The Struggle of Women with Depression: PMDD, PPD, Perimenopause, and Role Strain

The list of gender inequalities is long and alarming, with disparities in income, employment, and household chores being well-documented. However, a lesser-known fact is that women are twice as likely to suffer from depression as men.

The Center for Disease Control and Prevention (CDC) reports that Major Depressive Disorder (MDD) affects 11% of women compared to 6% of men. This significant disparity, known as the "depression gap," persists and must be addressed by understanding its causes.

In an ADDitude webinar titled "Managing Mood Disorders and Depression in ADHD Adults and Kids," William Dodson, M.D., LF-APA, explains that women are more likely to suffer from depression than men. This difference was previously thought to be due to women seeking psychiatric help more often than men, but large-scale population studies have now shown that women indeed experience depression and bipolar disorder more frequently than men.

The fact that women experience depression at higher rates is particularly concerning for the ADHD community since depression is more common among ADHD adults. For instance, a recent survey conducted by ADDitude showed that 70% of ADHD adults also experience depression, whereas this number is only 8% in the general population.

A study published in the American Journal of Epidemiology, using a sample of 813,189 respondents, confirms that a persistent gender gap in depression has persisted for 35 years, with the most significant difference between girls and boys happening between ages 13–15. The depression gap among teenagers has continued to widen since 1982.

These results are echoed in the 2021 CDC Youth Risk Behavior Survey, which found that three in five teenage girls experienced persistent sadness, double the rate of sadness experienced by teen boys and almost double the rate of depression found in teen girls ten years ago. However, the incidence of depression in teen boys increased only 8% over the past decade, with suicidal thinking and impulses among girls rising from 19% to 30%.

Girls with ADHD are at higher risk of depression with the dangers being even greater. Girls with combined type ADHD are three to four times more likely to attempt suicide than their neurotypical peers, and they are more than twice as likely to engage in non-suicidal self-injuring behavior, as explained by Stephen Hinshaw, Ph.D., in an APSARD presentation titled "Girls and Women with ADHD."

The causes of the depression gap are uncertain, but experts believe that it is likely a combination of biological and sociological factors that uniquely affect women. Fluctuations in estrogen and progesterone cause several mood disorders throughout a woman's lifetime, beginning in puberty and persisting through menopause, which disproportionately affects women with ADHD, according to a study published in the Journal of Psychiatric Research. Women with ADHD are more likely to experience hormone-related mood disorders, and their symptoms are often more severe than those of their neurotypical peers.

Premenstrual dysphoric disorder (PMDD) is a hormonal health condition that results in mood swings, impaired functioning, and even suicidality in the week or two leading up to a woman's period. Women who suffer from PMDD may experience irritability, hopelessness, anxiety, fatigue, difficulty concentrating, and sleep disturbances. Although PMDD and PMS share symptoms, PMDD symptoms are more severe and significantly interfere with a woman's functioning, requiring treatment.

A recent survey of 1,856 women with ADHD found that 68% experienced PMS, and 14% also experienced PMDD, nearly double the national average. The most debilitating symptoms reported are irritability, mood swings, cramps, discomfort, and tension or anxiety. Most participants began experiencing PMDD symptoms at age 13 or 14 and continued to feel the effects for 25 years or more.

PMDD is a challenging condition that affects the mental health of many women, as described by Ine, an ADDitude reader who shared her experience with PMDD, "Around a week before my period starts, I feel heavy, unmotivated, depressed. Hanging up the laundry and other household tasks are like climbing a mountain and 99% end with me in tears."

Kristi, an ADDitude reader from Michigan, added that "We get two weeks of mental anguish before our periods, one week of feeling physically bad on our periods, and one week a month to feel normal. PMDD sucks."

The depression gap affecting women presents a complex and troubling phenomenon that requires further attention. Addressing the potential biological and sociological factors that contribute to this gap can help minimize the risk of depression and improve the mental health of women who experience it.

The Centers for Disease Control and Prevention (CDC) reports that 12.5% of women experience postpartum depression (PPD). However, recent studies published in the Journal of Affective Disorders show that the number jumps to 17% for women with an ADHD diagnosis for PPD and 25% for postpartum anxiety. Symptoms typically emerge within the first six weeks after childbirth, but some women experience symptoms during pregnancy, while others report them up to a year after birth.

A recent survey conducted by ADDitude found that out of 1,152 women who have experienced pregnancy, a staggering 56% suffered from PPD—and more than half of them said their symptoms lasted 10 months or longer. Symptoms of PPD include irritability, crying spells, loss of interest in preferred activities, and suicidal thoughts.

If left untreated, PPD can persist for months or years and can have harmful effects on both mother and baby. However, it responds well to treatment, which generally involves a combination of medication and therapy. For instance, ADDitude reader Sara from New Hampshire recalls her experience of PPD, saying, “I felt disconnected emotionally from my daughter, like I was going through the motions of being a parent but could not feel the joy of parenting. I had a really hard time controlling my temper and got overwhelmed easily.”

Similarly, Jenny, an ADDitude reader from Nevada, explains, “My hormones and postpartum depression and anxiety were so bad. Instead of being able to enjoy my baby, I remember that time as very dark and challenging. It makes me so sad; I want to cry every time I think about it.”

Before menopause, perimenopause—or the years leading up to menopause—can bring on a host of emotional issues, including anxiety, mood swings, and possibly depression. Research shows that the likelihood of depression in perimenopause is up to three times greater than it is before perimenopause begins. Moreover, women with a history of depression are nearly five times more likely to develop depression during perimenopause, and those with ADHD are also at an elevated risk. It is encouraging to note, however, that within two to four years after menopause, the risk for depression significantly decreases. Effective treatment can include antidepressants in combination with therapy, and in some cases, doctors may suggest hormone therapy.

According to an ADDitude survey of 826 women with ADHD aged 50 and older, half of the respondents said their ADHD symptoms had a “life-altering” impact during their 50s. In contrast, only a third of women experienced the same level of symptoms from ages 10 to 19. While biological factors create unique risk factors for women, life events and circumstances that tend to impact women more often than men—such as sexual assault and intimate partner violence—also influence the “depression gap.”

RAINN reports that one in six women experience sexual assault, which is likely a contributing factor to the elevated rates of depression in women. A study published in JAMA Internal Medicine found a strong association between depression and a history of sexual assault; women who had experienced sexual assault were three times more likely to develop depressive symptoms than those who hadn’t.

While intimate partner violence affects all genders, the National Domestic Violence Hotline reports that four out of five victims are female. The connection between depressive symptoms and exposure to intimate partner violence is well-established, as evidenced by a recent study in BMC Public Health.

Work-life imbalance and the heavy burden of impossible societal expectations also contribute to poor mental health in women. The Lancet Public Health published a review of 19 studies examining the connection between unpaid labor (such as childcare responsibilities and housework) and mental health challenges including anxiety and depression. The authors of the study concluded: “The combination of a high unpaid workload with paid working commitments can lead to both role strain and time poverty, both of which can negatively affect mental health and wellbeing.”8 In the United States, women do an average 4.5 hours of this unpaid work each day compared with 2.8 hours for men; this strain and the ensuing stress likely play a role in the increased rates of depression in women.

These research studies are helpful in clarifying risk factors as well as underlying associations, and they offer a broad view of how depression is impacting women today. However, Dodson is quick to emphasize that every person is unique, and not everyone’s experience is represented by these statistics. “We deal with individuals,” he explained. “And if it’s happening to you, then it’s 100% prevalent.”

If you are experiencing symptoms of depression, know that it is highly treatable. You should speak with your doctor to figure out an optimal treatment plan; in general, a combination of antidepressants and therapy is shown to be the most effective course of action.

If you are experiencing thoughts of suicide, you can reach the 988 Suicide & Crisis Lifeline by calling or texting 988. The hotline is open 24 hours a day, 7 days a week and is free and confidential.

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