Men’s mental health

Described in various media as a “silent epidemic”¹ and a “sleeper issue that has crept into the minds of millions”² with “chilling statistics,”³ mental illness among men is a public health concern that begs attention. A tragic confluence of low rates of diagnosed depression and high rates of suicide,⁴ along with poor engagement with mental heath services,⁵ highlights the complex intersection of multiple factors that we must grapple with in order to begin helping men overcome the burden of mental illness. This commentary touches on a few of these issues and introduces a unique Canadian initiative that has taken up the challenge of developing innovative approaches to addressing mental illness among men.

One issue that affects the identification of mental illness in men relates to how emotional discord might be uniquely expressed by men. Consider the example of depression: Men suffer from depression as women do, yet how that depression is expressed can differ for men. Particularly in the early stages, it often manifests as irritability, anger, hostility, aggressiveness, risk taking, and escaping behaviour.⁶ Such expression of feelings, influenced by many contextual factors including gender socialization,⁷ can mask more typical symptoms of depression like sadness, crying, feelings of guilt, and changes in appetite. Only recently have we started to recognize that these types of signs and symptoms among men can be early indicators of depression. Left undetected and untreated, they can lead men to suffer from immense hopelessness, withdrawal, and a shutdown of normal activity. For this reason, family physicians play an important role in identifying the nuanced manifestations of depression and other mental illness among their male patients. If we speak their language and engage men in a nonthreatening way around mental health, we will be much more effective therapeutic partners with our male patients.

Ideas of masculinity

Certain issues that can contribute to mental illnesses including depression might also be especially relevant to men. In many ways, these issues often have some relation to a man’s adherence to masculine ideals and norms—that is, the extent to which he buys into socially prescribed “rules” about what it means to be a man. For example, many men have their sense of worth tied up in external indicators of success, such as career achievement, how much money they make, and things that they provide for their families.⁸ This can lead to unhealthy competitiveness and sacrifice of other things in life to achieve their “success.” Often the ideal is set so high that it is impossible to achieve, resulting in a sense of failure—failure to win the competition with other men and failure to meet their families’ needs. Too often many men do not talk about feeling down, sad, or depressed, and might not mention emotional or behavioural difficulties at all.⁷ When men do disclose problems, they tend to describe “functional” problems, such as issues at work or with sex. Sometimes they will talk of existential concerns like, “I don’t actually know what makes me happy.” These are not necessarily man-specific issues, as women can also struggle with them, but they are common among men.

An important issue that affects service delivery for men is that of help seeking. If a man actually comes to recognize a problem and acknowledges the need for help, will he look for it? Often, the answer is no. Although asking for help is difficult for many people, it is well documented that men tend to be reluctant to seek help in various contexts, including help for mental health concerns.⁵ How can we engage men in mental health services? What kinds of services will be appealing to and effective for men? These are crucial issues to address, as we know that despite tremendous pain, many men suffer in silence. Owing to various factors—stigma being prominent among them⁹—many men elect to avoid mental health services, and some simply do not know what is available to them. The end result, for too many men, is suicide. Statistics show that suicide rates are much higher for men than they are for women.¹⁰

Responding to these issues

The Men’s Depression and Suicide Network (www.menshealthresearch.ubc.ca), with the help of the Movember Foundation, is trying to make things right for Canadian men by creating new spaces and places that better meet their mental health needs.

First, we are disrupting how men traditionally think about depression and suicide by breaking down the stigma that surrounds these topics. Rather than having men think that they are weak, flawed, or different from other guys, we lobby men to recognize that we all occasionally have our struggles and that something like depression, for instance, is pretty common among men. Sometimes our coping strategies just get overwhelmed. Through the work of our Man-Up Against Suicide project, we are confronting the difficult topic of suicide among men through photographs and narratives of those who have been touched by the loss of a man in their lives, thereby raising awareness about one of the most common causes of premature death of Canadian men.

Second, we are changing men’s perspectives about health services. Because of the way men tend to be socialized—that is, how they are taught to be men—they often view asking for help—in any form—as something they just do not do. Help seeking is often construed as a sign of weakness that a lot of men want to avoid at all costs. Many men will suffer in silence because they cannot bring themselves to reach out for a hand. Unfortunately, for too many of these men, the consequences can be terrible: self-harm, violence, and suicide. We want to flip things around in guys’ minds, reframing help seeking as a show of strength, of taking control of their situation to get things back on track. Reaching out for a hand, getting some professional guidance or advice, is all about saying “I need to fix some stuff”—and then taking action to get it done. Responding to men’s desire for independence and autonomy, and providing a nonconfrontational way to start the help-seeking process, our HeadsUpGuys initiative offers Canadian men information, practical tips, and guidance for managing and recovering from depression. This online resource is an important tool in responding to men’s preferences for self-sufficiency while still building in messaging to cue men to connect with professional help. By building a laddered approach that normalizes help seeking, we are creating a bridge to support men’s self-management while also bringing others into the mix.

Changing the landscape

We are also changing the landscape of services available for men who are struggling with depression and suicide. The data are clear that men do not often use currently available mental health services, so we need to figure out how to adapt to fit men’s needs. A lot of guys have the perception that current mental health services are set up mainly to serve women. While this is not completely true, there are aspects of how services are delivered, and even the language that is used, that fail to resonate with men. Three of our projects represent unique approaches to meeting men’s needs. We know that older men have increased rates of depression and suicide. Among the factors that contribute to this is social isolation. Men’s Sheds offers a place for men—often (but not always) retired men—to come together to share companionship, learn from one another, and keep their hands busy with a range of activities, such as wood working, cooking, or bicycle repair. This community-based movement is not focused on treating depression, but rather can be likened to a preventive intervention for guys who might be at risk of depression. Following a similar model, the DUDES Club, serving First Nations men, is a space for events and activities that focus on spiritual, physical, mental, emotional, and social aspects of wellness, while simultaneously putting marginalized men in touch with health care professionals and other support services, instilling a sense of solidarity and empowerment within the community. The DUDES Club is described in more detail in the Cover Story (page 504) and in a Program Description (page e311) in this issue.^11,12 Finally, the Men’s Transition Program, adapted from the successful Veterans Transition Program for returning military veterans, focuses on providing group-based services for particular cohorts of men with high rates of depression and suicide: college men and men with prostate cancer.

In combination, this suite of projects, programs, and services has provided opportunities to evaluate and disseminate innovative approaches to addressing the silent epidemic of men’s mental illness in Canada.