Depression in Men - Part II
What do you call a miserable and irritable man? Normal.
Men and depression. Jed Diamond, a therapist and author of "Male Menopause" and "The Irritable Male Syndrome", 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:
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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.
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.
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.
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.
It may be useful 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.
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 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."
Unfortunately, male PMS 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, but there is a lot more to males acting out 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, 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.
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.
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.
Meanwhile, As Men Age
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 risk.
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.
So What Do We Call It?
An aggressive strain of depression? A variant of antisocial behavior? Male PMS? Any name will do.
Unfortunately, back in the 1990s, psychiatry got its fingers badly burnt in its one attempt (other than postpartum) to differentiate mental illness based on gender. That occured when premenstrual dysphoric disorder (PMDD, or severe PMS), was considered for inclusion in the DSM-IV of 1994. When various interest groups got wind of what was going on, suddenly, a medical and psychiatric issue became a political potato way too hot to handle.
Thus PMDD got banished to "NOS" (not otherwised specified) status, where it will remain in the DSM-5, due out in 2013. PMDD also got included in the DSM-IV appendix under "for further study," which is code for "we really hope this thing goes away."
Clearly, the same people who wimped out in 1994 were not about to be bold for 2013. The DSM-5 will continue to defy reality and pretend that depression (and all mental illness) is gender-neutral. Obviously, anything they would have come up with would have set off a political firestorm.
But to do nothing?
Published 2000, rewritten Jan 20, 2011
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