Depression in Men: It Happens More Than You Think

 

Women are thought to be twice as likely as men to be depressed, but that doesn’t fit with men’s disproportionate representation in “deaths of despair” (males are 72% of alcohol abuse deaths, 70% of drug overdoses, and 80% of suicides).

Could it be that depression in men is being missed? Could it be that the psychology field has a flawed system for identifying male depression symptoms? Some (including me) say the answer to both these questions is "yes."

Turns out, depression symptoms were defined by the way that women typically react to, and display, depression. Depression in men may look different.

 

What's in This Post

What are Deaths of Despair?

US Male Deaths of Despair Statistics

988 Suicide Helpline

My Interest in Male Depression

What is Depression?

Signs and Symptoms of Depression According to the DSM

The DSM Depression Symptoms are Based on Women with Depression

Signs of Depression in Men

Screening Tools for Symptoms of Depression in Men

Help for Depressed Men

 

 

 

What are Deaths of Despair?

The term deaths of despair was first used by Princeton economists Anne Case and Angus Deaton in their 2015 article Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century. Case and Deaton noticed that while many causes of death were on the decline, deaths from drugs, alcohol, and suicide were increasing. They saw that these deaths had a common element of despair. 

 

US Male Deaths of Despair Statistics

The vast majority of deaths of despair in the US and many other countries are male youth and men. 

US deaths of despair stats: 

• In 2020, 70% of opioid overdose deaths were male 

• In 2021, 70% of drug overdose deaths were male 

• "While overdose death rates have increased in every major demographic group in recent years, no group has seen a bigger increase than Black men. As a result, Black men have overtaken White men and are now on par with American Indian or Alaska Native men as the demographic groups most likely to die from overdoses." (2015-2020, Pew Research Center)

• In 2020, 72% of alcohol-related deaths (e.g.: alcohol-related liver disease, withdrawal, pancreatitis) were male 

• In 2020, 80% of suicides were by males 

• Another way to state the suicide stats: 4 times more men than women die of suicide

 

These statistics point toward emotional and psychological distress in men and male youth. They tell us that we need to pay more attention to boys' and men's mental health. 

 

988 Suicide Helpline

Before going any further, I just want to make sure you know about the National Crisis Helpline.

If you are having suicidal thoughts or are experiencing mental distress, there now is an easy to remember helpline number you can text or call in the US: 988. (There is a plan for Canada to have 988 up and running by fall 2023.) Tomorrow needs you. 

You can also call 988 if you are concerned about someone else. They can help you help. 

 

 

 

My Interest in Male Depression

While studying psychology at the University of Washington, I also pursued a Minor in Women's Studies. One of the final courses I took for the minor was focused on men. It was during this class that I came across Terrance Real's book, I Don't Want to Talk About It: Overcoming the Secret Legacy of Male Depression. His book shifted how I viewed the counseling career I was working toward.

Terrance Real sheds light on how male gender-role rules hurt men's mental health. And how these rules seed and grow depression in men.

He attempted to do for men in 1997 what Gloria Steinem and Betty Friedan did for women in the 1960’s and 70’s. Unfortunately, Real didn’t achieve what Steinem and Friedan did. Women blew up the female gender-role box, but men are still largely confined by the male training Real describes—what I call "Man Law": Don’t talk. Don’t express your feelings. Don’t ask for help. Be good at fixing stuff (including yourself and everything around you) . . .

Before reading "I Don’t Want to Talk About It," I pictured my future counseling career as one focused on helping women, specifically women who had been abused as children. After reading the book, I thought “There’s lots of therapists focused on helping women. That’s an easy path. But there aren’t many focused on helping men. I want to help men.” I didn’t know how to make that happen, but I knew I wanted to do it.

When I completed my bachelor’s and master’s degrees and started my counseling practice, I made conscious effort to create a male-friendly practice. But it wasn’t until I finished writing my first full-sized book, Abuse OF Men BY Women: It Happens, It Hurts, and It's Time to Get Real About It, that I realized I was achieving the goal of helping men that I had set out to do.

Enough of that trip down memory lane—back to men and depression.

 

What is Depression?

 

 

 

Depression is a set of symptoms that are sometimes rooted in a chemical imbalance. Sometimes, the cause of depression is more connected what is going on in someone's life and how they are handling it. 

Depressed thoughts, feelings, behaviors, and attitudes may be short-term or long-term.

Depression symptoms may:

• follow an event, such as the loss of a job, death of a loved one, or the birth of a child (Postpartum Depression),

• be stimulated by reduced sunshine (SAD, Seasonal Affective Disorder), or 

• be present most of the time.

Many mental health professionals—myself included—say that depression is anger turned inwards. As with anger, the question is: What emotional pain or discomfort is underneath it? What emotional discomfort isn’t getting dealt with directly and is getting turned into depression? It may be one emotion. It may be many. The underlying emotions may be from recent events or from events long ago.

Depression can also be a learned way of being. A parent may model depressed behaviors and attitudes to their children. When those children grow into adults, they may carry with them a depressed approach to life.

There are varying degrees of depression. Each person’s experience of depression can be placed on a continuum from not-at-all depressed (totally happy) to extreme depression (totally depressed).

Being somewhat depressed could describe the quarter-way mark on the continuum. Symptoms that would place someone half-way along the continuum or beyond interfere with everyday life to a greater and greater degree. Being so depressed as to commit suicide is something that would be placed on the totally depressed end of the continuum. 

  

Signs and Symptoms of Depression According to the DSM

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the manual that all medical and mental health professionals use for diagnosis. We are currently on version 5-TR. It’s a 2022 version that has a few additional revisions to the 2013 DSM-5 which is still the version currently used by most practitioners.

The DSM has lists of signs and symptoms for two types of depression: 

1. Major Depressive Disorder (commonly called Major Depression) can go on for more than 2 weeks but needs to be present for at least 2 weeks for a diagnosis.

2. Persistent Depressive Disorder (Dysthymia) may be the more suitable diagnosis for depression symptoms that are present for 2 years or more.

Major Depression Symptoms

 

 

According to the DSM-5, to meet the criteria for a diagnosis of Major Depressive Disorder, a person must exhibit the following for at least a 2-week period (and it must represent a change from previous functioning):

• 5 or more of items 1 through 9 

• “at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.”

1. Depressed mood

“Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g. feels sad, empty, hopeless) or observation made by others (e.g. appears tearful). (Note: In children and adolescents, can be irritable mood.)”

2. Loss of interest/pleasure

“Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation).”

3. Weight loss or gain

“Significant weight loss when not dieting, or weight gain (e.g.: a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.)”

4. Sleep disturbance

“Insomnia or hypersomnia nearly every day.”

5. Psychomotor disturbance

“Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).”

6. Fatigue

“Fatigue or loss of energy nearly every day.”

7. Excessive feelings of worthless or guilt

“Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).”

8. Decreased concentration

“Diminished ability to think or concentrate, or indecisiveness, nearly every day.”

9. Suicidal thoughts/behavior

“Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt, or a specific plan for committing suicide.”

 

Persistent Depressive Disorder (Dysthymia)

Persistent Depressive Disorder is described in the DSM-5 as requiring:

A. “Depressed mood for most of the day, for more days than not, as indicated by either subjective account or observation by others, for at least 2 years. Note: In children and adolescents, mood can be irritable and duration must be at least 1 year.”

B. “Presence, while depressed, of two (or more) of the following:

• Poor appetite or overeating.
• Insomnia or hypersomnia.
• Low energy or fatigue.
• Low self-esteem.
• Poor concentration or difficulty making decisions.
• Feelings of hopelessness.”

 

The DSM Depression Symptoms are Based on Women with Depression

 

 

Depression was not a diagnosis included in the first Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1952. It didn’t make its appearance until the 3rd edition in 1980.

In her 2006 Science, Gender, and the Emergence of Depression in American Psychiatry article in the Journal of the History of Medicine and Allied Sciences, professor Laura Hirshbein, M.D., Ph.D. points out that the roots of what we now call "depression" are in what used to be called "melancholia." Historically, melancholy has been associated with women.

Professor Hirshbein notes that early research on depression unapologetically focused on women and was based on the assumption that depression was mostly a woman’s illness. There became a closed circle of thought: depressed people are women, so we study depressed women and declare their symptoms as symptoms found in depressed people, and that reinforces the idea that most depressed people are women.

“Despite increased inquiry about the role of sex in depression, by the 1970s the supposition that depression was a disease of women had become entrenched to the point that studies that were done entirely on women were reported as studies on depression itself.” (Hirshbein, p. 16 of 30)

 

The Beck Depression Inventory (BDI) Gender Bias

In the 1960s, Aaron Beck, founder of Cognitive Behavior Therapy (CBT), developed a screening checklist for depression: the Beck Depression Inventory (BDI).

I just did a Google search for “most common screening tool for depression” and was directed to the American Psychiatric Association webpage for “Depression Assessment Instruments”. BDI is the first screening tool listed.

According to Hirshbein, 60% of the research subjects for creating and testing the BDI were women. Hirshbein finds fault in Beck’s depression checklist for its gender-bias:

“Beck’s scale was subsequently adapted as a screening tool for depression in the general population, and his emphasis on feelings was also incorporated into the diagnostic criteria for depression in the 1970s. But researchers and epidemiologists who used Beck’s scale did not address the issue of how men at that time (or in the future) might respond to a screening tool that asked multiple questions about feeling states.” (Hirshbein, p. 24-25 of 30)

Signs of Depression in Men

There is growing acceptance of the idea that depression can look different in men.

Depressed men might have the symptoms listed in the DSM for depression (e.g.: feelings of worthlessness, fatigue, diminished interest, etc.) But those symptoms might not be present or noticeable in a depressed man.

Men's depression may include:

• physical symptoms (headaches, gastrointestinal issues, pain),

• anger and aggression,

• increased active emotion suppression through drug and alcohol abuse, or risk-taking (e.g. gambling, reckless driving, having affairs), or

• escapist behavior such as spending obsessive amounts of time working, exercising, playing video games, etc.

A depressed woman might sleep a lot as an escape from painful emotions she doesn't want to address or know how to deal with. A depressed man might work a lot as an escape from painful emotions he doesn't want to address or know how to deal with.

 

 

 

Terrence Real talked about these symptoms in his book about male depression in 1997. It’s taken a while for his ideas to catch on, but there is a growing body of research backing up the need for expanding the defining depression symptoms to include those more likely to be found in depressed men. 

In a 2021 American Medical Academy Journal of Ethics article, entitled Depression's Problem with Men, Nathan Swetlitz summarized the results of a study that appeared in a 2013 JAMA Psychiatry article ("The experience of symptoms of depression in men vs women: analysis of the National Comorbidity Survey Replication"): 

"When alternative and traditional symptoms are combined, sex disparities in the prevalence of depression are eliminated. Further study is needed to clarify which symptoms truly describe men’s experiences of depression."

As you'll see in the next section, more work has been done to hone in on the signs of depression in men since 2013. 

 

Screening Tools for Symptoms of Depression in Men

 

 

In 2013, Australian and German male mental health researchers led by Simon Rice of Australia presented validation of a screening tool for male depression: the Male Depression Risk Scale (MDRS-22).

It has 22 statements for which the patient is asked to “Please think back over the last month and respond to each item considering how often it applied to you. Please respond where 0 = not at all; 7 = almost always.” The statements cover 6 subjects:

1. Emotion Suppression
2. Drug Use
3. Alcohol Use
4. Anger & Aggression
5. Somatic Symptoms
6. Risk-Taking

The MDRS-22 has undergone further validation studies including one performed in Canada. On Simon Rice's website, he states that “Test re-test reliability has also been established.”

A shorter version has been successfully validated as well. The MDRS-7 asks patients to provide scaled answers to the following statements:

1. I bottled up my negative feelings.
2. I needed alcohol to help me unwind.
3. I had unexplained aches and pains.
4. I overreacted to situations with aggressive behavior.
5. It was difficult to manage my anger.
6. Using drugs provided temporary relief.
7. I stopped caring about the consequences of my actions.

Full versions of the MDRS-22 and MDRS-7 are available for free download on Simon Rice’s website: Male Depression Risk Scale – Simon Rice PhD (drsimonrice.com)

 

Help for Depressed Men

If you would like to see me as a client, reach out using my contact info or form. 

I have written many self-help books about emotion skill building and processing, communication skills, anxiety, and partner abuse. For more information on each, check them out on this post.

 

 

If you are open to listening to a hypnosis recording, my Release and Refresh Emotional Detox Hypnosis mp3 recording is great for lowering your level of emotional burden. You can listen to it any time you have a half-hour to relax, or as you are going to sleep. Most people listen to it when they are going to sleep. Many report getting to sleep more easily and getting a more refreshing sleep. You can fall asleep two seconds in and still get the stress-relieving benefits.

If you are supporting a friend or family member who is stressed and down, here's a few tips: 

 

 

Disclaimer: The contents of this post and website are not intended to replace one-on-one advice and care from personal health professionals. It is always advisable to seek the help of health care providers who can focus on the specifics of your situation. 

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