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Race, sex and depression-free life expectancy in Brazil, 1998–2013

4. Discussion
This study estimated the depression-free life expectancy for Brazilian adults, in the years of 1998, 2008, and 2013 by age,
sex and race. In fact, improvements in DFLE were observed over time for all race/color groups. Our study corroborates
with previous research in Brazil whose findings show that from 2000-2010, life expectancy without depression increased
among older adults in São Paulo (Andrade, Wu, Lebrão et al., 2016). This may reflect living more years with higher
quality of life, less disability, and better health status (Reynolds, Haley, and Kozlenko, 2008). Whites generally displayed
the lowest DFLE.
Our results showed that depression was much more pronounced among white middle-aged women (between ages 40
and 60). Depression occurs most frequently in women aged 15 to 45 (Patten, Wang, Williams et al., 2006; WHO, 2017).
At ages older than 65 years, both men and women show a decline in depression rates, and the prevalence becomes similar
between them (Bebbington, Dunn, Jenkins et al., 2003; Patten, Wang, Williams et al., 2006). This age pattern is likely
linked with the higher rate of antidepressant use among mid- or old-age adults, which suggests that young adults with
depression may not always receive antidepressant treatment until many years after the onset of illness (Albert, 2015).
Depression has a great burden of disease in Brazil, especially for women. Our finding that the lower DFLEs were
found in women than in men across all race/color groups supports such an argument. Gender is a critical determinant
of mental health and mental illness. Depression is not only women's most common mental health problem but may be
more persistent in women than men (WHO, 2017). Women had a higher prevalence of most affective disorders and non-
affective psychosis and men had higher rates of substance use disorders and antisocial personality disorder (Kessler,
McGonagle, Zhao et al., 1994). Women also have significantly higher rates of post-traumatic stress disorder (PTSD) than
men (Kessler, Sonnega, Bromet et al., 1995). A comprehensive review of general population-based studies in the United
States of America, Puerto Rico, Canada, France, Iceland, Taiwan, Korea, Germany, and Hong Kong, reported that women
predominated over men in lifetime prevalence rates of major depression (Piccinelli and Homen, 1997).
Many elements in women may contribute to depression, including genetic and, biological factors, premenstrual
dysphoric disorder, postpartum depression, postmenopausal depression, and anxiety that are associated with hormonal
changes and could contribute to the increased prevalence in women. The fact that increased prevalence of depression
correlates with hormonal changes in women, particularly during puberty, prior to menstruation, following pregnancy
and at perimenopause, suggests that female hormonal fluctuations may be a trigger for depression (Albert, 2015).
Social factors may also lead to higher rates of clinical depression among women, including stress from work, family
responsibilities, economic pressures, unemployment, the roles and expectations of women and increased rates of sexual
abuse and poverty. Another argument widely cited to explain gender differences is that women would be more likely to
identify symptoms and seek help than men (Andrade, Viana, and Silveira, 2006).
In Brazil, race/color is directly associated with the individual’s socioeconomic situation. As blacks and browns face
severe socioeconomic disadvantages when compared to other racial categories, it is possible that they seek and use
healthcare services less frequently and are less likely to be diagnosed. On the other hand, evidence suggests that blacks
are somewhat more likely to be in better health than whites in advanced ages because blacks have a higher mortality
rate at younger ages, leaving behind a heartier group of survivors (Jackson, Hudson, Kershaw et al., 2011). According to
Albert (2015), the differential risk may primarily stem from biological sex differences and depend less on race, culture,
diet, education and numerous other potentially confounding social and economic factors.
When compared to white men, black and brown men and men of other skin colors had higher average time of
depression-free survival for all ages and in the entire period we studied. This result may be due to lower levels of
depression diagnoses among them. This issue has been brought up in the literature in the United States, where studies
have identified that black men do not usually seek routine medical care and could, in many instances, not be fully aware
of any health issues, including depression (Ware and Livingston, 2004). Socioeconomic disparities are at the heart of
racial inequalities in health in Brazil. Furthermore, racial discrimination and its impact on health are intimately related
to these inequalities (Chor and Lima, 2005). Therefore, lower levels of health care seeking behavior could be related to
racial discrimination. A comparative study between Brazil and the United States has shown that in both countries, black
men report more discrimination than white men/women or black women (Bugard, Castiglione, Lin et al., 2017).
One big limitation of the present study is the application of cross-section data, which does not include the exposure
time in the status of depression and dynamics in transitions of depression. Longitudinal datasets may improve this
methodological issue. Also, the limited availability of research about race and depression at the population level in Brazil
hinders the comparison of findings in other studies. Furthermore, we acknowledge that not using race-specific life tables (as
they do not exist for Brazil) may have created biased estimates in results. We classified people into one of three mutually
exclusive racial/ethnic groups, which may prevent comparisons with studies involving other categorizations. The small

6 International Journal of Population Studies | 2018, Volume 4, Issue 1