[Thesis defense] Eugenia Alcalde

On June 6th, 2025, Eugenia Alcalde defended her thesis in public health:

‘From Symptoms to Depression Care : A Continuum Shaped by Gender and Social Position’

Her thesis was directed by Laurent Rigal

Jury:

• Bruno Falissard, mathématicien et psychiatre, CESP (président)
• Emilie Courtin, professeure associée, LSE (rapporteur)
• Stéphane Cullati, sociologue et épidémiologiste social, Université de Fribourg (rapporteur)
• Michelle Kelly-Irving, directrice de recherche, CERPOP (examinateur)
• Laurent Rigal professeur, CESP (directeur de thèse)

Abstract:

In France, as in many other countries, women and socially disadvantaged groups are more affected by depression than men and privileged groups. These inequalities can be partly explained by more difficult living conditions. However, two paradoxes persist: suicide is primarily a ”male issue,” and disadvantaged groups consume more psychotropic drugs without seeing a reduction in their depressive burden. This thesis aims to better understand these paradoxes by adopting a continuum approach to the stages of depression, using data from the CONSTANCES cohort and the SNDS. First, we explore symptom manifestations using the CES-D scale through a psychometric network approach. This part highlights differences in symptom configurations and their link to an eventual diagnosis and self-recognition of the depressive episode by gender and social position. Some results suggest biases in clinical judgment that may contribute to the underdiagnosis of depression in men. The second part examines the initiation of antidepressants (AD) and dosage trajectories. Holding depression levels constant, men, highly educated people, and people without financial difficulties initiate AD treatment less often than women and their disadvantaged counterparts. Then, once treatment is initiated, most individuals follow stable dosage trajectories, but certain groups, particularly those living in socially deprived areas, start with high doses, raising concerns about access to appropriate dosing. Additionally, some women follow low-dose trajectories, suggesting the overmedicalization of their distress. The third part focuses on AD discontinuation through an intersectional lens, using survival models within the MAIHDA framework. This study highlights the role of social contexts arising from intersections between gender, education level, geographical origin, and generation. It shows that AD discontinuation is socially patterned, with groups intersecting forms of disadvantages tending to discontinue treatment more quickly. In conclusion, our continuum approach provides a comprehensive perspective on how gender and social factors interact across the different stages of depression and treatment. The identified social and gender mechanisms help refine our understanding of the persistent social and gender inequalities in depression.