The surprising rates of depression among MENA’s women


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Recently I attended a health strategy meeting, where indicators of health risks showed depression to be the top disease affecting women in the Middle East and North Africa (MENA) but not men (where it was on average 7th place). In one sense, this is not too surprising because depression affects women more than men everywhere. On average, globally, depression ranks 6th for women and 16th for men. 

Still, MENA is unique. The table below shows the average rank of major depressive disorder in terms of a standard measure of health costs, disability adjusted life years (DALY), using data from the  Institute for Health Metrics and Evaluation (IHME). Depression is ranked more highly among MENA’s women than any other region. While MENA’s men are also more prone to depression, the percentage gap between men and women is higher in MENA than all other regions, with the notable exception of Latin America and Caribbean (LAC).  This suggests that men in MENA look more like their counterparts in the rest of the world than women in MENA look like their global sisters.

The map below from IHME shows the ranking of depression across countries. Darker red indicates closer to top rank. Seven of the top 10 countries in the world by rank of depression in women are in MENA (2 of the other 3 are in Latin America and 1 in Europe).

What could explain the prevalence of depression in MENA’s women? One possibility is lack of agency — the capacity to act and make choices. Agency depends to a great extent on income, which provides people with a means to decide where and how to live and what to purchase.

To examine this relationship, I looked at the correlation between women’s labor force participation and the rank of depression. Labor force participation is defined by the share of working age women employed or seeking work. The chart below shows a scatter plot of the two variables. There is a strong positive correlation, indicating that as labor force participation rises the ranking of depression tends to fall (move farther from one). On average, a ten percentage point rise in participation is associated with a drop in the rank of depression by nearly one full spot. 

Of course this is a correlation not a causal indicator. But it could suggest that as women work they are less prone to depression. Indeed, there is a large body of evidence that shows a strong relationship between unemployment and depression.

There are other potential explanations, however, which also warrant further investigation.

Other country specific factors, might affect both women participation in the labor force and depression. For example, social norms that exclude women from participating equally in society might lead to low female participation and more depression. This would generate a correlation between labor force participation and depression, but would not point to women’s participation in the labor force as the culprit. Alternatively, general economic woes could lead to more depression and low labor force participation (after all periods of slow growth and high unemployment are themselves dubbed depressions). Indeed this could explain MENA’s relatively high rate of depression in both men and women, but it does not explain the relatively high cost to women as compared with men in the region, especially given men are the main breadwinners.

Finally, women’s relatively higher rates of depression might cause them to stay out of the labor market.This however seems less likely because there are many countries that rank depression near the top and yet attain high rates of labor force participation.  What is far less common are countries with relatively happy women when labor force participation is low.

In any case this relationship deserves more exploration. If limited employment opportunities for women in MENA are creating serious health risks, expanding them is that much more critical.  Our newly released report “Opening Doors: Gender Equality in the Middle East and North Africa” explores determinants of the low labor force participation in MENA, linking it closely with social norms, and offers policies for change.

Join the Conversation

Caroline Freund
March 19, 2013

Dear Sima,
Thank you for your interest. I was also very surprised and that is why I decided to write this up. As far as I know this is the best comparable data on diseases across countries that exist, and has the benefit of not being disease specific. The data are from the Global Burden of Disease study, and are available from the Institute of Health Metrics and Evaluation website. The full report detailing the methodology can be found here. The data are compiled from a variety of sources, including: vital registration systems, mortality surveillance systems, censuses, surveys, hospital records, police records, mortuaries, and verbal autopsies.
According to their website, the 2010 data are compiled as follows:
GLOBAL BURDEN OF DISEASES, INJURIES, AND RISK FACTORS STUDY 2010The Global Burden of Disease Study 2010 (GBD 2010) is a collaborative project of nearly 500 researchers in 50 countries led by the Institute for Health Metrics and Evaluation (IHME) at the University of Washington. It is the largest systematic scientific effort in history to quantify levels and trends of health loss due to diseases, injuries, and risk factors. GBD serves as a global public good to inform evidence-based policymaking and health systems design.
I hope this helps.

Sima Kanaan
March 18, 2013

I am very intrigued by this article and although I am surprised at the higher rates of depression amongst women compared to men in MENA, I find it remarkable that depression is ranked as the number 1 disease amongst women. I concur with the view that lack of agency could be amongst the explanations for this phenomenon. On the other hand, we also know that women in the MENA region have strong social and familial relationships and I am surprised that this does not seem to be offsetting, at least in part, the possible negative impact of unemployment and lack of active participation. I would appreciate it if the author could provide more information on the data used and its sources. I was under the impression that depression is not widely diagnosed and reported in MENA; hence, my curiousity and surprise at the statistics. Thanks.

March 19, 2013

Dear Caroline,Thanks so much for the additional information provided on the data. I will review the study with great interest. I want to also thank you for writing this blog. It is an important issue to raise awareness around.Much appreciated. Sima

March 23, 2013

The study is interesting, but the conclusions are a bit dangerous. Why do you assume women in the Middle East are unhappy because of their circumstances? This is ethnocentric at best, and excludes medical or genetic causes such as Vitamin D deficiency or B12 deficiencies which are quite common in this population.

If culture or poverty is supposed to be the cause of depression, then why do Sub-Saharan countries rank as some of the happiest? Please question your assumptions before you publish work like this.

Paul F Davis
March 24, 2013

Outstanding data and excellent graphs and charts to visually reveal the emotional state of women throughout the Middle East. Thank you for your in depth research and analysis.

Paul F Davis - author of 'Empowering & Liberating Women'

Caroline Freund
March 25, 2013

Dear Anonymous reader who commented on March 23, 2013:Thank you for your interest. I am sorry that you found the blog ethnocentric, I certainly did not intend that. In responding to your specific concerns, there are a few things I would ask you to keep in mind.First, this is a blog, and like any other opinion piece, it is expected to stimulate discussion, not necessarily be a refereed article. Your interest suggests I managed that - even if you found it provocative, at least we have a discussion started.Second, I have referred to neither poverty nor to culture, as an explanation--but rather to agency, which is what a clinical psychologist I consulted in writing the blog suggested.Thirdly, I highlighted the correlation with labor force participation, but I tried to be careful in interpretation, by pointing out it is not necessarily a causal relationship.Finally, I am very open to alternative interpretations, indeed I conclude with asking for more research. I welcome your ideas, and hope you explore them.Caroline

April 04, 2013

some possible further food for thought

John Hayes
January 29, 2014

These figures concerning depression are worryingly high.
John Hayes