The Myth of Mental Illness and the Truth About Mental Health: A Man’s Journey to Freedom

Part 5 – Male vs. Female Depression

            This is the 5th of a 7-part series. You can check out Part 1Part 2, Part 3, and Part 4 if you’d like to read any you have missed. Having confronted my own fears about “mental illness” and worry that I would end up in a mental hospital like my father, I wanted to better understand mood disorders like depression and bipolar disorder. I also wanted to explore the differences between male depression and female depression.

When my wife and I had both been given the standard questionnaire to assess depression, she scored high indicating her symptoms were consistent with depression, but I scored low, indicating my symptoms were not. Yet both of us benefitted from treatment. I wanted to learn more about male and female differences.

            I decided to return to graduate school and found a unique program where I could earn a PhD in International Health and do my dissertation study comparing male and female depression. It took seven years to complete all my courses, conduct the research, write, and defend my dissertation. My study was then published as book, Male vs. Female Depression: Why Men Act Out and Women Act In.

My Personal and Professional Interest in Male Depression

The impetus for my study and subsequent book was both professional and personal. As a psychotherapist who has been working in the field of gender medicine and men’s health for more than forty years, I have been concerned with the high rate of suicide found in males.  Although studies indicate that women experience depression at nearly twice the rate of  men, the suicide rate in males is 3 to 15 times higher than the rates found in women, with rates increasing significantly as men age. 

            It seemed clear to me that too many depressed men were under-diagnosed and under-treated.  Too many men were dying because their depression wasn’t recognized by themselves, the people who loved them, or health-care professionals who were tasked to treat them. 

            More personally, I grew up in a family where my father suffered from depression.  He had become increasingly depressed when he couldn’t support his family in his chosen profession. In despair, he took an overdose of sleeping pills. Though he survived, he was committed to a state mental hospital. Our lives were never the same. I grew up wondering what happened to my father, how I could keep it from happening to me, and how I could help other families to prevent the pain and suffering that we went through.

The research leading to the publication of this book began with a few simple questions:

  • If the traditional questionnaires used to diagnose depression leave out questions that might indicate depression in males, could this contribute to men being under-diagnosed and under-treated?
  •  Do depressed men exhibit different symptoms than depressed women? 
  • Would a new questionnaire that was more sensitive to male depression help prevent suicide?

Men and Women Have Different Experiences With Depression

When I began my research, one of the most consistent findings in the social epidemiology of mental health is the gender gap in depression. Many studies indicate that depression is approximately twice as prevalent among women as it is among men and increases with age. One of the most consistent findings in the social epidemiology of mental health is the gender gap in depression. Many studies indicate that depression is approximately twice as prevalent among women as it is among men.

            J. Douglas Bremner, M.D. is Professor of Psychiatry and Radiology and Director Emory Clinical Neuroscience Research Unit (ECNRU) where he conducts research on stress-related illnesses.  In a very interesting experiment, he gathered a group of former depression patients.  With their permission, he gave them a beverage that was spiked with an amino acid that blocks the brain’s ability to absorb serotonin (anti-depressant drugs help increase the levels of serotonin in the brain).

            What I found fascinating were the gender specific differences in the way men and women reacted to the potion that blocked the effects of the serotonin.  Typical of the males was John, a middle-aged businessman who had fully recovered from a bout of depression thanks to a combination of psychotherapy and Prozac. Within minutes of drinking the brew, however,

“He wanted to escape to a bar across the street,”

recalls Bremner.

“He didn’t express sadness … he didn’t really express anything. He just wanted to go to Larry’s Lounge.” 

            Contrast John’s response with that of female subjects like Sue, a mother of two in her mid-thirties. After taking the cocktail,

“She began to cry and express her sadness over the loss of her father two years ago,”

recalls Bremner.

“She was overwhelmed by her emotions.”

A New Way of Assessing Depression in Men: The Diamond Male Depression Scale

The hypothesis of my study was that men were being underdiagnosed and undertreated because the depression scales that were commonly used did not include many of the symptoms, such as irritability and anger, that depressed men experience. The study findings are summarized as follows:

Background:  Based on his research on the Swedish island of Gotland in the 1980s, Wolfgang Rutz postulated a “male depressive syndrome” with atypical symptoms that differ from common depressive symptoms found in females.  Recent studies assessing the link between gender and depression symptoms using the Gotland scale have been contradictory.  

Aims:  To investigate whether a new scale (Diamond Male Depression Scale) including atypical symptoms of depression would be useful in distinguishing between depressed males and depressed females and to assess whether suicide risk is predicted by atypical symptoms of depression.  

Method: A total of 1072 individuals (323 females and 749 males) filled out the on-line questionnaire including questions assessing typical depression (Center for Epidemiologic Studies Depression Screen), atypical depression ( Diamond Male Depression Scale; Gotland Male Depression Scale) and suicide risk. 

Results: Three Factors from the Diamond Male Depression Scale–Emotional Acting-In, Emotional Acting-Out, and Physical Acting-Out–were identified.  Both depressed and non-depressed men scored significantly higher than depressed and non-depressed women on Factor 2, Emotional Acting-Out and Factor 3, Physical Acting-Out.  There was a significant relationship between suicide risk and Factor 1, Emotional Acting-In.

Conclusions:  The study adds credence to the concept of a “male depressive syndrome” with atypical symptoms that relate to depression and suicide risk. The three factor Diamond Male Depression Scale may be a useful tool for assessing depression and suicide risk. Further research is needed to validate the scale. 

The three subscales and the items in each are listed as follows: 

Sub-Scale 1: Emotional Acting-In Depression

This scale focused on feeling negative, stressed, empty, and other internal expressions of depression and included the following items from the full fifty-one-item questionnaire:

•          d28: I feel I’d like to get away from it all.

•          d34: I feel that things are stacked against me.

•          d35: People I count on disappoint me.

•          d36: I feel stressed out.

•          d40: I feel emotionally numb and closed down.

•          d41: I feel hopeless about the future.

•          d42: I feel powerless to improve things in my life.

•          d43: I feel my life has little worth or value.

•          d44: I have little interest or pleasure in doing things.

•          d45: I find I am complaining about things in my life.

•          d46: I feel sorry for myself.

•          d48: I feel burned out.

•          d49: I feel empty inside.

•          d50: I feel tired even when there is no reason to be so.

•          d51: I have difficulty making everyday decisions.

Sub-Scale 2: Emotional Acting-Out Depression

This scale focused on such things as being difficult, irritable, angry, and other external emotional expressions of depression and included the following items from the full fifty-one-item questionnaire:

•          d1: I flare up quickly.

•          d2: I have trouble controlling my temper.

•          d22: I am easily annoyed, become grumpy, or impatient.

•          d27: Other people “drive me up the wall.”

•          d29: When others disagree with me, I get very upset.

•          d37: It doesn’t take much to set me off.

•          d38: I have difficulty maintaining self-control.

Sub-Scale 3: Physical Acting-Out Depression

This scale focused on such things as violence, gambling, alcohol abuse, and other external, physical expressions of depression and included the following items from the full fifty-one-item questionnaire:

•          d4: I have hit someone when I was provoked.

•          d8: I work longer hours because going home is stressful.

•          d10: I gamble with money I have set aside for other things.

•          d11: I drive fast or recklessly as a way of letting off steam.

•          d12: If I’m feeling low, I’ll use sex as a pick-me-up.

•          d23: I have felt I should cut down on my drinking or drug use.

•          d30: I feel like picking a fight with someone.

•          d31: I get so jealous or possessive I feel like I could explode.

I use these scales when I see clients. The questions help us assess what areas are problematic and give us a better understanding of possible depression. I don’t use it as a formal way to diagnose people but a way to collaborate with each person by finding ways to help them solve problems that are causing them to feel the way they do.

A more recent study by Lisa A. Martin, PhD and colleagues at University of Michigan and Vanderbilt University published in the Journal of the American Medical Association (JAMA), lends credence to these earlier findings that men and women express depression through different symptoms.  Dr. Martin concluded,

“We know that men are less likely than women to seek treatment, even when they recognize that they are depressed. Incorporating these symptoms may not only identify depression in more men, it may lead to ways to entice more men to get help.” 

More research is needed, but it is clear that men and women experience depression differently, men are still under-diagnosed and under-treated, and we need an expanded understanding of mental health and the emotional wounding we all experience. I will discuss more in upcoming articles.

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