AMA Journal of Ethics^®

Abstract

Too many men who suffer from depression remain undiagnosed. While men are diagnosed with depression at half the rate of women, they die by suicide 3 to 4 times as frequently. Gendered processes of socialization affect how some boys and men express depression. Notably, gender disparities in diagnosis disappear when “male-typical” symptoms of depression are incorporated. Historically and to this day, masculinities have created barriers to care. Addressing disparities in depression diagnoses and treatment requires making psychological services affordable, adopting collaborative care models, revisiting sex as a risk factor for depression, and reexamining major depressive disorder’s diagnostic criteria.

Depressed and Alone

I was severely depressed for the entirety of my junior year of college. My depression consumed me, breaking my identity into pieces so small I thought I barely existed. The person I had known for the past 20 years now seemed a carefully constructed illusion.

During that year, I never sought treatment. For months I could not acknowledge I was angry with myself, let alone depressed. There were days when I screamed so loudly in my head, I couldn’t hear what my professor was lecturing about. There were times when I thought about how easy it would be just to fall into traffic and escape the pain of daily living. But I told myself I could get through it alone.

I remember the horrors of my depression, how much I denied what I was feeling, and how getting care felt like an insurmountable obstacle.

Five years later, I returned to that experience as a medical student. I am exploring specific barriers to care that men with depression face, and my experience is far from unique.

Masculinities

Current data on depression in the United States indicate that women suffer from depression more than men.¹ A closer look reveals that, while men are diagnosed with depression half as often as women and are less likely to attempt suicide, men die by suicide 3 to 4 times more frequently.² Although there is no one-to-one correspondence between depression and suicide, depression is one of suicide’s most significant risk factors.³

Assumptions about traditional gender roles are critical barriers to diagnosing men with depression.

Many boys are taught by parents, teachers, and peers to express themselves and their emotions differently than girls,⁴ and gendered processes of socialization can affect how boys and men express depression.⁵ When a study accounted for “male-typical” symptoms of depression (eg, overworking, substance misuse, and aggression), the difference in rates of depression between the sexes disappeared,⁶ suggesting that depression in many men remains unrecognized. The data also indicate that female sex is not a risk factor. Rather, the gendered ways we think of ourselves and treat others influence how some men experience, manage, and present with depression.

Masculinities include ideals of what it means to be a man and are influenced by our intersecting identities and social and cultural environments. Experiences of people who are gender nonconforming are underrepresented in depression research, which constitutes a major clinical research gap. Some men draw on aspects of traditional Western masculinities (eg, self-reliance and emotional control) to improve their mental health on their own.⁷ Nonetheless, there are clear obstacles that these masculinities pose to depression help-seeking. When I wanted to die, I never sought out help, and I struggled to acknowledge my emotions. I might die, but I refused to compromise who I expected myself to be.

Gendering Men Out

Assumptions about traditional gender roles are critical barriers to diagnosing men with depression. Participants in studies conducted before major depressive disorder (MDD) was included in the Diagnostic and Statistical Manual of Mental Disorders in 1980 were predominantly female.⁸ The idea that depression afflicted women more frequently than men predated MDD’s canonization, and it persists to this day. An article published by the American College of Physicians includes a 1-page summary informing patients: “You may be at risk for depression if you … are female.”⁹ This is a powerful message to men—you are not depressed—and to clinicians, who might not as readily consider depression a source of suffering in male patients.¹⁰ Stigma against depression exists for everyone, and traditional Western masculinities (eg, toughness and stoicism) can make it even more difficult to acknowledge and express feelings.¹¹ Men who most strongly subscribe to these traditional masculinities are particularly liable to suffer from depression,¹² but they are the least likely to seek help for their symptoms.^13,14

Recommendations

With the COVID-19 pandemic, most people are more isolated than ever from their social support networks. Unemployment and poverty worsen uncertainty about the future. But the pandemic has also created opportunities. Expanded telehealth and the availability of virtual mental health resources could increase the accessibility of services to help men with depression.

Furthermore, the collaborative care model is an evidence-based way to cut costs and minimize barriers to mental health care.⁹ Appreciating the social and historical contingency of the assumption that women experience depression more often than men, clinicians, researchers, and medical institutions should revisit female sex as a risk factor for depression. More research into expanding MDD’s diagnostic criteria to include “male-typical” depressive symptoms should be conducted. Clinicians should consider the demands that gender makes on all of us, as well as its influence on patient-clinician relationships.¹⁵ Introducing these changes will make it easier for those of us who have grappled with depression to speak and be heard.