Sex and depression in the National Comorbidity Survey, I: lifetime prevalence, chronicity and recurrence
Abstract
Basic epidemiologic prevalence data are presented on sex differences in DSM-III-R major depressive episodes (MDE). The data come from the National Comorbidity Survey (NCS), the first survey in the U.S. to administer a structured psychiatric interview to a nationally representative sample of the general population. Consistent with previous research, women are approximately 1.7 times as likely as men to report a lifetime history of MDE. Age of onset analysis shows that this sex difference begins in early adolescence and persists through the mid-50s. Women also have a much higher rate of 12-month depression than men. However, women with a history of depression do not differ from men with a history of depression in either the probability of being chronically depressed in the past year or in the probability of having an acute recurrence in the past year. This means that the higher prevalence of 12-month depression among women than men is largely due to women having a higher risk of first onset. The implications of these results for future research are discussed in a closing section of the paper.
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Girls primarily account for the increase in adolescent depression, with a 2:1 sex difference continuing through reproductive years.
“It is primarily girls who account for the increase in adolescence,2,3 evidencing a 2:1 sex difference in depression that continues throughout the reproductive years.4”
From Subthreshold Symptoms of Depression in Preadolescent Girls Are Stable and Predictive of Depressive Disorders (2008) · cites this paper as [4]
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Sex-specific transcriptional signatures in human depression
Labonté, B., Engmann, O., Purushothaman, I., Menard, C., Wang, J., Tan, C., Scarpa, J. R., Moy, G., Loh, Y.-H. E., Cahill, M., et al. (2017) · Nature Medicine · doi:10.1038/nm.4386 · Cited by 748 · see citing works
Sex differences in posttraumatic stress disorder
Breslau, N. (1997) · Archives of General Psychiatry · doi:10.1001/archpsyc.1997.01830230082012 · Cited by 783 · see citing works
Revisiting the Relationships among Gender, Marital Status, and Mental Health
Simon, R. W. (2002) · American Journal of Sociology · doi:10.1086/339225 · Cited by 759 · see citing works
“Consistent with the recent research on adolescents, the National Co-Morbidity Study also reveals that female’s greater self-reported feelings of depression and male’s greater self-reports of substance problems begin to appear in adolescence—before they have assumed their adult social roles (also see Avison and McAlpin…”
ResultSex differences in stress-related psychiatric disorders: neurobiological perspectives
Bangasser, D. A., & Valentino, R. J. (2014) · Frontiers in Neuroendocrinology · doi:10.1016/j.yfrne.2014.03.008 · Cited by 737 · see citing works
“The increased rates of depression in women compared to men emerge following puberty (when ovarian hormone circulation increases) and remain high until menopause (when levels of ovarian hormones drop), which suggests that activational effects of ovarian hormones may be critical [17; 18; 317].”
Backgroundde Velde, S. V. V., Bracke, P., & Levecque, K. (2010) · Social Science & Medicine (1967) · doi:10.1016/j.socscimed.2010.03.035 · Cited by 765 · see citing works
Barth, C., Villringer, A., & Sacher, J. (2015) · Frontiers in Neuroscience · doi:10.3389/fnins.2015.00037 · Cited by 731 · see citing works
“A better understanding of functional and structural connectivity changes in the context of sex steroid fluctuations seems crucial to establish neurobiological models of neuropsychiatric diseases that display a strong sexual dimorphism, such as depression (Kessler et al., 1993; Kessler, 2003).”
BackgroundMoffitt, T. E., Harrington, H., Caspi, A., Kim-Cohen, J., Goldberg, D., Gregory, A. M., & Poulton, R. (2007) · Archives of General Psychiatry · doi:10.1001/archpsyc.64.6.651 · Cited by 41 · see citing works
“The past-year MDD prevalence (mean of ages 15, 18, 21, 26, and 32 years) of 14% in the Dunedin cohort is comparable with the past-year prevalence of 12% for 15- to 34-year-olds in the NCS.(44) Past-year GAD at ages 18, 21, 26, and 32 years was diagnosed as described in the previous paragraph for MDD.”
MethodInfluentialGender Differences in Treatment Response to Sertraline Versus Imipramine in Chronic Depression
Kornstein, S. G., Schatzberg, A. F., Thase, M. E., Yonkers, K. A., McCullough, J. P., Keitner, G. I., Gelenberg, A. J., Thomas, S., Harrison, W. M., & Keller, M. B. (2000) · American Journal of Psychiatry · doi:10.1176/appi.ajp.157.9.1445 · Cited by 712 · see citing works
Eaton, N. R., Keyes, K. M., Krueger, R. F., Balsis, S., Skodol, A. E., Markon, K. E., Grant, B. F., & Hasin, D. S. (2012) · Journal of Abnormal Psychology · doi:10.1037/a0024780 · Cited by 701 · see citing works
“Specifically, women show significantly higher prevalence rates of internalizing disorders, while men show significantly higher rates of externalizing disorders (Grant & Weissman, 2007; Kessler et al., 1993, 1994).”
Sackeim, H. A., Haskett, R. F., Mulsant, B. H., Thase, M. E., Mann, J. J., Pettinati, H. M., Greenberg, R. M., Crowe, R. R., Cooper, T. B., & Prudic, J. (2001) · JAMA · doi:10.1001/jama.285.10.1299 · Cited by 686 · see citing works
“There is inconsistent evidence from naturalistic studies of a higher relapse/recurrence rate among women.(14,66-70) Studies of patients with psychotic depression suggested a high post-ECT relapse rate.”
BackgroundAntidepressants increase neural progenitor cells in the human hippocampus
Boldrini, M., Underwood, M. D., Hen, R., Rosoklija, G. B., Dwork, A. J., John Mann, J., & Arango, V. (2009) · Neuropsychopharmacology · doi:10.1038/npp.2009.75 · Cited by 686 · see citing works
Rutter, M., Caspi, A., & Moffitt, T. E. (2003) · Journal of Child Psychology and Psychiatry · doi:10.1111/1469-7610.00194 · Cited by 672 · see citing works
Association of Hormonal Contraception With Depression
Skovlund, C. W., Mørch, L. S., Kessing, L. V., & Lidegaard, Ø. (2016) · JAMA Psychiatry · doi:10.1001/jamapsychiatry.2016.2387 · Cited by 675 · see citing works
Martin, L. A., Neighbors, H. W., & Griffith, D. M. (2013) · JAMA Psychiatry · doi:10.1001/jamapsychiatry.2013.1985 · Cited by 674 · see citing works
“Addis7 proposes 4 conceptual frameworks within the existing literature that address how gender shapes men’s experiences, expressions, and reactions to depression: (1) the sex differences framework, (2) the masked depression framework, (3) the masculine depression framework, and (4) the gendered response framework.”
BackgroundSimon, R. W., & Nath, L. (2004) · American Journal of Sociology · doi:10.1086/382111 · Cited by 664 · see citing works
“On the other hand, research on mental health also documents that there are no gender differences in overall levels of emotional distress when male and female types of emotional problems are both considered (Kessler et al. 1993).”
BackgroundResultElevated inflammation levels in depressed adults with a history of childhood maltreatment
Danese, A., Moffitt, T. E., Pariante, C. M., Ambler, A., Poulton, R., & Caspi, A. (2008) · Archives of General Psychiatry · doi:10.1001/archpsyc.65.4.409 · Cited by 641 · see citing works
“MAJOR DEPRESSION AT AGE 32 YEARS Clinical interviews for the diagnosis of depression at age 32 years were carried out using the Diagnostic Interview Schedule20 and DSM-IV criteria.21 At age 32 years, the past-year depression prevalence in the Dunedin cohort was 16% (62% female), which is comparable to the past-year pr…”
MethodInfluentialEffects of paternal depression on fathers' parenting behaviors: a meta-analytic review
Wilson, S., & Durbin, C. E. (2010) · Clinical Psychology Review · doi:10.1016/j.cpr.2009.10.007 · Cited by 603 · see citing works
Major Depression and Its Recurrences: Life Course Matters
Monroe, S. M., & Harkness, K. L. (2022) · Annual Review of Clinical Psychology · doi:10.1146/annurev-clinpsy-072220-021440 · Cited by 608 · see citing works
Pathogenesis of depression: Insights from human and rodent studies
Ménard, C., Hodes, G. E., & Russo, S. J. (2016) · Neuroscience · doi:10.1016/j.neuroscience.2015.05.053 · Cited by 593 · see citing works
“This represents approximately 35 million adults in the US that will experience an episode of major depression in their lifetime (Kessler et al., 2003), with women having a higher risk of first onset and twice the occurrence of men (Kessler et al., 1993).”
BackgroundInfluentialMajor depression after breast cancer: a review of epidemiology and treatment
Fann, J. R., Thomas-Rich, A. M., Katon, W. J., Cowley, D., Pepping, M., McGregor, B. A., & Gralow, J. (2008) · General Hospital Psychiatry · doi:10.1016/j.genhosppsych.2007.10.008 · Cited by 586 · see citing works
“Decline in estrogen, not the level of estrogen, remains a leading hypothesis regarding the high rate of reproductive endocrine-associated affective symptoms and depressive disorders seen in periods of acute estrogen decline [165–168].”
BackgroundNeurodevelopment of Children Exposed in Utero to Antidepressant Drugs
Nulman, I., ROVET, J. F., Stewart, D. E., Wolpin, J., Gardner, H. A., Theis, J. G. W., Kulin, N. A., & Koren, G. (1997) · New England Journal of Medicine · doi:10.1056/nejm199701233360404 · Cited by 572 · see citing works
Chwastiak, L., Ehde, D. M., Gibbons, L. E., Sullivan, M., Bowen, J. D., & Kraft, G. H. (2002) · American Journal of Psychiatry · doi:10.1176/appi.ajp.159.11.1862 · Cited by 555 · see citing works
Hormones and mood: from menarche to menopause and beyond
Steiner, M. S. (2003) · Journal of Affective Disorders · doi:10.1016/s0165-0327(02)00432-9 · Cited by 556 · see citing works
Women’s Attitudes, Preferences, and Perceived Barriers to Treatment for Perinatal Depression
Goodman, J. H. (2009) · Birth · doi:10.1111/j.1523-536x.2008.00296.x · Cited by 526 · see citing works
Kendler, K. S., Myers, J., & Prescott, C. A. (2005) · American Journal of Psychiatry · doi:10.1176/appi.ajp.162.2.250 · Cited by 544 · see citing works
Ge, X., Conger, R. D., & Elder, G. H. (2001) · Developmental Psychology · doi:10.1037//0012-1649.37.3.404 · Cited by 788 · see citing works
Psychopathology in Women and Men: Focus on Female Hormones
Seeman, M. V. (1997) · American Journal of Psychiatry · doi:10.1176/ajp.154.12.1641 · Cited by 542 · see citing works
“While the lifetime risk of bipolar or manic-depressive illness is approximately 1% for both sexes, unipolar depressions are twice as common in women as in men (80).”
BackgroundClarifying the Relationship Between Parenthood and Depression
Evenson, R. J., & Simon, R. W. (2005) · Journal of Health and Social Behavior · doi:10.1177/002214650504600403 · Cited by 534 · see citing works
“Interestingly, a greater percentage of parents with adult children at home, nonresidential adult children, and nonresidential adult stepchildren are female as well.4 Mirroring the female excess of depression in the United States, additional analyses (available upon request) indicate that women report significantly hig…”
BackgroundInfluentialNeonatal Signs After Late In Utero Exposure to Serotonin Reuptake Inhibitors
Moses‐Kolko, E. L., Bogen, D. L., Perel, J. M., Bregar, A. J., Uhl, K., Levin, B., & Wisner, K. L. (2005) · JAMA · doi:10.1001/jama.293.19.2372 · Cited by 532 · see citing works
Prevalence and Incidence Studies of Mood Disorders: A Systematic Review of the Literature
Waraich, P., Goldner, E. M., Somers, J. M., & Hsu, L. (2004) · The Canadian Journal of Psychiatry · doi:10.1177/070674370404900208 · Cited by 522 · see citing works
“The results of 2 studies reporting only 1-year age-specific rates are not reported here (35,44).”
BackgroundNatural Course of Adolescent Major Depressive Disorder: I. Continuity Into Young Adulthood
Lewinsohn, P. M., Rohde, P., Klein, D. N., & Seeley, J. R. (1999) · Journal of the American Academy of Child & Adolescent Psychiatry · doi:10.1097/00004583-199901000-00020 · Cited by 527 · see citing works
Hippocampal Changes in Patients With a First Episode of Major Depression
Frodl, T., Meisenzahl, E. M., Zetzsche, T., Born, C., Groll, C., Jäger, M., Leinsinger, G. L., Ronald Bottlender, A., Hahn, K. M., & Möller, H. (2002) · American Journal of Psychiatry · doi:10.1176/appi.ajp.159.7.1112 · Cited by 525 · see citing works
Perinatal Risks of Untreated Depression during Pregnancy
Bonari, L., Pinto, N., Ahn, E., Einarson, A., Steiner, M. S., & Koren, G. (2004) · The Canadian Journal of Psychiatry · doi:10.1177/070674370404901103 · Cited by 524 · see citing works
Kendler, K. S., Thornton, L. M., & Prescott, C. A. (2001) · American Journal of Psychiatry · doi:10.1176/appi.ajp.158.4.587 · Cited by 520 · see citing works
Risk factors for depression: an autobiographical review
Hammen, C. (2018) · Annual Review of Clinical Psychology · doi:10.1146/annurev-clinpsy-050817-084811 · Cited by 483 · see citing works
“…or sexual abuse; exposure to family violence; parental criminality; and parental substance abuse or mental illness) or in relation to more specific events, such as maltreatment, and the relationship of these events to depression (e.g., Green et al. 2010, Kessler et al. 2010, Lindert et al. 2014).”
BackgroundKane, P., & Garber, J. (2004) · Clinical Psychology Review · doi:10.1016/j.cpr.2004.03.004 · Cited by 498 · see citing works
“The National Comorbidity Survey (Blazer et al., 1994; Kessler et al., 1993) estimated the 30-day and lifetime prevalence of major depressive episode in adult males to be 3.8% and 12.7%, respectively.”
InfluentialFirst-Trimester Use of Selective Serotonin-Reuptake Inhibitors and the Risk of Birth Defects
Louik, C., Lin, A. E., Werler, M. M., Hernández–Dı́az, S., & Mitchell, A. A. (2007) · New England Journal of Medicine · doi:10.1056/nejmoa067407 · Cited by 500 · see citing works
Gender differences in chronic major and double depression
Kornstein, S. G., Schatzberg, A. F., Thase, M. E., Yonkers, K. A., McCullough, J. P., Keitner, G. I., Gelenberg, A. J., Ryan, C. E., Hess, A., Harrison, W. M., et al. (2000) · Journal of Affective Disorders · doi:10.1016/s0165-0327(99)00158-5 · Cited by 489 · see citing works
“clinical implications for gender-specific assessment Studies that have examined course features of and treatment planning, as well as theoretical impli- major depressive disorder have shown no sex differcations for achieving a more comprehensive under- ences in age of onset (Frank et al., 1988; Burke et standing of th…”
BackgroundMethodInfluentialEaton, W. W. (1997) · Archives of General Psychiatry · doi:10.1001/archpsyc.1997.01830230023003 · Cited by 489 · see citing works
Fonken, L. K., Xu, X., Weil, Z. M., Chen, G., Sun, Q., Rajagopalan, S., & Nelson, R. J. (2011) · Molecular Psychiatry · doi:10.1038/mp.2011.76 · Cited by 484 · see citing works
Sex and depression in the National Comorbidity Survey. II: cohort effects
Kessler, R. C., McGonagle, K. A., Nelson, C. B., Hughes, M., Swartz, M., & Blazer, D. G. (1994) · Journal of Affective Disorders · doi:10.1016/0165-0327(94)90147-3 · Cited by 486 · see citing works
Self-citationThe gender paradox in suicidal behavior and its impact on the suicidal process
Schrijvers, D. L., Bollen, J., & Sabbe, B. G. C. (2012) · Journal of Affective Disorders · doi:10.1016/j.jad.2011.03.050 · Cited by 477 · see citing works
Sociodemographics, self-rated health, and mortality in the US
Franks, P. J., Gold, M. R., & Fiscella, K. A. (2003) · Social Science & Medicine · doi:10.1016/s0277-9536(02)00281-2 · Cited by 481 · see citing works
Sex differences in cognitive impairment and Alzheimer’s disease
Li, R., & Singh, M. (2014) · Frontiers in Neuroendocrinology · doi:10.1016/j.yfrne.2014.01.002 · Cited by 527 · see citing works
“Although women have higher rates of depression and anxiety, and these are emerging as risk factors for AD (Kessler et al., 1993; Thielscher et al., 2013), one longitudinal study evaluating more than 1300 subjects found the depression is a risk factor for AD only in men, and not in women (Dal Forno…”
BackgroundVerhagen, M., van der Meij, A., van Deurzen, P. A. M., Janzing, J. G. E., Arias-Vásquez, A., Buitelaar, J. K., & Franke, B. (2010) · Molecular Psychiatry · doi:10.1038/mp.2008.109 · Cited by 470 · see citing works
Noble, R. E. (2005) · Metabolism · doi:10.1016/j.metabol.2005.01.014 · Cited by 467 · see citing works
Walf, A. A., & Frye, C. A. (2006) · Neuropsychopharmacology · doi:10.1038/sj.npp.1301067 · Cited by 461 · see citing works
“Women are twice as likely to experience major depression, particularly unipolar depression, compared to men (Earls, 1987; Kessler et al, 1993; Nolen-Hoeksema, 1987).”
BackgroundPrediction of Differential Adult Health Burden by Conduct Problem Subtypes in Males
Odgers, C. L., Caspi, A., Broadbent, J. M., Dickson, N. P., Hancox, R. J., Harrington, H., Poulton, R., Sears, M. R., Thomson, W. M., & Moffitt, T. E. (2007) · Archives of General Psychiatry · doi:10.1001/archpsyc.64.4.476 · Cited by 460 · see citing works
“Prevalence rates in the Dunedin cohort are similar to those from American epidemiological surveys.(30,31) For this report, we examined grouped anxiety disorders (generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, agoraphobia, social phobia, and simple phobia), major depressive disorder, canna…”
ResultTime trends in adolescent mental health
Collishaw, S., Maughan, B., Goodman, R., & Pickles, A. (2004) · Journal of Child Psychology and Psychiatry · doi:10.1111/j.1469-7610.2004.00335.x · Cited by 508 · see citing works
Teen‐aged mothers in contemporary Britain
Moffitt, T. E., & the E‐Risk Study Team (2002) · Journal of Child Psychology and Psychiatry · doi:10.1111/1469-7610.00082 · Cited by 439 · see citing works
Socioeconomic status in childhood and the lifetime risk of major depression
Gilman, S. E., Kawachi, I. I., Fitzmaurice, G. M., & Buka, S. L. (2002) · International Journal of Epidemiology · doi:10.1093/ije/31.2.359 · Cited by 437 · see citing works
Costello, E. J., Foley, D. L., & Angold, A. C. (2005) · Journal of the American Academy of Child & Adolescent Psychiatry · doi:10.1097/01.chi.0000184929.41423.c0 · Cited by 436 · see citing works
Sex Differences in Vulnerability and Resilience to Stress Across the Life Span
Hodes, G. E., & Epperson, C. N. (2019) · Biological Psychiatry · doi:10.1016/j.biopsych.2019.04.028 · Cited by 417 · see citing works
“Finally, the majority of basic research examining the mechanisms of resilience has done so only in male animals (12) when the majority of humans experiencing stress-related disorders are female (13, 14).”
BackgroundPregnancy Outcome Following Maternal Use of the New Selective Serotonin Reuptake Inhibitors
Kulin, N. A., Pastuszak, A. L., Sage, S. R., Schick-Boschetto, B., Spivey, G., Feldkamp, M. L., Ormond, K. E., Matsui, D. M., Schechtman, A. S., Cook, L. P., et al. (1998) · JAMA · doi:10.1001/jama.279.8.609 · Cited by 423 · see citing works
Gonadal steroid hormones and the hypothalamo–pituitary–adrenal axis
Handa, R. J., & Weiser, M. J. (2014) · Frontiers in Neuroendocrinology · doi:10.1016/j.yfrne.2013.11.001 · Cited by 408 · see citing works
“Of importance for this discussion are the findings that a number of human neuropsychiatric disorders are accompanied by a dysregulation of the HPA axis and that many of these disorders exhibit profound sex differences in risk implicating a modulatory role for gonadal steroid hormones (Kessler et al., 1993; Kessler, 20…”
BackgroundInfluentialMaternal Depression and Children’s Antisocial Behavior: Nature and Nurture Effects
Kim-Cohen, J., Moffitt, T. E., Taylor, A., Pawlby, S. J., & Caspi, A. (2005) · Archives of General Psychiatry · doi:10.1001/archpsyc.62.2.173 · Cited by 417 · see citing works
“However, a recent study found no significant difference in levels of depression between mothers of twins vs singletons.(70) Moreover, the lifetime prevalence rate we report for E-Risk Study mothers in their early 30s (33%) is comparable with that reported by Kendler et al(71) in a population-based sample of women in t…”
ResultDepression scale scores in 8–17‐year‐olds: effects of age and gender
Angold, A. C., Erkanli, A., Silberg, J. L., Eaves, L. J., & Costello, E. J. (2002) · Journal of Child Psychology and Psychiatry · doi:10.1111/1469-7610.00232 · Cited by 418 · see citing works
“…Catchment Area (ECA) studies (Burke et al., 1990) suggested that unipolar depression onset rates were equal in males and females until age 15–19, while the National Comorbidity Survey (NCS; Kessler et al., 1993) provided evidence for the emergence of an onset differential by age 10–14.”
BackgroundInfluentialEthnocultural Differences in Prevalence of Adolescent Depression
ROBERTS, R. E., Roberts, C. R., & Chen, Y. R. (1997) · American Journal of Community Psychology · doi:10.1023/a:1024649925737 · Cited by 409 · see citing works
Prevalence of Depressive Disorders in Individuals with Autism Spectrum Disorder: A Meta-Analysis
Hudson, C. C., Hall, L., & Harkness, K. L. (2019) · Journal of Abnormal Child Psychology · doi:10.1007/s10802-018-0402-1 · Cited by 411 · see citing works
Everyday stressors and gender differences in daily distress.
Almeida, D. M., & Kessler, R. C. (1998) · Journal of Personality and Social Psychology · doi:10.1037//0022-3514.75.3.670 · Cited by 406 · see citing works
Self-citationGater, R., Tansella, M., Korten, A., Tiemens, B. G., Mavreas, V. G., & Olatawura, M. O. (1998) · Archives of General Psychiatry · doi:10.1001/archpsyc.55.5.405 · Cited by 390 · see citing works
“Previous research has suggested that varying the number of symptoms required for a diagnosis of depression alters the ratio of women to men.(37,38) Thus, our findings may to some extent be the product of sex differences in the conceptualization and reporting of symptoms of depression and anxiety, rather than real diff…”
Background
- Authors
- Kessler, R.
- Affiliations
- University of Michigan (US)
- Corresponding author
- Kessler, R
- ORCID
- Kessler, R
- Venue
- Journal of Affective Disorders
- Publisher
- Elsevier BV
- Published
- 1993-11
- Volume
- 29
- Issue
- 2-3
- Pages
- 85-96
- ISSN
- 0165-0327 (ISSN-L)
- OpenAlex
- W1992284534
- Cited by
- 2,207
- References
- 67
- Citations by year
- 2026: 31 · 2025: 50 · 2024: 47 · 2023: 58 · 2022: 84 · 2021: 71 · 2020: 73 · 2019: 78 · 2018: 78 · 2017: 124 · 2016: 81 · 2015: 98 · 2014: 119 · 2013: 105 · 2012: 101
- FWCI
- 21.43
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Journal of Affective Disorders (publishedVersion)
- PubMed (publishedVersion)
- Deep Blue (University of Michigan) (submittedVersion)
- Funders
- State University of New York
- Johns Hopkins University
- York University
- University of Toronto
- National Institute of Mental Health (5RO1 MH46376, R01MH046376, MH 46376, 90135190)
- Topics
- Social Sciences › Psychology › Social Psychology › Mental Health Treatment and Access
- Health Sciences › Medicine › Pharmacology › Treatment of Major Depression
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Keywords
- sex differences, major depressive episode, depression prevalence, chronic depression, depression recurrence, age of onset, National Comorbidity Survey, men and women
- MeSH terms
- Adolescent, Adult, Age Factors, Chronic Disease, Cross-Sectional Studies, Depressive Disorder, Female, Humans, Male, Middle Aged, Personality Assessment, Psychiatric Status Rating Scales, Recurrence, Sex Factors, United States, Cohort Studies, Comorbidity, Incidence
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