Little Women: Building the Evidence Base for Preventing Depression in Girls

Abstract

In her classic 1868 novel, Little Women, Louisa May Alcott personified her internal struggle of equating traditional roles of wife and mother with the loss of personal autonomy through the independently spirited character Jo, who transitions to womanhood in the Victorian era. 1 In real life, Louisa May Alcott’s transition to early womanhood was remarkable for her decision to never marry and to assume other socially acceptable roles, such as her mother’s caregiver, a Civil War nurse, and later, an activist in the women’s suffrage movement. This novel endures as it often stimulates discussion about the significance of promoting the full emotional development of girls to become mature and productive women, the progress made, and what more needs to be done to achieve this ideal. As we fast-forward 140 years, adolescence for girls is a period marked by increasing rates of depression and its potentially devastating sequelae, 2 yet the evidence base for the prevention of major depression among girls is sparse, 3 although promising. 4 In this issue of the Journal, two large community-based longitudinal cohort studies examine predictors of early-onset depression among girls over time. 5,6 Patton et al. 5 examine the relation between pubertal development and the onset and persistence of depressive symptoms among a cohort of 5,769 students in grades 5, 7, and 9 from Victoria, Australia, and the state of Washington during a 3-year period. At three study waves, self-reported symptoms of depression were common and disproportionately high among female students. More than one quarter of female students (26%Y31%) reported a high level of depressive symptoms, compared with 16% to 22% of male students. Between mid-puberty and late puberty, the proportion of female subjects with high depressive symptoms increased almost twofold. The relation between pubertal stage and depressive symptoms is further strengthened by subsequent analyses. Using logistic regression, female subjects at an advanced pubertal stage had 2.5 to 3.6 the odds of reporting high depressive symptoms than female subjects in early puberty, even after adjusting for age, school year, and state. When the proportions of students with high depressive symptoms were categorized by pubertal transition, the 12-month increase was greatest among female subjects transitioning from mid-puberty to late puberty (21%Y29%). Among the students who were in late puberty at baseline and 12-month follow-up, more than one-third (35%) reported high depressive symptoms compared with 16% to 20% of the male subjects. When searching for possible explanations for sex differences, the investigators included social context and psychological style characteristics in the final regression models. For female subjects, late puberty remained a predictor of newonset high depressive symptoms at 12 months, even after adjusting for social context. However, when psychological style characteristics were entered, self-reported poor emotional control was the sole predictor of new-onset depression. In contrast, when predictors of the persistence of high depressive symptoms were explored, the impact of puberty persisted. Female subjects in mid-puberty and late puberty had more than twice the odds of reporting high levels of depressive symptoms at baseline and 12 months than girls at early puberty, even after adjusting for social context and psychological style. Findings from the regression models are exploratory, and Patton et al. 5 appropriately comment that the study design cannot assess whether poor emotional control is a marker of vulnerability for depression or is the result of the pubertal process. Nevertheless, these findings suggest potential target points for prevention interventions that support future research.