Depression: The Secret Men Won’t Admit

Sadness isn’t macho — this Eric Weaver knew. When depression engulfed the Rochester, New York, police sergeant, it took a different guise: anger.
To the former SWAT team leader and competitive bodybuilder, it was manly, and easy, to be mad.

The father of three, then in his early 30s, stewed in a near-constant state of anger. “One minute I’d be okay and the next minute I’d be screaming at my kids and punching the wall,” he recalls. “My kids would ask, ‘What’s wrong with Daddy? Why’s he so mad all the time?’ I probably heard that 1,000 times.” For years, Weaver didn’t know what was wrong. “I just thought I was a jerk.” The possibility that he was depressed never occurred to him until the angry facade began to crumble, leaving him with no feelings except utter despair. The tears finally came one night when he admitted to his wife the painful truth: “I’ve thought about committing suicide every day.”

Weaver’s confusion about what afflicted him was not unusual. Roughly a third of the 18 million or more Americans who suffer depression each year are men. Yet all too often, experts say, men fail to recognize the symptoms and get the treatment they need. “Men don’t find it easy to ask for help,” says Thomas Insel, MD, director of the National Institute of Mental Health (NIMH). “That’s a gene that must be on the Y chromosome.” In an effort to redress that masculine blind spot, in 2003 NIMH launched an educational campaign featuring real men talking about their experiences with depression. Their stories were markedly different from women’s.

For years, experts suspected that gender makes a big difference in depression. Studies from New York to New Zealand have repeatedly found the same startling statistic: About twice as many women as men suffer from depression. That finding was considered one of the bedrock facts of modern mental health. Yet it has recently come under attack from critics who, concerned about under-reporting of male depression, are raising the heretical question: Do men actually experience it as much as women do?

The Depression Gender Gap
Harvard psychologist William Pollack, PhD, is leading the charge against the well-entrenched depression gender gap. Director of the Center for Men at McLean Hospital, Pollack argues that men’s rate of depression may be nearly equal to women’s. Just look at suicide rates, he says: Male suicides outnumber females four to one. That ratio “is way too high to say that men’s depression numbers are so low,” he notes.

Pollack and others contend that male depression goes unrecognized because, unlike the female version, it often doesn’t fit the textbook signs — at least in the early stages, when it’s easiest to intervene. A full-bore clinical depression looks much the same in both sexes. But in the prelude to a breakdown, that deepening despair is often expressed in very different ways. Unlike women, “men don’t come in talking about feeling sad or depressed per se,” says Sam Cochran, PhD, a psychologist at the University of Iowa and co-author of Deepening Psychotherapy With Men. “They come in complaining about problems at work or their performance on the job.” Instead of being weepy, men are more apt to be irritable and angry — moods that aren’t included in the classic diagnostic tests. “Their sadness and helplessness are hidden behind a mask of anger,” says Pollack. Often, unfortunately, neither doctors nor men themselves recognize that as a red flag.

“Men tend to act out” to avoid dealing with uncomfortable feelings, adds Fredric Rabinowitz, PhD, Cochran’s co-author and a psychologist at the University of Redlands in California who works primarily with men. If they feel bad, they’re apt to get into fights on the job or at home, withdraw from family and friends, become obsessed with work or hobbies. Most significantly, men often turn to drinking or drugs.

That’s how Jimmy Brown knew he was in trouble. The New York City firefighter survived the collapse of the World Trade Center. He managed to dig himself out and miraculously suffered no serious physical injuries. But the psychological trauma lingered, and he began drinking, even at work, though he knew it could cost him his job. During breaks, he’d sneak back to his car for a beer. One beer a day turned into two, then three, and then a six-pack. “You’d have all these beers and still not be calmed down,” he recalls. Luckily, Brown had worked as a peer counselor with the police department and was able to see that he needed help. He went on “light duty” and began therapy.

“Many men turn to substance abuse as a way to ward off depression,” says Pollack. Men have two to four times the rate of substance-abuse problems as women, and Pollack contends that if this was recognized as a sign of depression, the gender gap would substantially narrow.

That’s what some researchers have found when they’ve taken alcohol out of the equation. In studies of two communities that prohibit alcohol or have very low rates of use — the Amish and Orthodox Jews — researchers have found that male and female rates of depression were the same.

But not all the evidence supports Pollack’s argument. Most experts are convinced that women’s higher rate of depression is not just a statistical illusion, but that it reflects real differences between the sexes. “I suspect that when you control for all the varying aspects of how the illness presents,” says NIMH’s Dr. Insel, “it will still be more common in women than men.”

An emerging body of research is also pointing to biological differences that may underlie the depression disparity. Female hormones, many researchers believe, likely play a central role, starting in adolescence. In studying girls between the ages of 9 and 15, Duke University psychiatrist Adrian Angold, MD, found that the greatest risk factor for depression was whether a girl had crossed the threshold to maturity, hormonally speaking.

Mood manipulators and DNA

“Just going from childhood levels of estrogen and testosterone to adult levels placed girls in a higher risk group,” Dr. Angold says. “This is likely to be a direct effect of those hormones on the brain.” Though it’s far from clear how estrogen or testosterone affect mood, he suspects the hormones may switch on genes that carry a predisposition toward depression. Hormone changes at puberty, however, do not appear to increase depression in boys.

Estrogen also enhances the actions of some of the brain’s chemical messengers that help regulate mood, such as serotonin. And there is intriguing evidence that women are most vulnerable to depression when estrogen levels are most in flux, such as postpartum or at menopause.

Sherri Walton of Paradise Valley, Arizona, hit an all-time low after the birth of her first daughter. “I used to stand in the shower and just sob because I had all this overwhelming fear and emotion that I did not know what to do with.” And when she reached her 40s and entered perimenopause, she says, “My symptoms went off the chart.” It took antidepressants and therapy to restore her sense of joy. Celebrities like Marie Osmond and Brooke Shields have gone on record about their own battles with postpartum depression.

Men don’t experience those dramatic hormonal ebbs and flows. Around age 30, testosterone levels undergo a long, slow decline. And it’s unclear whether dropping testosterone levels affect men’s moods. Studies have found conflicting results.

Sex hormones aren’t the only mood manipulators, however. The hormones that regulate our response to stress also get in on the act, and once again there’s early evidence that they operate differently in men and women. UCLA psychiatrist Robert Rubin, MD, compared how depressed men and women responded to a drug that stimulates stress hormones. The depressed women were more sensitive to stress chemicals than the men. Normally, young men have greater stress responses than women, but the depressed men had the least response of all. Though the findings need to be replicated, Dr. Rubin says they could help explain the greater incidence of depression in women: Some women may be predisposed to react to stress more acutely, making it tougher for them to shake off the problems and crises life brings.

Another key factor is the DNA you inherit. Depression often runs in families, as do conditions such as anxiety disorders (which occur more in women), and alcoholism (which affects more men). Researchers have studied twins from families with a history of depression in an effort to understand those genetic influences. The studies suggest that genes have a big say not only in your risk for depression, but also in whether that risk depends on your gender.

The most dramatic evidence comes from a study of 2,662 fraternal and identical twins conducted by psychiatrist Laura Bierut, MD, of Washington University in St. Louis. She found that female twins whose relatives had major depression were more likely to develop it than male twins. According to her analysis, genes accounted for 36 to 44 percent of the depression suffered by the female twins, but 24 percent or less of that suffered by the males. Individual life experiences also had a big impact on both sexes’ susceptibility. “Environment,” Dr. Bierut concludes, “seems to be playing a greater role in men’s depression than in women’s.” But it is still unknown why.

Other researchers suspect that not all the same genes affect male and female depression. While there’s substantial overlap, says Kenneth Kendler, MD, a psychiatrist at Virginia Commonwealth University, there also “are genes that appear to act specifically in men but not women, and in women but not men.” A number of researchers are now on the hunt for those genes.

Whether or not it turns out that men suffer more than the statistics show, there’s no question many men are depressed. And just like women, all the experts agree, the longer they go without getting help, the stronger the negative impact on their lives.

Luckily, treatments are largely gender-blind. Though the older tricyclic drugs, like amitriptyline and imipramine, are slightly less effective in women than men, there’s no such problem with the newer antidepressants like Prozac and its ilk. Most studies show that the many types of psychotherapy available can be equally beneficial for men and women.

Eric Weaver ultimately managed to put his illness behind him, but only after repeated hospitalizations, dozens of medications and, finally, an embrace of religion. Now retired from the police department, he is assistant pastor at his church. “I’m not saying I don’t have bad days every once in a while,” he says. “But now I can recognize it and deal with it.”