Depression in Men

Original Editor - Matt Huey

Top Contributors - Matt Huey, Ahmed M Diab, Lucinda hampton, Rachael Lowe and Rucha Gadgil  

Introduction

Male depression

Depression is in the top ten burdens of disability worldwide and the leading cause for nonfatal disorders . The rate of depression in women is twice as high as in men. It is believed, however, that this may not be accurate. It is believed that men are more likely to "mask" their depression and not seek treatment leading to underreports of the diagnosis. This underreporting may be due to the difference in presentation compared to men and women. In the physical therapy setting, men could have an underlying depression due to a life event that is affecting their reports of pain and functional status.

Difference in Presentation

Aggression

Men often do not present with the textbook signs and symptoms of depression, which include sadness, anxiety, feeling of hopelessness, or loss of interest in hobbies or activities that the person once enjoyed. A man's presentation of depression early on may present with the following symptoms:

• Irritability
• Anger
• Hostility
• Abusive Behaviours
• Substance Abuse
• Escaping Behaviour

Men do not often seek out medical help for their feelings of depression and if they do see a medial professional, will not discuss their emotions. They instead will "act out" to cover up their feelings. These actions may be to numb or distract themselves to the underlying problem or feelings. Common examples are men putting in more work at their job or abusing alcohol or even extramarital affairs.

Triggers of Depression in Men

The trigger for these behaviors could be in the societal gender norms that men have in themselves. Young boys are often prohibited from showing emotions such as sadness or helplessness. They are taught to be independent and in control of their life.

Major life events can occur that cause men to become conflicted with their inward feelings versus the expected outward appearance.

• Physical illness
• Loss of a partner or paternal bond
• Loss of status and/or prestige with employment
• Financial problems

Events such as these can challenge a man's ideal view of masculinity. Men can believe that they are now weak, a failure or undesirable. For example, a man may experience depression from a injury which causes him to not be able to work therefore cannot provide himself or family financial stability.

Screening

The PHQ-9 (Patient Health Questionnaire-9) is a brief, self-administered tool used to screen for and measure the severity of depression. It is based on the diagnostic criteria for major depressive disorder from the DSM-IV. The PHQ-9 is widely used in clinical settings to help healthcare providers identify patients who may be suffering from depression and to monitor their response to treatment.

Score Range	Depression Severity	Recommended Clinical Action
0 – 4	None-minimal	Watchful waiting; repeat the PHQ-9 at a later follow-up appointment.
5 – 9	Mild	Watchful waiting with a repeat PHQ-9 at follow-up. Consider counseling or other support.
10 – 14	Moderate	Treatment plan should be considered, which may include counseling, pharmacotherapy , or a combination of both.
15 – 19	Moderately Severe	Active treatment is recommended, typically involving a combination of pharmacotherapy and/or psychotherapy.
20 – 27	Severe	Immediate initiation of active treatment with medication and, if there is severe impairment, an expedited referral to a mental health specialist.

Effects of Untreated Depression

As stated before, men do not want to be viewed as weak or undesirable. They will ignore their internal feelings and avoid discussing their feelings with friends, family members, or physicians. Men will feel they need to rely upon themselves to overcome their feelings. If left untreated men can develop alcohol dependency and commit suicide. In the adolescent and young adult population, there is a clear paradox: females are 3–9 times more likely to attempt suicide, but males are 2–4 times more likely to die by suicide.

Erectile Dysfunction

Impotence or erectile dysfunction can be a trigger of depression in men, and unfortunately it can also be a side effect of many antidepressant medications. Research has established several key relationships between depression and erectile dysfunction:

• Men with sexual function problems are almost twice as likely to be depressed as those without.
• Depression increases the risk of erectile dysfunction.
• Many men are reluctant to acknowledge sexual problems, thinking it’s a reflection on their manhood rather than a treatable problem caused by depression.

Effects of Depression on Physical Therapy Outcomes

It has been found that patients do present to physical therapy with significant depression symptoms. It has been found that depression significantly affects reports of pain intensity and functional ability. Men presenting to physical therapy after experiencing a major life event which loss of masculine ideals have occurred should be addressed.

How Therapists can Help

Physical therapists and physical therapist assistants are positioned to be a useful resource in identifying early depression symptoms and directing patients to appropriate care. There are some steps that can be taken to help patients identified as possibly having depression.

• Do not ignore the symptoms. Men will deal with symptoms much longer before reaching out for help if they reach out at all.
• Do not directly ask if they are depressed. Men view depression as an issue women deal with so may brush off the symptoms.
• There are screening tools available to utilise. In one study the 2-item screening test taken from the Primary Care Evaluation of Mental Disorders Procedure (PRIME-MD) was found to be better at identifying patients' with depression.
• Assist in directing patients to appropriate mental health professionals.