Monday, February 26, 2007

Do Men and Women Express Depression Differently?

Men's Health has an article in its latest issue, entitled "Exercising Your Demons," about men and depression (thanks to the reader who sent the article to me). The caption reads: "Some people might call you highly competitive. Some might call you superfit. But a growing number of doctors would label you something else: Depressed." A 33-year-old male, Raymond Britt, who runs competitively is used as an example of a depressed man who takes up grueling sports to ward off anger, hurt and unhappiness.

The article speculates that men suffer from depression as readily as women but the symptoms in men show up as pushing themselves too hard at sports, working too hard, drinking and anger:

The numbers seem to show that men and women suffer from various mental illnesses at about the same rate, with some notable variations and exceptions. One of the differences, long accepted as gospel by the psychiatric professions, is that twice as many women as men suffer from depression. Kessler says his numbers show that a woman is twice as likely as a man to have a single episode of major clinical depression in her life. After the first episode, however, men and women don't differ in the number of episodes they'll have during a lifetime, or in whether they'll have another episode. Only the first step differs, he says. Then the statistics flatten out to equal.

But if repeat episodes of depression are equal for men and women, doesn't it stand to reason that they may be having first bouts at the same rate? Maybe the discrepancy lies not in the number of men and women who are depressed, but rather, in how depression is expressed.

According to an increasing number of experts, the diagnostic tallies don't take into account the real experience of a lot of men like Britt. They also ignore the fact that women are much more likely to report depression and seek help. Men are more likely to try to fight through their depression, using strategies ranging from hard work to extreme exercise to drinking to violence. Nearly four times more men than women kill themselves.


In my clinical experience with men and boys, it certainly seems that those around them are often clueless about their depression. I had one teen who was irritable and angry at school and often overreacted with other kids in class. When I met with the school staff to discuss some test results showing a significantly high level of depression, they were shocked. One female teacher said, "I never knew he was depressed -- when I am sad, I go home, cry and eat chocolate chip cookies, I don't get angry."

"Well, maybe not," I said, "but then, you are not an adolescent boy who is being bullied at school." Once the staff understood the dynamics of this young man's depression, they started to change the way they dealt with him and worked on reducing the depression, with the result that his anger subsided some. Yet the depression would have gone untreated if the staff had continued to think depression was only expressed by crying, eating too many cookies, and withdrawal.

In an article entitled Are Men Getting Shorted on Health? the author likens depression in men to heart disease in women: "Some experts think that depression contributes to these reckless and self-destructive behaviors, but that just as heart disease was initially defined by men's experiences and therefore ignored or missed in women, depression may have been framed by women's experiences and therefore may be missed and go untreated in men."

It is often said that anger is depression turned outward and this is often true (of course anger can be other things, such as a response to a sense of injustice or unfairness). Dealing with men's depression means that one cannot be afraid of anger or the underlying emotions that go with it. But the key is to know the difference between typical masculine behavior and true depression and to not pathologize the former, while being sure to properly treat the latter.

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48 Comments:

Anonymous TMink said...

I think we men short change ourselves. We are socialized that way in much the same way that women were socialized to ignore their postpartum depression. Women are told that childbirth is wonderful and a blessing. Well, it certainly is, but that is seperate from the neurological and hormonal changes that lead to postpartum depression. In a similar way, we men view depression as a sign of weakness instead of a brain disorder.

For me, I managed to seek treatment when I was depressed during a custody struggle. But when the medication was not helpful, I thought it was my fault and did not talk to my doctor about it. Too much self blame on my part, and not enough willingness to get the help I needed.

Trey

6:18 PM, February 26, 2007  
Blogger Helen said...

Trey,

What bothers me is that a good percentage of men who commit suicide have seen a doctors in the week or so before and never been asked about depression or if they are, they just say they are fine. As you know, there are so many ways to ask good questions in the medical and psychological field and get men to open up. It is a shame that more of us do not take the time and learn the proper way to respond to men in crisis. Many of our colleagues are afraid to treat men who are angry, disgusted, and ready to throw in the towel--I have seen men so angry and down that they see death as the only answer and the words they use to describe their feelings may sound threatening but they often are not, if you understand where they come from. Glad you got the help you needed.

6:31 PM, February 26, 2007  
Blogger Mad William Flint said...

See I've been dealing with depression to varying (and lessening) degrees over time.

I find it quite remarkably tough to tell the difference between "a lot on my mind" and "depressed".

Even when asks if something is bothering me, etc. depression just doesn't occur to me as an answer.

Is it possible to be that metacognitive?

7:16 PM, February 26, 2007  
Blogger Cham said...

I'm not so quick to see all men as victims of non-inquistive doctors. I've had boyfriends and male friends tell me when they are depressed, but only after lots of prodding. Sure they know they are depressed, but they loathe to admit it to anyone. If you are looking for men who experience depression, visit any bar.

8:01 PM, February 26, 2007  
Anonymous SaltedSlug said...

I think it's a template.

1.[Scan post for any inference that any male has not had an ideal life].
2.[Dispute] "all men" are "victims", despite the lack of the words "all" or "victim" in the post or any comment.
3.[Disparage men].

Is Cham a bot?

11:04 PM, February 26, 2007  
Anonymous Anonymous said...

Cham notes: "If you are looking for men who experience depression, visit any bar."

That's a pretty broad brush you're painting with Cham, perhaps the paint you're dipping that brush in is partially a mixture of your own making?

That's not to say that there are not depressed men (and women) that frequent bars. However, having worked behind the stick myself, and though I've served plenty of depressed (as well as depressing) people, that's far from the norm at least from my point of view.

In fact, the quiet, contemplative guy sitting at the end of the bar sipping his scotch, may seem depressed, but is likely to be a pretty happy guy under the facade, while the loudmouthed shot and a beer type is probably more likely depressed beyond imagination!

Still, the point remains that the mere act of frequenting a bar is not indicative of depression.

11:14 PM, February 26, 2007  
Anonymous TMink said...

Helen, I appreciate your post about health professionals and men. On reading your post and mine, it seems as if I was taking a very male (read individualistic) perspective while you were taking a more female (read community) view. That whole tend and befriend response difference. Damn, I hate being predictable!

I wonder if part of the reason behind professionals not attending to male depression is because irritable men can be intimidating? Many of the depressed men I have worked with had acting out fantasies, often moderately violent, but few of them acted them out. Still, it can feel more complicated in working with a depressed male.

I am reading a book given to me by a dear client (a pacifist that I am trying to help feel more pissed off and less depressed) about hidden male depression. I will endeavor to read that this weekend and look for some clues.

Trey

1:02 AM, February 27, 2007  
Anonymous Jack said...

But if repeat episodes of depression are equal for men and women, doesn't it stand to reason that they may be having first bouts at the same rate?

I haven't read this study, but the researcher's (Kessler) observation, as quoted, deals with the rate of reoccurrence among those who have experienced a 'first episode' of depression. He doesn't state that the experience of a 'first episode' is evenly distributed between men and women.

2nd point: the definition of depression seems to have become very elastic. If you read through the article, they attribute a very broad range of disciplined behaviors to depression.

Lastly 'Britt', has been diagnosed w/ a bipolar disorder.

2:15 AM, February 27, 2007  
Blogger Mercurior said...

theres several things here, men dont like to appear to be weak, its a cultural thing, and when a man is obvious about his "weakness" he gets demonised by men and by women, they tell him to suck it up, etc.

its hard for men due to the cultural reasons to speak about his feelings, partly he isnt taken seriously, and secondly a lot of the modern world is focused on women and womens mental health. only when men do a catastrophic thing like climbing onto a clock tower and killing everyone then himself, do some of these professionals say.. he must have been depressed.. the signs for male depression are there just it takes a little more effort to diagnose, then you have the male pride, the fear of looking weak, (to other men and women).

3:34 AM, February 27, 2007  
Blogger jw said...

I think there is some fairly serious sexism against men in mental health, especially depression. Certainly that has been my own experience.

Men are just plain not taken seriously or thought psychotic for stating reality: As I am a sex assault survivor I am WELL --too well-- aware of how mental health proefessionals simply wave off some reality as a psychosis. Family doctors are likely worse.

There's no possibility of dealing with some issues when the pro's simply refuse to admit that the issue could, even in theory, exist.

Dr. Helen, I like the comparison to heart disease in women: I think there is more than a bit of truth in it.

4:33 AM, February 27, 2007  
Blogger Helen said...

Trey,

I am not sure what you mean by my taking a "community view." Going for treatment for depression with one psychologist, psychiatrist etc. does not seem like a community view to me. I must be misunderstanding what you are saying. And yes, I do think mental health professionals are afraid to treat some patients. I often get referrals because someone "seems violent" and no one else wants to deal with them. I often find that the client is just angry and will willingly tell you why if you ask the right questions.

5:56 AM, February 27, 2007  
Anonymous Anonymous said...

I learned a few years ago from observing my male friends that getting angry is a great way to combat tears, and started using it myself unconsciously to seem tougher at work. Once I was in the habit of doing it, it became second nature. The habit became extremely difficult to break and when I went from being a single career girl to a disgruntled stay at home mom I had a time figuring out what I'd done to be so angry. I had to consciously reverse the process and learn to cry again. I wonder if the choice to be sad or angry has to do with how powerful we see ourselves as well. If we believe we have the power to change something we might choose the active anger rather than the passive sadness.

10:42 AM, February 27, 2007  
Anonymous TMink said...

Hey Helen,
Sorry for the confusing post. What I meant to point out was that in my original post I focused on what men as individuals bring to the problem. How we tend to under report. I looked at the individual.

You talked about what mental health workers and men could do together, how with the right questions and attention, the patient and the mental health worker could recognize and treat the depression. That is more of a relational approach as it involves two people. It is the tend and befriend response that is more typical in women. Relational would have been a more accurate descriptor for me to use as community references a larger group than a dyad.

Hope I got that one to make sense, I am short on coffee this morning!

Trey

10:52 AM, February 27, 2007  
Blogger Matthew said...

Dr. Helen,

This is obviously not the place to ask for a psychology lecture, but I am confused and maybe you can help.

What tells you that a patient is depressed if not the "symptoms"? That is, if the classical manifestation of being depressed is (e.g.) sleeplessness, crying, inactivity and inability to accomplish tasks (just picking some things at random that I've heard about depressed people), then what does it mean to say that someone who has none of these is nevertheless depressed?

For example, if the classic manifestation of a certain kind of brain tumor involves headaches, nosebleeds, etc., I understand what it means to say that someone has an atypical presentation of that tumor. They have none of the classic signs, but lo-and-behold, there's the darn tumor on the head CT (or whatever). But there is no analogue for the tumor in the case of depression, is there? No observable physical fact apart from the symptoms that would support the diagnosis in the absence of its usual presentation.

So what is it that distinguishes "atypical depression" in these men from "non-depression"? Conversely, what is it that makes "atypical depression" in these men depression?

Again, I realize that you are not here to give a psychology lecture, but your thoughts would be appreciated. Thanks.

11:13 AM, February 27, 2007  
Blogger dadvocate said...

My personal, male point of view is that I see feeling bad, sad, depressed as a symptom of something in my life. Hence, I tend to do something to relieve that symptom.

If I feel too fat, I exercise more. If I don't like my job, I improve my skills and knowledge to get a better job, etc, etc.

I've been in therapy/counseling a fes of times and only once found it, in itself, truly helpful. For the most part, I wanted to be taking action to improve my life. A psychiatrist once told me, during my divorce and custody battle, that I should give up on custody and work on my career.

But I did both. I won my custody battle and improved my career tremendously. I would have hated not being with my kids as much as I am now and no amount of therapy or medication would have "cured" that.

While depression in men needs to be better recognized, assuming that it should be treated it the same way in men as in women may be a mistake.

12:09 PM, February 27, 2007  
Blogger Joe said...

One possible reason men don't report depression is the very real fear of it being used against them mostly by losing their jobs, but also in divorce and custody cases.

12:15 PM, February 27, 2007  
Anonymous Anonymous said...

I have the same question as Matthew. Many of the symptoms attributed to depression in this article seem 180 degrees contrary to those commonly promoted. Sometimes it seems that psychologists use the diagnosis du-jure as a catch-all for very broad classes of psychic distress.

The researcher in this article certainly seems very eager to discover a pandemic of depression among men.

12:42 PM, February 27, 2007  
Blogger Mrs. du Toit said...

Wow. I always thought of this as a feature, not a bug.

The idea is that men are more like working dogs. Without something that keeps them focused and active, they get depressed and mischievous.

This article tends to suggest that this is some new thing or that it is surprising.

If you deny a man (or a boy) the opportunity to engage in physical activities, to protect his family (and all that this entails), and to engage in the company of other men, of course he's going to be depressed.

1:02 PM, February 27, 2007  
Blogger Helen said...

Matthew,

Just as an MRI tells you something about a person's brain functioning, psychological assessment can tell us about a client's emotional functioning. I often get clients who tell me they are angry and irritable and testing shows they are significantly depressed.

Persistent anger and irritability can actually be part of a depressive episode and in fact, an irritable and cranky mood in children and adolescents may develop during the course of depression rather than a sad or dejected mood--and caregivers have a hard time realizing that the child is depressed. So, to answer your question, being irritable and angry when depressed and having psychomotor agitation are not atypical--it may be common, it is just that men may present with more feelings of anger and women with sadness etc. and in our woman centered mental health system, the anger may not be as likely to be picked up on as depression in a man.

Trey,

It is not that I take a relational point of view necessarily--for example, if you told me you broke your foot and I said, "go to a doctor to get it set" would you say that was a relational approach? I doubt it.

If a man can solve his problems alone, great, but the concern here is that 24,000 men are taking their lives in the US each year. Something is wrong. Perhaps it is within the society, perhaps within the person, perhaps both etc. I do know that we have a high success rate for treating those men who come in for help vs. those who do not so it is all I have to offer at this point. Other suggestions are welcome.

2:34 PM, February 27, 2007  
Anonymous TMink said...

Hey Helen, I think therapy is definitionally relational in a different way than a physician is. When I had knee surgery, the doctor did the surgery, but the physical therapist (thanks Bob) not only provided the exercises, but also the encouragement. The PT was more relational than the physician.

Now if I get your point, it is that mental health workers as individuals need to do a better job asking about, recognizing, and treating male depression. As I type this, I see it is not relational, but individual responsibility on the part of the professionals. My projection was the relational component of the treatment.

Hope that is clearer than mud, and thanks for sticking with the topic with me.

Trey

2:54 PM, February 27, 2007  
Blogger Duck said...

Great topic. I've had to deal with depression, but my symptoms were the opposite. I ddidn't lash outward with anger, but retreated inward. But I've never been a type A personality, I'm more an introvert.

There is still a perception out there that most people who take antidepressants are somehow faking it or avoiding dealing with their real issues. Helen, have you read the book "Artificial Happiness" by Ronald Dworkin? His thesis is that people who turn to antidepressants to deal with difficult life situations are really just doping themselves into an artificial state without getting to the core problems that are making them unhappy to begin with. Unfortunately this is a very seductive attitude for many people who have not been depressed to take, especially on the right, and it just adds to the stigma for those who are contemplating their use to deal with depression. Men especially do not need any additional disincentives to forego treatment for depression, and quackery like Dworkin's only adds more fuel to the fire.

I engaged Dworkin in a debate on the Ashbrook Center blog in September last year when his book came out, and also had a very animated debate on my blog the Daily Duck. I also left a strident review of his book on Amazon.

I'd be interested to hear what opinions, if any, you've formed about his book.

9:17 PM, February 27, 2007  
Blogger br549 said...

I was diagnosed ADHD at the age of 44. Actually it was a relief to be able to put a handle on it after all those years. ADHD rarely rides alone. But I wonder if ADHD brings depression on because of the problems ADHD shoulders one with, or if they are just joined at the hip.

9:21 PM, February 27, 2007  
Anonymous TMink said...

Hey BR549, my understanding is that ADD and bipolar disorder happens, but I have not heard as much about depression in terms of genetic depression and ADD. Learning disorders are quite common with ADD, I got lysdexia, I mean dyslexia.

But in terms of reactive depression, that makes sense. I am a few years older than you, and I was told that I was lazy, underachieving, and other insults to my character because I scored high on standardized tests but maintained a B average. ADD was not widely understood at that time, but I believed what I was told and did not excell in school until I got to graduate school. There, I was interested in the subject matter and could use my hyperfocus to nerd out and kick ass academically.

But when I make a mistake, I still have to be careful to not call myself "stupid." Old habits etc. Now, understanding the way my brain works and does not, my self esteem is intact and approaching bullet proof. Let me recommend to you Dr. Amen, a psychiatrist and brain scan researcher at brainplace.com. His book Healing ADD is way cool. I disagree with his breaking ADD into 6 differing types instead of the more typical two, but YMMV.

But chin up pal! We are not attentionally challenged, we have a minority attentional process. Different, but vital.

Trey

10:36 PM, February 27, 2007  
Blogger jw said...

Individual mental health providers have a responsibility to test men for depression, even the ones who appear angry.

There is another part which more concerns me, the collective responsibility to see men as people who deserve to be treated fairly.

That, in my experience, has been missing. The various psychological and psychiatric associations seem to be far more woman focused and almost ignore men. That is a great wrong.

The one point I keep stating and want to impress on professionals is that too many do not seem willing to listen to men's experience if it deviates outside of a small behavioural box. The box is much too small and that hurts people, male people true, but people none-the-less.

4:17 AM, February 28, 2007  
Blogger Mercurior said...

then we get comments like suck it up, be a real man, a real man doesnt complain. so if we are clinically depressed and suicidal, we are told by some professionals, some family, that we shouldnt feel, because we are men.

4:50 AM, February 28, 2007  
Blogger Mercurior said...

http://www.utexas.edu/features/2005/mental/

According to Ebady, the most common reason for a male student to seek outside help is declining grades and a severe lack of motivation, to the extent that it may become almost impossible even to get out of bed and go to class.

“A lot of these men do not realize they’re depressed,” says Ebady. “They’re feeling irritable, frustrated and stressed. They say that they’ve lost motivation and don’t care about the things, like sports or going out with friends, that they used to enjoy so much. They can’t concentrate on anything and even though they’re sleeping much too much, they’re still dead tired.

“It’s not uncommon for them to deal with all of this by working twice as hard or maybe engaging in substance abuse and just trying to numb the awareness of an underlying problem. They tend to feel very guilty that they cannot come up with a solution on their own and are self-critical—they don’t realize that depression, for example, is very real and very debilitating.”

4:53 AM, February 28, 2007  
Blogger br549 said...

Thanks, Trey. I will look into that web site of Dr. Amen's.

ADHD has been a blessing as well as a curse, depending. Math, beyond algebra II and geometry was very difficult to grasp. And anything I don't do on a regular basis, takes a lot of time to get done. I agree though, even with ADD/ADHD, one can still hit a killer stride, once they find it.

Luckily, it has never affected my rugged good looks, boyish charm, and naturally curly hair!

My diagnosis was ten years ago. I don't take anything for the ADHD, but have recently began to take Zoloft. I can't emphatically state it is doing anything. I need a coach, I guess.

6:34 AM, February 28, 2007  
Anonymous TMink said...

BR, I treat mine with diet. I lack the hyperactivity, and a modified Atkins diet, high protein but complex carbs are fine, works wonders for me. I go ahead and eat some simple carbs at night after work cause my wife loves me even when I am addled.

Trey

9:57 AM, February 28, 2007  
Anonymous Anonymous said...

I am woman who suffered for many years before I sought treatment for what turned out to be dysthymia. Why didn't I think I was depressed? Because women's magazines list sadness, crying, sleeping too much, etc. as symptoms of depression, but rarely mention anger,irritability, self-criticism, guilt, and frustration. I thought there was just an insurmountable problem with my personality, but never attributed it to any type of depression. I have now been on medication for 2 months and feel like myself for the first time in years. It's too bad men AND women are lumped into categories instead of seen as individuals.

1:25 PM, February 28, 2007  
Blogger Helen said...

Anonymous 1:25:

Good points. Many of the women's magazines and other "feminist" outlets paint women with a broad brush, acting as if we are all the same, when individual variations are more the norm.

2:07 PM, February 28, 2007  
Anonymous Jim said...

Lasst Anomymous,

That's an interesting comment, because I wonder how much a person's cultural conditioning makes a difference, one that may override gender. I would expect a Scandinavian woman to much more stoic, more the suck-it-up type, and to present the symproms you list, than an Italian or Jewish man, or their versions in America.

And I think we all agree with your last comment about seeing the individual instead of being lazy and thinking in stereotypes.

2:15 PM, February 28, 2007  
Anonymous Anonymous said...

(Dr.H. ) -- "Dealing with men's depression means that one cannot be afraid of anger or the underlying emotions that go with it."

Unfortunately (and as you are well aware), the entire feminist legal apparatus vis a vis the Domestic Violence Industry has criminalized men's expression of anger; or even, as recently enacted Mexican law illustrates, a man's expression of indifference.

It's a bit hypocritical to ask a man to be comfortable sharing his depressive angry feelings when it can immediately lead to his arrest, don't you think?

I agree with your observation.

But, exactly who is it you propose should "not be afraid?"

Any woman can dial 911 and state --"I am afraid of him" ---

and the man -- depressed or not --
WILL BE ARRESTED.

Psychology is a house of cards, and the law is the law...

11:41 PM, February 28, 2007  
Anonymous Nom dePlume, Ph.D. said...

I'm glad you wrote this. I agree that anger can be a prominent symptom of depression in men, largely because that was the case for me. For three years, I lived in a constant state of nearly homicidal rage. I had severe depression, but did not realize it, because anger was not listed as a symptom. I also lacked the commonly-described symptoms (crying, lack of self esteem, feeling suicidal).

I did eventually get successful treatment, but it was very difficult. Part of the difficulty was my own idiosyncratic reaction to medications, but part was simply not being able to see myself in any of the descriptions of depression.

I hope the mental-health community is waking up to the reality of male depression. Articles such as yours should help.

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