2. Risk Factors and the Prevalence of Depression in Mormon Women

By David C. Spendlove and Dee W. West

David C. Spendlove, Dee W. West, and William M. Stanish, “Risk Factors and the Prevalence of Depression in Mormon Women,” in Religion, Mental Health, and the Latter-day Saints, ed. Daniel K. Judd (Provo, UT: Religious Studies Center, Brigham Young University, 1999), 33–46.

Risk Factors and the Prevalence of Depression in Mormon Women​

David C. Spendlove, Dee W. West, and William M. Stanish

 

David C. Spendlove was a psychologist at Saint Mark’s Family Medicine in Salt Lake City when this was published. This article was originally published in Social Science Medicine 18:491–495; reprinted with permission.

 

Abstract​

In response to reports suggesting that depression is common among women in Utah, this study compares the prevalence of depression between Latter-day Saint women, many of whom are homemakers, and non-LDS women who are typically more career-oriented. This sample includes white, married women with children fourteen years of age or younger living at home. No difference in the prevalence of depression was detected between the LDS and the non-LDS women. In both samples of women, certain risk factors were identified: less education, little perceived caring from spouse, perception of having less than good health, and low income. Each of these factors is comparable with the results of other studies.

 

Depression is a common problem in western societies, and women seem to be at greater risk than men (Levitt & Lubin, 1975; Radloff & Rae, 1979, p. 174; Weissman & Klerman, 1977, p. 98). Some of the determinants of depression for women are hypothesized to be lack of education (Frerichs, Aneshensel, & Clark, 1981, p. 691; Levitt & Lubin; Sayetta & Johnson, 1980), low income (Frerichs et al., p. 691; Sayetta & Johnson), children in the home (Brown & Harris, 1978; Stewart & Salt, 1981, p. 1063), little perceived support from spouse (Brown & Harris; Gove & Geerken, 1977, p. 66; Stewart & Salt), and allocation to a homemaker role instead of a career outside the home (Brown & Harris; Stewart & Salt, p. 1063). Some studies have demonstrated the career homemaker in today’s society to be at highest risk for depression (Brown & Harris; Stewart & Salt, p. 1063), since the demands of raising children and the low status associated with this role may contribute to emotional disorder (Gove, 1972, p. 34; Gove & Geerken, p. 66). This view is not shared by all, however, as two studies have not found an association between employment status and depression in married women (Aneshensel, Frerichs, & Clark, 1981, p. 379; Newberry, Weissman, & Meyers, 1979, p. 282).

To further examine risk factors for depression in women, especially the relationship between employment and depression, we conducted a study in the Salt Lake City, Utah metropolitan area. This population was chosen because some publications have suggested that depression is high in this geographic area (R. W. Burgoyne & R. H. Burgoyne, 1977, p. 39; Johnson, 1979; Warneski, 1978, p. 98) in which 72 percent (West, Lyon, & Gardner, 1980, p. 1083) of the women are members of The Church of Jesus Christ of Latter-day Saints (often referred to as “Mormons” or “LDS”). Depression in LDS women has been attributed to religious beliefs and norms that strongly encourage them to be full-time homemakers (R. W. Burgoyne & R. H. Burgoyne, p. 39). Indeed, such beliefs and norms are clearly defined in Church teachings (Benson, 1980, p. 69). In fact, it is not uncommon for Mormons to hear and read rather forceful statements about the irresponsibility of the working mother (Warneski, p. 98). Mormon women are also encouraged to have large families and are discouraged from practicing birth control (McConkie, 1966, p. 85). The effects of such religious beliefs and teachings are notable in that Utah has the highest birth rate in the United States (U.S. Bureau of Census, 1981, p. 403).

This study was conducted to estimate the prevalence of depression in a population of LDS women and to compare this rate to that of non-LDS women within the same geographic area. In addition, the study examined determinants of depression in LDS women to see if they were similar to or different from those found in other populations.

Methods​

Sample Selection and Interviewing. A random sample of LDS and non-LDS women were selected for this cross-sectional study which was conducted between 21 March and 31 May 1981, in the Salt Lake City, Utah metropolitan area. The sample was obtained using random-digit-dialing (M. R. Frankel & L. R. Frankel, 1977, p. 280), a procedure which ensures all households in the area with telephones (96 percent) an equal chance of inclusion in the study. Random-digit-dialing was considered to be the best procedure to minimize sampling biases and costs in identifying and interviewing a general population (nonclinical) sample. This method involves a three-step process. First, telephone numbers were randomly selected from the Salt Lake City telephone directory. Second, the last two digits were replaced with random numbers in order to insure that telephone numbers not in the directory had the same chance of being contacted as published numbers. Third, female interviewers called each number and conducted a short interview to determine eligibility for participation in the study.

Women were included in the study if they were (a) married, (b) Caucasian, (c) English-speaking, and (d) had children who were all fourteen years of age or younger. The study was limited to women with young children since these women tend to be at highest risk for depression. In addition, we wished to make the sample as homogeneous as possible. Women with children older than fourteen years of age, with foster children in the home, or with children living away from the home, were not included in the study.

To identify eligible respondents, 1,569 randomly selected telephone numbers were called by interviewers. They identified 962 residential numbers and obtained information to determine eligibility from 93 percent of these. Eligible subjects (213 women) were recontacted by letter to explain that they had been selected for the study, to explain the study to them, and to provide them with an outline of the questions to be asked and a list of the scales to be referred to during the interview. The letters were followed in about three days by a telephone interview conducted by a trained female interviewer. It was thought that female interviewers would be most appropriate for this study population since LDS beliefs accord males a strong patriarchal role, and therefore, male interviewers might influence the responses of subjects in a more socially desirable manner. Furthermore, King and Buchwald (1982) found that subjects who are interviewed by opposite sex interviewers tend to admit to fewer depressive symptoms because of a fear of rejection. The interviews lasted about twenty minutes, and 179 (84 percent) of the 213 women contacted completed the interview (143 LDS and 36 non-LDS).

A standard interview form was developed which contained questions relating to: socioeconomic status; depression, using the Beck Depression Inventory (Beck, Ward, Mendelsohn, Mock, & Erbaugh, 1961, p. 561); possible stressful life events, using a variation of the Holmes Rahe Scale (Holmes & Rahe, 1967, p. 213); church membership and attendance; religious motivation, using the Hoge intrinsic/ extrinsic scale (Hoge, 1972, p. 369); support from spouse; perceived health status; employment information; and demographic data.

Beck Depression Inventory. Depression was measured using the twenty-one item Beck Depression Inventory (BDI) (Beck et al., 1961, p. 561). The BDI provides a measure of the cognitive, affective, physical, and motivational aspects of depression. Scores range from zero to sixty-three with a higher score measuring more severe symptoms of depression. A score often typifies a mild level of depression and serves as a cut-off to dichotomize individuals as depressed and not depressed. The BDI has been standardized on clinical (Beck, 1972, p. 299;Becketal.,p. 561) and nonclinical (Bumberry, Oliver, & McClure, 1978, p. 150) populations and is considered to be one of the most valid and reliable inventories currently used to measure depressive symptoms (Hammen, 1981, p. 260; Pehm, 1976, p. 240). For example, concurrent validity coefficients of 0.72 have been obtained for clinically depressed populations (Pehm, p. 240) and 0.77 for a nonclinical population (Bumberry et al., p. 150). Regarding reliability, a test-retest coefficient of 0.74 was obtained on a nonclinical population over a three-month period (Miller & Seligman, 1973, p. 62).

Analysis . The depression scores and data on all variables considered to be risk factors or confounders were dichotomized. Crude estimates of relative risk (RR) were calculated for these cross-sectional data (Rothman & Boice, 1979, p. 11). These estimates were adjusted to control confounding by using stratified analysis. Confidence intervals for the adjusted data were calculated using Miettinen’s method (Miettinen, 1976, p. 226). The use of both confidence intervals and risk ratios allows one to assess both the existence and magnitude of any potential association.

Additionally, LDS and non-LDS differences on the raw BDI scores were analyzed with a t-test. Analysis of variance that included terms for the other risk factors was also used to compare LDS and non-LDS BDI scores.

Results​

Prevalence of Depression. Table 2.1 shows that 23.8 percent of the LDS women and 22.2 percent of the non-LDS women were classified as depressed. This comparison yields a relative risk (RR) of 1.1, and this RR remains unchanged when adjusted for possible confounders (educating, caring from spouse, health status, and income).

Table 2.1: Depression in LDS Women Compared to Non-LDS Women

Variable

High and Low Risk Group

Percent Depressed

Crude Risk Ratio

Adjusted* RR and 95% Confidence Interval

Religious affiliation

LDS

Non-LDS

23.8

22.2

1.1

1.1(0.6–1.8)

*Adjusted for education, caring from spouse, health, and income.

 

Table 2.2 shows that the two groups are similar in terms of the distribution of BDI scores, and that the mean scores are almost identical. A t-test shows no significant difference (t = 0.15, P = 0.88) between the means, and an analysis of variance adjusted for the possible confounders yields the same conclusion (F= 0.064, d.f. = 1, P=0.80). Thus there is no difference between LDS and non-LDS women in the prevalence of depression.

Table 2.2. Degree of Depressive Symptoms in LDS and Non-LDS Women as Measured by the Beck Depression Inventory

Degree of Depressive Symptoms

BDI

LDS*

Non-LDS**

 

Score

Range

Frequency

%

Frequency

%

None

0

9

109

(76.2)

28

(77.8)

Mild

10

15

22

(15.40

7

(19.4)

Mild moderate

16

19

9

(6.3)

0

(19.4)

Moderate severe

20

29

2

(1.4)

1

(2.8)

Severe

30

63

1

(0.7)

0

(0.0)

Total

 

 

143

100.0

36

100.0

*Mean LDS=6.90, SD-5.57

** Mean non-LDS=7.05, SD = 4.43

 

It is difficult to compare the prevalence of depression among subjects in our study with women from other populations. The different sample selection procedures, different instruments used to measure depression, and different analyses lead one to conclude that depression studies have little in common from which to compare results. However, in two recent studies conducted in the United States in which the Beck Depression Inventory was used, mild levels of depression were measured to occur in about the same percentage of women as found in our study (Baumgart & Oliver, 1981, p. 570; Golin &Harz, 1979, p. 323).

Risk Factors for Depression in LDS Women. In identifying risk factors for depression, it seemed important to do so for LDS and non-LDS women separately. However, there were too few non-LDS women for this analysis, so results are presented only for LDS women. Table 2.3 lists four variables which are significant risks for depression (a lower confidence interval equal to or greater than 1.0) after adjusting for confounding. This table gives the percentages of depressed subjects for each dichotomized factor, crude risk ratios, adjusted risk factors, and confidence intervals for the adjusted risk ratios. For example, 28 percent of the LDS subjects without bachelor’s degrees were depressed while only 4 percent with bachelor’s degrees were depressed. The crude risk ratio, which is the ratio of these two percentages, is 7.0. The adjusted risk ratio of 4.4 is our best estimate of the independent effect education has on depression: LDS women without bachelor’s degrees are 4.4 times more likely to be depressed than LDS women with bachelor’s degrees. The confidence intervals, however, suggest that this estimate of 4.4 could vary from 1.1 to 17.9. Table 2.3 shows that those variables associated with depression are less education, little perceived caring from spouse, perception of health as poor or fair, and less income.

Table 2.3: Measures of Association for Select Variables and Depression in LDS Women

Variable

High and Low Risk Group

Percent Depressed

Crude RR

Adjusted RR* 95% Confidence Interval

Education

No B.S. degree

B.S. degree

28.0

4.0

7.0

4.4 (1.1,17.9)

Caring from spouse

Little

A lot

60.0

17.9

3.4

2.8 (1.7,4.8)

Health

Poor, fair

Good, excellent

47.6

19.7

2.4

2.1 (1.2,3.7)

Income

<$16,000

>$16,000

37.8

17.3

2.2

1.7 (1.0,2.9)

*Risk ratios adjusted for education, caring from spouse, health and income.

Table 2.4 shows variables which do not significantly contribute to an increased risk of depression. However, one variable, employment outside the home, showed a trend toward being both statistically and clinically significant. None of the other variables (measures of religiosity, number of children, age, or presence of stressful life events) were risks for depression after adjusting for confounding.

Table 2.4: Measures of Association for Select Variables and Depression in LDS Women)

Variable

High and Low Risk Group

Percent Depressed

Crude Risk Ratio

Adjusted RR* 95% Confidence Interval

Employment

Yes

34.3

1.7

1.6 (0.8, 3.0)

 

No

20.4

 

 

Church attendance

Infrequent

41.7

2.3

1.2 (0.7, 2.3)

 

Frequent

17.8

 

 

Temple attendance

Infrequent

19.0

0.6

1.2 (0.7, 2.2)

 

Frequent

29.7

 

 

Prayer

Infrequent

37.5

1.8

1.2 (0.6, 2.4)

 

Frequent

20.5

 

 

Religious mixed marriage

Yes

45.5

2.1

1.2 (0.6, 2.6)

 

No

21.5

 

 

Religious motivation

Extrinsic

34.9

1.8

1.2 (0.7, 2.2)

 

Intrinsic

19.0

 

 

Number of children

2 or less

28.2

1.4

1.1 (0.6, 1.8)

 

3 or more

19.4

 

 

Age

> 25

34.4

1.7

1.1 (0.6, 2.0)

 

< 25

20.7

 

 

Life Events

200 +

29.0

1.3

1.0 (0.5, 2.2)

 

199 −

22.3

 

 

* Risk ratios adjusted for education, caring from spouse, health, and income.

Discussion​

This study was conducted to determine if LDS women are at a different risk for depression than non-LDS women. The LDS population was chosen for this study since their religious beliefs encourage, if not dictate, that they be full-time homemakers. As seen in Table 2.5, LDS women in this study were more likely to be homemakers than non-LDS women: fewer of them worked outside the home, and they had a higher number of children. They are also less likely to be employed and are likely to have more children, when compared to national statistics. In 1979, a national study (U.S. Bureau of the Census, 1980, p. 403) reported that 43 percent of white, married women with children six years of age or younger worked outside the home. In our study, only 26 percent of LDS women with children six years of age or younger reported working outside the home. United States Census data report an average of 1.9 children for women with children eighteen years of age or younger. LDS women in our study with children fourteen years of age or younger had an average of 2.8 children. Thus, LDS women do live a life-style that some have described as restrictive and confining, yet this study shows that they are no more at risk for depression as measured by the Beck Depression Inventory than non-LDS women.

Table 2.5: Comparison of LDS and Non-LDS Women for Select Demographic Variables

Utah

 

LDS

Non-LDS

Mean age

29.5

30.7

Mean number of children

2.8

2.1

% employed outside the home

24%

50%

 

In any study of this nature, it is important to examine possible alternative explanations to clarify the findings. For example, it is possible that no difference in depression was noted because LDS women were not as willing to admit to having depressive symptoms. We do not believe this to be the case because: (a) the study was explained to all women in the same manner and was not identified as a depression study; (b) the BDI is a scale using a series of questions which most people would not likely ascertain as a depression inventory; (c) half of the women were given a social desirability scale, and there were essentially no differences between LDS and non-LDS women in terms of answering in a socially desirable manner; and (d) most of the results of the study which looked at risk factors for depression are similar to those of other studies that have identified risk factors of depression in women.

We believe the measure of depression in this study to be fairly accurate and that LDS women are not at greater risk for depression than non-LDS women. One reason for this finding is that the majority of LDS women report that they prefer the role they are encouraged to live. In fact, 76 percent of LDS women said that they either enjoyed being at home, or if they worked, they would prefer being at home. This strong cultural expectation may explain why LDS women who work may be at a higher risk for depression. These religious beliefs, however, do not appear to alter any of the other major risk factors for depression.

The second part of the analysis was to determine risk factors for depression in LDS women. In looking at these factors, three trends can be recognized. First, those variables directly associated with being a homemaker (not working outside the home and number of children in the home) are not risk factors for depression—a finding contrary to other studies (Brown & Harris, 1978; Stewart & Salt, 1981, p. 1063). In fact, as seen in Table 2.4, it is possible that LDS women who work may be at a higher risk for depression than women who do not work. This has never been reported in other studies. Second, variables related to religiosity appear to be risks for depression until adjusted for confounding. In other words, after controlling for education, caring from spouse, health status, and income, the various religious factors are not predictive of depression. Finally, most of those variables not directly related to the homemaker role or to religiosity are associated with depression in a similar manner to that found in other studies: low education (Frerichs et al., 1981, p. 691; Sayetta & Johnson, 1980), little caring from spouse (Brown & Harris, 1978; Gove & Geerken, 1977, p. 66), poor health (Hurst, Jenkins, & Rose, 1976, p. 301; Radloff & Rae, 1979, p. 174; Schwab, Bialow, Brown & Holzer, 1967, p. 695; Wright et al., 1980, p. 1031), and low income (Frerichs et al., p. 691; Sayetta & Johnson).

There are several limitations associated with this study which should be noted. First, the study design is cross-sectional which does not allow causal inferences to be made. Second, the BDI has been administered over the telephone for clinical populations but not for research purposes. The amount of depression detected, however, is similar to studies which did not use the telephone (Golin & Hartz, 1979, p. 323). Also, other studies comparing telephone and face-toface interviews have shown the data collected to be similar (Klecke & Tuckfarber, 1978, p. 105; Rogers, 1976, p. 51). Finally, most of the subjects classified as depressed were mildly depressed. Since only 10 percent of the subjects were moderately or severely depressed (this is consistent with other studies using the BDI), the sample size was not adequate to look at these more severe levels of depression.

Conclusion​

This study found no difference in the prevalence of depression between LDS women compared to non-LDS women. Other studies have also failed to find differences in the prevalence of depression in religious groups (Frerichs et al., 1981, p. 691; Levitt & Lubin, 1975). The results of this study also suggest that many risk factors for depression are similar for women in different religious groups, but not identical. At least one factor, employment outside the home, may or may not be a risk factor depending on the cultural context of the respondent. Finally, this study shows that possible risk variables may be associated with each other and, therefore, crude estimates of risk may be erroneous due to this confounding. Future studies of depression, then, need to identify the cultural context of the respondent and control for confounding when identifying risk factors.

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