted as dependent and weak and sometimes depicted as powerful and independent. This contradiction is explained by Abbott as follows: .. exclusive attention to the formal structures of Kikuyu society and their attendant jural rights and duties, as well as to the value system supporting the structures, results in a characterization of women as relatively powerless. secondclass citizens, On the other hand, an emphasis on informal affiliation networks, economic productivity in subsistence, relative influence with children, and day-to-day decisionmaking responsibility, results in a picture of autonomous, relatively powerful women competently going about their duties and responsibilities” [9X, p. 211.

RESEARCH

METHODS

The data for this analysis consist of Health Opinion Surveys (HOS) collected by one of the authors as part of an extensive study among Kikuyu carried out between 1971 and 1972. As part of that study, 176 secondary school students (85 males, 91 females) attending six different culturally homogeneous

SHARON

308 Table Beck’s

I*.

The

MITCHELLand SUSAN ABBOTT

Health

Ommon

Survel,

HOS

categonest

2.:Do

wth

your hands ever tremble

sometimes Are

(2);

you

damp 4.

Have

8.

Are

never

ever

troubled

ever

categories

grouped

enough

to bother

you? Often

(3):

(I)

hands or feet sweatmg SO that they feel

by your

and clammy? you ever been

you

Beck’s

items-tentatively

bothered

bothered

by your

heart

by nightmares

beating

(dreams

hard?

that

frighten

and

upset you)? 9.

Have

you

ever

been

troubled

by ‘cold

17

Have

you

ever

been

bothered

by shortness

I

Somauc Somatic

7.

Somauc

IO.

not

exerung

Do

you

Yea

(3);

How Do

retardatmn

13.

retardation

1X.C;For

often

ill

19.5 Do

Pewmt\m

20.

Do

phyavzal

are you

feel that

problems

health you

by havmg

are bothered part\

affected

the amount you

would

do like

you

feel in good

you

wmetimes

to do’? Often spin&?

Often

wonder

(I); (I).

if anythmg

Do

you

tend

to feel tired

6.

Do

you

have

trouble

Anorexia

I?.

Do

you

ever

Somauc

I4

Do

you

feel weak

all

Somatic

1.

Do

you

ever have

spells of dxzme\s’?

16.

Do

you

tend

have

I I.

Kenya.

Ethos

Anthropological Scormg

from

7,

161,

Do

1979.

Association.

is indicated

for

you

Abbott

each

smoke

to

Lkprercion.

Crrrrsr.~~uu/ %rurmmt.

aems

I7

9Scoring

for

these Items

T.

2 to

and

is worthwhile

never never

(3) (3)

anymore?

to sleep and

staying

asleep?

over? when

you

worry?

1,P,?1\

R.

Depression

reprint

Hampshire

for

A.

(2); (2):

do’? the

this Ave.,

and

anxiety

among

table

was

granted

NW,

Washington.

rural by

DC

the

Kikuyu

in

American

20009,

U.S.A

item.

:Scoring

tBeck

sometimes sometlmeb

out

(or snuH)? Klein

Permission 1703 New

you

to carry

loss of appetite?

to Io’ie weight

S. and

(housework)

enough

m the mornmgs?

getting

I?&rtw?rlnrrrc~

reprinted

kinds)


whtv

5.

.Yore. *Table

time?

slomach?

sorts (different

of work

lnsomia

loa\

were

body?

feel healthy

lnsomla

Weight

you

at the present

an upset

by all

of your

part

S~~mp/<~rn.sp,>.\.rih/<, irr

Clniverslty

of Pennsylvania

Press. Philadelphw

1977.

20 IS the same

1s reversed.

schools in Nyeri District, Kenya,* were administered a questionnan-e composed of three parts: (I) questions adapted from Robert Edgerton’s “Culture and Girl’s School (N = 39) and Ngandu Girl’s School (IV = 22) are government supported boarding schools which enjoy excellent reputations. A school’s reputation depends largely on its success in preparing students for examinations. Of the six schools included In this study, these two schools are considered the best. The girls at these schools are able to attend them because they did well at the primary school level. In addition. they generally do well on the national exammation taken upon graduation from secondary school. Kenyatta Secondary School (iy = 32) is a government supported coeducational school and Chinga Boy’s School (.V = 25) is also government supported. Both were originally community-founded institutions. and are now supported by both the government and the community. with the government controlling admissions. Entrance standards at these two schools are less competitive than at Tumutumu Girl’s School or Ngandu Girl’s School and more competitive than at Chinga Girl’s School or Kiamuyu School. Chinga Ciirl’s School (N = 25) is superior in quality only to Kiamuyu School. Kiamuyu (N = 16) is a struggling institution. It is the worst school in thts sample in terms of quality of students. teachers, education and facilities. It was begun through local efforts In response to loss of local control of Chinga Boy’s School when the government took it over. It is also expensive, requiring families to sacrifice for uncertain rewards

*Tumutumu

or health

bothered

you

m dtfferent

the most

thmgs Sadnea\

when

no (I)

you

Has

Work

of breath

yourself?

have any

of ailments Work

sweats”?

Ecology Interview Schedule” [IOO], (2) sentence completions, and (3) the 20 question Health Opinion Survey [ 1011. Analysis of the answers to the questions These schools include all the secondary schools in the location (a governmental administrative unit) where the community study was being conducted (Chinga Boys, Chinga Girls. and Kiamuyu). The other schools were selected first because of their location-they were within a reasonable driving distance (no more than 20 miles) of the community where the primary research was being conducted, second because they would permit the addition of sufficient numbers of girls and boys so that the final sample would consist in at least 80 girls and 80 boys. and third they would permit some comparisons to be made between students from more prestigious schools with students from less prestigious schools. Based on an analysis of the demographic information provided by the students as well as the pattern of their answers to the full questionnaire that they completed (see [99] for details) as part of the larger study, there are no notable differences among the students from the different schools. The students are all Kikuyu and the enrollment at each school was composed of students from several locations scattered across Nyeri District. So, while differences do exist in the genera1 quality of the schools, and while more girls in the total sample attended better quality schools, the only difference we can ascertain between the boys and the girls is that the girls as a whole got higher marks on their secondary school examination at the end of primary school than did the boys as a whole.

Depression Table 2. Items with significant

and anxiety

quantitative

among

Kikuyu

students

in Kenya

309

differences in response by gender as revealed by Chi’ (N = 85 females, 74 males) Item category Possible in either

Deuression

Gender Femaler-report

Males--report *P

< 0.05.

fP

more symptoms

Anxiety

7. Upset stomacht 13. Work retarded? 20. Negative expectations$

more symptoms

condition 6. Sleep disturbed* 12. Loss of appetire’

9. Cold sweats

5. Tired in morning:

< 0.01; :P < 0.001.

Part I of the questionnaire have been reported in Abbott and Arcury [99]. These openended questions queried the students regarding their attitudes and values about family, sex roles, and work. The questionnaire was written in English which is the language of instruction in Kenyan schools beginning in the primary grades. Most students in the sample were in their third or fourth year of secondary school. The total sample ranged in age between 14 and 25 years with a mean age of 17.7 years. Because the HOS is most appropriately used to compare groups within limited age ranges, we excluded students below the age of 15 and above the age of 20. This analysis is based on an N of 159, 85 females and 74 males with a mean age of 17.7 years. In all schools, students were selected for the study on the basis of the school’s headmaster or headmistress designating classes available for testing. The students completed the questionnaire as a group during a regular class period under Abbott’s supervision. They were not permitted to confer with each other while completing the task and had no knowledge of its purpose. Since its initial construction and use in the Stirling County Study [102-1041, the HOS has been utilized in many cross-cultural studies as a measure of psychoneurotic and psychophysiologic impairment (see [IO51 for a listing of these studies). It was devised in order to meet the need for a brief, inoffensive test that could be utilized on a community-wide basis. composing

*The HOS is constructed with a three point scale. For data with this structure, Chi’ is a satisfactory test of significance. Analyses such as stepwise regression, factor analysis, discriminant analysis, and multivariate analysis of variance are not appropriate for ordinal scale data. Despite the violation of scale assumptions these data were subjected to more complex analyses. These analyses revealed no striking clusters of items as were found in the adult data which were analyzed with correspondence analysis, a kind of factor analysis suitable for nominal and ordinal scale data. These data were also subjected to correspondence analysis which revealed a similar structure for the secondary school girls and the adult women, though the pattern was weaker for the school girls. The structure of the secondary boys’ responses was too diffuse to be interpreted. Given the developmental stage of the students, it is not surprising that their patterns should not yet be as distinct as the adults’ patterns. This is consistent with response patterns for U.S. students and adults. tOveral1. the percentage of students reporting ‘often’ was small. Males reported ‘often’ 9.5%; females reported ‘often’ 7.7%. Males reported ‘sometimes’ 43.1%; females reported ‘sometimes’ 49.6%. Males reported ‘never’ 41.4%; females reported ‘never’ 42.7%. See Mitchell [I 121 for frequency tables for each item.

The HOS is not used to diagnose disorder. It is most appropriately used to compare groups intraculturally within limited age ranges [106], as in this study. As Abbott and Klein [I] and more recently Murphy [3] point out, it is composed of items frequently found to be symptomatic of either depression, anxiety, or common to both syndromes. The instrument has been critiqued by Dohrenwend and Dohrenwend [107], Tousignant et al. [108], and Abbott and Klein [I]. Table 1 lists the HOS questions arranged by symptom type. This particular classification of the HOS items was originally developed by Abbott and is fully described in Abbott and Klein [I]. The classification of items as anxiety symptoms follows Marks and Lader [109], while the classification of depression items relies on Beck [I IO], Collomb [I 1 I], and Binitie [66]. This study does not utilize the HOS to reach a global adjustment score as is the usual practice. Instead we are interested in looking for gender differences in responses on each item so that we can compare the secondary school student’s responses to the married adults’ responses described by Abbott and Klein [I]. For this study, question 11, ‘Do you smoke?’ was not considered because it is inappropriate for this age group.

RESULTS

The responses of each gender to each of the 19 questions were compared using Chi2. Table 2 presents the nine items on which there were significant differences in the responses of males and females at the 0.05 level of significance or higher.* While mean total scores did not differ significantly, there were significant quantitative differences between males and females for seven of the 19 HOS questions. For five of these seven questions, females clearly reported more symptoms than did males. These include three depression questions and two ‘both’ questions. Males reported more symptoms than did females for one anxiety question and one ‘both’ questi0n.t A depression score was calculated by adding the scores of the seven depression items to one-half the scores of the six items possible in either condition. An anxiety score was obtained by adding the scores of the six anxiety items to one-half the scores of the six items possible in either condition. The mean depression score for females was 17.3; for males, 16.6. The mean anxiety score for females was 14; while for males it was 14.3. The differences between these means are not statistically significant. However, as expected the results are again in the direction of

310

SHARON Table

3. Comparison

significant

quantitative

of

Chl’

MITCHELL and

differences

and SUSAXABBOTT

significance

levels

were obtained.

adult

for

HOS

group

Female+ HOS

Item\

which group

M&S Adults

Student\

sterns for

and student

Students

Adults

P < 0 947 P < 0.0049 10.73x P < 0 O(lOfl 42.070 PcOOllh x YOY I’ < 0 0037

I’ < 0.0306 h.Yli I’ <

o.om x91

[I 131 on somatic complaints

among a cross-section of Nigerian women including secondary students concludes that female Nigerians as a whole are characterized by a high frequency of somatic complaints as measured by the Enugu Somatization Scale (a 60-item questionnaire). Ebigbo attributes this to the preference for a somatization defense in egothreatening situations which in his opinion, abound for Nigerian women. We suspect that Kenyan women would present a similar profile if the data were available. We concur with his conclusion that there is no reason to avoid attempting to draw out psychodynamic, psychocultural. and/or psychosocial explanations for the symptom patterns we are discovering

Depression and anxiety among Kikuyu students in Kenya given our growing understanding interrelations that exist between body.

of the dynamic the mind and the

DISCUSSION It is not surprising that Kikuyu young adults responded to this questionnaire differently depending on gender. One factor which may contribute importantly to this outcome concerns the Kikuyu views of male and female. As discussed earlier, the Kikuyu view male and female as distinct categories, emphasizing differences between the sexes rather than similarities. These differences are noticed and accentuated throughout an individual’s life. Many of the interests, occupations, values, and attitudes of men and women are dissimilar. It is to be expected that the males and females would differ in reported symptomatology as well. Abbott and Klein [I] concluded that Kikuyu males and females have clearly different status and different sets of constraints and stresses and that the impact of these differences results in differential patterning of symptoms for males and females. What are the differences between these female and male students in their social roles and relative status? A paper by Abbott and Arcury [99] reported the results of the rest of the questionnaire completed by the students at the time they completed the Health Opinion Survey. Four of the questions asked the students to describe desirable traits for males and females. These were:

(1) What kind of man do the Kikuyu most respect? (2) What kind of woman do the Kikuyu most respect? (3) What kind of man does a woman want to marry? (4) What kind of woman does a man want to marry? Most valued for men were individually achieved status indicators like a high level of formal schooling and conditions of the person such as good health that impact one’s ability to earn a living. Most valued for women were social relational skills, traits, or behavioral predispositions such as being well-mannered, obedient, and respected by the community. There is a statistically significant discrepancy between the sexes on the fourth question. Young males say a Kikuyu man wants to marry a more individuated, achievement-oriented woman-someone more like themselves. The young females believe that men prefer to marry a woman who is obedient, wellmannered, and who is respected in the community. Prior to the impact of the Western world on Kikuyu culture and society, women and men were reared into a set of predominantly ascribed roles, although there apparently was some room for men to achieve some distinction based on their own initiative as warriors and later as elders. Some pursued acquisition of wealth as traders with great success and progress beyond the first stage of elderhood was not automatic [69, 1141. Little girls and boys saw the pattern of their own lives being lived out in their parents’ and grandparents’ lives. That world is now gone and the old verities no longer hold. The

311

contemporary Kenyan world places a premium on achieved status based on individual competitiveness. The questionnaire responses suggest that the boys as a group may be adapting more readily than the girls as a group to these new demands. There seems to be more pressure on young women to continue conforming to traditional role expectations. This pressure may be in part self-induced in the sense that the girls’ male peers do not share traditional expectations to the same extent, however, there is other evidence that suggests that local rural communities expect these girls to still perform their traditional female role even if they complete secondary education. The remarks of a local woman from the same location where these data were collected are illustrative of these attitudes: Women are strong. They can and are supposed

to go to the river and draw water in addition to doing other duties that man is not supposed to do. If our women do not learn how to perform women’s duties, how are they going to be good wives and mothers? We do not want these girls to forget that they are women just because they are attending secondary schools [72, p. 941.

These remarks were made in response to a query about why they had piped water from the river to the boy’s school but had not piped water to the girl’s school even though it was further from the river. Another informant commented during the collection of these data that if a young person went to secondary school, their values were sufficiently different by the time they left that they would have difficulty conforming to traditional expectations. This informant was herself a graduate of the local girl’s secondary school. The data suggests that these girls are experiencing a great deal of conflict between the expectations and attitudes of their community which expect conformity to the traditional, female role while they are being trained in the individualizing, competitive values and attitudes of the new order represented by achievement in school and attainment of a job after school. H. B. M. Murphy [13, p. 1431 has suggested that the shift from a social system based primarily on ascribed status to one based on achieved status rooted in individual competitiveness leads to increased depression in the transitional groups. The Kikuyu are currently engaged in just this shift and we believe it is impacting the young women more intensely than the young men. Another possible source of difficulty for the female students is premarital sexual activity. Abbott and Arcury’s study [99] revealed that many males and females in this group of students do not share attitudes regarding premarital sex. Most males (74%) believe that men should have premarital intercourse; a majority of males (56%) also believe that females should have premarital intercourse. In contrast, few females (27%) believe that males should have premarital intercourse; few females (28%) believe that females should have premarital intercourse. In answer to the question, ‘Do women have premarital intercouse?’ most males said ‘yes’ (90%); fewer females said ‘yes’ (60%). Put another way, nearly three-fourths of the females believe that they should not have premarital intercourse, while less than half of the males believe that females should not have

312

SHAROK MITCHELL and SUSAN ABBOTT

premarital intercourse. Young females in this region are pressured by young males to engage in intercourse. While they may desire to do so. for most of the girls in this group this conflicts with their beliefs. The risks of pregnancy for a girl add a further conflict for them. The attitudes of this group toward an unmarried pregnant girl arc negative. Sixty-four percent of the young men and 72% of the young women say that people are extremely unhappy with her. A premarital pregnancy usually severely limits a woman’s marital prospects [74]. It has an even more devastating effect on her schooling-she will be forced to leave school. Attitudes toward the father are less negative. In fact, 40% of the males and 27% of the females report that people are pleased with him. Local adults regard premarital pregnancy as a recent social problem. Prior to Chrismajor, tianizationduring the adolescence of these students‘ grandparents-Kikuyu youth were explicitly instructed as part of their post-initiation novitiate in the proper form and technique of sexual behavior for unmarried youth& nguiko JU npnh (restricted sexual intercourse). Penetration was forbidden but a form of a interfemoral intercourse was allowed and initiated youths were encouraged to experience a number of lovers, typically in group settings. The girls bound up their pelvic areas in a leather apron which acted as a mechanical barrier to penetration. and this combined with the young man’s fear of a ruined reputation among the other girls and within the community apparently was effective in limiting the incidence of premarital pregnancy [69, pp. 738 7401. These customs have disappeared in the face of new religious ideologies creating a vacuum in the training these young people receive regarding sexual behavior and knowledge about how to prevent pregnancy. Most of the girls seem to have adopted the attitude that abstinence is the best policy. an attitude their male age mates do not share. (See [I 151 for another discussion of some of these issues.) In summary, certain difficulties may be present to a greater degree for females than for males. While both females and males face an extremely tough job market (about 40% unemployment when these data were collected), the females also must deal with their conflicts about traditional role expectations and their social disadvantages as women in a culture that explicitly favors males and sees schooling as simply not as important for females (see [72]). The girls are also conflicted about sexual activity (conflict with males, internal conflict with beliefs, and fear of pregnancy). The major stressors affecting these young women appear to be those centering around their role as women in a society that is shifting from predominantly ascribed to predominantly achieved status. The major stressors affecting the young men in this study are centered on their success in school [74]. What they are doing is crucial to the achievement of their goals regarding prestige and material success. These young males are driven by an intense desire for financial success, but many will find it difficult to meet the subsistence needs of their future families, This desire for wealth emerged clearly in their answers to the questionnaire [99], and is congruent with the earliest descriptions of Kikuyu culture and social

life [69,97]. The young men mentioned a concern with the acquisition of wealth twice as often as they mentioned a concern with home and family. They also pointed to the extremely negative attitudes that most people hold toward the poor. Possession ol wealth is highly valued but while it is valued. it is also appreciated that if one succeeds and becomes wealthy, he will then be the target of envy. jealousy. and perhaps sorcery,or witchcraft. The environment is intensely compettttvc and these students are aware of the fact that many will fail in their attempts to become successful in the modern world. As we have seen, the roles of males and females ol this age and their accompanying stressors differ. As with the adult Kikuyu. we conclude that these roles and stressors are one of the factors contributing to different responses to the HOS.

This study revealed differences in reported symptoms of Kikuyu male and female secondary school students. While the mean total scores were similar, differences included females selecting more depression items than did males. For tivje of the questions which are possible symptoms of depression the gcndcr differences in response are statistically significant and females reported more symptoms than did malts. These questions refer to loss of appetite. upset stomach, work retardation. sleep disturbance. and negative expectations. Three of these five are depression items; two are questions possible in both depression and anxiety. Thus. sonic of the classic symptoms of unipolar depression were reported more often by the female students than by the male students. It should be noted that this result occurred despite the fact that this group of students was biased in favor of more successful females. We now want to go beyond the limits of the data presented here. and drawing on knowlcdgc from the rest of the Kikuyu field work as well as published materials. frame our findings in the largest possible context. The results of this study lend support to previous studies, the majority of which report similar findings in a wide variety of cultural groups. As we have seen. the association between females and higher incidence of depression is a frequent though certainly not invariable finding. Most studies show that depressions are approximately twice as common m females than males [3, 51. Satisfactory explanations for this relationship are still forthcoming. It is most likely due to a combination of some of the factors which have been suggested. Returning now to the theories described at the beginning of the paper. it has been suggested that the roles of women tend to be more difficult than the roles of men and that this leads to more depression in women. Gove and Tudor [42] as well as others describe the stressful aspects of the female role in American and European-derived cultures. In Kenya the stresses differ to the extent that the women’s roles differ, the culture differs, and the larger socioeconomic and political systems differ. Kikuyu women are expected to make significant contributions to the family’s economic well-being: traditionally they are the farmers and control the

Depression and anxiety among Kikuyu students in Kenya distribution of their produce. These secondary school students are hoping for different occupations in offices, or classrooms or hospitals, but they must contend with conflicting values from two different cultural systems-the traditional Kikuyu system and the British-European-Judeo-Christian-capitalistmarket economy system. Among the questions foremost in the minds of these young women are “Can I find a husband with a good job?, Can I get a job?, or Will I be stuck on a shamba (family homestead) dealing with a mother-in-law who wants to control me, who wants me to conform to her traditional values and expectations?” If they fail to make a marriage with a successful man, and if they fail to get a job for themselves, they will most likely find themselves in a rural community farming their husband’s land and attempting to earn additional income through cash cropping and trading while they bear and rear several children. Their husbands will expect them to be hard-working and fertile, while their mothers-in-law will try to establish traditional role relationships of control while demanding proper attitudes of respect from the daughters-in-law-an awkward situation when the daughters-in-law have acquired so much education and no longer share the same values and aspirations. Custom relegates Kikuyu women to positions of less authority and prestige than men, but women did have power in the traditional system based in their central importance to the economy and symbolized in the past in their required presence at traditional religious rituals. The Kikuyu represent what Peggy Sanday [I 161 calls a system of male dominance and female power. In today’s complex world, the women are finding it difficult to maintain their power due to factors described by Rogers [ 1171in her critique of Third World development policies and practices promulgated by international development agencies like U.S.A.I.D. and others which aim most of their activities at men. Women are not allowed to inherit land in this patrilineal system; they gain access to land through marriage. They are the farmers but they do not own the land. It is much more difficult for women to accumulate capital and to obtain loans. Girls as a group are given less education because girls leave the parental home while boys stay forever [72]. The status inequality of Kikuyu women is clear. They are given enormous responsibilities while their ability to experience success in advancing their own and their family’s interests is increasingly handicapped in the contemporary environment. As a group they will not attain many of the valued goals that the young men will be able to attain. These include jobs, land holdings, political and legal power, and prestige. Their rewards will be limited to fewer spheres. Considering the overall pattern of Kikuyu women’s lives it may well be that many of them feel caught in unsolvable binds like the school girls’ dilemma of their conflicting beliefs about what behaviors will make them marriageable contrasted with the behaviors being trained into them through their competitive schooling experiences. Feelings of helplessness and hoplessness may be the result for many women. The symptoms they report young significantly more often indicate that they are less hopeful of a positive outcome for themselves than are

313

the males. This seems a realistic appraisal of their situation. The pattern of emotional constraint typical of Kikuyu may also contribute to these feelings. In general, men are allowed more freedom of expression of anger and have a greater variety of outlets than do women in aggressive acts and displays. Anger in reaction to frustration is often not expressed as freely or frequently by women. Depression has been viewed by some theorists as anger turned inward. anger directed toward self rather than the actual or symbolic frustrating object. If an individual is not allowed expression of angry feelings, depressive feelings and symptoms may arise. Although we know of no detailed studies of Kikuyu emotional patterning, it is one of the author’s impressions based on her Kikuyu fieldwork, that girls and women are differentially socialized regarding anger than boys and men. Girls and women should not openly express anger. A particularly apt observation regarding the expression of anger was made to one of the authors by an intelligent Kikuyu women in her late twenties. This women was a widow with children at home. In addition to teaching school, she grew the family food and raised coffee on the few acres her sons would someday inherit. After seeing a movie together that was based on D. H. Lawrence’s novel Women in Low, Wanjuku thoughtfully asked. “Your women have more freedom, don’t they?” “What do you mean, ‘more freedom’?” “You can show it when you’re angry. can’t you? We can’t. and I think its better if you can” [ 1, p. 1831. The expression of anger appears to be more constrained for Kikuyu females than for Kikuyu males. A frequently cited review of the literature on depression and women concluded that “The male-female differences in rates of depression are real.. Further studies in non-Western countries, particularly in Africa and Asia, are necessary before any conclusions can be drawn as to the universality of these rate differences” [S, p. 1091. While this study has not examined rates of depression, it does reveal that this group of African young women reported more symptoms of depression than did a comparable group of African young men. The results of this study lend further support to the findings that indications of depression are found more frequently in females than in males in many cultural groups. Particularly promising leads for future comparative, cross-cultural research include: (1) Is the gap between male and female rates of depression less in more egalitarian cultural groups [5] and greater in less egalitarian groups? A controversial issue at present is whether the degree of sexual egalitarianism in hunter-gatherer groups is as great as has been claimed by some. Nonetheless, it appears that these groups do have a comparatively high degree of sexual equality. Are their male-female rates of depression closer than are those of other groups? (2) Is the gap between male and female rates of depression less in groups where the socialization of emotional expression allows for more equal expression of aggressive, hostile, angry feelings? Edgerton’s [loo] comparative study of pastoralists and farmers in

SHAKON MITCHELL and SUSAN AHHOTI

314

East Africa demonstrated that farmers as a group are much more controlled in their emotional displays than are pastoralists. Do pastoralist women with their freer emotional expressivity experience fewer depressive symptoms than waomen from traditionallq horticultural subsistence systems in which the display of anger and other intense feelings is considered to be deviant? (3) Where maleefemale drinking patterns and/or criminal rates are similar. is the gap in depression rates less, as has been found for the Amish [ l9l]? These might be considered as indirect measures of both status and ability to openly express anger and hostility towards the object of that anger. (4) Studies which compare rates of depression in various cultures among subgroups of significance such as students. non-student youth. adults with resident children and adults without resident children are indicated at the present time. Are the patterns found in Western, industrialized countries replicated in other settings? If so. why? Cross-cultural research designed to address thcsc questions would shed some light on the hypothcscs for the gender differences in depression which arc currently debated. A~,X-t~o~~k,d~c,nf~,~~f,\~ Original data collection wa\ funded b) Carnegie Corporation through the Child Development Research Unit. Harvard Univervty and the LJniversltl ot Nairobi. John W. M. Whiting and Beatrice B. Whiting. Directors; data analysis v+as funded hq the Ilnivcrslty 01 Kentucky. We wish to thank Helen Crauford and Teresa Eppersc.n for their assistance 111 manuscript preparation.

IZ

I4

15

I6 I7

IX

I9

20

71

22

73.

‘4 2s

1. Abbott 2.

3. 4.

5.

6.

7.

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S. and Klein R. DepressIon and anxlcty among rural Kikuyu m Kenya. E/ho.\ 7. 2. 161. 1979. Dohrenwend B. P. and Dohrenwcnd B. S Sex difference and psychiatric disorders. .~lnr. .I. .SC>C,/O/. 81. 1447. 1976. Murphy J M. Trends in depression and anxiety: men and women. Acrcr ps~~chicrr..SC,CI?I~. 73, 113. 19X6. Goldman N. and Ravid R. Communlt) surveys: \cx difrerences in mental illness. In ‘7% .M~tl/rr/ I//,rc.v.\ of Womcv (Edited by Guttentag M.. Salasin S. and Belle D.). p. 31. Academic Presc. Ncu York. 19x0. Weissman M. M. and Klerman Cr. L. Sex differences and the epidemiology of depression. .4r&s ,qc’n. Ps)chia/. 34, 98, 1977. Hammen C. I.. Gender and depressIon In C;cntlvr ~rnti f.\~~c~hopcrrho/o~~~ (Edited by Al-Issa 1.). p I33 Ac:tdemic Press. New York. 19X2. Belle D. and Goldman N. Pattern\ of diagnoses rcceived by men and uomen In T/I<, Clcrlrtrl Hwlth of U’wmv~ (Edited by Guttentag M.. S&sin S. and Bellc D.). p. 21. Academic Prcsa. NC\\ York. 1980. Aneshensel C. S. (‘I (I/. Family roles and sex ditrerences in depression. J H//h SOC. B&r. 22, 379. IOX I. Eaton J. W. and Weil R. J. Culrurca unt/ .ve,zl~r/ Di.wrtkw.v: A Compcrruriw .Stucl>, r!/’ t/w Hu/~wrtr.s md ot/wr Popu/trrwrr.r. Free Press. Glencoe. III.. 1955. Frerichs R. R.. Aneshensel C. S. and Clark V. Prcvalence of depression in Los Angeles County ,401. .I Epiden~. 113, 691. 1981. Kaplan H. B. Gender and depression: a soclolo@lcal analysis of a conditional relationshlp. In Pllcvvnrrno/qq cr,zd Trerr/nlmt qf Depw.v.sior~ (Edited by Fann W. E. 6’1 (I/.). p. Xl. Spectrum, New York. 1977. Midanik L Alcohol prohlcms and dcpresslon symp-

26

27

‘X

29

30

31

i2

3?

34

35

i6

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Depression

37.

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56. 57.

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and anxiety

among

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