Conflict in Men’s Experiences With Antidepressants

Abstract

While men’s experiences of depression and help seeking are known to be shaped by gender, there is little research which examines their experience of using antidepressants to treat this. This study is based on in-depth, narrative-style interviews with 20 New Zealand men who had used antidepressants. The analysis identified a number of areas of conflict in the men’s accounts of using this medication. Conflict centered on the way taking antidepressants was seen as undermining personal control while also allowing users to take charge of their problems; facilitating general functioning while undermining sexual functioning; relieving emotional distress while undermining emotional vitality; and the tension participants felt between making autonomous judgments about the value of antidepressants and relying on the “expertise” of others. Participants negotiated these conflicts in a variety of ways. In some cases, antidepressants were positioned as being able to affirm aspects of traditional masculinity, while a smaller number of participants managed these conflicts by redefining aspects of their own masculinity in ways that contrasted with dominant constructions. This research is limited by the sample of older, more privileged men in the context of New Zealand culture which favors macho forms of masculinity. In similar contexts, mental health practitioners should be mindful of the conflicts that men might experience in relation to their antidepressant use. Facilitating men’s exploration of these issues may enable them to make better decisions about treatment options or to provide more effective support to those who have opted for antidepressant treatment.

Using any long-term medication is likely to evoke complex emotional responses (Pound et al., 2005). This may be especially so for antidepressants which are designed specifically to impact on people’s emotional experiences. Research suggests the way that people experience mental health problems and their treatment is significantly shaped by gender, but most studies have focused on understanding women’s higher rates of depression (e.g., Nolen-Hoeksema, 2001; Ussher, 2010). In recent decades, researchers have drawn attention to the way that masculinity influences men’s experiences of depression and help seeking (Hernandez, Han, Oliffe, & Ogrodniczuk, 2014; Johnson, Oliffe, Kelly, Galdas, & Ogrodniczuc, 2012). While studies of men’s experiences of depression have provided some discussion on antidepressant use (e.g., Emslie, Ridge, Ziebland, & Hunt, 2006), this has not been articulated as a particular focus in previous research.

Antidepressant prescribing has increased rapidly in recent decades, and although women are prescribed them more often than men, there are some indications that the gap may be closing (Zhong et al., 2014). This article analyzes interviews with men who have taken antidepressants and explores how the use of this medication evokes particular conflicts in relation to their masculine identity.

Conflict in Antidepressant Use

In recent times, there have been fierce debates about the efficacy of antidepressants (Fountoulakis & Möller, 2011; Kirsch et al., 2008) and widespread concern about whether they are being overprescribed (Jureidini & Tonkin, 2006) or have harmful effects (Middleton & Moncrieff, 2011). These debates have occurred in the context of competing discourses which position mental health problems as being primarily a function of biochemistry with antidepressants as the primary treatment option, or as a legitimate response to difficult life circumstances, pointing to personal or social change as the solution (Rose, 2003). Given the contested terrain of antidepressant use, it is not surprising that people have reported having conflicting feelings about their own antidepressant use (Garfield, Smith, & Francis, 2003; Grime & Pollock, 2003; Karp, 2006).

Research exploring participants’ accounts of their experiences with antidepressants have suggested a range of contradictory feelings about antidepressant use (Gibson, Cartwright & Read, 2014). Users have been described as being torn between hopes that antidepressants will take away their emotional distress and fears about becoming dependent on medication (Kessing, Hansen, Demyttenaere, & Bech, 2005). These medications also produce apparently paradoxical effects, with users saying they help them feel normal, but on the other hand, they highlight the sense that something is wrong with their lives (Garfield et al., 2003).

The potential for conflict around antidepressant use can be understood as part of an inherent contradiction in the way that illness is represented in contemporary society. In their seminal article, Radley and Billig (1996) elaborate on the complexity of accounting for illness: a process which involves the negotiation of a moral position within which the self must be seen as being legitimately in need of help while also being seen as worthwhile enough to be deserving of it. This demand to present the self as being worthwhile through illness is even more relevant in the terrain of mental health problems which carry particular stigma related to abnormality and moral failure (Lafrance, 2007). In this context, antidepressants become a visible sign of failure and people taking antidepressants have been described as experiencing double stigma in which the initial stigma of having a mental health problem is compounded by the stigma associated with antidepressant use (Knudsen, Hansen, Traulsen, & Eskildsen, 2002). In recent research, Ridge et al. (2015) describe how, in the context of these social meanings, antidepressant users feel compelled to account for the legitimacy of their choice and to protect their moral integrity in the face of potential social criticism (Ridge et al., 2015). Research describes how the stigma around antidepressant use plays out within antidepressant users’ own experiences (Goodman, 2009; Sirey et al., 2001). The situation is a complex one for antidepressant users who may feel that antidepressant use challenges moral imperatives to be authentic, autonomous, and in control of their lives (Givens et al., 2006; Karp, 2006) but also offers legitimation to their suffering (Lafrance, 2007).

While much of the research on antidepressant use has focused on the “moral” decision making involved in taking this medication (Malpass et al., 2009), there has been less recognition of the way that the psychotropic effects of the medication might interact with the social meanings given to antidepressant use. The research has pointed to antidepressants producing benefits for users, allowing them to function in their everyday lives (Fullagar, 2009). However, the chemical effects of antidepressants are also known to cause unpleasant side effects (Read, Cartwright & Gibson, 2014a; Pestello & Davis-Berman, 2008; Price, Cole, & Goodwin, 2009). Unlike other medications, the effects of antidepressants go beyond physical side effects to affect those areas that are generally considered to constitute the very self—the experience of emotions and relationships with others (Karp, 2006). Research has, for example, highlighted decreased ability to feel emotion or to care about others as antidepressant side effects (Read, Cartwright & Gibson, 2014a; Price et al., 2009).

The notion of conflict used in this article acknowledges the influence of current social debate surrounding the use of this medication and the moral dilemmas antidepressant use evokes for individuals in relation to the construction of a socially acceptable self. Conflict is also recognized to be likely a function of the psychoactive effects of antidepressants themselves on emotional and social experience (Read, Cartwright & Gibson, 2014a). In relation to the latter, the current research explores the way that antidepressant use poses a moral dilemma but also recognizes the impact of both positive and negative embodied experience of medication use (Adams, Todorova, Guzzardo, & Falcón, 2015).

Gender and Mental Health Problems

While there may be commonalities for men and women in their experiences of distress and its treatment (Danielsson & Johansson, 2005), research suggests that dominant representations of masculinity contribute to men’s experiences of psychological distress and their ways of dealing with this (Gough, 2013).

Connell and Messerschmidt’s (2005) notion of hegemonic masculinity refers to normative ideas of masculinity that “[embody] the current most honored way of being a man” (p. 832). This concept has been important in recognizing the way that men themselves may be subordinated to, or marginalized by, dominant ideas about masculinity. While men can take up different positions in relation to hegemonic masculinity, it often operates as a benchmark for acceptable masculine behavior even when, by definition, its prescriptions are almost never attainable.

Galasinski (2008) argues convincingly that men with depression are constructed as “lesser men” (p. 221) insofar as depression challenges some of the key attributes of dominant masculinity including autonomy, aggression, achievement, and stoicism. Other research in this area has also drawn attention to difficulties men have in recognizing their own emotional distress (Brownhill, Wilhelm, Barclay, & Schmied, 2005) and their reluctance to disclose this to others (Cleary, 2012). Help seeking has been seen to run counter to values that position men as autonomous and in control (Courtenay, 2000; O’Brien, Hunt, & Hart, 2005; Oliffe & Phillips, 2008).

Some critics of the notion of hegemonic masculinity have argued that this conceptualization is too rigid to capture a more dynamic view of masculine roles and point out that men may perform their masculinity in a variety of ways in different contexts and are active in negotiating this on an ongoing basis (de Visser & McDonnell, 2013). In keeping with this view, research on men’s health has shifted away from necessarily pathologizing masculinity as a source of men’s health problems while still recognizing that gender influences their experiences (Gough, 2013). For example, it has also been argued that mental health problems may in fact provide an impetus for men to challenge normative expectations and to shape their masculine identity differently (Valkonen & Hanninen, 2012).

A recent systematic review of 14 qualitative studies looking at the way that men cope with depression noted that, while men are still constrained by traditional values that prevent them from acknowledging distress or seeking help, there are indications that that they can engage more flexibly with constructions of masculinity to better align them to their needs and experiences (Spendelow, 2015). Both this review and other research indicates that men continue to hide their depression in public suggesting there may be a difference between the legitimacy they allow their distress in private and what they consider to be socially acceptable (Spendelow, 2015; Whittle et al., 2015). This suggests that dominant masculinity remains an important point of reference for the way in which men negotiate their experience of depression—even when they cannot, or do not wish to, aspire to this idealized representation of who they should be as men (Galasinski, 2008).

While there has been some consideration of the way in which men engage with treatment options in relation to mental health problems in a general sense, their experience of antidepressants has not been given particular consideration. There is a limited amount of research which has explored women’s use of antidepressants and the meanings associated with this which suggests that women’s relationship with antidepressants is highly ambivalent (Fullagar, 2009; Lafrance, 2007). Antidepressants appear to bring relief, comfort, and legitimation of distress but they also threaten women’s sense of agency, cause unwanted side effects, and distract attention from the gendered environment which helps produce depression (Fullagar, 2009; Fullagar & O’Brien, 2012; Lafrance, 2007). Little is known, however, about how men experience antidepressant use. It may be that their experience harnesses similar conflicts to those experienced by women but it is also likely that these will be shaped somewhat differently by constructions of masculinity.

The overall aim of this research was to explore how men experienced antidepressant use against the background of social constructions of masculinity and the effects of the medication itself.

Methodology

Theoretical Perspective

The researchers adopt a critical realist view which recognizes the significance of both material and discursive constraints on the production of experience (Ussher, 2010). This methodological position was chosen because it was thought particularly important to acknowledge the material influence of the genuine suffering experienced by participants as well as the chemical effects of antidepressants themselves. In addition, it was important to recognize that material experiences such as these are also interpreted within and transformed by the social discourses that surround medication use and the construction of masculinity. People’s experiences are then understood as product of interaction with the broader discursive terrain which opens up or closes down different ways making meaning of antidepressant use. Conflict is a key organizing concept in this article, aimed at capturing the discursive identity and embodied potential for conflict in relation to antidepressant use.

Participants

This study was part of a follow-up to an anonymous Internet survey of New Zealanders’ experiences of antidepressants, open to people who were over the age of 18 years and had been prescribed antidepressants in the past 5 years. The methodology of the survey and the makeup of larger sample have been described in detail elsewhere (Read, Cartwright & Gibson, 2014a; Read, Cartwright, Gibson, Shiels & Haslam, 2014; Read et al., 2015). Twenty interviews were conducted with men who clicked on a survey link to register their interest in talking further about their experiences with antidepressants. The number of men who registered their interest in doing this was far lower than the number of women who responded. All of those who volunteered and lived close to one of the main city centers of New Zealand were interviewed. The anonymity of the survey meant that the researchers did not have access to the responses of participants to this and the interview data were analyzed without reference to the survey data.

Open-ended narrative-style interviews were conducted face-to-face with the men who volunteered for the study. They ranged in age between 29 and 81 years with the average age being 54. All participants were of New Zealand European origin with the exception of one who identified some Maori heritage. All were heterosexual with 15 married or in a long-term relationship at the time of the interview. Most had been in a relationship sometime during the period of their antidepressant use. All the men were working in or were retired from, “white-collar” jobs, often in professional or management positions. Participants had taken antidepressants for different periods of time. Two participants had taken them for about a month and two had taken them on and off for 30 to 40 years. Most of the men saw themselves as having suffered from depression while a few seemed to describe their problems as having a stronger component of anxiety. As clinical literature suggests that these two problems commonly co-occur (Kessler, Berglund, Demler, Jin, & Koretz, 2003), this did not seem to signify major differences in the nature of their experiences with antidepressants. As this study was intended to capture the men’s own accounts of their experience, the researchers followed them in using the words “depression” and “anxiety” in a nonclinical way through the article and sometimes also used the more general term, “distress,” to represent their difficulties.

Data Collection

The researchers used narrative-style interviews that allowed participants to shape and select aspects of their experience they considered to be important (Riessman, 2008). This approach was considered a good fit with the aim of this study which was to highlight users’ perspectives in contrast to the agendas usually imposed by clinical research. The interviews were conducted by the first author of this article who asked participants to tell their “story” of antidepressant use. Participants were encouraged to elaborate their ideas in a conversational style but the interviewer tried not introduce new topics or different directions in the participants’ accounts. The interviews lasted between 1 hour and 90 minutes.

Data Analysis

The data were analyzed thematically using an approach that drew from Braun and Clarke (2006). This approach challenges the conventional wisdom that themes “emerge” from the data and instead requires the researcher to adopt a clear theoretical position in relation to the data and then search for themes within the data that help answer the research question. The researchers were primarily interested in the way that men made sense of their experiences and also conscious of the way in which gender shapes this experience. After transcribing, reading, and rereading the data, the researchers highlighted areas in which participants expressed conflict about antidepressant use. Following Braun and Clarke (2006), the researchers initially coded elements of the text before linking them into overarching themes that seemed to capture a distinct area of conflict in relation to antidepressant use. In the process of the analysis, the researchers contextualized the “conflict” within a gendered understanding as well as an understanding of the psychotropic effects of the medication. Each conflict theme is represented as a tension between two different ways of constructing the same experience. This is not intended to suggest each participant could be located in one or other unitary position, but rather to capture the terrain in which the conflict occurred. Many participants, in fact, described a range of mixed and sometimes contradictory ways of positioning themselves in relation to these conflicts.

There is always a difficulty in balancing the potential of a theoretical position to constrain researchers or to open up and illuminate new findings in the data. In this case, the researchers tried to use their understanding of gender to contextualize the men’s responses but also remained open to the limits of the framework and the potential for the participants’ accounts to contradict the researchers’ own perspective.

Conducting Sensitive Research

The researchers were very aware of the sensitive nature of this research. Participants were given information about the research and signed informed consent to take part in the study. Assuring the men’s anonymity was also recognized as important and the researchers were careful to write up the narrative interview data in a way that protected the men’s identities.

Beyond these standard ethical practices, the researchers were also attentive to what it might mean for men to talk openly about their experiences of depression and antidepressant use. As Witty et al. (2014) note, talking to men about sensitive personal health issues that reflect on their masculinity carries emotional challenges for both participants and researchers. As Oliffe and Mroz (2005) recommend, the interviewer took care to set participants at ease in the context of informal discussion before discussing more sensitive issues around their depression and antidepressant use. The interviewer, a mature woman who was a qualified clinical psychologist, also attempted to probe areas of concern with tact and gentleness, remaining responsive to subtle signals from the participants that some issues were too difficult to talk about. In this context, participants seemed to welcome the opportunity to talk, some noting that they had often felt unable to talk openly with others in their life because of fears of being a burden or being judged. It appeared that the neutral context of a research interview and the idea that their stories might help others provided the impetus for participants talk about issues they had not been able to discuss previously. During the discussions, the interviewer acknowledged and validated the men’s experiences of distress and also provided them with information about how to get further psychological support if they needed this. This research was approved by the University of Auckland Human Participants Ethics Committee.

Establishing Rigor

Reflexivity is a key issue in establishing the rigor of qualitative research of this kind (Morrow, 2005). As Stephens (2011) notes, the way that people construct their experience in the context of an interview are a product of both the researchers’ and participants’ involvement and the researchers were attentive to potential for participants’ reflections to be shaped by the interviewer and the interview context and particularly by the fact that the interviewer was a woman. Some of the participants expressed the view that they had less fear of being judged in talking to a woman rather than a man, but the researchers were conscious that the narratives might have been different with a male interviewer. The research team, however, included a man and used self-reflection and discussion within the team and in other research discussion contexts to challenge the current analytic assumptions (Hollway & Jefferson, 2013). Some of the challenges in this regard were in relation to the authors’ positioning as feminists and shared concerns about the widespread use of antidepressants; recognizing both positions might close down views that differed from the authors’ own.

The trustworthiness of the research was achieved by carefully reviewing the codes and themes between members of the research group to gain consensus on the extent to which they provided an honest reflection of the data, were reasonably coherent and conveyed meaningfully different ideas (Morrow, 2005). Differences in opinion on these areas were resolved through collective discussion in a manner described by Hill et al. (2005). While not all participants’ accounts reflected all themes described here, the analysis presented here reflects the range and diversity of accounts.

Findings

Of the sample of 20 men, 17 had attempted to stop taking antidepressants at one point or another. Many had made the decision to return to antidepressants and only 7 were not taking antidepressants at the time of interview. All, with the exception of 1 participant, expressed ambivalence in relation to their antidepressant use, even where they felt that they had benefited from taking the medication. The themes below reflect the main areas of conflict men described.

Taking Charge or Giving up Control

Researchers have highlighted the way that antidepressant use might undermine users’ sense of control and agency (Givens et al., 2006; Karp, 2006). A number of the men in this study alluded to difficulties in managing concerns that using antidepressants suggested their inability to assert control over their own lives as well as the contrary idea that this was a legitimate way of “taking charge” of their lives and their difficulties.

Many of the men spoke about the importance that they attributed to being able to cope with the demands of their lives—and particularly the responsibilities they carried in relation to their jobs and role as the family breadwinner. In this context some participants spoke about taking antidepressants as a kind of defeat: “Makes you feel like a failure . . . like giving in” (Participant 1). One participant elaborated on how he understood antidepressant use as a reflection of weakness:

Maybe that’s also wrapped up in this idea about, you know, I should be able to cope with it without medication as well. It’s maybe it’s some sort of failing, maybe it’s some sort of sense of failure about having, you know, I’m not doing what I could do, I’m not achieving what I could achieve because I need medication, I should be able to manage these sorts of things. (Participant 13)

Another participant contextualized this against the background of expectations that men carried in relation to being able to cope with difficulties in their lives. As he put it: “generally men tend to think that they can overpower any situation with just pure physical-ness” (Participant 20).

Some of the men interviewed experienced the feeling of giving over control to a “pill” intolerable and chose to stop taking antidepressants. One man who had stopped antidepressants articulated his perception of the sort of person who would rely on antidepressants rather than their own resources: “We’ve always had people that used to talk about taking their happy pills and yeah I was never sure that they’d done enough themselves to try and fix things” (Participant 4).

While antidepressants were seen to undermine personal control others dealt with this challenge by emphasizing the way the decision to take antidepressants was a way of taking charge of their difficulties. As one participant put it: “It’s not a sign of weakness, it helps your own mental stability sort of get back on even keel again” (Participant 5). Others emphasized their own continued agency as significant alongside medication as the following extract suggests: “You’ve got to help yourself . . . there’s only so much that people from the outside can do. It’s got to come from within” (Participant 6).

A number of participants who had opted to remain on antidepressants seemed to negotiate this conflict by actively taking control of the process of medication use. One participant, for example, explained how he took an active role in evaluating, reviewing, and making decisions about his antidepressant use:

I’ve got pretty good at sitting back and analyzing what’s going on and looking back over a week I’m able to chop and dice and go “mm I’m going to stop those meds now, I’m going to monitor myself for a couple of days and if I don’t improve after those two days I’ll go back on the meds knowing that it’s something else.” (Participant 10)

Other participants also described how they experimented with different dosages, often without their doctor’s knowledge or permission. One participant, for example, explained how he took charge of the process of stopping the medication himself:

I didn’t want to be bothered going to the GP. I told the GP after I had done it . . . I made up my mind I was going to do it, I didn’t want the doctor to say no, it’s bad. I don’t think he would have. But I thought I can control this myself. (Participant 16)

Most of the men in the sample conveyed the importance of being able to exercise control over their own lives and in relation to antidepressant use. Only one participant, who had taken antidepressants for many years and experienced intense discontinuation effects on stopping, seemed to feel that that he had no ability to control his reliance on antidepressants and no ability to manage his life without them. His account conveyed a sense of his despair at what he felt to be the loss of control over his own life. As he put it: “ . . . my brain belongs to Mr. Pfizer” (Participant 12).

The research on women’s use of antidepressants has suggested that they may also experience difficulties in the process of “giving up control” to medication (Fullagar, 2009). However, dominant social discourses position control as a particularly desirable and integral aspect of masculinity and may create particular challenges for men (Oliffe & Phillips, 2008). This might go some way toward explaining why almost all the participants highlighted their decision to go off medication or to remain on it as an expression of their ability to exercise control over their lives. In this conflict, loss of control was often an unspoken threat revealed largely in the extent to which the men asserted their ability to remain in charge of their antidepressant use and their lives.

Functioning in Life or in Sex

The effect that antidepressants, and particularly selective serotonin reuptake inhibitors, have on sexual desire and functioning is well recognized in research (Read, Cartwright & Gibson, 2014; Williams, Edin, Hogue, Fehnel, & Baldwin, 2010). Not surprisingly, all but one of the men in this study spoke about some change in their sexual functioning. Participants attributed a range of different meanings to this experience.

Some participants described the loss of their ability to perform sexually as a source of distress which further increased their feelings of depression as the following extract suggests:

The whole unpleasant thing, you know, your libido is absolutely stripped. I might as well live in a monastery because I’ve got no libido and when it does come then I have erectile problems and so it’s really, for something that’s supposed to stop depression, it causes me a lot of depression, you know. (Participant 12)

Participants also spoke about how they weighed this loss of functioning against the gains in functioning in other important parts of their lives. The idea of antidepressants helping the men “function” was repeated in many of the interviews. Largely, this functionality seemed to refer to the importance of being able to function in work contexts. Many explained how they had struggled to manage the stressors related to their employment and how antidepressants enabled to manage these roles. One man explained how he needed antidepressants to keep functioning in his highly demanding job:

There’s a stigma attached to, and particularly for a man, to be suffering from depression. So I kept wanting to get off [antidepressants] and so from time to time I would wean myself off. But I found that I couldn’t function under high pressure without them. (Participant 7)

Men had to balance this functionality against the perhaps more private effects on sexual functioning in the context of their relationships as one participant described:

And so here they are, they give you functioning for day to day activities but possibly take away marriages for certain people. . . . It makes you feel good but you can then coast into a separation that perhaps might not have happened. (Participant 20)

It seemed that the visibility of men’s failure to perform sexually made new relationships particularly anxiety provoking. One of the single men in the study captured the conflict he experienced in his “choice” between sex and the more general impact that depression had on his ability to function. He explained that at first, the effects of depression were so far reaching that he chose antidepressants above sexuality:

Well I think getting rid of the depression probably is the most important thing of all because it affects everything whereas impotence only affects part of your life. . . . But then on the other hand as you say it’s like do you sacrifice your sexuality or do you sacrifice your life and that’s what it felt like. (Participant 19)

The choice became less clear when this man began to feel better enough to want to find a relationship. He conveyed the view that his inability to perform penetrative sex would make a heterosexual relationship impossible:

Well it meant that I could never have another relationship. I mean how many people do you meet who might be interested in you for taking things further through a relationship once they know that you can’t perform a sex act. It would have to be a very special person. You can’t advertise on the net “this and this and this wonderful—but no sex.”

While the greatest majority of participants spoke about the impact of antidepressants on their sexual performance as a significant challenge for them, a few discovered different ways of negotiating this challenge. In some cases, participants chose to remain single and a few who were in relationships seemed to deprioritize or redefine the sexual aspect of the relationship. These participants spoke, for example, about how sex was less important in their relationships because of their age or situation: “Having said that when you get to your 60s your sex life is not as active as it used to be anyhow” (Participant 7). Some took comfort from what they saw as their partners’ lack of interest in sex or emphasized the value of nonsexual intimacy.

A few explained that their sexuality and relationships had already been compromised by their depression and, in some cases, they spoke about how antidepressants enhanced their capacity to engage in the emotional aspects of intimate relationships in the way the following participant describes:

I re-engaged. I became a loving and I think a better partner in the fact that it made me more facilitating, like I wasn’t sweating the small stuff. Now some people would say that’s disengagement again but for me it wasn’t. I actually re-engaged. (Participant 20)

While antidepressants are well recognized to have a negative effect on sexual functioning, they have also paradoxically been noted to increase sexual performance by delaying ejaculation (Emslie et al., 2006). One participant described the way that antidepressants allowed him to continue sex for longer which he felt increased his sexual prowess and his confidence: “So I actually find the performance is actually great as well, because that means I can go for it quite a long time” (Participant 9).

Dominant forms of masculinity often define men through a clear heterosexual identity associated with competent sexual “performance” and impotence has strong association with the failure of masculinity (Fergus, Grey, & Fitch, 2002; Oliffe, 2005). While women have also been reported to struggle with the sexual side effects of antidepressant medication (Mullen, Doherty, Coates, & Tilley, 2014), the association of penetrative sex with masculinity is likely to make erectile problems a particularly salient source of conflict for men. Not surprisingly, the sexual impacts of antidepressants were clearly important for all men in this study and although some men negotiated this conflict by emphasizing intimacy above sexuality in their relationships or reinterpreting the sexual side effects as enhancing their sexual prowess, most experienced this side effect of antidepressants very challenging. The loss of sexual functioning had to be weighed against the importance the men gave to being able to function in other aspects of their lives. As Galasinski (2008) argues, masculinity is defined by being able to function and depression is felt as distress precisely because of its impact on men’s ability to perform in relation to expected roles, especially in relation to work. Antidepressants were seen as simultaneously undermining masculine sexual functioning while restoring the ability to function in other important areas.

Relieving Distress or Reducing Emotional Vitality

A number of studies have noted the difficulties that men have in acknowledging and expressing emotional vulnerability (Cleary, 2012). Antidepressants are recognized to reduce the intensity of emotional distress and it might have been anticipated that this would be seen as a valuable aspect of antidepressants for men in the current study. While it was the case that a number of participants expressed relief at the decrease in the intensity of emotions, many also experienced antidepressant use as robbing them of emotional vitality.

Many of the men spoke about how they had felt extreme emotional distress in the period before seeking an antidepressant prescription: “Pretty much all the classic things . . . highly emotionally unstable I guess in the sense of bursting into tears at a moment’s notice” (Participant 14). For some, this period had been fraught with anxiety that they might reveal their emotional distress in public:

Well I’m quite a rational, stable sort of person but that would get me at times, in areas that were completely beyond my control. So I was worried that I might be in the middle of a business presentation and suddenly crack up for no reason. (Participant 19)

Another participant conveyed what he saw as the general unacceptability of a man showing his emotion in public, explaining that men remained on antidepressants as a way of managing this eventuality:

When you crack you show the signs that you see in a woman, crying, not being able to cope, you know, just bursting into tears at the drop of a hat, and no one wants to go there. I guess that’s why we take the pills. (Participant 3)

Most participants suggested that antidepressants had seemed initially to dilute the intensity of their distress which left them feeling “calmer” than they had before: “[They] kind of take the edge off if you like” (Participant 8). For almost all participants, this muting effect on emotion was experienced as a relief at least in the short term. Some spoke about how they valued the way it allowed them to reconnect with a more rational sense of themselves:

You can’t think about how you feel if you are too clouded by emotion. You can’t step back from it. And even though I hate to admit it that was a really beneficial part of it. (Participant 1)

However, a number of participants gave accounts that suggest that this changed as time passed and they began to struggle with what they described as a kind of emotional “numbness.” Some discussed how the reduced intensity of emotion left them unable to feel either good or bad feelings: “They’re terrible things because they take away, yeah they take away the lows, there’s no doubt about it, but they take away the highs and they put you in the ‘nothing zone.’ So you don’t feel things” (Participant 3). Others spoke similarly about how this detracted from their enjoyment of sensory pleasure as the following extract suggests:

And then I found I wasn’t interested in movies. Oh I can’t be bothered. Couldn’t be bothered going to Art Galleries. No pleasure in it. Um sense of taste, just sort of flat. . . . I would eat in a completely functional way. (Participant 11)

Many of the participants spoke about the frustration at the loss of emotional vitality in themselves; however, only one participant described some frustration with the potential loss capacity to care about others weighing this up against the value he saw in being distanced from his emotions:

Yeah I guess in one way [less emotion] is good. And in another way it’s not going to be good if you want to, you know, become more empathetic, more compassionate, or learn how to be more relational with people. (Participant 1)

This participant’s unique focus on empathy may in part be explained by the nature of his work in the health professions and it is notable that none of the other men spoke this aspect of their emotional lives being affected by antidepressants.

Some participants explained that they had stopped taking antidepressants because they could not bear their loss of vitality while others saw this as a necessary compromise to avoid the return of intense and perhaps visible distress. However, there was a relatively small number of men in this sample who saw antidepressants as having a somewhat different meaning in relation to emotion. For them, antidepressants seemed to lend a kind of legitimacy to a preexisting emotional sensitivity that was inconsistent with dominant masculinity. As one participant explained it:

I know in New Zealand especially, I mean you know you’ve got to sort of man up and be a man and do everything else and all the rest of it. But I think a lot of people nowadays are sort of realizing that people do have feelings, whether you’re male or female. But you can still have feelings without degrading yourself or belittling yourself. (Participant 5)

Most of the men in this study seemed to struggle to weigh up the relative benefits of reducing their emotional response against the experience of “numbing” which has been described as a side effect of antidepressants for both men and women in other research (Read, Cartwright & Gibson, 2014a; Price et al., 2009). For many participants, the loss of emotion seemed more strongly associated with a loss of vitality and sensory engagement with their environment than empathy or concern for others, which researchers have suggested is a particular concern for women experiencing the side effects of antidepressants (Fullagar & O’Brien, 2012). While both men and women may be understandably afraid of returning to a state of distress if they stop taking antidepressants, there is a suggestion that that there may be concerns with visible signs of emotional vulnerability and the challenge this posed to the participants’ masculinity. A relatively small number of men, however, saw antidepressants as legitimating their emotional sensitivity. While these findings contradict a simplistic notion of dualism between constructions of masculinity as rational or stoic and femininity as emotional (Cleary, 2012), they seem to still point to emotion as a significant focus of conflict for men using antidepressants.

Autonomous Decision Making or Relying on “Experts”

As Karp (2006) has noted, using antidepressants can leave people with uncertainty about their very sense of self. Because both depression and antidepressants change the way a person feels about themselves and their world, antidepressants users may also feel uncertain about the validity of their own decisions in relation to antidepressant use. Yet autonomous decision making was important to the men in this study and they struggled to determine the extent to which they should rely on their judgments about the value of antidepressants or accept the expertise of others to do this for them.

Many of the men in this study spoke about only having become aware of the need to seek help for their distress when someone else pointed this out to them. For some, the first experience of being told they had depression (or another mental health problem) came through their doctor who had prescribed antidepressants. The recommendation to take antidepressants was mostly greeted with initial relief by participants who saw this as a solution to their difficulties. Some spoke about how they willingly “trusted” their doctors to do the best for them, especially in light of their own uncertainty as the following participant explains: “So I was trusting someone because I had lost all confidence, so I didn’t know what to do. It’s an all new experience for me, and you know” (Participant 15).

A small number of participants described how they had continued to put their faith in medical expertise. As the participant quoted above put it, it was all about “trusting the doctor.” However, the majority of participants described how they became increasingly skeptical about the “expertise” of their doctors in regard to decisions about antidepressants. Some described began to reclaim their own autonomy to decide whether or not they would take antidepressants:

I can’t remember how many I cycled through with [my doctor] in that five months. There was always the question of we’ll give it a bit longer and see if it works. But I just got to the point where I said “Doc it’s not working. I’m not prepared to elongate the timeline because it makes no difference for me physiologically. It’s not going to help.” (Participant 10)

This participant was active in researching different medications recognized that he had to work with what his general practitioner wanted for him but also felt that in the end, he had to make use of his own judgment about what worked: “So you’ve just got to roll with it but I’m old enough and experienced enough now to know how to trust my own gut. This is telling me it’s not the thing for me then you know . . . ”

However, participants also alluded to the way in which antidepressants themselves had undermined their certainty about their own abilities to make decisions about their “wellness.” One participant offered this explanation of the conundrum he found himself in:

There are times when you go well I don’t need to take the pills because I feel good. But of course you feel good because you are taking the pills. I’m like well I don’t think I’m depressed, but that’s because I am depressed, so I’m not thinking properly in terms of knowing whether I am depressed or not. (Participant 8)

This uncertainty was exacerbated by fears that the medication itself might have changed them in some way and that stopping medication might reveal another unknown aspect of themselves as the following extract highlights: “You are left feeling insecure in your own ability to understand what you are going to become like, what you could be like, what is the real you anymore?” (Participant 20).

This conflict played out in relation to prescribers but was also described as manifesting in relationships with girlfriends and wives, for those who were in relationships. One participant provided a detailed description of how he had only become aware of his “depression” through his partner’s observations. He himself expressed some skepticism about whether in fact he was “really” depressed:

Certainly a lot of the symptoms of depression that I exhibit, you know, I wonder whether they’re actually symptoms of depression or it just so happens to be that that’s the way that I am, if you know what I mean. (Participant 8)

However, he explained, he acceded to her suggestion that he seek help partly because he valued the relationship: “No doubt there was an element of going along with it because I was in the relationship and I enjoyed that and she thought this would help and I thought well maybe it will.”

Looking back on this experience, this participant was able to make sense of the relational pressure he felt to see himself as depressed and to take antidepressants as a treatment for this: “I’m sure there would have been [my partner’s] expectations of what she wanted or expected me to be like, that would have been some kind of force.” Other participants seemed more convinced that they “had depression” but still spoke about deferring their judgment of their own emotional state to their partners as the following extract suggests: “My wife is very good obviously at now identifying where I am at and saying: ‘Hey come on, don’t you think you need to be taking your antidepressants again’” (Participant 14).

Their partners’ views did not always match the men’s own assessment of their emotional state but were most often given precedence over their own as one participant explained: “I wasn’t aware of the depression myself but [my wife] tells me my mood was much further down [than I thought]” (Participant 16). While some expressed some resentment at their partners’ judgments, others seemed to expect and want their partners to play this role in their lives as this extract suggests: “because I can’t trust my judgement anymore and you’re my wife, you’re supposed to know that I’m not well” (Participant 10).

Several of the men spoke about how their partners were actively invested in them continuing to take antidepressants. One (Participant 16) joked that his wife would “divorce” him if he stopped, while others spoke about how their partners seemed to appreciate them more when they were taking antidepressants. Some understood their partners’ encouragement to take antidepressants as sign that they were uncomfortable with their emotional vulnerability:

It’s just it seems to be, [my wife] expects you to be a male and be the strong one, and she’s a pretty strong person herself, but she expects me to be, I can’t really show too much vulnerability, which is hard work. (Participant 7)

Others spoke about how their wives and partners had difficulty with aspects of their behavior when they were not on antidepressants:

For me it was a matter of my wife pointing out to me that I need to be responsible for my own behaviour and if you can’t control it you need to see somebody about it or do something about it, like “You are a complete asshole and I am not prepared to tolerate it, now are you prepared to do something about it.” (Participant 20)

In most cases, the men’s partners were described as actively discouraging them from stopping antidepressants as the participant above also describes:

My wife was saying: “[Participant’s name] you have to do something. You’re depressed, you’ve changed. You’re not the man I knew.” And so I found that each time. I discontinued it three times before I found a way off it.

Many of the men in this study seemed to struggle to weigh up their own autonomy to make decisions about antidepressant use or to trust the evaluations of those around them. But while the men seemed sometimes to resist or subvert the judgments of professionals, those who had partners seemed to find it more difficult to hold onto their own judgments about antidepressants in these relationships. While research suggests that masculinity is defined through men’s ability to act autonomously (Galasinski, 2008), women are often positioned as more expert on emotion than men (Duncombe & Marsden, 1993). This may render men particularly vulnerable to “outsourcing” evaluations of their emotional state to the women in their lives. This contributed to a conflict the men in this study experienced about whether they should hold onto their own evaluations of the value of antidepressants in their lives.

Discussion and Conclusions

This study highlights a number of areas of conflict that men experience in relation to antidepressant use. These conflicts are shaped by multiple influences including the distress that motivates antidepressant use and the chemical effects of the drugs themselves. The side effects of the antidepressants on emotional numbing and sexual functioning are well established in the research literature and it is important to recognize, as Pound et al. (2005) do, that one of the primary reasons people experience conflict about medication use is because of the medications themselves. Beyond the material effects of the medication, the data also suggest that the men attributed a range of different meanings to antidepressants that went beyond their chemical effects. Not all these meanings can be attributed to gender and it is clear that many of the areas of conflict that the men in this study described are also issues for women; however, it did seem that dominant ideas about masculinity seemed to focus men’s conflicts around antidepressants in a particular way.

The analysis suggests that participants experienced conflict in relation to aspects of their identity that are thought to be particularly significant in relation to dominant forms of masculinity including control, adequacy of sexual performance, emotion, and autonomy (Courtenay, 2000). Antidepressants were seen to challenge personal control while also being a way in which men asserted their control over difficulties. The effect of antidepressants on the men’s sexuality was also clearly an area of struggle for the men in this study, but the decision about whether to come off antidepressants had to be weighed the more general need to function in masculine roles. Emotional distress, and particularly the risks of the visibility of this, had to be assessed against the loss of emotional vitality attributed to antidepressants. Autonomy was also central to the tension men described between an investment in autonomous decision making and accepting the “expertise” of others.

While masculinity seemed to shape particular aspects of the antidepressant experience as potential sources of conflict for men, the way in which participants negotiated these conflicts was less predictable. Coming off antidepressants was one way of resolving the dilemmas the men faced. The number of those who returned to use antidepressants again highlights that this is not an easy option. It seemed clear that coming off or staying on antidepressants involved a complex process of weighing up the losses and gains, with potential risks to their masculine identity possible in both decisions.

Other ways of negotiating the conflict with antidepressants involved reinterpreting any threats entailed in antidepressant use in a way that emphasized its consistency with desired masculine attributes. For example, in asserting their ability to actively manage the way they used antidepressants, the men were able to take charge of an experience that may have threatened their control. Similarly, the sexual side effects of antidepressants could be reinterpreted as facilitating sexual prowess. In these ways, the men seemed to harness aspects of traditional masculinity to reclaim power in situations in which they might conceivably have felt disempowered in a way that Emslie et al. (2006) have also described.

But while the data suggested that dominant ideas about masculinity might focus conflict in particular areas, it also reflected how the men seemed to be struggling to find different ways of representing their masculinity that could better accommodate their experiences. In contrast to simplistic polarizations of women’s emotionality and men’s rationality, the men in this study seemed to have a strong appreciation of the value of emotion in their lives although this related more to vitality than to softer forms of emotion such as empathy and sensitivity. A very small number of participants, however, actively contested the idea that emotional sensitivity should be seen as unmanly. Some tempered also their concerns about sexual prowess with a more relational conception of intimacy with their partners. These nondominant ways of thinking about aspects of their masculinity may be aligned with more general contestations about what constitutes manliness (de Visser, 2009). However, it is possible that the participants in this study had been forced to think differently about their masculinity in light of experiences which forced them to reevaluate aspects of their identity (Valkonen & Hanninen, 2012).

Through these conflicts, the underlying thread is the stigma that is associated with men experiencing depression, with taking antidepressants and ultimately with the moral failure associated with not living up to social expectations. While women also experience the social and self-stigma associated with depression and using antidepressants, men may be especially vulnerable to these effects (Vogel, Heimerdinger-Edwards, Hammer, & Hubbard, 2011).

While these social influences were clearly important, the men also clearly struggled with the psychotropic effects of the medications themselves on their sexual functioning, their emotional functioning, and their relationships. These material effects helped create and compound some of the conflicts they experienced. This embodied experience also needs to be acknowledged in the research on antidepressant use.

While this article does shed light on potential areas of conflict men may experience with antidepressants, it should be acknowledged acceptable forms of masculinity are shaped by context and may not been seen in exactly the same form elsewhere (Connell, 2005). New Zealand is also known to favor a particularly macho form of dominant masculinity which may be different to other cultures (Campbell, Law, & Honeyfield, 1999). Furthermore, the relative social privilege of this particular group of participants may not reflect the experiences of all men who use antidepressants. The largely senior occupational roles occupied by the men in this group suggest they may have a particular investment in being “in charge” of their lives and experiences. Limitations also arise from the sample which included largely older and only heterosexual men who may have experienced issues such as sexuality and emotionality in a different way to a younger group with greater diversity in their sexuality (de Visser, 2009). It is unfortunate that in the context of New Zealand, there was very little representation of Maori among the participants. This was also reflected in the original survey sample out of which participants volunteered for this study; just over 1% of this sample was Maori. This may suggest the limits of an on an Internet-based survey for accessing the views of this group but is also likely to reflect antidepressants being less acceptable to Maori (Thomas, Arlidge, Arroll, & Elder, 2010).

In spite of its limitations, this study has a number of implications for men using antidepressants, for those who prescribe these medications, or who work with men to facilitate their recovery from depression. It seems clear that using antidepressants involves considerable conflict for men. On the face of it, the conflicts they deal with seem to represent an added burden to a group who may already be struggling to come to terms with distressing experiences. The men were sometimes able to transform their conflict with antidepressants into a creative solution that worked for them. There were also many examples that suggested that men might experience an impasse in negotiating their antidepressant use, seeming to be trapped between a “rock and a hard place” in terms of whether or not to use them. It is important not to romanticize the capacity of men who use antidepressants to negotiate these conflicts in ways that suited their needs. There were also suggestions that their fears and uncertainty might be driving them to remain on the antidepressants for longer than necessary. In particular, their fear of revealing their emotional vulnerability and their uncertainty about trusting their own evaluations of their emotional well-being might contribute to men remaining on antidepressants in spite of their concerns about the medication.

As other researchers have suggested, there may be a need to adapt mental health services to the concerns that men have about help seeking (Oliffe & Phillips, 2008). Professionals who work in men’s mental health may be well placed to have discussions about the sources of conflict that men experience with antidepressants and to facilitate their better understanding of treatment choices that best meet their needs, recognizing that this may not be an easy decision.