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Men Get Angry, Not Sad

By Gina Shaw
WebMD Feature

Reviewed by Michael W. Smith, MD

Call them George and Jerry. The two commuter buddies rode the train to work together in southern California for years, trading office war stories, commiserating about the stock market, and handicapping the Lakers' fortunes. They thought they knew each other. But both men were stunned one day recently when they walked into a men's support group for depression and found each other there.

"They'd traveled together on the train for years and had never spoken a word about what was going on inside," says Fredric Rabinowitz, PhD, the University of Redlands psychologist who runs the men's group. "That's what goes on for a lot of men. They tend to downplay emotional distress to anyone on the outside."

But I Don't Feel Sad

Although studies show that depression is more than twice as prevalent in women as in men, some experts feel that men with depression may be seriously underdiagnosed. Why? Their symptoms aren't necessarily what we expect. "Some of us believe that men are just showing depression differently," says Rabinowitz, who with University of Iowa psychologist Sam Cochran has written Men and Depression and Deepening Psychotherapy With Men.

A study published in the American Journal of Medical Genetics in March 2002 even suggests genetic differences between depression in men and women. Researchers from the University of Pittsburgh identified 19 chromosomal regions linked to a type of major depressive disorder, but only three of them were significantly linked in both men and women. The other 16 were only linked to one sex.

Whatever the reason, men's symptoms of depression can be misleading, because they often don't involve crying or feeling sad. Frequently, male depression first shows up in physical symptoms, such as headaches, gastrointestinal distress, and sexual dysfunction. Other symptoms can include:

• Irritability, anger, and lashing out
• Substance abuse
• Inability to function at the office
• Interrupted sleep patterns

Anything but Depression

Now running a web-based support group for other men with depression, www.maledepression.com, Imparl talks to many men who feel exactly as he did: "Not depression. Anything but that."

He understands how they feel: Depression remains stereotyped as "not manly" in American culture, although icons such as home run king Mark McGwire talking openly about their therapy have helped reduce the stigma. "I still have trouble talking to others about it sometimes. It's perceived many times as a woman's disease, which keeps a lot of men out of treatment," Imparl says.

"The problem is that men don't come forward and discuss their depression as much as women do," says Melodie Morgan-Minott, MD, past president of the Ohio Psychiatric Association and an instructor in psychiatry at Northeastern Ohio University's College of Medicine. "Women are generally more expressive and more willing to acknowledge the suffering from depression."

That picture, however, is gradually changing. Morgan-Minott estimates that 30% of her patients are men, up from just 10% a few years ago.

Still, Rabinowitz says men have a long way to go in acknowledging depression. "A lot of men come into therapy coerced, unfortunately," he says. "A partner says, 'If you don't get help, I'm leaving.' Or the relationship has already blown up. Typically, it has to get pretty bad for a man to come in on his own."

Dangerous Denial

Reluctance to seek treatment can be dangerous, and even deadly. Men with depression commit suicide at much higher rates than women, although more women attempt it. And depression has been linked to heart problems -- men with depression are more than twice as likely to develop coronary heart disease than those who are not depressive.

"Don't feel weak or ashamed of the condition. That's a trap we've all fallen into," says Imparl. "It holds us back from getting the help that we need. We feel like 'I should be able to do something about it.' Well, what I'm doing is taking charge of my condition. I'm seeking treatment, managing it effectively, and working with my doctor as part of a treatment team. That's doing something about it."

"When men go to therapy, they do as well as women," Rabinowitz says. "It's a safe place to be yourself. So the response rate to therapy and to medication is actually very good."

What should you do if some of the symptoms described before sound familiar, and you're concerned about depression?

• First, realize that depression is nothing to be ashamed of. It's nothing you've "done wrong." Scientists now believe that clinical depression stems from a combination of genetic, biochemical, and environmental factors, most of which you've had no control over.
• See your primary care doctor and describe your symptoms. "More and more primary care doctors are being trained to recognize symptoms of depression," says Morgan-Minott. Your doctor can either start treatment or refer you to a psychiatrist or psychologist. Mention to him or her that you're wondering about depression.
• Consider both therapy and medication. "Typically men will go to their family physician privately and get an antidepressant. But without having therapy at the same time, some of the same patterns just continue," says Rabinowitz. Most current research indicates that while both antidepressant medications and therapy are effective in combating depression, the most potent treatment combines the two.

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