Male Depression

Is underlying depression the “smoking gun” for men?

(Adapted from Men and Therapy: A Case of Masked Male Depression Frederic Rabinowitz, PhD and Sam Cochran, Ph.D., 2008)

It can be difficult to diagnose depression in men. The muting of behavioral expression of mood states often makes it difficult for clinicians to identify clear and straightforward indications of male depression.

Some men simply present themselves as depressed and show the traditional DSM-IV symptoms: dysphoria, thoughts of death, appetite and sleep disturbance, fatigue, diminished concentration, guilt, psychomotor change and loss of interest in typical activities. However, a sizeable portion of male patients present more oblique and difficult to decipher cluster of symptoms related to depression.

Recent research has postulated that the experience and expression of depressed mood in many men is “masked” by culturally derived norms that encourage acting out and self-medication and that prohibit the expression of grief and sadness.

Statistics show that women are diagnosed with depression at twice the rate of men but that men are overrepresented in the categories of drug abuse and dependence and are four times more likely to successfully commit suicide. Given this high rate of suicide among men, researchers have investigated non-obvious manifestation of depression in men characterized by masculine-specific modes of experiencing and expressing depression. These masculine-specific features include a tendency for depressed men to:

• exhibit increased anger and interpersonal conflict,
• experience conflict between gender-role related expectations and accomplishment,
• experience work-related problems and conflicts,
• perceive threats to self-esteem and self-respect, • exhibit antisocial and narcissistic traits
• exhibit increased levels of alcohol and other drug abuse and dependence.
• exhibit increased worry about health

Cochran and Rabinowitz believe that these masculine specific features of depression can be best understood as manifestations of a masked depression that is characterized by a masculine tendency to:
• externalize distress into action – high risk behaviour, over work, other obsessive activities
• engage in ruminative responses that may lead to alcohol or drug abuse
• express irritation, anger and withdrawal in reaction to narcissistic injury

Many of the concerns that men report are quite pressing (relationship or job loss, bereavement, developmental transitions or alcohol or substance abuse) and coupled with the fact that anger and irritation is a frequent pathway for men to express depression, it is not surprising that it is common for the longer-term and more pernicious underlying mood disorder to be overlooked.

The good news is that men who do receive treatment for depression respond as well to medication and psychotherapy as women.

Although there are as yet no specific norms for diagnosing male depression, these symptoms are useful to consider with male patients as an adjunct to the DSM-IV:
• anger, aggression, irritability
• substance abuse
• over-focus on work/school
• blunting affect
• inability or unwillingness to experience/express soft emotions • impulse control/sensation seeking
• aches and pains
• stress tolerance
• need for autonomy/self reliance
• sense of failure and measuring up
• blaming others
• burden/disillusionment with life

Further Reading: Men and Depression (2000) Men and Therapy: A Case of Masked Male Depression (2008) Fredric E. Rabinowitz and Sam V. Cochran