Men and depression

Depression is routinely positioned as a woman’s disease,¹ in part because of the recognition of a lower incidence of depression among men compared with women.² However, the lower incidence among men might be a by-product of men’s tendencies to deny illness, self-monitor and self-treat symptoms, and avoid professional health care providers and services as a means to enact and preserve their masculinity.³ This has contributed to a poor understanding of depression in men, including how to identify it and how to treat it. In an effort to promote greater awareness, we present a series of questions and answers about depression in men.

What is depression?

Depression is an illness that can affect how a person thinks, feels, and acts. According to the Diagnostic and Statistical Manual of Mental Disorders, 4th ed, text revision,⁴ the signs and symptoms of depression include persistent sad, anxious, or “empty” mood; feelings of hopelessness and pessimism; feelings of guilt, worthlessness, or helplessness; and loss of interest or pleasure in hobbies and activities that were once enjoyed.

Are men’s symptoms different than women’s?

Depression in men, at least in the early stages, often does not fit the aforementioned textbook description. It often manifests as irritability; anger; hostile, aggressive, abusive behaviour; risk taking; substance abuse; and escaping behaviour (eg, overinvolvement at work).⁵ Another escaping behaviour that has been noted concerns some men’s tendency to become overly sexually active, usually in the form of extramarital affairs or a series of brief, emotionless sexual encounters.⁶ It is thought that such behaviour might reflect a man’s effort to demonstrate his sexual prowess in order to counter feelings of inadequacy and to avoid intimacy in relationships that could potentially expose his vulnerability.⁷ These signs and symptoms can mask the more typical symptoms of depression (eg, sadness, crying, feelings of guilt, changes in appetite).

This suggests that the acting-out symptoms seen in men might serve as a cover-up mechanism to hide the internal turmoil that these men are experiencing. But at some point this compensation fails and exposes the men’s distress and depression as immense hopelessness, withdrawal, and a complete shutdown of normal activity.

How would a man describe his depression?

Men do not typically arrive at their doctors’ offices talking about feeling sad or depressed per se. In fact, they will rarely mention any emotional or behavioural difficulties to their doctors at all. Yet, if they do happen to disclose any problems, they tend to describe problems at work including diminished job performance or difficulty functioning.⁷ Generally, men seem to talk about their emotional problems in terms of “stress” rather than sadness or feeling down.

Instead of verbally communicating emotional problems, men tend to act out their stress. It is not uncommon for them to deal with their stress by working more, engaging in risky activities, and most important, turning to alcohol and other drugs, all in an effort to avoid or numb the awareness of an underlying problem.⁸ Anger, irritability, and social isolation are problems that men will often exhibit but not necessarily identify as problems that need to be rectified.⁵

Why does depression seem to be different in men?

Understanding how men in our society are brought up to behave is particularly important to answering this question. Young boys, as they grow and develop, learn socioculturally prescribed male roles about gender-appropriate behaviour. Studies have revealed a constellation of masculine ideals prohibiting emotional awareness and expression and visible signs of sadness including crying.⁸ Instead, independence, competitiveness, emotional stoicism, and self-control are expected of men.

The catch phrase “big boys don’t cry” prevails, to suggest that boys and men in particular should not “whine.” Such values, implicitly and sometimes explicitly promoted by parents and other caretakers, profoundly shape boys’ and men’s gender identities, roles, and relations as well as their health care practices. Thus, boys can learn to dissociate from aspects of emotional experience, especially any visible feelings of sadness. Anger, shame, and control-oriented defences often arise as a means of self-protection.

What can trigger depression in men?

There is little evidence to suggest that there are large differences between men and women when it comes to triggers for depression. However, it appears that certain situations or circumstances are particularly difficult for men and thus strong precipitators of depression. Some authors have argued that for men, issues related to loss and grief are paramount at diverse points across the lifespan.⁹

When contextualized in various life domains (eg, absence or frustrations in the paternal bond; financial hardships; or facing issues related to one’s mortality), many men’s “stresses” become, on various levels, issues of grief and loss.¹⁰ This happens regardless of whether they manifest concretely in the loss of an intimate relationship or more symbolically through the loss of status and prestige associated with employment or reductions in physical or sexual prowess over time. The emergence of physical illness, financial problems, and divorce can challenge men’s masculine ideals, in that rather than being robust, powerful, successful, and desirable, weakness and failure can occur.

How long do men usually suffer from depression?

Depression tends to recur, coming and going with various levels of intensity. Some men can “pass” as emotionally well or typically male in their demeanour for years. It is not always a progressive downward spiral but often occurs over time, whereby the “ups” tend to be fewer and the “downs” seem to be worse. It usually takes a long time for men to seek spousal or professional help.¹¹ Women are much more attuned to their bodies and familiar with health care services and tend to be quicker to realize they need help. The longer it takes men to seek help (if they ever do), the more entrenched the negative feelings, thoughts, and behaviour become, making depression more difficult to overcome.

Why do men not get help?

There are likely many factors that inhibit men from seeking help for depression, few of which are fully understood. The way that men think about themselves as men can be quite unhelpful. Compared with women, they tend to be far more concerned with being competitive, powerful, and successful.⁸ Most men do not like to admit that they feel vulnerable or uncertain, and so are less likely to talk about their feelings with their friends, loved ones, or doctors.⁸ Data also reveal that men are far more likely to present to the emergency department than to general practice, and this relates to men’s denial of illness, longer self-surveillance, and reliance on self-management strategies.¹²

Men tend to feel that they should rely only on themselves and that it is somehow weak to need help or depend on someone else, even for a short time. There is also evidence to suggest that men have difficulty articulating their problems when talking with health care providers.¹³ The onus is often on the clinician to interpret not only what is said, but also the body language and affect of the man to accurately identify depression.

Are men more likely to commit suicide?

Even though suicide attempt rates are similar between men and women, men are more likely to succeed. Indeed, the suicide rate among men in general is 4 times higher than that for women.¹⁴ In some populations, including the elderly, the suicide rate among men is more than 7 times higher compared with women.¹⁴ Men tend to use more lethal means, including firearms and hanging, yet show fewer warning signs of impending attempts.¹⁵ Thus, a heightened awareness that men are more likely than women to succeed at suicide is required of clinicians in order to identify those at risk and intervene.

What should I do if a male patient is depressed?

Do not ignore it. In a gentle and friendly way, bring it up. Use prompts like the following: “You don’t seem to have energy. Do you feel OK?” If you say that you think the man is depressed, you risk deterring him from admitting any problems. Remember that many people, including men, position depression as a female affliction that few men get. Do not avoid inquiring about thoughts of suicide, as men will rarely bring these up on their own.

Depression in men can be treated successfully with antidepressant medication, psychotherapy, or a combination of both. Several pharmacologic agents have evidence of efficacy.¹⁶ These include selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors, tricyclics, and monoamine oxidase inhibitors. There is no evidence to indicate that pharmacologic antidepressant treatment is any more or less effective for men compared with women.¹⁷ Unfortunately, it is well documented that antidepressants, particularly SSRIs, negatively affect erectile function and ejaculation.¹⁸ Balon has provided a useful and succinct summary of management strategies for SSRI-associated sexual dysfunction.¹⁹ Among strategies to consider is prescribing bupropion or mirtazapine, as these agents tend to have a lower incidence of sexual dysfunction. Also, because antidepressant-associated sexual dysfunction seems to be dose dependent, reducing the dose to the minimum effective level might help; however, caution needs to be exercised because depressive symptoms might return if the dose is lowered too much. A recent study of 35 men demonstrating that paroxetine can cause genetic damage to sperm has also led to some concern about the use of SSRIs for men, but these findings are preliminary and need further investigation.¹⁸

Several forms of short-term, time-limited psychotherapy, including psychodynamic psychotherapy, cognitive behavioural therapy, and interpersonal therapy, have been demonstrated to be effective for treating depression.^16,20 Psychotherapy is offered by a variety of licensed mental health providers, including psychiatrists, psychologists, social workers, and registered clinical counselors. Therapy provided by nonphysicians might or might not be covered by patients’ extended health benefits. Hospital-based outpatient psychiatry departments provide free access to psychotherapy. Meta-analyses have found equal effects for medications and psychotherapy,^21,22 yet a combination of both can be highly effective in certain cases.²³ All-male group therapy might provide men with a safe environment to discover and express intense and vulnerable emotions associated with their depression, and allow them to connect through a shared cathartic experience.²⁴ Group therapy offers men an opportunity for interpersonal connectedness and a chance to regain a sense of purpose and well-being. It is important to consider the patient’s preference for treatment, as studies have found that this can substantially influence outcomes.²⁵

There are many resources available to help people with depression. The Canadian Mental Health Association (http://cmha.ca) offers a great deal of information. Other online resources include www.heretohelp.bc.ca and www.maledepression.com. Web-based treatments include www.bluesbegone.co.uk (for a fee) and http://moodgym.anu.edu.au/welcome (free). There are also self-care resources available through the Web, such as www.comh.ca/antidepressant-skills/adult.

Conclusion

Family physicians are ideally situated to be at the forefront of identifying and treating depression in men. It is challenging given the demands on family physicians’ time; yet, the consequences of undetected and untreated depression can be devastating. Knowing and actively investigating the signs and symptoms of depression in men, and being aware of and able to connect men to various treatment options, can have an immense positive effect on the lives of many men and their families.