- (2011) Volume 5, Issue 3
PhD, MSc, RN, Sismanoglio General Hospital, Athens, Department of Psychiatry
Background: Men’s experience of depression has not been as well understood as women’s experience of depression. Men are more likely to suffer in silence. It appears that what men “feel” is likely to be kept in for longer while women act upon their symptoms more readily as the symptoms arise. Purpose: To present the current research findings on depression and gender, with a focus on the factors that account for gender differences in rates of depression among women and men, and emphasis on the relationship between the male gender role and men’s experience of depression and coping with the symptoms. Method and Material: A critical review of this body of literature was carried out. Evidence was collected through Medline database. Results: Although depression is often traditionally thought of as a woman’s illness, there is growing evidence to suggest that men may not be adequately counted in studies examining rates of depression, that men are equally vulnerable to depression, and that depression in men is a serious and, if untreated, potentially fatal condition. This phenomenon is better supported by several explanations, namely, the gender bias explanation, and the gender role socialisation explanation. Conclusions: Depression predicted as the second leading cause of global disability burden by 2020 may well be underestimated if the direct and indirect effects of depression in men are not taken into account. Understanding depression in both men and women and help-seeking behaviours across genders is important because there are implications of the findings in the context of primary care in order to detect and cope with depressive symptoms in men.
Keywords
gender role, depression, socialization, help-seeking
Introduction
Mental health is gendered. One of the most consistent findings in the study of mental health is that women have higher rates of depression and psychological treatment than men do [1]. The association between gender and mental health therefore has become a prominent topic not only in sociology but also in the fields of psychology, epidemiology, and public health.
Depression is a serious illness that negatively affects how people feel, think, and act. Depression is very common. Currently, depression is the fourth most common cause of disability worldwide. It is estimated that by the year 2020, depression will be the second most common cause of disability in the developed world, and the number one cause in the developing world [2,3].
Coping with depression and underutilization of mental health services
Coping, which is defined as the sum of behavioural and cognitive efforts that a person uses to adjust to a stressful event or condition, consistently and through different research studies, has been found to mediate people’s adjustment in stressful situations. Some people may unfortunately view depression as weakness or laziness. For mental health professionals this is not the case; they regard depression as a real and common illness, like heart disease, diabetes, or arthritis [4]. To them, like any disease or illness, it has symptoms, types and causes.
A depressive illness involves feeling sad intensely and for a long time. Such feelings are severe enough to interfere with people’s daily lives, and persist for weeks or months rather than days. Depression causes a huge amount of suffering. It is a major reason for people taking time off work, causes great problems in peoples' home lives, and can lead to death from suicide or from self-neglect [5].
Fortunately, depression is very treatable. The majority (80-90%) of people who receive treatment and counselling experience significant improvement, and almost all individuals derive some benefit from seeking professional help [2]. There are three avenues: medication, such as antidepressants, psychological therapies or social treatments.
Unfortunately, people may not recognise their symptoms as signs of depressive illness, or they may fear the reactions of co-workers, friends, and family to their diagnosis, due to social stigma about mental illness. Consequently, millions of people with depression do not seek help or support, and unnecessarily experience problems at their jobs or in their relationships [6]. It has been claimed that entire countries are facing a loss in productivity because of depression [7]. People’s ignorance about depression, its causes and symptoms, and the available therapies or help is at its peak when depression strikes men.
There is growing evidence to suggest that men are equally vulnerable to depression for the same reasons that make women depressed, but they remain unidentified, undiagnosed, and untreated. The findings have consistently shown that, as a group, men are on average, less willing than women to seek professional help for psychological problems [6], and they are more reluctant to seek help in the case of depression, even casually from friends. Furthermore, large numbers of men, more than women, suffer from problems closely related to depression, such as alcohol and drug abuse [8], and the suicide rates in men continue to be alarmingly high [6].
Gender differences in depression
When it comes to health, it matters whether you are a woman or a man. Research shows that both sex (biologically based differences) and gender (the socially constructed roles ascribed to men and women) have a profound impact on determining health status. “Gender can determine different exposures to certain risks, different treatment seeking patterns, or differential impacts of social and economic determinants of health” [9].
Explanation of the Differences in Rates of Depression between Women and Men
While depression is historically thought of as an illness that mainly affects women, and the rates of mental disorders from hospital and outpatient census figures [2,4] have tended to support this viewpoint, and the belief that men, in contrast to women, are protected from depression [10], there is growing evidence to suggest that men may not be adequately counted in studies examining rates of depression, that men are equally vulnerable to depression for the same reasons that make women depressed, and that depression in men is a serious and, if untreated, potentially fatal condition [6].
The growing evidence that men may not be adequately counted in studies examining rates of depression is better supported by several explanations, namely, the gender bias explanation, and the gender role socialisation explanation.
The Gender Bias Explanation for the Difference in Rates of Depression between Women and Men
According to various researchers [11,4] gender bias occurs in the treatment of psychological disorders.
The Difference in Referral between Men and Women : Women are more likely to be diagnosed with depression because they are more likely than depressed men to be referred and admitted to hospital. According to many researchers [4,12] women being referred more than men could be related to the cultural construction of woman as having greater biological vulnerability to psychological disorders (i.e. hysteria). In addition according to Terrence Real [8] women are more likely to be diagnosed with depression than men because many medical doctors and mental health professionals, as well as family members and friends, may find it easier to diagnose women with depression more than men because of the fear of the stigma and shame surrounding depression for men, a disorder which is regarded as an emotional and not a manly illness.
The Difference in Seeking Help Attitudes between Men and Women : Another gender bias appears because women are more likely than men to admit to having mental health problems and thus they are more likely to seek professional help [4]. There is a large and consistent body of experimental research which supports the common belief that men of different ages, ethnicities and social backgrounds are on average, less willing than women to seek professional help for depression, or for other problems either closely related to depression, such as substance abuse and stress or not related to depression, like physical disabilities [13,14]. Other studies have found that men, in comparison to women, rarely use mental health services [6]. Thus, assessing gender differences in depression by looking at those who receive treatment is not an appropriate way for determining whether there is a true gender difference [11].
Men’s hidden depression: the difference in manifestation of depression between men and women : A further gender bias explanation is that many of the depression symptom measures include items that reflect depression responses that are more likely to be experienced by women, such as crying, change of appetite or weight, than by men [15]. Men tend to manifest depression differently from women via problems such as suicide [6] alcohol and drug abuse [8].
Suicide : Suicide is a significant mortality risk factor for men of all ages and races. Men are around 3 to 4 times more likely to kill themselves than women in all age categories. The mortality rate for men by suicide is four times the rate of women but women are hospitalized for attempted suicide at 1.5 times the rate of men [16]. However, the report noticed that in some countries the ratios of committing suicide could be even higher than 3 to 4 times, for example in Finland the ratio of male-female death by suicide is 10:1 while in Ireland the ratio is 11:1. Reports from the United States and United Kingdom show that suicide rates for men vary in range from 20 to 25 per 100,000 for males between 18 and 35, to as high as 30 to 70 per 100,000 for men over age 65. Research shows that 2 out of 3 people who kill themselves have seen their GP in the previous 4 weeks and nearly 1 in every 2 would have done so in the week before they kill themselves. Moreover, about 2 out of 3 people who kill themselves would have talked about it to friends or family. An Australian study found that on average, for every completed male suicide there are five attempts, while for every completed female suicide there are 35 attempts [17-19].
Different Addictive Behaviours : Apart from the above lethal way of coping with depression, depressed men, far more than women, may try to make themselves feel better by relying on avoidance as a coping strategy, which may include distraction, denial, social diversion, behavioural disengagement, alcohol or drug use [20,15], as well as compulsive actions, such as gambling, spending, sex or even excessive exercising [8].
Any person can turn to mood-altering behaviours such as drinking, gambling, watching television, drugs or other activities, but while non-depressed people usually use alcohol, drugs, television for fun, relaxation and to enhance an already adequate sense of self esteem, depressed men rely on such stimulants to gain relief from distress and to rectify an inadequate self esteem. This is dangerous and will usually make things worse in the long run [8]. According to addiction experts any form of defence used in depression, whether addiction to substances (alcohol and drugs), persons (known as erotomania) or activities (gambling, violence, stalking, workaholism) will temporarily alleviate, but at the same time can exacerbate depression and simultaneously each form of addiction will bring with it more problems.
Substance addiction is considered to be one of the major forms of problems closely related to depression, and it affects far more men than women. In matters of violence, men are known to be more violent than women. For Real [8], the addiction to violence is the most plain and direct form of elevating intoxication, because the man acts as a superior by torturing and domineering others.
Masculine Gender Role Socialization and the manifestation of depression in men
Historically, clinicians as well as scientists have believed that men, in contrast to women, are protected from depression and the rates of mental disorders from relevant studies [2,4] have tended to support this viewpoint. Men are thought to hide or “mask” their feelings of depression and not to seek professional help [6].
Some men are particularly affected by culturally prescribed gender-role concerns. Many scholars [21,22] have hypothesised that men may experience a loss of psychological well-being trying to achieve the masculine goals related to the restrictive nature of gender role socialisation. Research shows that traditional gender roles for men have both positive and negative effects on their psychological well being [23]. Those studies examining the relationship between gender role conflict and psychological well being had shown that adherence to the traditional male role has been linked to poorer psychological health. Gender role conflict was positively correlated with higher levels of depression and anxiety, low self-esteem, and low capacity for intimacy [24].
Gender role socialisation paradigms begin with the assumption that men and women learn stereotyped gender attitudes and behaviours from cultural values, norms, and ideologies about what it means to be men and women. For example, traditional gender role stereotypes portray men as strong, self-reliant, stoic, aggressive, physically tough, and having control of their emotions [25]. Furthermore compared with women, men tend to be far more concerned with being competitive, powerful and successful [26]. O'Neil et al. [27] have defined this strain as gender-role conflict and noted that the fear of the feminine is a guiding force for adult men concerning what is appropriate gender-role behaviour, and it is also a harsh part of the perpetually restrictive gender-role socialisation process for boys and young men. Men reject those gender-specific behaviours considered traditionally as feminine. This includes, but is not limited to, emotional intimacy, vulnerability, and emotional dependency.
To research the effect of gender role and gender role conflict on mental health, O'Neil and colleagues developed the gender role conflict scale (GRCS) and proposed that four factors underlie gender role conflicts: (1) success, power, and competition; (2) restrictive emotionality; (3) restricted affection between men; and (4) conflict between work and family [27]. Studies have found that gender role conflict in men is negatively related to mental health [23,27]. Men high on gender role conflict were found to be less likely to seek psychological help [28]. Such men also reported higher anxiety and decreased social intimacy. Good and Wood [29] found that all four subscales of the Gender Role Conflict Scale [27] were related to the level of depression in college men. The highest correlations with level of depression were reported for conflict between work and family and restrictive emotionality. In addition, Shepard [30] found that three of four gender role conflict subscales (1-success, power, and competition; 2- restrictive emotionality; and 3- restricted affection between men) were associated with depressive symptom patterns, with restrictive emotionality being associated with all three symptom patterns. Both of these investigations confirm a relationship between conflict related to masculine gender role and depression in men.
As Addis and Mahalik [31] noticed “there is little doubt that traditional helping services are underutilized by many men experiencing a wide range of problems in living. It is also likely that a variety of masculinity ideologies, norms, and gender roles play a part in discouraging men’s help seeking for depression....Men’s difficulty with accessing health services may be attributed to a mismatch between available services and traditional masculine gender-roles emphasising self-reliance, emotional restrictiveness, and power” [31]. Many studies called attention to the importance of providing an explanation for the differences between men and women in help-seeking patterns, and why men as a group should be less likely to seek help and to cope with their depression on their own. Brooks and Good [32] emphasised the necessity to treat men as a unique culture to be understood in relation to depression and seeking help.
Conclusion
In conclusion, as was outlined studies have consistently found that men of different ages, ethnicities, and social backgrounds are, on average, less willing than women to seek professional help for physical and mental health problems, particularly depression, and thus many men who are depressed remain unidentified, undiagnosed, and untreated. As suicide rates in men continue to rise and large numbers of men suffer from problems closely related to depression, such as alcohol and drug use, it is clear that depression is a matter of serious concern for men. Increased attention is needed to ensure effective responses to this issue in policy, program, and service provision.
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