Depression in Men: Why We Need to Pay Attention

Patient Expert

My good friend and blogging buddy Therese Borchard just posted an important piece on depression in men. Please, go read it. Okay, this is an issue I have strong feelings about. Let’s begin.

Way back, on my own, I began to question why twice as many women were diagnosed with depression as men. It didn’t seem right. I turned up research by Jed Diamond, Terrance Real, and William Pollack, and suddenly it all came in loud and clear. Following is a fusion of their views, combined with my own …

Basically, men express their depressions in ways very different to women. The DSM symptom checklists reel off behavior that far more fits the stereotype of weepy and over-ruminating women. Men, by contrast, tend to hide their emotions, or express them as grouchy or aggressive behavior.

Coping behaviors are also different: Women are communicative, men sullen. Women are more willing to face their difficulties head on and seek help. Men go into denial and distract themselves such as by throwing themselves into their work.

Gender expectations feed into the mix. Men are expected to be strong, show no sign of weakness.

Add to that, a host of hormonal influences. Women’s ebbs and flows get all the attention, but men may be the ones with the more serious problems: Too much testosterone in early adulthood, too little of it in old age. No wonder men are so difficult to get along with.

In the end, men are far more likely to pay the ultimate price: Four times as many men than women commit suicide.

According to Dr Pollack in a show on NPR:

A lot of men get angry, irritable, mean, impulsive, and we say they're ... SOBs and they're a pain, and let's get rid of them, let's fire them, let's divorce them, when, in fact, behind that mask of masculinity is actually the same sadness, hurt and pain expressed in a male-based fashion.

Jed Diamond and his wife Carlin both took depression tests at the same time. Jed's wife scored high on the test while he scored low. As a result, Carlin sought and received help for her depression while her husband struggled in his hellish fool's paradise.

I have written elsewhere about my chance meeting with Robert Spitzer, the man responsible for the DSM-III of 1980. This was the first modern DSM, and the current one sticks very closely to its criteria for major depression.

I had pulled up a seat at a dinner symposium at a psychiatric conference in San Francisco in 2003. Dr Spitzer took a seat next to me. What to talk about?

I asked him about the depression symptom checklist, and how it might not pick up depression in men. Was he interested? He gave me permission to proceed.

Symptom number one: "Depressed mood most of the day.” Its only example is the unfortunate one of "appears tearful."

Symptom three: "Significant weight loss when not dieting or weight gain." Okay, think of who runs to the fridge for Ben and Jerry's when feeling low, and now reflect on what men go to the fridge for.

Symptom seven: "Feelings of worthlessness or inappropriate guilt." The male equivalent is probably closer to Dr Pollack's irritable and angry SOBs.

The ninth and final symptom concerns suicidality: More men commit suicide, and they may or may not think about suicide as often as women, but because women make far more attempts, they are much more likely to come to the attention of the psychiatric profession.

The speakers started their presentation. Later, during a break, Dr Spitzer took his leave, but not before stating that he thought about what I said and didn’t agree with anything I said. Then he was gone. Poof Just like that.

As I was to read in an article in the New Yorker two years later, this was typical Robert Spitzer behavior. Basically, his social cluelessness and huge ego and ease in antagonizing people cost him his chance at heading up the DSM-IV.

Unfortunately, by this time Spitzer’s checklists were set in concrete and impervious to change. It would have been so simple to add in something along the lines of “irritable or aggressive or antisocial behavior,” or “sullenness or uncommunicative,” and perhaps something about drinking or abusing drugs.

Anything that would put clinicians on notice to take male behavior into account.

We can fault Dr Spitzer for the obvious defects of that original depression checklist. But the DSM was meant to be a work-in-progress, to be updated and corrected as new insights emerged. His successors have had more than three decades to get with the program.

In the meantime, to the disgrace of psychiatry, men are suffering and even dying.

If you are a man, please seek out an open-minded clinician. If you are that man’s loved one, please don’t be afraid to initiate a discussion. Your partner is likely to resist and not want to talk about it - stick to your guns. Now, more than ever, we need to be talking about this.