Depressed woman with hands over her face. Crying.

A 2015 survey of North Carolina women found higher rates of depression in the state’s women compared to men, likely due to adverse childhood events.

Mackenzie Self, Center for Women’s Health Research

North Carolina women are at a higher risk for poor mental health due to an increased exposure to stress throughout their lifecycle. The increased prevalence of mental health disorders affects their physical, emotional, psychological and social well-being.

According to the NC Center for Health Statistics, 2015 Behavioral Risk Factor Surveillance System (BRFSS), 23.2 percent of North Carolina women reported a diagnosis of depression.

North Carolina men self-reported a 13.9 percent diagnosis of depression- almost 10 percent lower than that of North Carolina women.

“Women are exposed to more stress than men in our society,” said Dr. Susan Girdler, professor in the Department of Psychiatry at UNC and clinical researcher in the Center for Mood Disorders. “In terms of not only being victims, particularly of sexual abuse, we continue to suffer from greater socioeconomic [and caregiver] stress than men.”

Victimization and early childhood adversity, according to Dr. Girdler, are accurate predictors of a woman’s mental health later in life. Traumatic events such as childhood sexual or physical abuse often lead to depression in women due to the way in which these events affect one’s physiologic response to stress.

According to the CDC-Kaiser Permanente Adverse Childhood Experiences (ACE) Study, 15.2 percent of women included in the study had an ACE score of four or more. One’s ACE score indicates the number of adverse childhood experiences he or she had, and the percentage of women was more than five percent higher than that of men who had a score of four or more.

In the specific ACE category of sexual abuse, 24.7 percent of women reported sexual abuse compared to only 16 percent of men.

“When this exposure occurs, particularly during critical developmental windows of time—when the brain is still forming and networks are still forming, or critical periods such as during pubertal development—our research has shown that it sets you up for life-long dysregulation in your stress response,” Girdler said. “So a traumatic event naturally sort of activates this fight or flight stress response.”

These events, especially if they repeatedly occur during early life and at times of development, make women more vulnerable when it comes to being able to cope with mild stressors later in life. This, in turn, increases one’s risk for developing depression and anxiety.

When it comes to depression, according to Girdler, gender differences don’t emerge until puberty. They last throughout a woman’s adult life and tend to disappear, or diminish, after menopause.

The epidemiological evidence suggests that female sex hormones have a lot to do with mood disorders in women.

“The onset of puberty and monthly fluctuations of hormones in the menstrual cycle is one period of increased risk for mood disorders for premenstrual women,” Girdler said.

“Another is postpartum—the pregnancy and delivery of a baby, that’s a window of increased risk for mood disorders in women, and then during the menopause transition.”

This long period throughout a woman’s life in which she has exposure to rapid changes in hormone levels raises the risk of depression, which contributes to the disparity between the number of men and women experiencing depression.

Whether triggered by female sex hormones, early childhood adversity or some other factor, there are forms of intervention that can help those struggling with depression and other types of mental illnesses. Patients have found great success through counseling, medication, and other mainstream treatments. However, Girdler sees the opportunity for even further research in the area of resilience training.

“There are a lot of people that are exposed to a lot of horrible things in life, and some people are incredibly resilient—they don’t end up with negative mental health,” Girdler said. “I think that that would be such an important area of research intervention—how to build resilience in people who are faced with adversity.”

For victims of childhood sexual abuse, having someone who validates what has happened and intervenes to protect is one form of intervention. Validation seems to play a large role in not only the way people deal with depression and anxiety caused by a traumatic event, but also how high their risk is for developing it.

What many tend to overlook, though, is that mental health isn’t just about whether or not someone suffers from depression, anxiety or some other type of mental illness.

“When I think about mental health, I think about overall well-being, you know, just, are you well? Are you functioning at a high level, are you productive, are you able to meet your goals?” Girdler said. “It also includes stress. That’s your well-being, and that’s related and correlated with mental health.”

Mental illness, on the other hand, is more diagnosable. Certain criteria must be present for diagnosis, but it is a continuum. Even if one doesn’t meet specific criteria, that doesn’t mean he or she wouldn’t benefit from some intervention or stress reduction. There are many downstream effects, whether from a diagnosed illness or just a poor state of mental health, such as substance abuse, lack of motivation, poor physical health and eating habits, that can be prevented by using intervention methods on a more common basis.

Healthy People 2020 has set a goal that only 5.8 percent of adults aged 18 and over will experience a depressive episode in their life. Conversely, however, predictions say that, by the year 2020, depression will be the second-most common cause of morbidity worldwide. While we are making strides toward lowering the percentage of women with depression worldwide, in North Carolina, dropping from 23.2 percent to 5.8 percent is a goal that may be too far-fetched.

“I do think, unfortunately, there’s still a stigma,” Girdler said.

This stigma is reversible by making mental health a higher priority and discussing it openly.

“I think it’s all a continuum,” she said, “And I think we could all benefit from improving well-being and perspectives in life.”

For more information about childhood adverse events and the effects they have on adults later in life, visit the ACE study website, then take an informal evaluation.


The mission of Center for Women’s Health Research (CWHR) at the University of North Carolina at Chapel Hill is to improve women’s health through research by focusing on diseases, disorders and conditions that affect women only, women predominately, and/or women differently than men. Research efforts that require the most attention are identified through the collection and analysis of data for CWHR’s biennial North Carolina Women’s Health Report Card. Current areas of research targeted by the Center include perinatal health, cancers affecting women, obesity, diabetes, women’s cardiovascular health, women’s mental health and substance abuse.

Data collection and analysis for this article courtesy of Elizabeth Chase, a biostatistics and history major at UNC.