Being a teen female in a rural area might mean you’re more likely than your male counterparts to have undiagnosed asthma and depression, according to a new study out of the Medical College of Georgia (MCG) at Georgia Regents University.

The study was based off data that had been gathered during a three-year trial of an asthma program targeting teenagers. The results showed that while the prevalence of both diagnosed and undiagnosed asthma was the same in both rural and city areas, more girls had undiagnosed asthma than boys.

“There’s a lot of speculation about why females are more likely to be undiagnosed [for asthma],” Dr. Jeana Bush, an Allergy and Immunology Fellow at Medical College of Georgia and the lead author of the study, said in the press release. “Maybe it’s because boys are more likely to get a sports physical for athletics and they catch it then. Or maybe it’s because girls attribute asthma symptoms to something else, like anxiety. That needs further study.”

The same study also found that teens living in rural areas, regardless of gender, were more likely to have depression than the national average. The researchers used the Depression Intensit Scale Circles (DISC) questionnaire on 332 boys and girls with asthma living in four rural counties in Georgia. Twenty-six percent of that number, or 87 participants total, screened positive for depression; 67 out of the 87 were girls.

“The overall percentage of depression is higher than has been shown in the literature for other chronic diseases, including inflammatory bowel disease, diabetes, congenital heart disease, and even among cancer survivors,” Bush said in the press release. “That was staggering.”

While this is only one small study, it may make sense that the researchers found that girls were significantly more likely to be depressed than boys. Overall, women are 70 percent more likely than men to experience depression, according to the National Institutes of Health (NIH).

Depression also appears to be more prevalent in Southern states — particularly Oklahoma, Arkansas, Louisiana, Mississippi, Alabama, Tennessee, and West Virginia — states that are generally more associated with rural areas. The states with higher rates of depression also tend to have high rates of obesity, heart disease, stroke, sleep disorders, lack of education, as well as less access to medical care, as shown in the infographic by Healthline below.

Depression statistics infographic

Several past studies have attempted to identify whether depression is more prevalent in rural or urban areas, but most research has led to conflicting results. While it’s hard to say where depression reigns more, it’s likely that mental health treatment is less available in more rural areas, where houses, towns, and hospitals are further spread apart.

Another factor that is perhaps responsible for the higher rates of asthma and depression among teens in rural areas is that smoking is more prevalent in these areas as well. In addition, “[a]dolescents who are depressed may be less likely to talk about their symptoms or may attribute them to something else,” Bush said in the press release. “And so much of asthma treatment is about self-management — figuring out your symptoms and preventing an attack when you recognize those symptoms. If you’re depressed, you are less likely to be aware of and have the ability to interpret those symptoms.”