Major Depressive Disorder 167
Gender-Related Diagnostic Issues
Although the most reproducible finding in th e epidemiology of major depressive disorder
has been a higher prevalence in females, th ere are no clear differences between genders in
symptoms, course, treatment response, or functional consequences. In women, the risk for
suicide attempts is higher, and the risk for suicide completion is lower. The disparity in
suicide rate by gender is not as great among th ose with depressive disorders as it is in the
population as a whole. 
Suicide Risk
The possibility of suicidal behavior exists at  all times during major depressive episodes.
The most consistently described risk factor is a past history of suicide attempts or threats,
but it should be remembered that most comp leted suicides are not preceded by unsuccess-
ful attempts. Other features associated with  an increased risk for completed suicide
include male sex, being single or living alone,  and having prominent feelings of hopeless-
ness. The presence of borderline personality disorder markedly increases risk for future
suicide attempts. 
Functional Consequences of 
Major Depressive Disorder
Many of the functional consequences of major depressive disorder derive from individual
symptoms. Impairment can be very mild, such th at many of those who interact with the af-
fected individual are unaware of depressive symptoms. Impairment may, however, range
to complete incapacity such that the depressed individual is unable to attend to basic self-
care needs or is mute or catatonic. Among individuals seen in ge neral medical settings,
those with major depressive disorder have more pain and physical illness and greater de-
creases in physical, social, and role functioning.
Differential Diagnosis
Manic episodes with irritable mood or mixed episodes. Major depressive episodes
with prominent irritable mood may be difficu lt to distinguish from manic episodes with