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Depression: Exposing Men's Hidden Killer

Issue: October 2009

By: Will Courtenay, PhD, LCSW

The gender gap in depression is steadily narrowing. Once up to three times higher in women than men, the female to male ratio for depression is now 1.5 to 1. More than six million U.S. men become depressed each year. That amounts to at least one man in every 20. There’s a good chance that one man will be seen at some point by his physician. And, there’s a good chance his doctor won’t recognize he’s depressed.

One reason men’s depression goes undetected is because men often hide the pain of their depression – from themselves and from others. Another reason is that men with depression don’t always look depressed. As a result of men’s lifelong training in how to “be a man,” men often don’t cry and don’t express sadness or hopelessness when they’re depressed. They’ve been taught that it’s “unmanly” to express feelings, and especially shameful to express feelings that might reveal “weakness.” Among people who are depressed, men are more likely than women to try to rely on themselves and to not seek professional help, so their pain remains hidden.

Men’s hidden depression contributes to a myth in our society that men simply don’t get depressed. But there’s no better – nor more tragic – proof of men’s depression than suicide. Depression is the most common condition linked with suicide, and every day, more than 70 U.S. men take their own lives, up to 12 times the number women who do. And it’s not just suicide that kills depressed men. These men are twice as likely as men who aren’t depressed to die from any cause.

The cultural reluctance to acknowledge men’s depression makes it challenging to diagnose. In fact, even trained mental health clinicians are less likely to correctly diagnose depression in men than in women. It’s no surprise then, that a man’s physician won’t always detect it.

To diagnose depression in male patients, it’s important to be familiar with symptoms unique to men. Depressed men can present with classic signs of depression, such as feeling helpless or hopeless, a loss of interest in previously pleasurable activities, changes in weight, sleeping too much or too little, loss of energy, and a sense of worthlessness or guilt. But this isn’t always the case. Other symptoms of men’s depression include irritability and being easily frustrated, increased anger and conflict with others, increased stress, impulsiveness and risk taking – like reckless driving and extramarital sex – increased alcohol use, working constantly, and withdrawal or isolation from family and friends. Depressed men are also more likely than women to report somatic complaints or ongoing physical problems. These include headaches, stomach or digestive problems, or pain that doesn’t respond to medical treatments.

Even with knowledge of these symptoms, it can remain challenging to determine whether a male patient is depressed. It is helpful for a physician to ask some questions that assess a man’s level of irritability, isolation, withdrawal, preoccupation with work, drinking, and risk-taking activities. When a physician diagnoses depression in a man, some education and coaching are useful. Informing the patient that depression is a medical condition is important, for example, because men often see it simply as a weakness of character.

For men, one of the obstacles to seeing a mental health professional is the concern that if others – like coworkers – found out about it, something bad would happen or they’d lose respect. So, it’s helpful for a man to hear from his doctor that depression is common, and that there’s no need to hide it; that it’s just as common, and just as real, as a physical problem like heart disease. It’s also beneficial for him to be reminded that everyone needs help sometimes, and to be persuaded to muster the courage necessary to get professional assistance. Thinking through the possible consequences of not getting help can also motivate some men to get the treatment they need.

It is well documented that medication and psychotherapy are effective in treating depression. According to Thomas R. Insel, M.D., Director of the National Institute of Mental Health, one of the reasons depression goes untreated is that physicians are uncertain about mental health clinicians to whom they can refer their patients. Creating a ready list of local, licensed psychotherapists to refer to as needed can remedy this problem.

Unfortunately, only one in five people with depression receives adequate treatment. In one national survey, 10% of men said they needed to consult with a clinician because they felt depressed or anxious, but only half of these men actually saw one. Left untreated, a man’s depression will often worsen and can result in damaging, long-term consequences for himself, his career, his relationships, and his family and children. These consequences are all preventable. Although it’s very serious, and potentially life-threatening, depression is also very treatable.

Fortunately, as the myth of men’s immunity to depression is increasingly dispelled, more men will receive the treatment they need.

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Dr. Will Courtenay, “The Men’s Doc,” is a psychotherapist in San Francisco and Berkeley, CA, and an internationally recognized scholar and expert in helping men. He has served on the clinical faculty of McLean Hospital, Harvard Medical School, and the University of California, San Francisco, Medical School. He is the founder of a number of web sites for men, including Mens-Depression.com and www.TheMensDoc.com. He can be contacted at 415-346-6719 or DrC@TheMensDoc.com.

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