Men and depression

Depression is so common that it is sometimes easy to overlook. This is especially true when it occurs in men, who seem to have a harder time than women recognizing it in themselves. And they also are more reluctant to talk about it.

In the United States, about half as many men as women become seriously depressed at some time in their lives. Men suffer less major depression, less dysthymia (chronic mild to moderate depression), and probably less bipolar depression (although the rate of bipolar disorder is the same in both sexes).

The reasons for these differences are not entirely clear. The main risk factors for an episode of depression are the same in both sexes: certain personality traits, drug and alcohol abuse, acute and chronic stress, traumatic experiences including child abuse, a family history of depression, and a previous depressive episode. Twin and adoption studies show that a depressed man and a depressed woman are equally likely to have a depressed parent. There are two differences between the sexes: Low self-esteem and loss of a parent in childhood are more closely linked to depression in men than in women.

The most important clue to the mystery of gender differences in depression is that women are more susceptible than men only in their childbearing years, from puberty to menopause. One theory is that women are more vulnerable to depression because of problematic interactions between stress hormones and female reproductive hormones. In a person who is under stress, estrogen promotes anxiety and depression, while testosterone does the opposite. That might account in part for the fact that men are apparently less physically sensitive to their emotions than women.

Of course, the relatively low rate of depression in men could be entirely explained by their relative silence about it. Men may feel that it is weak or unmanly to show despair or self-doubt; they may fear what might happen if employers or colleagues found out. So they withdraw into silent misery or develop a "male depression syndrome" in which the disorder masquerades as anger, irritability, alcoholism, or drug abuse. Because they do not seek treatment, the story goes, their depression is never diagnosed or recorded.

It's doubtful, though, whether male reluctance to acknowledge feelings can account for all of the gender difference in depression. Surveys show that women have a higher rate of depression than men even among people who are not seeking professional help.

But it's important for men who are depressed to get help. Depression is a key risk factor for suicide, and men commit suicide four times more often than women — up to 10 times more often in old age. One reason may be men's reluctance to convey their feelings and seek help when they are in despair.

Another mortal concern for men with depression is cardiovascular disease. Depression affects blood pressure, blood clotting, and the immune system. It's a well-known risk factor for coronary heart disease, heart attacks, and stroke. Men are especially vulnerable because they develop these diseases at a higher rate and at an earlier age than women. After a heart attack or bypass operation, some research shows that depression and anxiety are, paradoxically, less common and serious in men than in women. But one large study found that this advantage lasted only for the first two years.

The most important thing others can do for a man who shows signs of depression is to help him contact a physician or mental health professional. If necessary, accompany him to treatment and encourage him to continue until his symptoms begin to improve.

The treatment itself is the same for both sexes — talking with a therapist about problems and taking antidepressants for symptoms. The talk may take the form of psychotherapy, mutual support groups, or marital counseling.

It may take a few weeks, even months, to notice results. But the effort will be worth it—both for the man who wants to overcome depression and the people who love him.

Are you a man who is living with depression, or do you know a man in this situation? Was it difficult to recognize the symptoms? What types of treatment have proved beneficial?

Dr. Michael Miller has been on staff of the Beth Israel Deaconess Medical Center, a large teaching hospital in Boston, for more than 25 years. He is also an Assistant Professor of Psychiatry at Harvard Medical School.

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