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DSM 5th Edition
Men.Male vs. female depression: Why men "act out" and women "act in"
Depression Different in Women and Men?
Depression specific:Beck Depression Inventory (BDI) (3 page PDF - self scoring)
Depression & Suicide
Strong Connection to Your Therapist Improves the Results of
Your Treatment for Depression
in Review: Major Depressive Disorder COVID-19
pandemic shined spotlight on rise of
Suicide Warning Signs
Depression isnt always easy to detect, and people with depressive conditions can experience different symptoms. It may be expressed through lack of appetite or overeating; insomnia or an unnatural desire to sleep; the abuse of drugs and alcohol; sexual promiscuity; or hostile, aggressive, or risk-taking behavior.
Depression symptoms can vary from mild to severe and can include
Depression is a serious medical illness; its not something that you make up in your head. More than a feeling of being down in the dumps or blue for a few days, the symptoms of Depression are severe and debilitating. Depression is characterized by feeling down, low and hopeless for weeks at a time. Factors that can contribute to the onset of Depression include stress, poor nutrition, physical illness, personal loss, relationship difficulties and the presence of other physical disorders.
Depression isnt always easy to detect, and people with depressive conditions can experience different symptoms. It may be expressed through lack of appetite or overeating; insomnia or an unnatural desire to sleep; the abuse of drugs and alcohol; sexual promiscuity; or hostile, aggressive, or risk-taking behavior.
Depression (major depressive disorder) is a common and serious medical illness that negatively affects how you feel, the way you think and how you act. Fortunately, it is also treatable. Depression causes feelings of sadness and/or a loss of interest in activities once enjoyed. It can lead to a variety of emotional and physical problems and can decrease a persons ability to function at work and at home.
Depression symptoms can vary from mild to severe and can include
Symptoms must last at least two weeks for a diagnosis of depression.
Also, medical conditions (e.g., thyroid problems, a brain tumor or vitamin deficiency) can mimic symptoms of depression so it is important to rule out general medical causes.
Depression affects an estimated one in 15 adults (6.7%) in any given year. And one in six people (16.6%) will experience depression at some time in their life. Depression can strike at any time, but on average, first appears during the late teens to mid-20s. Women are more likely than men to experience depression. Some studies show that one-third of women will experience a major depressive episode in their lifetime.
Depression Is Different From Sadness or Grief/Bereavement
The death of a loved one, loss of a job or the ending of a relationship are difficult experiences for a person to endure. It is normal for feelings of sadness or grief to develop in response to such situations. Those experiencing loss often might describe themselves as being depressed.
But being sad is not the same as having depression. The grieving process is natural and unique to each individual and shares some of the same features of depression. Both grief and depression may involve intense sadness and withdrawal from usual activities. They are also different in important ways:
Risk Factors for Depression
Depression can affect anyoneeven a person who appears to live in relatively ideal circumstances.
Several factors can play a role in depression:
How Is Depression Treated?
Depression is among the most treatable of mental disorders. Between 80% and 90% of people with depression eventually respond well to treatment. Almost all patients gain some relief from their symptoms.
Before a diagnosis or treatment, a health professional should conduct a thorough diagnostic evaluation, including an interview and possibly a physical examination. In some cases, a blood test might be done to make sure the depression is not due to a medical condition like a thyroid problem. The evaluation is to identify specific symptoms, medical and family history, cultural factors and environmental factors to arrive at a diagnosis and plan a course of action.
Medication: Brain chemistry may contribute to an individuals depression and may factor into their treatment. For this reason, antidepressants might be prescribed to help modify ones brain chemistry. These medications are not sedatives, uppers or tranquilizers. They are not habit-forming. Generally antidepressant medications have no stimulating effect on people not experiencing depression.
Antidepressants may produce some improvement within the first week or two of use. Full benefits may not be seen for two to three months. If a patient feels little or no improvement after several weeks, his or her psychiatrist can alter the dose of the medication or add or substitute another antidepressant. In some situations other psychotropic medications may be helpful. It is important to let your doctor know if a medication does not work or if you experience side effects.
Psychiatrists usually recommend that patients continue to take medication for six or more months after symptoms have improved. Longer-term maintenance treatment may be suggested to decrease the risk of future episodes for certain people at high risk.
Psychotherapy: Psychotherapy, or talk therapy, is sometimes used alone for treatment of mild depression; for moderate to severe depression, psychotherapy is often used in along with antidepressant medications. Cognitive behavioral therapy (CBT) has been found to be effective in treating depression. CBT is a form of therapy focused on the present and problem solving. CBT helps a person to recognize distorted thinking and then change behaviors and thinking.
Psychotherapy may involve only the individual, but it can include others. For example, family or couples therapy can help address issues within these close relationships. Group therapy involves people with similar illnesses.
Depending on the severity of the depression, treatment can take a few weeks or much longer. In many cases, significant improvement can be made in 10 to 15 sessions.
Electroconvulsive Therapy (ECT) is a medical treatment most commonly used for patients with severe major depression or bipolar disorder who have not responded to other treatments. It involves a brief electrical stimulation of the brain while the patient is under anesthesia. A patient typically receives ECT two to three times a week for a total of six to 12 treatments. ECT has been used since the 1940s, and many years of research have led to major improvements. It is usually managed by a team of trained medical professionals including a psychiatrist, an anesthesiologist and a nurse or physician assistant.
Self-help and Coping
There are a number of things people can do to help reduce the symptoms of depression. For many people, regular exercise helps create positive feeling and improve mood. Getting enough quality sleep on a regular basis, eating a healthy diet and avoiding alcohol (a depressant) can also help reduce symptoms of depression.
Depression is a real illness and help is available. With proper diagnosis and treatment, the vast majority of people with depression will overcome it. If you are experiencing symptoms of depression, a first step is to see your family physician or psychiatrist. Talk about your concerns and request a thorough evaluation. This is a start to addressing mental health needs.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5), Fifth edition. 2013.
National Institute of Mental Health. (Data from 2013 National Survey on Drug Use and Health.)
Kessler, RC, et al. Lifetime
Prevalence and Age-of-Onset Distributions of DSM-IV
Disorders in the National Comorbidity Survey Replication.
Arch Gen Psychiatry. 2005;62(6):593602.
According to the 5 th edition of the DSM, a person must exhibit at least five of the following characteristics to be diagnosed with a depressive disorder:
The above represent a "major
depressive episode". The other two criteria as stated by
DSM-5 is that "the occurrence of the major depressive
episode is not better explained by schizoaffective disorder,
schizophrenia, schizophreniform disorder, delusional
disorder, or other specified and unspecified schizophrenia
spectrum and other psychotic disorders" and there has never
been "a manic episode or a hypomanic episode."
What are the
symptoms of Depression?
Loss of energy and
Feeling down from time to time is a normal part of life, but when emotions such as hopelessness and despair take hold and just won't go away, you may have depression. Depression makes it tough to function and enjoy life like you once did. Just getting through the day can be overwhelming. But no matter how hopeless you feel, you can get better. Learning about depressionand the many things you can do to help yourselfis the first step to overcoming the problem.
How do you experience depression?
While some people describe depression as living in a black hole or having a feeling of impending doom, others feel lifeless, empty, and apathetic. Men in particular may even feel angry and restless. No matter how you experience it, depression is different from normal sadness in that it engulfs your day-to-day life, interfering with your ability to work, study, eat, sleep, and have fun.
Some people feel like nothing will ever change. But its important to remember that feelings of helplessness and hopelessness are symptoms of depressionnot the reality of your situation. You can do things today to start feeling better.
What are the symptoms of depression?
Depression varies from person to person, but there are some common signs and symptoms. Its important to remember that these symptoms can be part of lifes normal lows. But the more symptoms you have, the stronger they are, and the longer theyve lastedthe more likely it is that youre dealing with depression.
Symptoms of depression include:
Is it depression or bipolar disorder?
Bipolar disorder, also known as manic depression, involves serious shifts in moods, energy, thinking, and behavior. Because it looks so similar to depression when in the low phase, it is often overlooked and misdiagnosed. This is a problem, because antidepressants for bipolar depression can make the condition worse. If youve ever gone through phases where you experienced excessive feelings of euphoria, a decreased need for sleep, racing thoughts, and impulsive behavior, consider getting evaluated for bipolar disorder. See: Bipolar Disorder Signs and Symptoms.
Depression and suicide risk
Depression is a major risk factor for suicide. The deep despair and hopelessness that goes along with depression can make suicide feel like the only way to escape the pain. If you have a loved one with depression, take any suicidal talk or behavior seriously and watch for the warning signs:
If you think a friend or family member is considering suicide, express your concern and seek help immediately. Talking openly about suicidal thoughts and feelings can save a life.
The symptoms of depression can vary with gender and age
Depression often varies according to age and gender, with symptoms differing between men and women, or young people and older adults.
Depression in men. Depressed men are less likely to acknowledge feelings of self-loathing and hopelessness. Instead, they tend to complain about fatigue, irritability, sleep problems, and loss of interest in work and hobbies. Theyre also more likely to experience symptoms such as anger, aggression, reckless behavior, and substance abuse.
Types of depression
Depression comes in many shapes and forms. Knowing what type of depression you have can help you manage your symptoms and get the most effective treatment.
Depression causes and risk factors
While some illnesses have a specific medical cause, making treatment straightforward, depression is more complicated. Depression is not just the result of a chemical imbalance in the brain that can be simply cured with medication. Its caused by a combination of biological, psychological, and social factors. In other words, your lifestyle choices, relationships, and coping skills matter just as muchif not more sothan genetics.
Risk factors that make you more vulnerable to depression include:
The cause of your depression helps determine the treatment
Understanding the underlying cause of your depression may help you overcome the problem. For example, if you are depressed because of a dead end job, the best treatment might be finding a more satisfying career, not taking an antidepressant. If you are new to an area and feeling lonely and sad, finding new friends will probably give you more of a mood boost than going to therapy. In such cases, the depression is remedied by changing the situation.
What you can do to feel better
When youre depressed, it can feel like theres no light at the end of the tunnel. But there are many things you can do to lift and stabilize your mood. The key is to start with a few small goals and slowly build from there, trying to do a little more each day. Feeling better takes time, but you can get there by making positive choices for yourself.
What you can do
Reach out to other people. Isolation fuels depression, so reach out to friends and loved ones, even if you feel like being alone or dont want to be a burden to others. The simple act of talking to someone face-to-face about how you feel can be an enormous help. The person you talk to doesnt have to be able to fix you. He or she just needs to be a good listenersomeone wholl listen attentively without being distracted or judging you.
Get moving. When youre depressed, just getting out of bed can seem daunting, let alone exercising. But regular exercise can be as effective as antidepressant medication in countering the symptoms of depression. Take a short walk or put some music on and dance around. Start with small activities and build up from there.
Eat a mood boosting diet. Reduce your intake of foods that can adversely affect your mood, such as caffeine, alcohol, trans fats, sugar, and refined carbs. And increase mood-enhancing nutrients such as Omega-3 fatty acids.
Find ways to engage again with the world. Spend some time in nature, care for a pet, volunteer, pick up a hobby you used to enjoy (or take up a new one). You wont feel like it at first, but as you participate in the world again, you will start to feel better.
10 tips for reaching out and staying connected
For more information, see: Coping with Depression
When to seek professional help
If support from family and friends and positive lifestyle changes arent enough, find a therapist who can help you heal.
Therapy can help you understand your depression and motivate you to take the action necessary to prevent it from coming back.
Medication may be imperative if youre feeling suicidal or violent. But while it can help relieve symptoms of depression in some people, it isnt a cure and is not usually a long-term solution. It also comes with side effects and other drawbacks so its important to learn all the facts to make an informed decision.
Related HelpGuide articles
Resources and references
Signs and symptoms of depression
Signs and Symptoms of Mood Disorders Lists the common signs and symptoms of depression and bipolar disorder. (Depression and Bipolar Support Alliance)
Types of depression
The Different Faces of Depression Discussion of the different subtypes of depression, including atypical depression, melancholic depression, and psychotic depression. (Psychology Today)
Depression causes and risk factors
What Causes Depression? Page 1 & Page 2 Learn about the many potential causes of depression, including genes, temperament, stressful life events, and medical issues. (Harvard Health Publications)
Well start out with my experiences
My first experience with treatment was at the mental health clinic at the local hospital. I was fairly indifferent toward the first psychiatrist I had there, but I was unpleasantly jarred to find out that he was leaving after six months. Apparently they were on some sort of rotation. When I walked into the new psychiatrists office, I immediately got a bad feeling. It looked like he felt this was a temporary situation, as the office was completely bare except for the desk and two chairs. The reason for my visit was to ask him to raise my medication, as I was feeling the familiar signs of depression after being fairly stable for a year. He never even looked at me, and only asked me one question to determine whether I was depressed again or not, Do you have thoughts of harming yourself or others? I said, Well, no, but I never have, so thats not really an indication for me. He ignored all the signs of depression I was recounting and refused to raise my medication. I absolutely hated him, and wouldnt go back until he was gone six months later. This time when I walked into the new psychiatrists office I was very wary, but the difference he had made in that cold office was amazing. Im a little fuzzy on the specifics, but I immediately noticed that the place smelled great. He had air fresheners in the office that made you want to inhale when you walked in. He had prints on the walls and (Im pretty sure) healthy plants. I may be just remembering the plants because he was such a nurturing person. He also had a photo of himself with a child on his bulletin board, which I took as a good sign. He was very accessible, listened to me, and ordered a blood test to find out the level of meds in my blood, which indeed was too low. He stayed longer than six months before moving on, and I was very sorry to see him go.
I had trouble with severe mood swings for years and my condition was getting worse. Upon finding out that several close relatives were bipolar, I did some research and found that without a doubt I had the symptoms. I took my information and family history to a local psychiatrist. He stated with sarcasm, If you went out and bought five Corvettes Id believe you were bipolar, but youre not. I believed him, left and did not seek any further treatment as I descended deeper into a horrible depression. Finally I went to a local clinic, and talked to a nurse practitioner who believed me enough to give me a trial of lithium. Literally within days I rounded a corner. The medication literally saved my life. The moral of the story for me is; if at first you dont get listened to, keep looking until you do. Also, Id rather talk to a nurse who listens than an MD who doesnt. Kate from Idaho
OK, finally I put off suicide until I could at least get in to see the psychiatrist. The Paxil that my GI put me on isnt working. Im slipping down a drain. I had 1 1/2 hours of sleep last night and in another 2 hours I have to go to work. But .I went to the shrink today like I promised. Told him of my plans to end it. Told him how close I came. Told him I was already dead inside. Told him I had 2 hours of sleep and had to work again. I told him I can hardly get through a day anymore. He said increase the paxil to 1 1/2 tabs and come back in a month. Oh well. I didnt deserve the help anyway. angelica
About six years ago I was suffering from incredible depression. (I have since been diagnosed w/Borderline Personality Disorder, and depression comprises only a part of this). At any rate, because I was cutting myself, wanting to die, and locking myself in my apartment for weeks at a time (where I would sleep for days on end), my employer (who happened to be my churchI was a church secretary) demanded that I see the licensed family therapist they had on staff. I went. He looked like a dish of spumonihe wore mixed pastels (polyester), and a horrifyingly bad toupee. On top of everything else, he told me (I am quoting here), that I was evil, that God was protecting other people from me, and that he felt sorry for anyone who knew me because I really was a bad person. This, said to a severely depressed person by a supposed professional, is BAD. I quit seeing him, obviously.
Heres the REALLY juicy part: he then attempted to blackmail me with my patient records, which he said (Im quoting again) that he would keep for his own protection, in case I said anything unflattering about him. He said he would make those records public if anything bad I said got back to him. I have since found out that in my state, ANYBODY can be a licensed family therapist, just by paying a fee for the license. Scary, huh? (NOTE: this loser has since been taken off the church staff, and I have long since gotten some QUALIFIED help. And I had a Government agency confiscate my records from his officewith my permission, because I work for a defense contractor and had to obtain a security clearance. I have no idea how many other people this pig damaged, though.) Anita from Alabama
After reading your story, I started to think about my psych, hes from India, he thinks Im really off my rocker. He tells me to do other things from what my therapist tells me, and I think he uses me for his guinea pig. Hes been trying to start me on some of the strangest meds, and all I want to do was to get my Effexor refilled. Then he gave me a 2-week supply, but this medicine takes effect in about 30 days. When I go back and see him, what does he do, he prescribes me something else. Im going to find another psych and keep my therapist. Shes more understanding of my problem. Tom
Even though I had had depression for years and mild mania, I started off with a psychologist who did not refer me to a psychiatrist until it got so bad I had to be hospitalized. Thankfully, the psychiatrist knew what he was doing (actually at that point it had become quite obvious). So he became my doctor for the last 6 years and was great. Except in October he was too close to a tree that got hit by lightning and he had to stop practicing while they evaluated him. The doctor he left as a back-up was too busy for any sessions. I had to go out and interview doctors. That was fun. Finally, my doctors office called me and told me to call this other doctor, that he would see me. Well, he started off the conversation stating he was a mood expert and started diagnosing me over the phone. He tells me I have to increase my medications and I have to be totally reevaluated and maybe hospitalized (a week before the holidays). I told him that I had no problem raising the medication and that he would find that I took my medications as I was told. He actually said Thats an oxymoron. After that experience, I did the incredible. I actually called the insurance company and asked them to find me a doctor. They did, he was nice and he took care of me until my old doctor came back. No, I never did make my appointment with the mood expert. You should always interview a doctor before actually going into their office. In this state, a doctor has the power to hospitalize you if they think you are in danger or a danger to others. Lourdes from Miami
I knew I had a bad shrink when he called me at home on Saturday morning to ask me my advice for how he should deal with his problems with his girlfriend. Eee-gads! Meg
It was my first experience with a psychiatrist, but I knew it was a mess when one of his assistants/office staff/next door neighbors/whatever kept walking into the office. On the second visit, the doctor spent most of his time on the phone with apparently his stock broker as they were talking all about money, selling this, buying that, etc. Needless to say, I did not go back, and shortly after that he was arrested for DWI and essentially run out of town on a rail. (Turns out I was not the only person that hed ignored in favor of his stock broker.) Current primary care doctor wants me to see a psychiatrist again, and after one bad experience, Im not sure this is a good idea. I called the insurance company just to clarify what the benefits were. Turns out that they really dont want you to use their mental health services. I cant use any doctor in the plan, nope, it has to be one who is also in their merit services program (which probably means money in one way or another). My other doctors (primary care doctor, orthopod, etc.) are located at the biggest hospital in the area but none of their merit services people are, and they could only give me two names of anyone in town that I could *maybe* see! Needless to say, I wont be seeing a psychiatrist, and Im not terribly upset about that! Laurie
When I first met Dr. X I had an almost unwelcome feeling. I felt like I should be paying for his services and only then he would treat me like I worthy of his therapy. Anyway, I told him that I wanted some sort of psychotherapy rather than drugs because of sideffects, etc. Although he listened to me he decided that drugs would be most useful in this case. Well I didnt take them, but I did continue to see him. Being a psychology student I am sure my beliefs about drugs were emanating from my psyche. With time, however, I gained respect for this person with a British accent and snotty attitude. When he started sharing some of his personal history and I found that we had a bit of history in common I began to trust him. I guess trust was a real issue for me. I began taking the meds and gradually became healthier. We developed a bit of a friendship which was in the end briskly cut off by him. I guess because he didnt want me to become too dependent on this one and only friendship. Anyway I still hear his voice once in while and find comfort in knowing that he knew me enough to get me to help myself. Anonymous
I have been having a hell of a time, lately, with psychiatrists (i.e., finding one and keeping one) during this last bout of depression. My heart sinks when I walk into a practitioners office and it barely looks as if they write scripts there. We probably just cant help it, but women are probably more sensitive to this. The past two pdocs Ive seen (and didnt go back to when I couldnt take it anymore) hardly looked at me, either, except to say these are the rules type statements and ask me if was suicidal. Funny thing it made no difference in their reaction if I said I was suicidal or swore I wasnt. Not really very humorous. The psychiatrist I saw previously was (is!) a real human being, who listened, empathized, and did his damnedest to help me feel that I too, am a human being, defects and all. He had an office with real furniture, old worn oriental carpets, real works of art, including that of friends of mine. Offices of both my current individual therapist and someone my husband and I see occasionally are warm, inviting, not fancy, but with pictures of both their kids and artwork done by the same. In other words, if they see themselves as human beings, perhaps they can give us the same courtesy. I resolve to walk right out of the robot practitioners offices as soon as I walk in from now on! Our instincts may be all we have left . Robin
I have been to untold numbers of these people over the last 5 years that I have been suffering from depression. One told me that I could blame it all on my parents and that I should let them know. (Thank God that I did not do so). The next one would give me a depression test every week that I saw him. He placed me on different drugs over the years, all with the same results, but at least the data was of use.
I then found a good man who showed me how to use my brain to help control the pain in my left arm. Two years of little depression. Then he had a stroke. Depression back. Back to other psychiatrist, still more drugs.
Then last year a breakdown in public; result pending police charges (a man with one good arm with two assault police charges), depression deeper, placed in a psych hospital; depression even deeper.
Then my good man came to my rescue, got me out of the hospital and he now treats me (at no charge), ring or visit him at any time. Anonymous
I refer to the first 3 psychiatrists I saw as quacks #1, #2, and #3. I suffer from severe, chronic clinical depression and have tried nearly every psychiatric medicine known with no permanent success. I was referred to the psychiatrists I saw by an EAP. It turns out that the only requirement to get on the EAPs list was that these providers apply and send in copies of their licenses.
Quack #1 was relatively innocuous. She prescribed a combination of two tricyclics which gave me severe anxiety attacks. Every other doctor I have seen wonders why she combined those two drugs as no one seems to have ever heard of using them together. She left the area before doing any more damage.
Quack #2 apparently did not believe in taking blood levels. I wound up in the hospital (not once, but twice) with toxic blood levels at therapeutic dosages of the antidepressant I was taking. I later found out that that was not unheard of for those particular drugs.
Quack #3 used to fall asleep in therapy sessions and would tell me it was because my monotone voice put him to sleep. When I finally got angry enough to fire him, he told me I was leaving because we were finally getting to the root of my problems and I was afraid to address my issues. When I asked him what those issues were, he said that I needed to discover them myself. Gal
I think I know shes a good therapist because, when friends/family ask how my session went or what my therapist thinks of me, I cant really give them a pat answer. In other words, she isnt authoritative or didactic. She listens, responds non-verbally, and then when Im finished with my latest spiel, she asks me questions about how what Ive just said relates to past sessions, relationships, my experiences growing up, etc. It feels as if she is quite solidly on my side, no matter what, and I trust her. Ive described our sessions as my weekly anchor to sanity (no advice from well-meaning friends, no belligerent orders to stop my behaviors, no fear or frenzy for one hour a week ).
I used to be very suspicious of therapy, I think, because of the bad press it gets in our culture. I assimilated this and thought of myself as a spoiled white female who couldnt solve her petty problems and who wanted to run to therapy (even though she wasnt bad enough to deserve treatment) so someone else could run her life. So I raged and screamed to get attention from my parents (alcoholic father, shy and enabling mother), fell into deep depressions at my lack of perfection, and cut my arm repeatedly to put my anger and pain into a place I could focus on.
Now I feel as if my life is my own and I dont want to spend another second feeling bitter or loathing myself. I just want new tools and perspectives so I can keep searching. I take 50 to 100mg of zoloft daily (I also take short breaks from it as I see fitmy therapist and psychiatrist both accept my need to control my medication and dont view my treatment as a power play). I still cut my arm occasionally, but we discuss it and dont treat it as some terrible backslide. I feel very lucky. I look at my chronic depression and realize that, given my lifes circumstances, much of it was a sane response to insane situations. I feel that Ive been easy to treat, but had I had a series of nightmare therapists, Id be so much worse off. Im very grateful to susan for her support. Laura
I think the thing that amazes me the most about some of the doctors Ive seen for my episodic depression is that theyve been so cruel. I wouldnt say some of the things theyve said to me to my dog. The first time I got depressed, I was terrified. Therapy was urgent, because of my strong anxiety and complete inability to cope. Naturally, I was referred (by my kind, gentle therapist) to a psychiatrist, which was scary. Was I really that sick? I was highly resistant to the idea of meds, but she didnt try to allay my fears. What makes you think you dont need medication? she barked, I think you do. She convinced me, and Im glad she did although Ill never forgive her for treating a suicidal but intelligent teenager like an imbecile. Other doctors I saw were nicer, but there was one last year who was pure evil. Ill always remember the disgust in her eyes when, in response to the question, Can you tell me something about this drug Im taking? she said, Dont you want to have children someday? You are going to harm your children, destroy their lives, if you dont fix your problems. Ugh. I think the reason antidepressants take so long to work is that it takes you a month to get over your appointments with your psychiatrist. Wendy from New Jersey
My first therapist was a social worker (MSW) whom my college roommate (also an MSW) recommended to me. I felt very comfortable with her, but after less than a year, I felt my therapy was at an impasse. (she had suggested meds, which petrified me) and I shut down after that.
I thought I could get along without a therapist but after a few months I realized it was not the case. The next therapist was a social worker too, with training in Freudian analysis, which I have since read is not very good for depression. She was not very empathetic. When I was worried about my parents finances because my mother has depression, she said dont worry about it, they have health insurance and then tried to change the subject, despite the fact that I was worried because their insurance wasnt paying for some very expensive x-rays. And she wanted to know why I was so upset to find out my mother has lung cancer. (Depressives tend to get overly upset at things, but really, shes my MOTHER!)
After being with her for almost a year, I realized I needed to do something or I would end up dead. I went to my primary care physician for a referral to a psychiatrist. He asked me a few questions, and a few minutes later he wrote a prescription for Paxil and told me to come back in 6 months.
Well, after that, I called my health insurance, got names of some psychologists. Our first session was an interview, I followed some suggestions from one of my books and asked her a lot of questions how often she treats depression, etc., etc. I began seeing her and saw a psychiatrist that she recommended. Its been a hard time finding meds for me (PAXIL was a bad choice for me and its taking a while to wean me off.) But all in all I am comfortable with both my psychologist and psychiatrist. Susan from NYC
I recently had a panic attack. I went to the local clinic and was given Paxil. I found a shrink in the yellow pages, its a small town and there was only a choice of two. The one just worked on state cases. I choose shrink number two.
I just got his bill for three sessions. Are you ready for this $890. My first session I asked his charges. He said $125 for a 50 minute hour, and the first session would go longer, getting background etc. My second session lasted over two hours until I finally said, hey doc, I gotta go. Im thinking, hey its a small town, hes not busy, maybe hes interested in my case.
Session number three was going into two hours and I just excused myself, never thinking he has got the clock running.
To sum up, Ive written the state
board of medicine and spoken to their ombudsman, whose first
comment was Jesus. Ive flushed the dope
down the toilet, and I feel much better thank you very much.
When a family member or friend suffers from depression, your support and encouragement can play an important role in his or her recovery. However, depression can also wear you down if you neglect your own needs. These guidelines can help you support a depressed person while maintaining your own emotional equilibrium.
Helping a depressed friend or family member
Depression is a serious but treatable disorder that affects millions of people, from young to old and from all walks of life. It gets in the way of everyday life, causing tremendous pain, hurting not just those suffering from it, but also impacting everyone around them.
If someone you love is depressed, you may be experiencing any number of difficult emotions, including helplessness, frustration, anger, fear, guilt, and sadness. These feelings are all normal. Its not easy dealing with a friend or family members depression. And if you dont take care of yourself, it can become overwhelming.
That said, there are steps you can take to help your loved one. Start by learning about depression and how to talk about it with your friend or family member. But as you reach out, dont forget to look after your own emotional health. Thinking about your own needs is not an act of selfishnessits a necessity. Your emotional strength will allow you to provide the ongoing support your depressed friend or family member needs.
Understanding depression in a friend or family member
Depression is a serious condition. Dont underestimate the seriousness of depression. Depression drains a persons energy, optimism, and motivation. Your depressed loved one cant just snap out of it by sheer force of will.
Is my friend or loved one depressed?
Family and friends are often the first line of defense in the fight against depression. Thats why its important to understand the signs and symptoms of depression. You may notice the problem in a depressed loved one before he or she does, and your influence and concern can motivate that person to seek help.
Be concerned if your loved one...
Doesnt seem to care about anything anymore. Has lost interest in work, sex, hobbies, and other pleasurable activities. Has withdrawn from friends, family, and other social activities.
How to talk to a loved one about depression
Sometimes it is hard to know what to say when speaking to a loved one about depression. You might fear that if you bring up your worries he or she will get angry, feel insulted, or ignore your concerns. You may be unsure what questions to ask or how to be supportive.
If you dont know where to start, the following suggestions may help. But remember that being a compassionate listener is much more important than giving advice. You dont have to try to fix the person; you just have to be a good listener. Often, the simple act of talking to someone face to face can be an enormous help to someone suffering from depression. Encourage the depressed person to talk about his or her feelings, and be willing to listen without judgment.
Dont expect a single conversation to be the end of it. Depressed people tend to withdraw from others and isolate themselves. You may need to express your concern and willingness to listen over and over again. Be gentle, yet persistent.
Ways to start the conversation:
"I have been feeling concerned about you lately."
Questions you can ask:
"When did you begin feeling like this?"
Remember, being supportive involves offering encouragement and hope. Very often, this is a matter of talking to the person in language that he or she will understand and respond to while in a depressed mind frame.
What you CAN say that helps:
Source: The Depression and Bipolar Support Alliance
Taking care of yourself
Theres a natural impulse to want to fix the problems of people we love, but you cant control a loved ones depression. You can, however, control how well you take care of yourself. Its just as important for you to stay healthy as it is for the depressed person to get treatment, so make your own well-being a priority.
Remember the advice of airline flight attendants: put on your own oxygen mask before you assist anyone else. In other words, make sure your own health and happiness are solid before you try to help someone who is depressed. You wont do your friend or family member any good if you collapse under the pressure of trying to help. When your own needs are taken care of, youll have the energy you need to lend a helping hand.
Tips for taking care of yourself
Think of this challenging time like a marathon; you need extra sustenance to keep yourself going. The following ideas will help you keep your strength up as you support your loved one through depression treatment and recovery.
Speak up for yourself. You may be hesitant to speak out when the depressed person in your life upsets you or lets you down. However, honest communication will actually help the relationship in the long run. If youre suffering in silence and letting resentment build, your loved one will pick up on these negative emotions and feel even worse. Gently talk about how youre feeling before pent-up emotions make it too hard to communicate with sensitivity.
Set boundaries. Of course you want to help, but you can only do so much. Your own health will suffer if you let your life be controlled by your loved ones depression. You cant be a caretaker round the clock without paying a psychological price. To avoid burnout and resentment, set clear limits on what you are willing and able to do. You are not your loved ones therapist, so dont take on that responsibility.
Stay on track with your own life. While some changes in your daily routine may be unavoidable while caring for your friend or relative, do your best to keep appointments and plans with friends. If your depressed loved one is unable to go on an outing or trip you had planned, ask a friend to join you instead.
Seek support. You are NOT betraying your depressed relative or friend by turning to others for support. Joining a support group, talking to a counselor or clergyman, or confiding in a trusted friend will help you get through this tough time. You dont need to go into detail about your loved ones depression or betray confidences; instead focus on your emotions and what you are feeling. Make sure you can be totally honest with the person you turn tono judging your emotions!
Encouraging your loved one to get help
While you can't control someone elses recovery from depression, you can start by encouraging the depressed person to seek help. Getting a depressed person into treatment can be difficult. Depression saps energy and motivation, so even the act of making an appointment or finding a doctor can seem daunting. Depression also involves negative ways of thinking. The depressed person may believe that the situation is hopeless and treatment pointless.
Because of these obstacles, getting your loved one to admit to the problemand helping him or her see that it can be solvedis an essential step in depression recovery.
If your loved one resists getting help:
Suggest a general check-up with a physician. Your loved one may be less anxious about seeing a family doctor than a mental health professional. A regular doctors visit is actually a great option, since the doctor can rule out medical causes of depression. If the doctor diagnoses depression, he or she can refer your loved one to a psychiatrist or psychologist. Sometimes, this professional opinion makes all the difference.
Supporting your loved one's treatment
One of the most important things you can do to help a friend or relative with depression is to give your unconditional love and support throughout the treatment process. This involves being compassionate and patient, which is not always easy when dealing with the negativity, hostility, and moodiness that go hand in hand with depression.
Provide whatever assistance the person needs (and is willing to accept). Help your loved one make and keep appointments, research treatment options, and stay on schedule with any treatment prescribed.
The risk of suicide is real
It may be hard to believe that the person you know and love would ever consider something as drastic as suicide, but a depressed person may not see any other way out. Depression clouds judgment and distorts thinking, causing a normally rational person to believe that death is the only way to end the pain he or she is feeling.
When someone is depressed, suicide is a very real danger. Its important to know the warning signs:
If you think a friend or family member might be considering suicide, talk to him or her about your concerns as soon as possible. Many people feel uncomfortable bringing up the topic but it is one of the best things you can do for someone who is thinking about suicide. Talking openly about suicidal thoughts and feelings can save a persons life, so speak up if you're concerned and seek professional help immediately!
Related HelpGuide articles
Resources and references
Helping a depressed person
Helping Someone with a Mood Disorder Covers how to support a loved one through depression treatment and recovery. (Depression and Bipolar Support Alliance)
Helping Someone Receive Treatment What to do (and not to do) when trying to help a loved one get help for depression. (Families for Depression Awareness)
Helping a Friend or Family Member with Depression or Bipolar Disorder How to help your loved one while also taking care of yourself. (Depression and Bipolar Support Alliance)
What is the role of the family caregiver? Tips on how families can work together to manage depression treatment. (Families for Depression Awareness)
Helping a suicidal person
How to Help Someone in Crisis Advice on how to deal with a depression crisis, including situations where hospitalization is necessary. (Depression and Bipolar Support Alliance)
National Suicide Prevention Lifeline Suicide prevention telephone hotline funded by the U.S. government. Provides free, 24-hour assistance. 1-800-273-TALK (8255).
Crisis Text Line - US 24/7 confidential line for any crisis. 741741 text SOS
Samaritans UK 24-hour suicide support for people in the UK and Ireland call 116 123. (Samaritans)
Lifeline Australia 24-hour suicide crisis support service at 13 11 14. (Lifeline Australia)
Crisis Centers Across Canada Locate suicide crisis centers in Canada by province. (Canadian Association for Suicide Prevention)
IASP Find crisis centers and helplines around the world. (International Association for Suicide Prevention).
International Suicide Hotlines Find a helpline in different countries around the world.
What to do if
you are depressed?
For more information: National
Institute of Mental Health www.nimh.nih.gov/publicat/depression.cfm#ptdep5
Where can I get
more information about Depression?
National Alliance for the Mentally Ill (NAMI), Colonial Place Three , 2107 Wilson Blvd., Suite 300 , Arlington, VA 22201, 800.950NAMI (6264) or 703.524.7600 or www.nami.org
A support and advocacy organization of consumers, families, and friends of people with severe mental illness-over 1,200 state and local affiliates. Local affiliates often give guidance to finding treatment.
Depression & Bipolar Support Alliance (DBSA), 730 N. Franklin St., Suite #501, Chicago, IL 60610-7204, 312.988.1150, Fax: .312.642.7243 or www.DBSAlliance.org
Purpose is to educate patients, families, and the public concerning the nature of depressive illnesses. Maintains an extensive catalog of helpful books.
National Foundation for Depressive Illness, P.O. Box 2257, New York, NY 10116, 212.268.4260; 800.239.1265 or www.depression.org
A foundation that informs the public about depressive illness and its treatability and promotes programs of research, education, and treatment.
National Mental Health Association (NMHA), 2001 N. Beauregard Street, 12th Floor, Alexandria, VA 22311, 800.969.6942 or 703.684.7722, TTY 800.443.5959, www.nmha.org
An association that works with 340 affiliates to promote mental health through advocacy, education, research, and services.
Many people who have depression turn to drugs and alcohol to make them feel better or to numb themselves from their feelingsestimates state that approximately 10.2 million adults live with a co-occurring mental health and addiction disorder.3 This relationship between mental health and addiction is dangerous, particularly because substance abuse can worsen depressive symptoms.
But there are many ways to find help, including calling a depression hotline for information about treatment centers and 12-step programs.
The connection between depression and substance abuse can place you at a higher risk for self-harm, injury, and suicide, so having a 24-hour depression hotline crucial for many people who are in crisis. You can be assured that all calls are private and confidential and that you will speak to a person with experience in helping people with similar issues.
Depression is a significantly debilitating mental health condition that can prevent you from living life to your fullest potential because you feel hopeless, sad, and tired. Additionally:1
There are effective ways to manage depression; calling a hotline can help you or a loved one begin your search for treatment.
What Questions Should I Ask?
When you call a 24-hour depression hotline, it is important that you share as much information as possible with the person on the other end of the line so they can better gauge your situation and provide relevant treatment information.
Before you call a depression helpline, you may want to write down questions you have, which might include:
If you are concerned about a family member, significant other, friend, classmate, or colleague, it can take an emotional toll on you. When calling a depression helpline, you can ask:
When you call, you may be asked your first name as well as your age, which helps the counselors figure out what types of programs you are eligible for. You may also be asked any of the following questions when you call:
Should I Call a Hotline?
Most people experience periods of sadness in their lives after major events, such as a job loss, a divorce, or the death of a loved one. However, clinical depression is different than regular sadness or a period of grief. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), depression is diagnosed when you have 5 or more of the following symptoms in a 2-week period:4
Mental Health Information
If you have depression and a substance abuse disorder, it can be very difficult to pick up the phone and ask for help. If you feel nervous and arent sure you can talk to someone on the phone, you can always try another time. Because all calls are confidential, you can feel safe about being open and honestthe person you speak to has experience and training and understands what you need.
If you want information about mental health in general, these resources can help:
Other Depression Hotlines
For many people, depression is an extremely lonely experience. Calling a hotline gives you the opportunity to talk to a caring person who can help you work through whatever negative thoughts or feelings you have.
If this is an emergency and you need immediate assistance, please call 911.
1. World Health
Organization. (2017). Depression.
Depression Overlooked; Pandemic Stress and Jaw Pain
News and commentary from the psychiatry world
After an advisory panel voted in favor of approval, the FDA declined to okay the investigational ALKS 3831 (olanzapine/samidorphan), a schizophrenia and bipolar I disorder treatment, after issues were raised about the tablet-coating process at its manufacturing site, Alkermes announced.
Antibiotic use in infants may increase their risk for a host of chronic conditions, including attention deficit-hyperactivity disorder. (ScienceDaily)
Overactivation of the subgenual anterior cingulate cortex could be the source of many people's depression and anxiety. (PsyPost)
A Mendelian randomization study found a genetic link between prescription opioid use and an increased risk for major depressive disorder. (JAMA Psychiatry)
Another adverse outcome of COVID-19-related stress and anxiety? Teeth grinding and jaw pain. (MedicalXpress)
One possible way to help stave off
disease: deep sleep. (NPR)
Here's How Bad It Is for Heart Health: Baseline
depressive symptoms associated with CVD incidence
Drawing upon pooled data on over 162,000 participants (mean age 63 at baseline; 73% women) in 21 cohorts from the Emerging Risk Factors Collaboration, each one standard deviation higher that people scored on a depression scale was tied to 6% increased risk (HR 1.06, 95% CI 1.04-1.08) for a composite of coronary heart disease (CHD) and stroke, reported Lisa Pennells, PhD, of the University of Cambridge in England, and colleagues.
When broken down, each standard deviation higher in depression score was associated with 7% increased risk for fatal or nonfatal CHD and 5% increased risk for stroke during a median 9.5-year follow-up, they wrote in JAMA.
As measured by the Center for Epidemiological Studies Depression scale (score of 16-plus indicates possible depressive disorder), incidence rates for heart events were far higher among people who fell into the highest quintile for depressive symptoms (average score of 19) versus the lowest quintile (average score of 1):
Pennells' group further analyzed data on over 400,000 participants from a single cohort in the U.K. Biobank, which showed very similar findings. Over a median 8.1-year follow-up, these participants saw a 10% (95% CI 1.08-1.13) higher risk for having any CV event per each standard deviation higher in depression score.
Similar to the data on the previous 21 cohorts, this was driven by slightly more fatal or nonfatal CHD risk. Each standard deviation higher in depression score was tied to an 11% and 10% higher risk for CHD and stroke, respectively.
The U.K. Biobank utilized the two-item Patient Health Questionnaire-2 to measure depressive symptoms, scored on a scale of 0-6, with a score of 3 or higher indicating a possible depressive disorder. And similar to the previous findings, incidence rates for heart events during follow-up were higher for those who scored 4 or higher on this scale versus those who scored zero:
"Depressive symptoms, even at levels lower than what is typically indicative of potential clinical depression, were associated with risk of incident cardiovascular disease although the magnitude of the association was modest," Pennells' group stated.
They also noted that these associations cannot simply be explained by just the traditional CV risk factors, like blood pressure, cholesterol, BMI, diabetes, and lifestyle.
"Previous studies have proposed mechanisms including altered brain and neuronal function affecting neuroendocrine pathways, autonomic nerve dysfunction, immune responses, platelet activation and thrombosis, life behavior, and cardiac metabolic risk factors," the authors stated.
One question that still remains is whether treating depression -- even mild cases of depression -- could reduce CV risk, they concluded.
Study limitations included the fact that it was not a systematic review and that depressive symptoms were evaluated at a single baseline examination, the authors noted.
Is Depression Different in Women
and Men? Understanding the Subtle Differences
Most people with depression experience at least a few of these hallmark symptoms, though they may not have them all and they may have others. Research has suggested that individual factors combine to determine what someones experience of depression looks and feels like.2?
No two people with depression will have identical experiences, but understanding how each contributing factor affects a person's risk and symptoms could lead to more effective treatment.
Biological Sex, Gender Identity, and Depression
Biological sex and gender identity are among these contributing factors. It's long been thought that men and women experience and express depression in different ways, but that doesn't mean the condition could be divided into two distinct forms. Its more akin to the way mental illness can manifest differently in children and teens than it does in adults.
On their own, biological sex and gender differences may not have a powerful impact. When combined with other factors, such as life stressors, sexism, toxic masculinity, trauma, and co-occurring mental health conditions like anxiety, substance use disorders, or eating disorders, these influences may make a person more prone to depression.
Are Some People More Prone to Depression?
In 2018, a study published in the journal Biological Psychiatry proposed that there are molecular differences in the brains of men and women with depression; the study only looked at the brains of cisgender men and women.3
For the study, researchers examined postmortem brain tissue samples from 50 subjects to see if there were any differences between the brains of people who had been diagnosed with major depressive disorder and those who had not. Although previous studies had set out to explore the same question, most only looked at the brains of cis men. The 2018 study looked at both cisgender men and cisgender women.
The researchers evaluated the level of gene expression in the brain tissue, specifically looking at how genes were expressed in three regions of the brain linked to mood regulation. According to their findings, brains contained different gene variants. These variants were also different from those of people who didnt have depression.
Most of the genetic changes the researchers noted occurred in only the male or female brains, but not both. One of the major differences researchers noted was that the female brains expressed more of the genes that determine synaptic activity (the electrical impulses that brain cells use to communicate).
The Chemistry of Depression
Researchers made an interesting discovery about the genes that were altered in both male and female brains: The same gene might have changed, but those changes werent necessarily the same.
In fact, in some cases, the change observed in the male brain was the opposite of the change seen in the female brain. For example, if a certain region showed increased gene expression in the female brain, gene expression in that region of the male brain was decreased.
The findings were intriguing, but the researchers concluded that more research is needed to understand their value. The study did have limitationsmost notably that the brains were only examined after death. Therefore, it's not clear what genetic changes in the brain would mean for people living with depression.
While molecular and physical evidence of a difference is fairly new, doctors and mental health professionals have long suspected that men and women experience and express depression in different ways.
A 2019 study published in the journal Progress in Neurobiology proposed that biological sex differences could influence not just how depression manifests in men and women, but how it responds to treatment.4
The researchers paid specific attention to the effect of pregnancy and the postpartum period on depression risk for biologically female subjects. The results of the study provided supportive evidence that a person who is biologically female is more at risk for depression directly after giving birth than at any other period in their life.
It's likely that the hormonal changes of pregnancy, childbirth, and lactation, combined with the psychological stress of becoming a parent, increase a postpartum individual's vulnerability to depression.5 Similarly, menopauseanother time of hormonal changewas also associated with an increased risk of depression.6
Research has repeatedly indicated that women are twice as likely as men to be diagnosed with depression.7 One possible explanation is that hormonal changes that are specific to the female body could influence the onset of depression. Studies in support of the theory also indicate that there is a disparity in depression risk between males and females that peaks in adolescence.8
Teens and young adults of either sex face a cascade of shifting hormones and social stressors that can contribute to depression, as well as other mental health conditions like anxiety, eating disorders, substance use disorders, and suicide.9
Gender Roles and Identity
It may not be that a greater number of women are depressed, but rather, that a woman is more likely to receive a diagnosis. Research has indicated that women who are depressed are more likely to show typical (or recognizable) emotional symptoms, such as crying. Women also tend to show more symptoms of depression than men.10
This observation is one example of how social factors influence the way people experience and express their emotions. While there may be a pattern, its not a strict relationship: Some women struggle to express their feelings while some men may be comfortable doing so.
The Different Types of Emotional Responses
But broadly speaking, Western societys traditional gender roles accept women openly expressing their feelings. Women tend to be more likely to talk about how they feel with a partner or friend, as well as seek help for symptoms of depression by sharing their concerns with a doctor or therapist.
Conversely, society often pressures men to take a more stoic approach. Men can be less likely to express or demonstrate their emotions openly and are often more reluctant to ask for help.11
When someone cannot freely express their feelings, these emotions may emerge in other forms. For example, sadness that's been pushed down might eventually bubble up to the surface as anger.
Research has indicated that men are often more likely to express depression in ways that differ from the more classic presentation. This difference may be one reason why depression in men is often missed or attributed to other causes.12
Men may be more likely to express depression in the following ways:
If you suspect a loved one needs treatment for depression, but they are abusive, you need to put your safety first. There are resources available that can help you stay safe and get your loved one the help they need.
Biological and social stressors can also be overwhelming for people in sexual minority groups. Studies have consistently shown that the rates of depression, anxiety, and suicide are high in the LGBTQ+ community.13?
Research also indicates that the increased risk of depression in transgender people, including those who are nonbinary, starts young. A 2018 study found that the prevalence of depression, anxiety, and suicidal ideation in transgender and gender non-conforming youth was sevenfold higher than their cisgender peers.14
Studies have also shown that kids and teens experiencing gender dysphoria and/or questioning their sexual orientation are more vulnerable to depression.15
To further compound these difficulties, people in sexual minority groups often lack equitable access to health care, including mental health services. While they may begin in youth, these disparities can persist into adulthood.
The rate of depression in transgender adults is high and often linked to cissexism (the assumption that most people are cisgender) and transphobia, as well as a lack of knowledge in health care providers.
Transgender people seeking gender affirmation surgery who are unable to access support and treatment are at an even greater risk for depression and suicide. However, research has shown that gender-affirming hormone therapy can improve the mental and physical well-being of people navigating gender dysphoria.16
Impact on Depression Treatment
One of the foremost questions for researchers is whether studies on the effect of biological sex and gender could lead to improved treatment for everyone with depression. While each person's experience of depression depends on many factorsnot just biological sex or gender identityidentifying important differences could help doctors prescribe treatments or even lead to new treatments.
For example, many medications (including those commonly prescribed to treat mental illness) are dosed according to weight. Female bodies tend to have a higher body fat percentage than male bodies, which can affect how medications are metabolized.
Hormonal fluctuations that occur throughout the lifespan of a person with a functioning uterus can also influence how medications work.17 The specific events that are often associated with changes, such as puberty, pregnancy, and menopause, need to be considered when deciding on any form of treatment for depression.
Every person dealing with depression can benefit from learning about the different approaches to treating the condition, including psychotherapy, medication, and interventions like cognitive behavioral therapy (CBT) or electroconvulsive therapy (ECT).1
If you're dealing with depression, the first step is to discuss your symptoms and concerns with your doctor or mental health care provider.
If you or a loved one are struggling with depression, contact the Substance Abuse and Mental Health Services Administration (SAMHSA) National Helpline at 1-800-662-4357 for information on support and treatment facilities in your area.
For more mental health resources, see our National Helpline Database.
From there, you can consider the risks and benefits of each treatment and make an informed decision about the safest and most effective choice for you.
Find Help With the Best Online
Tools for Assessing Suicide Risk
The tools are included in the new Section III of the DSM-5 and are intended to better support clinicians in identifying risk factors for suicide as well as scales for assessing suicidal behaviors (which includes differentiating self-harm from suicide attempts).5
Whitemore A. Understanding the changes in DSM-5. Clinical Advisor. Published November 14, 2013
Epidemiological and health care
utilization rates document potential underidentification and
under-treatment of men who may suffer from major depression.
Limitations in diagnostic criteria may prevent health care
professionals from clearly recognizing depression in the men
they treat. Societal norms related to masculine gender role
socialization may create barriers to help seeking for men
who could benefit from treatment for depression. This review
integrates up-to-date research with clinical reports and
offers recommendations for health care professionals. The
primary goals of the recommendations are to increase
sensitivity to male patients who may suffer from depression
and to equip professionals with scientifically informed
strategies for recognizing and responding to men who are
identified with depression.
Background: The underestimation of depression among men may result from atypical depression symptoms and male help-seeking behaviour. However, higher suicide rates among men than among women indicate a need for gender-specific services for men with depression. In order to develop gender-specific services, it is essential to examine professionals attitudes towards mens depressive symptoms and treatment needs as well as barriers to and facilitators of treatment. This study examined gender-specific treatment needs in male patients and treatment approaches to male patients from a professional perspective.
Methods: Semi-structured face-to-face interviews were conducted with 33 mental health professionals (MHPs) from five German psychiatric institutions. The study assessed the characteristics and attributes of male patients with depression risk factors for the development of depression among men, their condition at the beginning of treatment, male patients depressive symptoms, the needs and expectations of male patients, the importance of social networks in a mental health context, and MHPs treatment aims and treatment methods. Transcripts were analysed using qualitative content analysis.
Results: The professionals reference group of male patients were men who were characterised in accordance with traditional masculinity. Attributes reported as in line with this type of men were late initiations of inpatient treatment after crisis, suicidal ideation or attempted suicide, and high expectations towards treatment duration, success rate in recovery and therapeutic sessions. In contrast, male patients who deviate from these patterns were partially described with reference to female stereotypes. Professionals referred to psychosocial models in their explanations of the causes of depression and provided sociological explanations for the development of masculine ideals among men. The consequences of these for treatment were discussed against the background of normative expectations regarding the male gender. From the professionals point of view, psychoeducation and the acceptance of depression (as a widespread mental illness) were the most important goals in mental
Conclusions: In order to improve mental health among men, gender-specific services should be offered.
Awareness of the role of gender and
its implications on mental health treatment should be an
integral part of MHPs education and their daily
implementation of mental health treatment practices.
Men and women experience different
kinds of mental health problems. While women exceed men in
internalizing disorders such as depression and anxiety, men
exhibit more externalizing disorders such as substance abuse
and antisocial behavior, which are problematic for others.
These differences also vary by race and social class: for
example, African Americans possess better mental health and,
thus, a smaller gender gap in psychiatric problems. What
explains these differences? We concentrate on conceptions of
gender and gender practices. Research on gender and mental
health suggests that conceptions of masculinity and
femininity affect major risk factors for internalizing and
externalizing problems, including the stressors men and
women are exposed to, the coping strategies they use, the
social relationships they engage in, and the personal
resources and vulnerabilities they develop. This chapter
investigates explanations in these areas for gender
differences both in general and by race and class.
Background: It is often reported that men have lower rates of depression than women, but this does not necessarily signify better overall mental health in the male population.
Objective: This article discusses the presentation of depression in men and how it may differ from that of women. It also provides strategies for improving the assessment of depression in men.
Discussion: Men's lower overall
rate of depression than women reflects a number of issues,
including psychosocial barriers to seeking help. Depression
rates vary according to age groups, and certain subgroups of
men may be particularly vulnerable. Men often display
different symptoms and behaviours in response to depression
and experience anxiety disorders less frequently. Men's
greater risk taking and substance abuse have health outcomes
that can impact on depression later in life. Women have
greater emotional literacy and are more likely to volunteer
how they feel, while men are more likely to do something
about their negative affect. While men are usually wary
about talking about their depression, they will discuss
their feelings if provided with a safe environment in which
to do so.
Women are diagnosed with depressive
disorders twice as frequently as men, and yet evidence from
differential rates of substance abuse, incarceration, and
especially suicide calls into question the assumption that
men are less susceptible than women to depression. It is
possible that there is a masculine form of
depression that is under-diagnosed and under-treated. Health
professionals should work toward a greater understanding of
cultural masculinity in the service of conceptualizing,
diagnosing and treating male clients/patients who may be
suffering from a disguised form of this common mental
illness. Therapists who treat conventionally gendered male
clients/patients should educate these men about masculinity
as an important context of their problem, and should attend
closely to issues of emotional expression, premature
termination of therapy, and
Fewer men than women are diagnosed
with depression, although commentaries about men's
depression suggest that the lower reported rates may be due
to the widespread use of generic diagnostic criteria that
are not sensitive to depression in men, as well as men's
reluctance to express concerns about their mental health or
access professional health care services. This article
provides an overview of the connections between depression
and masculinities and, based on that literature,
recommendations are made for how we might better understand,
identify and treat men's depression in gender-sensitive
This study reports on the experiences
of 45 male focus group participants with a history of
depression. Men responded to questions addressing the
interaction between the male role, masculinity, depression,
and experiences with treatment for depression. Using a
qualitative, thematic-based coding strategy, three primary
themes emerged. First, participants described aspects of the
male gender as being in conflict or incongruent with their
experiences of depression and beliefs about appropriate
help-seeking behaviors. Second, men outlined alternative
symptom profiles that could interfere with the recognition
of depression and willingness to seek help. Finally, men
expressed a range of positive and negative reactions toward
depression treatment and treatment providers. Implications
for health care providers are provided.
Psychologists increasingly recognize
depression as a serious, albeit often undiagnosed, condition
in men. In fact, undiagnosed and untreated depression in men
may be one reason why many more men than women commit
suicide. However, because of cultural conditioning that
discourages expression of depressed mood in men, assessment
as well as treatment of depression in men are sometimes
difficult. Use of gender-sensitive assessment strategies and
interventions will assure that more men will be identified
and treated for depression. This article integrates
scientific findings related to depression in men with
specific gender-sensitive assessment and psychotherapeutic
intervention strategies designed to enhance psychologists'
skills in working with this significant problem in men.
preliminary examination of the "Real Men. Real Depression"
Men are a numerical minority group receiving a diagnosis of, and treatment for, depression. However, community surveys of men and of their mental health issues (e.g. suicide and alcoholism) have led some to suggest that many more men have depression than are currently seen in healthcare services. This article explores current approaches to men and depression, which draw on theories of sex differences, gender roles and hegemonic masculinity. The sex differences approach has the potential to provide diagnostic tools for (male) depression; gender role theory could be used to redesign health services so that they target individuals who have a masculine, problem-focused coping style; and hegemonic masculinity highlights how gender is enacted through depression and that men's depression may be visible in abusive, aggressive and violent practices. Depression in men is receiving growing recognition, and recent policy changes in the UK may mean that health services are obliged to incorporate services that meet the needs of men with depression.
Men and depression is a complicated and contentious issue and many will even disagree about whether clinicians should concern themselves with it, because the prevalence of depression is greater in women. Although the work of the mythopoetic men's movement in using fairy tales such as Iron John (Bly, 1990) to explore archetypes of gender, for example, may be overzealous and naive, it does not mean that we have to be equally overzealous in ignoring men with mental health issues. Despite the greater prevalence of depression in women, there are three important reasons for exploring depression in men.
First, even if men represent a numerical minority group among patients with depression they still require effective interventions. Second, although healthcare services find that they are diagnosing and treating many more women with depression than men, community surveys suggest that this disparity is disproportionate. In the UK, for example, figures from general practice for 19941998 show a male:female ratio of 0.4:1.0 for depression (Office of National Statistics, 2000), and data from a national household survey in 2000 show a ratio of 0.8:1.0 for depressive episode and disorders (Singleton et al, 2000). The greater prevalence of depression in women might, for example, be an artefact of how depression is recognised and treated or of how men self-diagnose and seek help. Third, mental health issues such as alcohol dependency (Alcohol Concern, 2005) or being subject to compulsory detainment and treatment (Healthcare Commission, 2007), which predominantly involve men, might be related to emotional distress and depression. Worldwide, the rate of suicide mortality for men is four times higher than that for women (White & Holmes, 2006) China is the only country where women's suicide mortality is greater than men's (Hawton, 2000) and research by Möller-Leimkühler (2003) argues that suicide is linked to depression in men.
Current approaches to men and depression draw on theories of sex differences, gender roles and hegemonic masculinity explored in this article.
Sex differences: male depression
When introducing sex differences it is important to define the term sex and its relation to the term gender. However, providing definitions is difficult because the research that we have drawn on here uses these terms in different ways. It is therefore perhaps better to outline the general approaches to these terms. Broadly, gender denotes the sexual distinction between male and female that is an amalgamation of biological, cultural, historical, psychological and social factors, although the word is often used deliberately to exclude biological factors. In terms of gender, sex refers to just those biological factors that distinguish male and female, and sex differences are factors (biological, cultural, etc.) related to sex. It is important to emphasise that a sex difference is not necessarily biological, although it does rest on an assumed common understanding of a biological distinction between men and women.
Establishing sex difference in research is simple and powerful (perhaps because of its simplicity), particularly in depression. As with epidemiological studies on depression, more specific studies on symptoms have found that women experience more symptoms of depression than men but that there are no sex differences in the quality of symptoms. A 15-year prospective community study found no sex differences in the number or duration of depressive episodes but, importantly, women reported more symptoms per episode (Wilhelm et al, 1998). In clinical samples, however, sex differences in the number of symptoms are less marked and show similar functional impairment and global severity (Young et al, 1990), but women are more likely to have a history of treatment for depression (Kornstein et al, 2000).
The reduction in sex differences from community to clinical samples seems to suggest that diagnostic procedures or self-care practices are resulting in a population of depression that is not representative. More specifically, there might be underdiagnosis of men, overdiagnosis of women, or systematic misdiagnoses of both men and women, which could be explored by looking at what happens in routine clinical practice. It is interesting to note that where studies have found a symptom to occur more frequently in one sex, it is the symptoms for women that appear in diagnostic criteria. In depressed women, symptoms that have been found to occur more frequently are worry, crying spells, helplessness, loneliness, suicidal ideas (Kivelä & Pahkala, 1988), augmented appetite and weight gain (Young et al, 1990). Non-diagnostic symptoms found more frequently in depressed women are bodily pains and stooping posture (Kivelä & Pahkala, 1988). However, symptoms that have been shown to occur more frequently in depressed men are slow movements, scarcity of gestures and slow speech (Kivelä & Pahkala, 1988), non-verbal hostility (Katz et al, 1993), trait hostility (Fava et al, 1995) and alcohol dependence during difficult times (Angst et al, 2002), which are not common to diagnostic criteria for (adult) depression. Increased hostility might be indicative of a conduct disorder mixed with depression (ICD10 F92.0; World Health Organization, 1992), but is limited to onset in early childhood. International diagnostic criteria and non-diagnostic symptoms for depression are listed in Box 1, with footnotes showing which symptoms the sex differences research shows to be more prevalent in men or women. These criteria may not be entirely representative of contemporary mental health practice for example, aggression may be recognised as part of adult depression by many practitioners but the list at least provides a useful summary of this body of research.
Box 1 Diagnostic criteria and non-diagnostic symptoms for depression
ICD10 F32 Depressive episode (World Health Organization, 1992)
DSMIV Major depressive episode (American Psychiatric Association, 1994)
Although differences in symptom presentation may be explained as different behavioural patterns of depression or dimensions of distress, it is not entirely implausible that there might exist a form of depression that has hitherto remained absent from international diagnostic criteria. Indeed, this possibility has led some to theorise a male depressive syndrome (Rutz et al, 1995; van Pragg, 1996) that is characterised by sudden and periodic irritability, anger attacks, aggressive behaviour and alexithymia. The Gotland Scale of Male Depression (Zierau et al, 2002) has been developed with such a syndrome in mind. In an out-patient clinic for alcohol dependency, standard diagnostic criteria identified major depression in 17% of male patients, whereas the Gotland Scale found depression in 39%. In a clinical sample, the Gotland Scale could find no gender differences (Möller-Leimkühler et al, 2004). However, the Gotland Scale looks for signs that are not usually understood as symptomatic of depression so it is not surprising that there is little difference between men and women diagnosed with depression using this scale. Nevertheless, in the clinical sample there was a greater intercorrelation of symptoms of male depression in men, which is something that could be explored in community samples. This scale, when utilised in a study of 607 new fathers, identified a prevalence of 6.5% suffering what could be classed as post-natal depression and of these, 20.6% were not identified by the use of the Edinburgh Post Natal Depression Scale alone (Madsen & Juhl, 2007).
The sex differences approach to depression in men has the potential to provide the diagnostic tools to allow psychiatric services and clinicians to recognise and treat a new form of (male) depression. Nevertheless, it is unclear how such an approach might be used to inform treatment, for example whether antidepressants will be appropriate or effective. In addition, focusing on sex differences can mean that differences between men, such as socio-economic status, are ignored.
Gender roles masked depression
Gender role theory sees gender in terms of the cultural and historical ways in which biological sex differences are played out at the individual and social level. As cultural constructs, gender roles rarely provide an accurate description of any individual man or woman; rather, they are social lenses (Bem, 1993) through which men and women perceive themselves and each other. Roles are learnt through processes of socialisation such as modelling (copying) one's parents which means that gender roles self-perpetuate and come to constitute material reality. For example, family law often deals with cases of child abuse and domestic violence, and requires its legal professionals and their clients to deal unemotionally with the facts of the case no matter how upsetting these may be (Pond & Morgan, 2005). Successful professionals are those that can negotiate the system by the use of reason while keeping any sentiment private, which proliferates a particular way of being a professional. This creates what we might call the role of a legal professional and illustrates how aspects of that role may be learnt (e.g. through rewarding professionals that stick to the facts) as a function of the structure (such as the factual requirements of evidence in court) in which the role is enacted. Presumably, given the right context anyone can enact any role, which means that men can enact male and female roles, and women can enact female and male roles. Epidemiological sex differences in the symptoms of depression may be evidence not of a different type of depression but of ways of expressing or coping with depression that are appropriate to a particular gender role.
The male and female roles are understood as norms that individuals aspire to and enact differently. An individual can adhere strictly to one role (masculine or feminine), weakly to both roles (androgynous), strongly to both (undifferentiated) or to neither (ambiguous). Although the definition of a particular role may be culturally dependent we can presume that because gender roles are self-perpetuating through processes of socialisation they are rarely subject to substantial change. For issues of mental health and illness the coping style of each gender role is particularly apt. In gender role theory, the feminine style of coping is to deal with the emotion associated with the stressor (emotion focused), whereas the masculine style is to deal directly with the stressor (problem focused) (Li et al, 2006). Feminine, emotion-focused coping is associated with higher levels of depression than masculine problem-focused coping (Compas et al, 1988; Ebata & Moos, 1991). However, the research on sex differences mentioned above suggests that diagnostic criteria fail to include a male depressive syndrome, which may mean that depressive symptoms in masculine, problem-focused individuals have remained hidden. Indeed, Good & Wood (1995) point out that the masculine role is antithetical to recognising and expressing depression and to utilising emotion-focused interventions such as psychotherapy. For example, seeking help might be interpreted as incompetence and dependence (Möller-Leimkühler, 2002), and research has shown that individuals who adhere to the masculine role have negative attitudes towards using counselling services (Good & Wood, 1995). This has led some to theorise a disorder of masked depression, where the reduced affect is, for example, manifest in physical symptoms (Kielholz, 1973). Interestingly, associating masculinity with mental ill health has been important for the antisexist men's movement (e.g. the male role leads men to be violent to women) and for an antifeminist backlash (e.g. the male role damages men and privileges women), and this has been taken up in gender role theory with little recourse to empirical evidence. Regardless of whether masculine individuals are more likely to experience depression it is important to note that if they do, it seems that they will be less likely to recognise it as depression and to seek help.
The gender role theory approach to men and depression suggests that services could be redesigned to target masculine, problem-focused individuals. In addition, services could adopt practices to help men with depression challenge gender role norms, which would theoretically leave them better able to recognise and accept help for their own depression. Although gender role theory does acknowledge possible differences between men, it relies on a fundamental opposition between male and female. This risks overemphasising gender when other factors, such as class and ethnicity, may be more important. In particular, gender role theory largely focuses on women or, when focusing on men, is based on affluent White US college students, who are unlikely to reflect the diversity of men with depression.
The list of gender role characteristics shown in Table 1, predominantly from the 1970s, may seem dated and difficult to take seriously. However, the point is that if we cannot take historical gender role characteristics seriously then current gender role research may suffer the same fate. Indeed, a review (Choi & Faqua, 2003) of factor analytic studies validating the definitive gender role psychometric measure the Bem Sex Role Inventory (BSRI; Bem, 1974) suggests that the understanding of masculinity and femininity in gender role theory is insufficiently complex. Another difficulty with gender role theory is that it seems to conceptually confuse gender norms with an individual's behaviour, which could result in potentially unhealthy male role norms being seen as normal things for men to do.
Hegemonic masculinity depression enacting gender
Connell's (1987) concept of hegemonic masculinity is perhaps the most popular approach to gender in academia at present. Like gender role theory, hegemonic masculinity focuses on the social, rather than biological, aspects of gender. Gender is understood as something that is actually done by people. Thus, if men regularly do something in a certain way such as waking early, being last to leave work, working at home in the evening and this is accepted by both men and women it becomes a masculine feature, a masculinity. Gender is multiple, as practices may construct many ways of being a man, and historical, as these ways of being a man change. Power is particularly important: hegemony refers to insidious processes of domination where the majority of people come to believe that particular ideas are not only natural but are for their benefit. Different masculinities must therefore compete to define what it is to be a man, and the dominant masculinity in any particular context is not simply the one that forces itself on people but the one that is so socially ingrained that it is almost impossible to imagine anything else. Hegemonic masculinity must also compete with other identities such as femininity, class and age. Consequently, masculinities are not always dominant and are instead subordinate to another identity. As hegemonic masculinity is defined in particular contexts, it can never be fixed and must instead be continually reworked as people move through their lives. Sex differences in the symptoms of depression may be evidence of underlying and common gendered practices.
Enacting depression could be part of enacting gender. Indeed, being depressed would seem to be unmasculine. In an interview-based study involving men who had been diagnosed with depression but were well enough to participate in the research, Emslie et al (2005) found that the recovery process was talked about as successfully renegotiating a masculinity. Thus, actually being depressed would constitute a failure to be masculine. Nevertheless, for a few of the men Emslie et al interviewed, the isolation and loneliness of depression were incorporated as signs of their difference (as more sensitive and intelligent) from others, which seems to suggest that actually being depressed would reaffirm their own masculinity.
As so few men are diagnosed with depression it is important also to look at depression-related practices in non-clinical samples. A focus group study that sought a diverse sample of men from both clinical and non-clinical populations looked at how they talked about seeking help for physical and mental health problems (O'Brien et al, 2005). The authors found considerable resistance to talking about mental ill health, particularly among young men, for whom masculinity appeared to require being strong and silent about emotions.
Masculinity can be practised by both men and women, which means that women need to be included when considering depression in men. Brownhill et al (2005) conducted focus groups with a non-clinical sample of men and women and found that the important difference was not how depression was experienced but how it was expressed. Their study seems to suggest that depression is part of an inner emotional world that is contained, constrained or set free by gendered practices. The big build (Fig. 1) is the descriptive model Brownhill et al developed to explain how masculine practices in relation to depression result in a debilitating trajectory of destructive behaviour and emotional distress. These practices start as avoidance, numbing and escaping behaviours that may escalate to violence and suicide. The point seems to be that there is no difference in the depression men and women experience but that there are important differences in how depression is done or enacted in terms of masculinities or femininities.
From the research on depression and hegemonic masculinities, it might be suggested that the destructive behaviours such as violence in intimate relationships, substance misuse and suicide are ways of doing depression that enact particular masculinities. Further, current mental health practices in the diagnosis and treatment of depression might be seen as enacting femininities. From the concept of hegemonic masculinity, depression in men is not masked but is often visible in abusive, aggressive and violent practices; nor are these behaviours a sign of a male form of depression: women can do masculinity and may cope with their depression in similar ways. The point for service provision is that depression may underlie wider issues of mental health (such as substance misuse) and criminal behaviour.
Although hegemonic masculinity may offer clinicians a more nuanced view of their clinical practices and how their clients act out their difficulties, it fails to offer any specific treatment possibilities.
To date, the research on hegemonic masculinity and depression has utilised focus group and interview methods. As masculinity is understood in terms of constantly recurring practices, research needs to adopt methods that identify and study depression-related practices as they occur in real life. Studies have already looked at how masculinities are achieved through destructive behaviours such as crime (Messerschmidt, 1993) and hooliganism (Newburn & Stanko, 1994), and it would be interesting to explore them for depression.
The socialisation of developing boys
In our introduction we presented three reasons for considering men and depression: men are a numerical minority among patients with depression, and they require effective interventions; in community samples there seem to be more men with depression than are receiving treatment for it; and emotional distress in men might indicate depression. Theories of sex differences, gender roles and hegemonic masculinity can be combined in an effort to explain why men are the numerical minority patient group when so many seem to have depression. Although Kraemer (2000) argues that men may be biologically disadvantaged by a fragile X-chromosome, he claims that this disadvantage is immediately mitigated once an infant's sex is known. Boys are subject to their own biological and psychological development that cannot be separated from the cultural and historical context in which they are socialised. The advantage of taking a combined approach is that it should force us to consider the individual and social together.
In a pioneering study of schoolboys, Frosh et al (2002) found that masculinity seemed to be lived through attempts to avoid being seen as feminine or homosexual. In particular, femininity and homosexuality seemed to be associated with displays of emotions and the schools reported that if boys displayed such emotions they were subject to, and would subject others to, insidious bullying. Although usually associated with younger children, the cliché big boys don't cry is an example of how a young boy may be denied a masculine identity because he has displayed emotion. It is important to consider what this means for men and depression in practice, as the suggestion seems to be that developing boys are socialised into emotionally inarticulate young men, unable to express depression. If adolescent girls hold the monopoly on discussions relating to emotions, then by implication boys are restricted from entering these domains. This rather stark bipolarisation of emotional-feminine and unemotional-masculine must influence men's ability to recognise their own emotional difficulties, how they express them and how they seek help to cope with them. A further suggestion is that health more generally is seen as a feminine issue, which means that the problems of genders roles and masculinities are not limited to emotional health (White, 2006).
Future: gender equality policy
The Real men. Real depression campaign of the US National Institute for Mental Health (Rochlen et al, 2005) and the publication of the leaflet Men Behaving Sadly by the UK Royal College of Psychiatrists (2006) demonstrate the growing recognition of depression in men. However, recent changes towards proactive gender equality may mean that health services have to adapt and incorporate an explicit focus on men and depression. The UK Equality Act 2006, which came into force April 2007, places a statutory duty (termed the gender duty) on public bodies to ensure that where men and women have different needs services are planned and developed in ways that successfully meet them. If, for example, a local coroner's office were to report a rate of suicide greater in men than in women, we would presume that under the gender duty the local health services would need to do something to reduce male suicide. Nevertheless, health services currently lack the expertise required for providing solutions targeted specifically at men (Men's Health Forum, 2006), which means that they may fail to meet their obligations under the gender duty. Health service projects have been designed to meet men's health needs and it is important that we learn from these as services are developed on the basis of the different needs of men and women.
MCQs and EMI
1 A man attends your surgery and you consider him to be typical of the masculine gender role. The most productive tactic to explore the possibility that he has depression is to:
a ask how he feels about his emotional difficulties
2 Assuming that male depression exists, diagnosis should be based on:
a international diagnostic criteria with both men and women
3 Hegemonic masculinity is best described as:
a the taken-for-granted view of what it is to be a man in a specific context
Theme: clinical diagnosis
a weight loss
For each patient in the scenarios below, select from the above list the symptom that is absent from international classifications of depression:
i A 40-year-old man is cheerful and friendly when he attends your surgery. When pressed, he reports that for as long as he can remember he has had periods when he loses interest in his hobbies, eats too much and puts on weight. When asked about his strategies for dealing with these periods he reports that the only thing that helps him is drinking, otherwise things get out of control as he cannot relax.
ii A 22-year-old man attends your surgery with visible bruising to his face and knuckles. Since graduating from university, he has separated from his long-term partner and had to relocate away from friends and family to start his job. After further discussion, he reports that has been feeling low and has moments when he becomes inexplicably angry, starting fights for no reason.
1 Shown to discriminate between sexes, occurring more frequently in women.
2 Shown to discriminate between sexes, occurring more frequently in men.
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44 Zierau, R., Billie, A., Rutz, W. et
al (2002) The
Gotland Male Depression Scale: a validity study in patients
with alcohol use disorders.
Nordic Journal of Psychiatry, 56, 265271.
Objective: To investigate men's experience of depression.
Method: A sample of male and female teachers and students was recruited from four sites of a tertiary education institution to a series of focus groups. A grounded theory approach to qualitative data analysis was used to elucidate men's experience of depression. Content analysis was applied to the women's data to examine similarities and contrasts with the men. Standard measures of mood and dispositional optimism confirmed the non-clinical status of the group.
Results: The findings suggest that some men who are depressed can experience a trajectory of emotional distress manifest in avoidant, numbing and escape behaviours which can lead to aggression, violence and suicide. Gender differences appear not in the experience of depression per se, but in the expression of depression.
Conclusion: Emotional distress,
constrained by traditional notions of masculinity, may
explain why depression in men can often be hidden,
overlooked, not discussed or 'acted out'. There are
implications for the types of questions asked of men to
detect depressive symptoms.
How do boys see themselves? Their peers? The adult world? What are their aspirations, their fears? How do they feel about their own masculinity? About style, 'race', homophobia? About football?
This book examines aspects of 'young masculinities' that have become central to contemporary social thought, paying attention to psychological issues as well as to social policy concerns. Centring on a study involving in-depth exploration, through individual and group intererviews, the authors bring to light the way boys in the early years of secondary schooling conceptualise and articulate their experiences of themselves, their peers and the adult world. The book includes discussion of boys' aspirations and anxieties, their feelings of pride and loss. As such, it offers an unusually detailed set of insights into the experiential world inhabited by these boys - how they see themselves, how girls see them, what they wish for and fear, where they feel their 'masculinity' to be advantageous and where it inhibits other potential experiences. In describing this material, the authors explore questions such as the place of violence in young people's lives, the functions of 'hardness', of homophobia and football, boys' underachievement in school, and the pervasive racialisation of masculine identity construction.
Young Masculinities will be invaluable
to researchers in psychology, sociology, gender and youth
studies, as well as to those devising social policy on boys
and young men.
To investigate the previously untested
hypothesis that college men with higher levels of male
gender role conflict (MGRC) experience both increased risk
of depression and more negative attitudes toward seeking
counseling services, this study used latent variable
modeling to examine these relations. Two components of MGRC
were identified: restriction-related MGRC, which predicted
25% of the variance in help-seeking attitudes, and
achievement-relatedMGRC, which predicted 21% of the variance
in depression. It is suggested that outreach programs
designed to increase college men's willingness to use
counseling services attempt to counter the option-limiting
aspects of male gender roles, whereas counseling with
depressed college men incorporate an examination of their
perceptions of success and
Downhill from conception to birth
At conception there are more male than
female embryos. This may be because the spermatozoa carrying
the Y chromosome swim faster than those carrying X. The
male's pole position is, however, immediately challenged.
External maternal stress around the time of conception is
associated with a reduction in the male to female sex ratio,
suggesting that the male embryo is more vulnerable than the
female.1 From this point on it is downhill all the way. The
male fetus is at greater risk of death or damage from almost
all the obstetric catastrophes that can happen before
birth.2 Perinatal brain damage,3 cerebral palsy,4 congenital
deformities of the genitalia and limbs, premature birth, and
stillbirth are commoner in boys,5
Consultation rates and help-seeking
patterns in men are consistently lower than in women,
especially in the case of emotional problems and depressive
symptoms. Empirical evidence shows that low treatment rates
for men cannot be explained by better health, but must be
attributed to a discrepancy between perception of need and
help-seeking behavior. It is argued that social norms of
traditional masculinity make help-seeking more difficult
because of the inhibition of emotional expressiveness
influencing symptom perception of depression. Other medical
and social factors which produce further barriers to
help-seeking are also examined. Lines of future research are
proposed to investigate the links between changing
masculinity and its impact on expressiveness and on the
occurence and presentation of depressive symptoms in
Suicide and premature death due to
coronary heart disease, violence, accidents, drug or alcohol
abuse are strikingly male phenomena, particularly in the
young and middle-aged groups. Rates of offending behaviour,
conduct disorders, suicide and depression are even rising,
and give evidence to a high gender-related vulnerability of
young men. In explaining this vulnerability, the gender
perspective offers an analytical tool to integrate
structural and cultural factors. It is shown that
traditional masculinity is a key risk factor for male
vulnerability promoting maladaptive coping strategies such
as emotional unexpressiveness, reluctance to seek help, or
alcohol abuse. This basic male disposition is shown to
increase psychosocial stress due to different societal
conditions: to changes in male gender-role, to postmodern
individualism and to rapid social change in Eastern Europe
and Russia. Relying on empirical data and theoretical
explanations, a gender model of male vulnerability is
proposed. It is concluded that the gender gap in suicide and
premature death can most likely be explained by perceived
reduction in social role opportunities leading to social
It is often assumed that men are
reluctant to seek medical care. However, despite growing
interest in masculinity and men's health, few studies have
focussed on men's experiences of consultation in relation to
their constructions of masculinity. Those that have are
largely based on men with diseases of the male body
(testicular and prostate cancer) or those which have been
stereotyped as male (coronary heart disease). This paper
presents discussions and experiences of help seeking and its
relation to, and implications for, the practice of
masculinity amongst a diversity of men in Scotland, as
articulated in focus group discussions. The discussions did
indeed suggest a widespread endorsement of a
hegemonic view that men should be
reluctant to seek help, particularly amongst younger men.
However, they also included instances which questioned or
went against this apparent reluctance to seek help. These
were themselves linked with masculinity: help seeking was
more quickly embraced when it was perceived as a means to
preserve or restore another, more valued, enactment of
masculinity (e.g. working as a fire-fighter, or maintaining
sexual performance or function). Few other studies have
emphasised how men negotiate deviations from the hegemonic
view of help-seeking.
Lately, you've been feeling down and depressed. While you've certainly felt this way before, you've never felt so fatigued that you feel weighed down. Feeling worthless and hopeless, you decide to see a therapist in the hopes of getting help. You tell a friend, who suggests that you call their therapist. According to your friend, this is the best therapist in the world. Thankful for the referral, you call and make an appointment. However, after several appointments, you just don't feel as though you and your therapist have connected. But because your friend simply loves this therapist, you wonder if trying out a different therapist is the right thing to do. Maybe the lack of connectedness is just in your head. Or maybe it's just the depression getting in the way of connecting with your therapist.
Make a Real Connection
While it's certainly true that symptoms of depression can interfere with connecting with others1, it's important to not just dismiss the lack of connection, particularly if it's your first experience with therapy. In fact, a large body of research indicates that the therapeutic alliance, or the extent to which you feel connected to your therapist, is one of the primary mechanisms leading to change in depressive symptoms across several types of psychotherapy.2, 3 Additionally, research indicates that the therapeutic alliance is particularly important to the outcome for those who have had a history of fewer depressive episodes.4
In a new study conducted from the University of Pennsylvania, Brown University, VU University Amsterdam, and Akrin Mental Health Care, a team of researchers examined the effect of the therapeutic alliance on the relations between the number of prior depressive episodes and treatment outcome between two types of therapy: cognitive behavior therapy (CBT) and psychodynamic therapy.5 In the study, individuals meeting criteria for depression completed surveys about their alliance with their therapist and their depressive symptoms over the course of 16 sessions of either CBT or psychodynamic therapy.
The results of the study indicated that, although the number of prior depressive episodes did not affect treatment outcome of either treatment, having a strong therapeutic alliance predicted positive treatment outcomes. Additionally, although having a strong therapeutic alliance was an important factor in both treatments, how important the alliance was differed based on the type of therapy and number of prior episodes. Specifically, for those individuals undergoing psychodynamic therapy, the alliance had a large effect on treatment outcome, regardless of the number of prior depressive episodes. In contrast, for those undergoing CBT, having a strong therapeutic alliance had a larger effect on treatment outcome in those with a history of fewer prior depressive episodes. Depending on the treatment and the number of prior depressive episodes, having a strong therapeutic alliance was an important mechanism of change in depressive symptoms.
The results of this study point to the importance of considering not only a therapist match to areas of expertise and type of therapy, but also to your interpersonal fit and feeling of connectedness. While it may be frustrating and time-consuming to shop around for a therapist, finding someone that you feel connected to may increase the likelihood of reducing your symptoms of depression.
1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
2. Arnow, B. A., Steidtmann, D., Blasey, C., Manber, R., Constantino, M. J., Klein, D. N., Fisher, A. J. (2013). The relationship between the working alliance and treatment outcome in two distinct psychotherapies for chronic depression. Journal of Consulting and Clinical Psychology, 81, 627-638. Doi: 10.1037/a0031530
3. Ulvenes, P.G., Berggraf, L., Hoffart, A., Stiles, T. C., Svartberg, M., McCullough, L., & Wampold, B. E. (2012). Different processes for different therapies: Therapist actions, therapeutic bond, and outcome. Psychotherapy, 49, 291-302. doi: 10.1037/a0027895
4. Lorenzo-Luaces, L., DeRubeis, R. J., & Webb, C. A. (2014). Client characteristics as moderators of the relation between the working alliance and outcome in cognitive therapy for depression. Journal of Consulting and Clinical Psychology, 82, 368-373. Doi: 10.1037/a0035994.
5. Lorenzo-Luaces, L.,
Driessen, E., DeRubeis, R. J., Van, H. L., Keefe, J. R.,
Hendriksen, M., & Dekker, J. (2017). Moderation of the
alliance-outcome association by prior depressive episodes:
differential effects in cognitive-behavioral therapy and
short-term psychodynamic supportive psychotherapy. Behavior
Therapy, 48(5), 581-595.