Populations

Depression in Men

Real men don't need help, right? Think again.

Ray Bradbury’s 1953 short story, "The Playground," says it all:

A father drops off his boy at nursery school for the first time and observes the following with increasing trepidation: "The rushing children were hell cut loose in a vast pinball table colliding and banging a totality of hits and misses, thrust and plunging to a grand and yet unforeseen total of brutalities." The father’s sister assures him everything will be fine: "He’s got to take a little beating and beat others up; boys are like that."

This being science fantasy, the father makes the ultimate sacrifice and switches places with his son, finding himself in the body of a boy at the top of a slide: "He shrieked, he covered his face, he felt himself pushed, bleeding, to the rim of nothingness. Headfirst, he careened down the slide, screeching, with 10,000 monsters behind. One thought jumped through his mind a moment before he hit bottom in a nauseous mound of claws. ‘This is hell,’ he thought, ‘this is hell.’"

Why Men Don't Talk About Depression

Early in 2000, when I polled my Newsletter readers, I was astounded to discover a mere 22 percent of them were men, and nothing has happened since then to make me believe that has changed. Men may suffer depression in half the numbers as women, but clearly something more was going on here. "I Don’t Want to Talk About It: Overcoming the Secret Legacy of Male Depression" by Terrence Real didn’t offer me any marketing tips on how I could get more men to subscribe, but I did gain some important insights into how fragile we actually are.

Terrence Real was physically and emotionally abused by his father, was a D student, drug addict, and petty criminal before eventually finding his calling as a family therapist in the Boston area, with clients typically sharing similar patterns of abuse and dysfunction. It’s a jungle out there, make no mistake about it, even for men with idyllic childhoods, with rites of passage as brutal as those found in any rain forest. There is nothing new about this, of course, but the depression aspect adds a novel spin.

Boys and men internalize their hurt into what the author calls "covert depression," a psychic band around the heart sufferers respond to by engaging in destructive addictive behaviors - from classic alcohol and drug dependence to affairs outside the marriage to workaholism to neglecting or abusing their own children. Typically, they are incapable of making the emotional investment necessary to sustain a lasting loving relationship, either with their wife or kids. These are not the type of people who turn up for therapy on their own volition. They are there because they have to be - because the courts have sent them or because their wife has delivered an ultimatum. In many ways they are the lucky ones, for there is someone there to catch them, before or during the inevitable transition from covert to "overt" depression.

Overt depression erupts when a man’s addictive behaviors no longer assuage the hurt. Sometimes it occurs in the middle of therapy, after the client’s defenses have been unmasked. Often medication is part of the treatment, but in the author’s view it represents at best a partial response, as "an unhappy, immature, relationally unskilled man on medication becomes at best, a happier immature relationally unskilled man."

The author describes depression as an "auto-aggressive disease," of the self attacking the self. Recovery is about connecting with the hurt and trauma that lies beneath. Boys feel as much as girls, but this is hardly the message we send them. Ultimately, in the author’s words, "boys become men by lopping off, or having lopped off, the most sensitive parts of the psychic, and, in some cases, physical selves."

Terrence’s own healing came at age 37, when his father finally opened up to the horrors of his own poverty-stricken childhood, of his mother dying at age seven and of being shunted from one relative who didn’t want him to another. One evening, the author’s father found himself bundled in the car in the garage with the engine left running. As the gas fumes began to overtake him, the boy had to struggle to break free of the embrace of his suicidal father.

"Don’t let the way I talk fool you," the author’s father confides, as he admits, probably for the first time, how precious his son is to him.

"Healing," Terrence Real concludes, "interrupts the legacy of depression’s transmission from parent to child ... Depressed men, by healing themselves, bring peace to their ancestors and protection to their offspring."

Boomer Men and Depression

An article on Medscape by Steven Roose MD of Columbia University indicates a major public health timebomb beginning to tick louder. There are approximately 35 million people over age 65 living in the United States and it is estimated that this number will increase to 70 million by the year 2030. The percentage of the population over age 65 is projected to increase from 13 percent to more than 20 percent by 2030. Currently there are more than four million people in the United States over age 85 years and that number is expected to more than double in the next 30 years.

Men who reach 50 are often at the peak of their careers and are generally in excellent health, but they are also entering a period of life-threatening and quality-of-life illnesses including cardio- and cerebrovascular illnesses, sexual dysfunction, hypogonadism, and suicide. According to the author: "It is striking that vascular disease, erectile dysfunction, decreased testosterone, and suicide are all strongly associated with depression."

The link between depression and heart disease and stroke is well-known. As for the relationship between depression and erectile dysfunction, a number of studies have documented depressed men who returned to all systems go once their depression was resolved. Erectile dysfunction is also a side effect of antidepressants. Additionally, depression may flow
from erectile dysfunction. Finally, vascular disease may underlie both depression and erectile dysfunction.

Starting at age 30, testosterone levels decline one percent a year. By age 60, 25 percent of men are clinically "hypogonadal." Symptoms include decreased libido, erectile dysfunction, fatigue, irritability, dysphoria, and confusion. Testosterone replacement reverses most of these symptoms. Unfortunately, too many men over sixty take what they think is the only way out. According to the author: "In the United States the suicide cohort is overwhelmingly white, male, and older than age of 60. Strikingly, the relationship between age, gender and suicide is consistent throughout the world and across cultures."

A 2003 Harvard study of 56 depressed men not responsive to antidepressants found 24 had low testosterone levels. Of these, 12 were administered a transdermal testosterone gel and 10 a placebo, along with their antidepressants. At the end of eight weeks, a third of the men receiving testosterone showed significant improvement in their depression and anxiety scores. The remaining men showed some or no improvement. The authors caution that these findings are preliminary.

One Man's Experience

Jed Diamond, a therapist and author of Male Menopause, and his wife Carlin both took depression tests as part of a drug treatment program involving their son. Jed's wife scored high on the test while he scored low. As a result, Carlin sought and received help for her depression while Jed lived in a hellish fool's paradise of believing there was nothing wrong with him.

Years later, in response to Carlin's persistent suggestions that he, too, may be suffering from depression, Jed kept insisting, “I’m not depressed, damn it, leave me alone,” clinging to his score from that depression test as "proof" that he was okay.

But all was not well. As Jed describes it:

"I was irritable and angry all the time. But there were reasons for that. I had a lot of stresses on my job, raising kids was not easy, and my wife was going through menopause and having her own problems. 'Who wouldn’t be angry,' I would bellow to anyone who would listen."

Carlin received the brunt of his anger, which she fought to deflect. But what did she expect? Jed thought. She kept doing all these things that irritated him. If she’d just be nicer, more loving, more interested in sex, everything would be okay. It never occurred to him that his constant anger made it nearly impossible for her to be nicer, more loving, more interested in sex.

"I was worried most of the time," Jed reports. "But wasn’t that normal? After all I had to worry about making enough money to pay the bills. I had to worry about losing my job in an economy where someone else got rich while most of us got poorer and poorer. I worried about the children, grown and gone, but still needing help. I worried about my aging parents. I worried about the state of the world. I worried about getting old. I worried that I worried so much."

It failed to dawn on Jed that his worry was a symptom of an inner problem, not a response to problems which someone else was causing in his life. It never occurred to him that his irritability, anger, and blame were symptoms of a type of depression psychiatry is only beginning to wake up to. "My insistence that I wasn’t depressed," he finally acknowledged, "nearly ended my marriage and came close to ending my life."

Why Men's Depression Can Be Different

Do men actually manifest depression differently than women? Consider Neal Conan's intro to NPR's Talk of the Nation, which in late October of 2002 aired a show on male depression:

"There are many theories about men and depression. Some researchers argue that men experience depression differently than women. Men are more likely to describe depression as feeling burnt out, for example, rather than excessive sadness. And men are more likely to deny or forget feelings of depression. Some therapists also say that male depression is accompanied by drug and alcohol abuse and other self-destructive behaviors, like gambling, and that some men behave more aggressively, which can manifest itself as wife beating or child abuse."

According to Neal Conan's main guest, William Pollack PhD, a psychologist at Harvard's Medical School and the director of the Centers for Men and Young Men at McLean Hospital, and author of Real Boys: Rescuing Our Sons from the Myths of Boyhood: "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.

Says Jed: “We are missing millions of men who suffer from depression because we are not asking the right questions."

Why the DSM Misses Male Depression

The DSM-IV's first and perhaps most important symptom for major depression is "depressed mood most of the day," and its only example is the unfortunate one of "appears tearful."

Skipping down to symptom three, we find: "Significant weight loss when not dieting or weight gain." 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.

Then we come to symptom seven, "feelings of worthlessness or inappropriate guilt." The male equivalent is probably closer to Dr Pollack's irritable and angry SOBs. Interestingly enough, Jed points out that irritability is listed as an example of depressed mood for youth depression, but is unaccountably absent for adult depression.

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.

Lest we get tempted to split depression into Hamlet and Ophelia subtypes, we need to be reminded that many men suffer from "female" symptoms and vice versa. It is far more useful, instead, to think of depression as a beast of many faces, ranging from feeling sad to being anxious to expressing anger to out-of-character aggression. It is an illness that engages all processes of the mind and body, from not being able to think straight to throwing our eating and sleeping out of whack to setting us up for cardiac failure. It is more an illness of not being our usual self than simply being depressed, and hopefully one day the name will reflect that fact.

Unfortunately, psychiatry ghettoizes men, all too often tagging the ones who seek help as antisocial or substance abusers, and shunting them off to treatment that may not be appropriate or at best only a partial answer. The American Psychiatric Association is expected to issue a new edition of the DSM in 2010. Fortunately, thanks to an emerging awareness among therapists and psychiatrists, it appears likely that male depression will get a full airing.

As for Jed:

"Fortunately, I listened to my wife’s entreaties that I get help. Too many men die, never realizing they are depressed, never recognizing they have a treatable illness. If you’re one of those men, don’t wait as long as I did. Your decision may be a matter of life and death."

Is There a Male PMS?

What do you call a man who is always tired, miserable, and irritable? Normal.

“Ask a guy an innocent question and he jumps down your throat,” writes therapist Jed Diamond. “God, it’s like he’s so hormonal,” one woman told him. When he replied she wasn’t too far from the truth, she snapped back, “I knew it.”

Could it be that we had it wrong all this time, that men are the ones who experience PMS? A lot of wives and girlfriends would answer in the affirmative, decidedly so. Jed Diamond even has a term for it, “the irritable make syndrome,” the title of his latest book. The term is somewhat misleading, as the author here describes a range of destructive behaviors identified with men, from feeling a bit grouchy and uncommunicative to flying off the handle, from being inwardly fearful to outwardly belligerent. “Destructive male syndrome,” or DMS, may be more appropriate.

Unfortunately for men, DMS is not restricted to a particular time of month or period of major life transition. The idea of male menopause (andropause) – or grumpy old men syndrome – has been steadily gaining ground in recent years, and Jed Diamond covered the issue in a previous book. But DMS is a lot more than declining testosterone in middle and old age. It’s also about surging hormones in adolescence and young adulthood and even just right levels when life is supposed to be good.

Dangerous at any age, every day of the month – that about sums it up. Yes, raging estrogen may temporarily turn our wives and girlfriends into Public Enemy Number One or Saddam Hussein, but women aren’t the ones sitting on death row or awaiting trial for crimes against humanity. Men are the true prisoners of their sex.

Add to testosterone five million years of evolutionary programming and the brutal rites of passage by which boys become men, not to mention the pressures of modern living, and one can see why “irritable” doesn’t begin to describe men in crisis. Men are in a constant state of siege, contends Jed Diamond, caught in the deadly pincers of high-stakes (and typically male) social warfare on one front and changing (and often feminizing) social norms on the other. Bullied and confused, they find themselves increasingly failing in their ability to hold onto their jobs and families. Loss of sense of manhood and self-respect follow like Martian night after Venusian day.

Bring on DMS. Sometimes, it’s simply comical, as when men become lamentably and ludicrously immobilized when faced with the trivial task of asking for directions. Other times it’s far more serious and even deadly.

Much of this behavior is in the form of “acting out,” but the author also emphasizes “acting in” behavior, including depression.

It would help if men learned Venusian, but equally important, women need to figure out Martian. A suitable subtitle to this book would have been: “Everything You Need to Know About Why Your Husband or Loved One or Colleague Acts So Strange.” Make no mistake: this book is a cry for help aimed at women. Those from Venus who are able to glean a glimmer of insight into our fragile and battered Martian psyches will be doing both sexes a great favor.

Updated Feb 15, 2008