∎Discover the key criteria for major depressive disorder. ∎Understand the signs and symptoms of male depression. ∎Understand the assessment tools and therapeutic options. ∎Understand the different types of medication.
Depression is one of the most commonly diagnosed diseases in the world. Depression in men is one of the most underdiagnosed and misunderstood forms of depression within this category of mental illnesses. According to the World Health Organization; in 2019 alone there were 280 million people living with depression, this included 23 million children and adolescents. Treating depression is surprisingly common and several effective treatment options are available.
Research literature has indicated that diagnosing depression in men has grown substantially since 2019 with the American Psychological Association’s recent changes to guidelines in treating men. Further, there has been a growing body of research evidence suggesting that men experience depression differently. We will be exploring many of these variables, as well as the types of depression, the connection between male depression and suicide, as well as some treatment options for men dealing with depression.
What is depression?
According to the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders) Major Depressive Disorder falls under the class of Mood disorders and requires the 5 following categories of A diagnosis.
A1. Yourself or others have noticed a depressed mood for a long period of time.
A2. You take less interest in almost all activities in your day to day life.
A3. You have weight gain or weight loss fluctuations of more than 5% in a given month.
A4. You’re having a hard time sleeping and showing signs of insomnia or hypersomnia.
A5 You physically slow down or appear to be agitated in your motor control (movements) that you’ve noticed or others have noticed.
A6. Tiredness, fatigue, or low energy, or decreased efficiency with which routine tasks are completed.
A7. A sense of worthlessness or excessive, inappropriate, or delusional guilt (not merely self-reproach or guilt about being sick.)
A8 You or others notice that you have an impairment in your ability to concentrate on given tasks, think, or make decisions.
A9. You’re having recurring thoughts of death outside of the fear of dying, you have a constant thought stream of suicidal ideation.
These symptoms are causing significant distress in your social life, work life, and other areas that are important to your functioning.
The symptoms are not associated with ongoing use of drugs or banned and/or illicit substances.
There has never been a manic episode or hypomanic episode.
These are general guidelines for the overall prevalence of one type of depression; more notably Major Depressive Disorder. It should be noted that in order to meet the criteria for this you should be experiencing at least 5 of these categorical symptoms and it may be time to seek professional help.
Sub-types of Major Depressive Disorder:
There are a variety of different types of depressive disorders based on subtypes within the depressive episode. These subtypes are as follows:
- Anxious distress: Symptoms of anxiety are present.
- Mixed features: Presence of manic/hypomanic symptoms, however; it does not meet all of the requirements of a manic episode.
- Melancholic features: You have an inability to experience pleasure, your depression is notably worse in the morning, you’re waking up earlier in the morning, you have noticed your movements are slowing down or you’re more agitated than usual, excessive guilt, significant weight loss or weight gain.
- Psychotic features: There is a stable pattern of delusions or hallucinations not linked to your mood.
- Catatonic features: Behaviors not actively relative to your environment, lack of speaking (mutism), agitation, mimicking someone else’s speech or movements.
- Atypical features: You have a positive mood to some events, significant weight gain or an increase in your appetite overall, you’re excessively tired throughout the day, your arms and legs feel heavier than normal, longstanding sensitive nature to interpersonal rejection.
Different types of Depression in men:
There are also a variety of different types of depression experienced in people going through a depressive episode. These different types of depression, in men, are as follows:
Persistent Depressive Disorder (Men and Women)
Formerly known as dysthymic disorder or chronic major depressive disorder in the DSM-IV this style of depression is marked with a depressed mood for most of the day, lasting for a period of two years or more. This can also be present in youth and only has to last a period of 1 year in youth in order for the diagnosis to be established by a trained health care professional. Interestingly, individuals who have persistent depressive disorder oftentimes show a high comorbidity of other disorders as well, noting in particular that 70% of people diagnosed with Major depressive disorder or persistent depressive disorder are also diagnosed with some other disorder within their lifetime.
Seasonal Affective Disorder:
Seasonal affective disorder is unique in the sense that those meeting the diagnostic criteria for the disorder recover from a major episode of depression once every two years. This recovery is cycled through as a result of seasonal change and daylight hours. Notably, it is those that reside within the Northern hemispheres that are affected most by this disorder. Commonly, those affected will experience depression typically between the months of November through to February and notice the symptoms are not present from June through to August. Some individuals may experience mild forms of mania and are often diagnosed with bipolar disorder during the summer months. In order to be diagnosed with the criteria, the mood changes cannot be associated with events such as unemployment during the winter. The mood change must come without a cause.
Postpartum Depression in men:
Postpartum depression has often been associated with women after the experience of childbirth. However, significant research has come out to indicate that this phenomenon can occur in men as well. As of 2019 there is no established criteria for Postpartum Depression in men, however, it can be defined as a major depressive disorder episode following the birth of a child (Scarff, 2019).
Signs and Symptoms of depression in men:
While the general guidelines for depression are useful in determining whether or not you have depression. There is significant research explaining that the above diagnostic criteria shows a distinct feminine pattern. What is notable about women experiencing depression is thay have a tendency to “act inwardly” because gender roles in women traditionally focus on internal inadequacies.
In contrast to female depression, male depression has a notable respect of “acting out”. Oftentimes these will manifest in forms of chronic anger and other self destructive behaviors associated with the depressive behavior. These behaviors can include; self-destructiveness, drug use, gambling, womanizing, and workaholism.
Even though the emotional hallmarks of depression are marked by feelings of hopelessness, helplessness, and worthlessness – it should be understood that men are oftentimes socialized to avoid introspective behaviors in regards to their emotional states and instead choose destructive outward behaviors in order to effectively “medicate” the symptoms they may experiencing internally. Ultimately, many men fail to realize they are experiencing a mental health issue as a result (Kilmartin, 2005).
The often undiagnosed nature of depression in men:
It should be noted that men will often avoid seeking assistance with mental health issues for a variety of reasons. This is known as the “silent epidemic” amongst mental health researchers – especially in the field of depression. Unfortunately, it has been found that there has traditionally been fewer diagnostic tools in working with symptoms of depression within men – as a result many clinicians have not been informed of many of the externalizing factors involved in male depression.
The assessment tools that have excited have also typically only recorded feminizing traits of depression within many men. As a result, there have been a few tools developed regarding identifying depression within men such as the Gotland Male Depression Scale. Traditionally, clinicians have relied on the Beck Depression inventory which has been criticized for attempting to test for internalizing symptoms often present within women.
While it has been identified that men are just as likely as women to experience illness, they are often socialized to seek assistance regarding the potential for their mental illnesses. Many men simply seek health care options regarding mental health less than women (Smith et al., 2018).
Assessment Tools for depression in men:
There are a variety of depression assessment tools utilized and widely available. While we will not be featuring all of the tools in this article, this article will feature three of the most commonly used tools in North America.
Beck’s Depression inventory
The Beck Depression Inventory II is one of the most widely utilized Psychometric tools used in the assessment of depression worldwide. There are 21 questions utilized to determine the severity of the depression. All of the items are summed together to create a total score tapping into the measure associated with Major Depressive Disorder. The test is typically utilized for research purposes, however, it has been used in clinical settings (Garcia-Batista et al., 2018).
Gotland Male Depression Scale
The Gotland Male depression scale is a psychometric utilized for the purposes of recognizing major depressive disorder in males. This depression inventory was created in response to the gender biased nature of the BDI-II and other psychometric tools used to assess depression in patients (Stommel et al., 1993). The Gotland Male Depression Scale assesses for items on the questionnaire such as irritability, anger, alcohol consumption, and a variety of other mechanisms identified in male depression.
Patient Health Questionnaire 9 (PHQ-9):
The PHQ 9 otherwise known as the Patient Health Questionnaire is a self administered tool used for common mental health disorders used worldwide. It is often also used as a research tool. It consists of nine criteria which the DSM-5 is based on for Major Depressive Disorder. The unique feature of this questionnaire is its 2 step methodology for depression measurement. When the scores for depression are high in the first portion of the measure the patient is asked to complete a second portion in order to determine the DSM diagnosis (Kroenke, K. et al., 2001).
Causes of depression in men:
It should be noted that depression is a complex disease and there is often no single factor associated with a correlation cause/effect relationship with depression. Many individuals can be associated with serious medical illness, loss of a relationship, divorce, significant health issues, a variety of social factors, medications, substance misuse and genetic proclivity to the disease. Psychology as a field is a multi factor field and oftentimes suggests a biological, psychological, and sociological explanation of disorders.
Male depression and suicide:
Male Suicide rates are three times higher than female suicide rates. There are a number of factors that are currently being researched in determining a causal link driving this statistic. Notably, men have one half of the reported rates of depression than women. Researchers believe that the reason for this is mens stigmatizing views surrounding mental health and help seeking. In one study conducted in Canada, a greater proportion of men endorsed stigmatizing views of depression and suicide than did women (Oliffe, J. 2016).
Increasingly; studies have been reporting the link between the externalizing nature of depression in men being associated with non-fatal suicidal behaviour. Non-fatal suicidal behaviour, or suicide attempts, according to men are often associated with feminine behaviour. However, research is making the general public increasingly aware of these behaviors within men. Where women will traditionally practice self harm in the form of skin cutting, suicidal thoughts, and other methods of suicidal attempts. In men, this is often linked to externalizing behaviors such as excessive alcohol and drug use (Kaess, M., 2011).
Medication for treatment of depression & their associated risks:
With the growth of mental health awareness efforts, so too has there been a growth of medication use in the treatment of many of these disorders. Medication for depression began in the twentieth century and is currently increasing with each passing year. While ant depressants have been shown to be generally effective, they usually aren’t effective in cases of mild depression with treatment being preferred in cases of moderate to severe depression. Studies have shown that it reduces depression in about 50-60% of those that take the medication (Gitlin, 2015).
SSRI’s (Selective Serotonin reuptake inhibitors) are amongst some of the most commonly prescribed antidepressants in the world. They have been shown to ease the symptoms of moderate to severe depression and have less side effects than the other antidepressants described within this article. SSRIs work by preventing the reabsorption of serotonin into the neuron making existing serotonin more available for use by structures in the brain called neurotransmitters.
Some of the most commonly prescribed anti depressants in the market today are fluoxetine, Sertraline, Paroxetine, escitalopram, and Citalopram. All of these have been show to have a range of side effects. The most common side effects include gastrointestinal symptoms, tremor, nervousness, insomnia, daytime sleepiness, diminished sex drive, and difficulty achieving orgasm. Around 5-10% of patients will discontinue their use of SSRI’s due to ongoing complications with the medication. Positively, SSRI’s have been shown to reduce symptoms of depression and have further shown to have had a positive effect on disorders associated with depression such as anxiety, impulsive behaviors such as aggression, and eating disorders.
This class of drugs are designed to work on receptors involving serotonin as well as norepinephrine. Norepinephrine is an adrenal hormone as well as a neurotransmitter released by your kidneys adrenal glands. These drugs have been shown to prevent a slight advantage to SSRI’s in preventing relapse of depression. Further, this class of drugs is often utilized to treat nerve pain, ADHD, and fibromyalgia syndrome. Some of the most commonly prescribed drugs in the SNRI family include Venlafaxine, Duloxetine, Desvenlafaxine, Milbnacipran, and Levomilnaipran. While effective at treating many diseases related to depression some side effects include Nausea , Dry mouth, dizziness, headache,anxiety and agitation, and excessive sweating (Sansone, 2014).
Bupropion lesser known as norepinephrine-dopamine reuptake inhibitors are treated oftentimes in conjunction with SSRI’s assuming patients are dealing with sexual dysfunction as a side effect from the SSRI. Further, Bupropion is a common prescription in dealing with the cravings associated with cigarette craving. Bupropion addresses the role of dopamine reception (the reward center) in the brain and is effective in its treatment for agitation, smoking cessation, sexual dysfunction, hypersomnia, and cognitive slowing. Some adverse effects experienced by around 10% of the patients using bupropion will include weight loss, insomnia, racing heart, constipation, blurred vision and in extreme circumstances can worsen suicidal ideation (Huecer et al., 2022).
Tricyclic antidepressants were first released into the market in 1959 and were some of the first drugs to consistently relieve symptoms of depression and in some rare circumstances are still prescribed. The primary reason they aren’t prescribed as frequently is because they often are associated with higher rates of unwanted side effects and they are quite easy to overdose on – the results of an overdose are often fatal. Further, tricyclic antidepressants have been shown to reduce blood pressure dramatically. The most commonly prescribed tricyclic antidepressants include: Amitriptyline, Amoxapine, Desipramine, Doxepin, Imipramine, Nortriptyline, Protriptyline, and Trimipramine. Some complications with drugs are blurred vision, dizziness, sexual dysfunction, hypotension, increased appetite, weight gain, and confusion (Moraczewski & Aedma, K. 2022).
Therapy shown to work for depression:
Men are often looking for effective tools. Given that men already stigmatize mental health supports; it’s important to note efforts that have been taken toward helping men in distress. Often, men are looking for tools that simply work and finding a therapy that works quickly. In this section, we will explore the therapeutic interventions that have a large base of evidence regarding empirical support when determining effective treatments for men.
Mindfulness Based Cognitive Therapy:
Mindfulness based cognitive therapy was specifically designed for the prevention of depression relapse. This therapeutic intervention is goal directed in nature and consists of eight, two hour groups sessions with an average of ten participants within the group. The goals of this therapeutic intervention are to prevent relapse into a depressive episode by training the participants about the factors that lead to it (Segal et al., 2013). The techniques involved work toward the elimination of negative thinking, increasing clients recognition of relapse potential, change the clients mindset from self-sabotage to goal direction, and teaching clients to be involved in life while observing what is happening. While there is very little understanding as to how MBCT actually works to prevent relapse (Allen at al., 2009). Some of MBCT strengths are that it has been shown to prevent relapse rates in over 60% of its participants and has been shown to reduce suicidality (Williams and Swales, 2004).
Cognitive behavioral therapy:
Originally a combination of Cognitive therapy (CT) and Behavioral therapy (BT); Cognitive Behavioural Therapy (CBT) has quickly become one of the best scientifically supported therapies regarding a variety of disorders. It’s founded in the assertion that it is unhelpful ways of thinking that maintain the problems we face in our day to day lives (Gaudino, 2008). One of the reasons CBT is effective is because it provides the client with homework that they can take with them outside of therapy sessions, giving them an opportunity to practice skills learned in therapy during the time in between sessions. While CBT does have a wide body of evidence supporting its efficacy in research literature, it has also been criticized for it’s lack of focus on past experiences that may be causing the mental health issues.
Dialectical Behavioural Therapy:
Dialectical behavioral therapy is a type of Cognitive Behavioural Therapy. It differs from standard cognitive behavioral therapy in that it teaches the participant to accept their challenging thoughts instead of attempting to combat them (Dimeff & Koerner, 2007). Initially, DBT was designed for patients that met the diagnostic criteria for Borderline Personality Disorder. It was created by Marsha Linehan as a way of working with clients that may have experienced a childhood where their feelings were repeatedly invalidated while also teaching the participants to work with emotional dysregulation issues that may be a result of biological factors. As a result, DBT is considered one of the few biosocial theories of psychotherapy. DBT has been shown to work with a variety of disorders including anger management, intimate partner violence, and substance abuse often associated with male depression (Linehan, 2015).
Research indicates that many episodes of depression follow a significant death of a loved one, a struggle with an intimate relationships, or some other major life upheaval such as a move, the beginning or end of a marriage, or physical illness. These events often interfere with someone’s interpersonal functioning and most patients turn inwardly and blame themselves. Interpersonal therapy help the patient by living a goal directed life, building positive social skills, and solve the problems currently pressing them. Once resolved, it is theorized that the depression often does lift (Markowitz and Weissman , 2004).
Psychodynamic psychotherapy is a therapy that focuses on the unconscious processes involved in the formation of behavior. It focuses on the influence of the pasts effect on the present issues the client is dealing with. Psychodynamic therapy is a break away from traditional psychoanalysis as psychodynamic therapy is considered a time limited therapy (12-16 weeks) where psychoanalysis has traditionally taken years. Psychodynamic therapy has been empirically supported to treat psychological issues that are also combined with substance abuse disorder (Treatment and improvement protocols, 1999).
Helping someone I love with depression:
Depression is a common, highly treatable disease and we know that it is easy to feel helpless and overwhelmed watching our loved one go through an episode of depression. Men can be especially challenging as due to traditional masculine identity norms men usually do not want to speak about the issues that they are facing.
Ask them openly, and fearlessly – persistently:
There is a social stereotype regarding male ambivalence to health. Certainly, research has indicated that men do more frequently stigmatize mental health conditions (Pattyn, 2015). We cannot let the generally ambivalent or flippant nature of the men in our lives prevent us from approaching them regarding our concerns about their health. We can however, shape how we respond to them once we have reached and spoken about our concerns regarding their mental health. The first thing that needs to be understood is that we cannot “fix” someone else’s depressive symptoms. We can offer love and support! Social support is a key ingredient in the recovery process from a depressive episode. Those that have a network of individuals they can reach out to often have a quicker recovery process as well as a lower risk of relapse into another depressive episode. The second thing that we can do is become compassionate listeners. It is often all too easy for us to want to offer advice to someone that may be struggling with their mental health. Ultimately, they are the only people that can fix their mental health issues. That aside, one conversation may not be the end of it. You may have to be persistent about some of the issues with the person’s health that you are concerned with and each and every time, you may need to practice compassionate listening.
Approach them with open ended questions –
It’s important to note that open ended questions are going to be your sword and shield in this conversation. Some questions you might be able to ask to start the conversation include:
- I’ve been thinking about you a lot lately, I’ve been a little worried. How have you been?
- I’ve noticed your social media posts seem to be a little bit down, is there anything going on?
- I’ve been noticing some changes in you recently that have me a little worried; are you doing ok?
Leading them with ongoing open ended questions might look like:
- Is there anything I can do to support you through this time!
- You know, I know it’s not like most men to talk about these things, but have you considered getting help?
- How long have you been feeling like this for?
- Did something happen that recently caused you to start feeling like this?
- Do you have a social network outside of me that can help you through this? Is there anyone you can reach out to?
What if me or someone I know is in a crisis?
In the event you or someone you know is planning suicide or stating that you have made plans to commit suicide, please call 911 or the suicide intervention line for the following countries:
- United States: Call 988
- Canada: 1-833-456-4566
- UK: https://www.nhs.uk/mental-health/feelings-symptoms-behaviours/behaviours/help-for-suicidal-thoughts/
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