Real Men Get Depressed

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By Irene S. Levine

Steve Imparl, 39, a successful lawyer and businessman in Chicago, views the discussion boards at www.maledepression.com several times a day. Sometimes he posts a comment. The Web site gets as many as 150 hits per day, mostly from men.

Imparl created the "guy-friendly" site in March 2002 to provide support and to encourage open discussion about mood disorders. But men aren't the only ones flocking there. Girlfriends, spouses and concerned friends visit the site because they're often the first to notice when a man gets depressed.

Imparl was in his late 20s when things started to unravel, he says. Although he was able to maintain his job as an information technology manager, he couldn't sleep well. It was hard to get out of bed each morning and the lack of sleep was taking its toll. Imparl was edgy and irritable, blowing up at the slightest provocation. His relationship with a girlfriend began to deteriorate; it was one more responsibility that felt overwhelming at the time. The woman thought he was self-absorbed. And he was. Before long, the relationship ended.

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Like most men, Imparl was reluctant to seek help. "I had a lot of misconceptions about the medications that are used in psychiatric treatment," he now says. "I thought I would lose my personality or lose my creativity. Ironically, I had lost them both already."

He was working an average of 50 hours of week at the time and attending law school in the evenings. "Strangely enough, with all this suffering, I was still functioning at a high level," he says. "Keeping busy at work became a way of self-medicating."

As things slowed down at work, he became more aware of the symptoms. Then, when he found himself thinking about suicide and even planning the mechanics of how to kill himself, he approached an employee assistance program at his firm and took a difficult step. He admitted that he needed help.

The Gender Gap
A new study (conducted as part of the World Mental Heath Surveys Initiative) has looked at the prevalence of mood, anxiety and alcohol disorders across six European countries. In a community sample of 21,185 individuals in Belgium, France, Germany, Italy, the Netherlands and Spain, women were twice as likely as men to be diagnosed with major depression. These findings are consistent with data from the U.S. National Institute of Mental Health (NIMH) reporting that depression is diagnosed twice as often in American women as it is in men.

The reasons for the gender differences can't be fully explained, but some researchers suggest that the definition of depression itself doesn't adequately capture the condition as it is experienced by men. According to the World Health Organization, doctors are more likely to diagnose depression in women than in men, even when they have similar scores on standardized measures of depression or manifest similar symptoms.

"Depression in men is often hidden behind drug or alcohol addiction, compulsive attitudes and behaviors toward work, or an over-attachment to religious rituals," says Professor Giovanni Cassano, chairman of the Department of Psychiatry, Pharmacology, Neurobiology and Biotechnology at the University of Pisa, Italy. "Even though depressed men are able to maintain their involvement in work, they tend to lose interest in everything else that once mattered, including their family," says Dr. Cassano. "Their lives are deprived of what is called 'elan vital' by the French, 'entrieb' by Germans, or 'slancio vitale' by Italians. In essence, they have lost their 'drive for life,' an emotional halo that colors perceptions, thoughts and everyday behaviors."

While depressed men are less likely to recognize the symptoms of their depression or to ask for help, depressed women have trouble "adapting'' to depression. Because they encounter more difficulties performing their roles as wives and mothers, they seek treatment sooner, says Dr. Cassano.

Dr. John Zajecka, Director of Treatment Research at Rush-Presbyterian-St. Luke's Medical Center in Chicago says that the initial symptoms men experience usually don't conform to the "classical textbook symptoms" of depression.

"They come in with physical complaints like back pain, headaches and general musculo-skeletal problems," says Dr. Zajecka. "Some have problems that are masked by relationship issues. The depression emerges when they get divorced or lose their job. When you start probing, you find out about the lack of sleep or loss of appetite. Then they tell you about their lack of energy, lack of interest in things they once enjoyed, and the sexual apathy. But men don't come in complaining about these things up front."

Depression Isn't Only 'In Your Head'
Regardless of gender, clinical depression is a serious medical condition that interferes with a person's ability to function. No two individuals experience depression exactly the same way, but it dramatically alters an individual's body, mood and thoughts. It isn't merely a passing blue mood or something that someone can "snap out of" without help. To the contrary, it can linger for weeks, months or years, leading to feelings of emptiness and despair, broken relationships and disrupted careers.

Depression affects 121 million people worldwide. The loss of productivity in the United States alone due to absenteeism and decreased performance resulting from depression is estimated at $44 billion per year. That doesn't include the costs of treatment.

The causes of depression are complex and still are not well understood. Brain imaging studies reveal that the disorder may result from neural circuits that fail to function properly, or from neurotransmitters (chemicals used by nerve cells to communicate) that are out of balance. Genetic studies suggest that a vulnerability to depression may be the result of multiple genes, acting together, that are influenced by environmental stressors -- such as medical illness, losing a loved one or substance abuse.

The good news is that depression is very treatable. "More than 60 percent of those who are treated have marked improvement," says Barnett Meyers, M.D., a professor of psychiatry at Weill College of Cornell University in White Plains, N.Y. Depending on the patient's diagnosis, severity of symptoms and preferences, a range of medications and short-term psychotherapies are available to treat these disorders. Severe and chronic cases often require a combination of treatments, but the vast majority of patients achieve a full recovery with optimal treatment.

"There has been an increase in choices and types of drugs, and increased information about how to use antidepressants to maximize tolerability," says Meyers. "When people were treated 20 years ago, the worst part of antidepressant drugs was their side effects. Now most patients have minimal or no side effects but the problem of assuring that antidepressants are taken at sufficient doses for sufficient durations continues to be a public health problem."

Despite the great strides made over the past decade in our understanding of the genetics and neurobiology of depression and of its treatment -- shame, embarrassment and stigma still prevent many men from seeking help. The feelings of hopelessness that are part of the disorder only compound the problem.

There are many harbingers of change. Even the mass-media blitz of direct-to-consumer advertising by pharmaceutical companies is helping promote greater awareness of the symptoms of depression. Interactive Web sites like Imparl's are providing safe havens for depressed men to share their concerns. It is encouraging also that the Internet isn't being used as a substitute for professional treatment; a study by researchers at Johns Hopkins University School of Medicine (U.S.) reported in JAMA found that 96 of 103 study participants who participated in such groups were also receiving professional treatment for depression.

Symptoms of Depression
Adapted from: Men and Depression, NIMH, 2003

Persistent sad, anxious, or "empty" mood