The ICD‐11 opens the door for overdue improved identification of depression in men

Population prevalence rates indicate that depression is twice as common in women as in men ¹ . But, is this estimate an accurate reflection of men's mental health, or rather an artifact of diagnostic criteria favouring female‐typical manifestations of depression ² ?

We and others would argue that the latter is, in fact, the case ² , ³ , ⁴ , ⁵ , ⁶ . Indeed, results from decades of epidemiological and clinical studies point to the existence of a depressive syndrome with marked externalizing features (e.g., irritability, aggression, risk‐taking and alcohol/substance misuse) which is particularly prevalent among males (especially younger ones) and likely related to an increased risk for suicide ² , ³ , ⁴ , ⁵ , ⁶ .

Yet, detecting and treating male depression is seriously complicated by the fact that the two major diagnostic manuals currently used in psychiatry, the DSM‐5 and the ICD‐10, do not consider these externalizing symptoms. Most importantly, the key role of irritability in male depression ⁴ , ⁵ , ⁶ is not reflected in the DSM‐5 diagnostic criteria for major depression. According to these criteria, irritability can superseed depressed mood only in children and adolescents, but not in adults, which seems to be an arbitrary distinction.

In the recently introduced ICD‐11 ⁷ , which is set to replace the ICD‐10 over the course of the following years, both irritability and an absence of emotional experience (“emptiness”) can replace depressed mood as the so‐called affective component requirement for a depressive episode, irrespective of age ⁷ . This represents a substantial improvement with regard to the identification of depressive disorders in men who present with an externalizing phenotype ⁴ .

Indeed, irritability is among the core symptoms included in male‐specific inventories of depression ⁵ , ⁶ , and likely underlies and relates to other symptoms that characterize male depression, such as aggression, alcohol/substance misuse and risk‐taking, all of which are also assessed in those inventories. Notably, according to one of these inventories, the Gotland Male Depression Rating Scale ⁵ , feelings of emptiness are also a feature of male depression. Hence, by allowing for both irritability and absence of emotional experience (emptiness) to replace depressed mood in the symptom requirements for a depressive episode, a group of predominantly male individuals who did previously not meet criteria for depression will likely fulfill them with the introduction of the ICD‐11 ⁸ .

While those with special interest in this topic will find the described change in the ICD‐11 to be both substantial and important, this change may go unnoticed by most practitioners seeing the men who will benefit from being identified and treated. Therefore, information and training initiatives to raise awareness about this change and its implications for clinical practice will be required. Relatedly, health care systems will have to prepare for the increased demand for (specific) care caused by this diagnostic change.

Furthermore, the externalizing depression phenotype contributes to the help‐seeking barrier experienced by men. To overcome this, screening initiatives may be needed within environments with predominant male representation and typical masculine values, such as military services, manual labor organizations, and sports clubs. There is a known relationship between the male depression phenotype and suicidality ³ , ⁴ , ⁸ . Assuming that the men affected can be treated successfully, these initiatives are likely to reduce the number of suicides among men. With approximately 700,000 suicides globally every year, the majority among men, even relatively minor improvements to detection rates could potentially save thousands of lives and improve the quality of even more lives.

The described changes to the ICD‐11 will hopefully inspire the American Psychiatric Association (APA) to make analogue changes in the next edition of the DSM. Recently, the DSM‐5‐TR noted that “men with depression may be more likely than depressed women to report greater frequencies and intensities of maladaptive self‐coping and problem‐solving strategies, including alcohol or other drug misuse, risk taking, and poor impulse control” ⁹ . Thus, as the ICD‐11 incorporates diagnostic changes in line with the evolving evidence base, it also seems that the door remains open for an (overdue) update of forthcoming DSM criteria for major depression.

Although supportive of the above changes, we are aware that they will not occur without associated challenges. Both the number of, and the symptom heterogeneity among, individuals meeting diagnostic criteria for depression will increase. This will, in turn, increase the need for treatment stratification by depressive subtypes. Relatedly, for individuals meeting depression criteria according to the ICD‐11, but not according to the ICD‐10 (or the DSM‐IV and DSM‐5), it can be argued that currently approved treatments may not be (equally) effective, as these individuals have not been adequately represented in the studies in which these treatments were tested. Therefore, changes to the diagnostic requirements for depression must spur research initiatives focusing on this specific group, including validation of the efficacy of available treatments.

In conclusion, we argue that the changes in the conceptualization of depression in the ICD‐11 will open the door for an overdue improved identification of depression in men. If implemented wisely and integrated with appropriate information and screening initiatives, this may lead to reductions in the number of suicides and improved mental health among men. Hopefully, the benefits of this change to the diagnostic criteria for depression will be sufficiently evident to the APA for it to make analogue changes in the DSM system when due.