Researchers estimate that at least six million men in the United States suffer from a depressive disorder every year.3 Research and clinical evidence reveal that while both women and men can develop the standard symptoms of depression, they often experience depression differently and may have different ways of coping with the symptoms. Men may be more willing to acknowledge fatigue, irritability, loss of interest in work or hobbies, and sleep disturbances rather than feelings of sadness, worthlessness, and excessive guilt.12,13 Some researchers question whether the standard definition of depression and the diagnostic tests based upon it adequately capture the condition as it occurs in men.13
"I'd drink and I'd just get numb. I'd get numb to try to numb my head. I mean, we're talking many, many beers to get to that state where you could shut your head off, but then you wake up the next day and it's still there. Because you have to deal with it, it doesn't just go away. It isn't a two hour movie and then at the end it goes 'The End' and you press off. I mean it's a twenty four hour a day movie and you're thinking there is no end. It's horrible." -Patrick McCathern, First Sergeant, U.S. Air Force, Retired
Men are more likely than women to report alcohol and drug abuse or dependence in their lifetime;14 however, there is debate among researchers as to whether substance use is a "symptom" of underlying depression in men or a co occurring condition that more commonly develops in men. Nevertheless, substance use can mask depression, making it harder to recognize depression as a separate illness that needs treatment.
Instead of acknowledging their feelings, asking for help, or seeking appropriate treatment, men may turn to alcohol or drugs when they are depressed, or become frustrated, discouraged, angry, irritable, and, sometimes, violently abusive. Some men deal with depression by throwing themselves compulsively into their work, attempting to hide their depression from themselves, family, and friends. Other men may respond to depression by engaging in reckless behavior, taking risks, and putting themselves in harm's way.
"When I was feeling depressed I was very reckless with my life. I didn't care about how I drove. I didn't care about walking across the street carefully. I didn't care about dangerous parts of the city. I wouldn't be affected by any kinds of warnings on travel or places to go. I didn't care. I didn't care whether I lived or died and so I was going to do whatever I wanted whenever I wanted. And when you take those kinds of chances, you have a greater likelihood of dying." -Bill Maruyama, Lawyer
More than four times as many men as women die by suicide in the United States, even though women make more suicide attempts during their lives.15,16 In addition to the fact that men attempt suicide using methods that are generally more lethal than those used by women, there may be other factors that protect women against suicide death. In light of research indicating that suicide is often associated with depression,17 the alarming suicide rate among men may reflect the fact that men are less likely to seek treatment for depression. Many men with depression do not obtain adequate diagnosis and treatment that may be life saving.
More research is needed to understand all aspects of depression in men, including how men respond to stress and feelings associated with depression, how to make men more comfortable acknowledging these feelings and getting the help they need, and how to train physicians to better recognize and treat depression in men. Family members, friends, and employee assistance professionals in the workplace also can play important roles in recognizing depressive symptoms in men and helping them get treatment.
Depression in Elderly Men
Men must cope with several kinds of stress as they age. If they have been the primary wage earners for their families and have identified heavily with their jobs, they may feel stress upon retirementloss of an important role, loss of self esteemthat can lead to depression. Similarly, the loss of friends and family and the onset of other health problems can trigger depression.
Depression is not a normal part of aging.18 Depression is an illness that can be effectively treated, thereby decreasing unnecessary suffering, improving the chances for recovery from other illnesses, and prolonging productive life. However, health care professionals may miss depressive symptoms in older patients. Older adults may be reluctant to discuss feelings of sadness or grief, or loss of interest in pleasurable activities.19 They may complain primarily of physical symptoms. It may be difficult to discern a co occurring depressive disorder in patients who present with other illnesses, such as heart disease, stroke, or cancer, which may cause depressive symptoms or may be treated with medications that have side effects that cause depression. If a depressive illness is diagnosed, treatment with appropriate medication and/or brief psychotherapy can help older adults manage both diseases, thus enhancing survival and quality of life.
"As you get sick, as you become drawn in more and more by depression, you lose that perspective. Events become more irritating, you get more frustrated about getting things done. You feel angrier, you feel sadder. Everything's magnified in an abnormal way." -Paul Gottlieb, Publisher
Identifying and treating depression in older adults is critical. There is a common misperception that suicide rates are highest among the young, but it is older white males who suffer the highest rate. Over 70 percent of older suicide victims visit their primary care physician within the month of their death; many have a depressive illness that goes undetected during these visits.20 This fact has led to research efforts to determine how to best improve physicians' abilities to detect and treat depression in older adults.21
Approximately 80 percent of older adults with depression improve when they receive treatment with antidepressant medication, psychotherapy, or a combination of both.22 In addition, research has shown that a combination of psychotherapy and antidepressant medication is highly effective for reducing recurrences of depression among older adults.23 Psychotherapy alone has been shown to prolong periods of good health free from depression, and is particularly useful for older patients who cannot or will not take medication.18 Improved recognition and treatment of depression in later life will make those years more enjoyable and fulfilling for the depressed elderly person, and his family and caregivers.
Depression in Boys and Adolescent Males
Only in the past two decades has depression in children been taken very seriously. Research has revealed that depression is occurring earlier in life today than in past decades.24 In addition, research has shown that early onset depression often persists, recurs, and continues into adulthood, and that depression in youth may also predict more severe illness in adult life.25 An NIMH sponsored study of 9 to 17 year olds estimates that the prevalence of any depressive disorder is more than 6 percent in a six month period, with 4.9 percent having major depression.26 Before puberty, boys and girls are equally likely to develop depressive disorders. After age 14, however, females are twice as likely as males to have major depression or dysthymia.27 The risk of developing bipolar disorder remains approximately equal for males and females throughout adolescence and adulthood.
The depressed younger child may say he is sick, refuse to go to school, cling to a parent, or worry that the parent may die. The depressed older child may sulk, get into trouble at school, be negative and grouchy, and feel misunderstood. Signs of depressive disorders in young people are often viewed as normal mood swings typical of a particular developmental stage. In addition, health care professionals may be reluctant to prematurely "label" a young person with a mental illness diagnosis. However, early diagnosis and treatment of depressive disorders are critical to healthy emotional, social, and behavioral development. Depression in young people frequently co occurs with other mental disorders, most commonly anxiety, disruptive behavior, or substance abuse disorders, as well as with other serious illnesses such as diabetes.28,29
Among both children and adolescents, depressive disorders confer an increased risk for illness and interpersonal and psychosocial difficulties that persist long after the depressive episode is resolved; in adolescents, there is also an increased risk for substance abuse and suicidal behavior.25,30,31 Unfortunately, these disorders often go unrecognized by families and physicians alike.
Although the scientific literature on treatment of children and adolescents with depression is far less extensive than that for adults, a number of recent studies have confirmed the short term efficacy and safety of treatments for depression in youth. An NIMH funded clinical trial of 439 adolescents with major depression found that a combination of medication and psychotherapy is the most effective treatment.32 Additional research is needed on how best to incorporate these treatments into primary care practice.
Bipolar disorder, although rare in young children, can appear in both children and adolescents.33 The unusual shifts in mood, energy, and functioning that are characteristic of bipolar disorder may begin with manic, depressive, or mixed manic and depressive symptoms. It is more likely to affect the children of parents who have the illness. Twenty to 40 percent of adolescents with major depression go on to reveal bipolar disorder within five years after the onset of depression.
Depression in children and adolescents is associated with an increased risk of suicidal behaviors.25,34 This risk may rise, particularly among adolescent males, if the depression is accompanied by conduct disorder and alcohol or other substance abuse.35 In 2002, suicide was the third leading cause of death among young males, age 15 to 24.36 NIMH supported researchers found that among adolescents who develop major depressive disorder, as many as 7 percent may die by suicide in the young adult years.25 Therefore, it is important for doctors and parents to take seriously any remarks about suicide.
NIMH researchers are developing and testing various interventions to prevent suicide in children and adolescents. Early diagnosis and treatment, accurate evaluation of suicidal thinking, and limitations on young people's access to lethal agentsincluding firearms and medicationsmay hold the greatest suicide prevention value.