Signs of Depression That Are Often Missed in Men and How to Help

The newspaper article describes the death of a firefighter: He had fought wildfires for weeks in long, low-paying shifts away from home, worked through alcohol use and a recent separation from his wife and seen the aftermath of death and destruction. He completed his shift, drove to a high bridge — and jumped.

It was just one article, but it crystalizes how men cope with pain … until they can’t. Oftentimes, men may not appear distressed, may not be receptive to a diagnosis of depression, and may be reluctant to participate in therapy or take medication. The challenge of identifying warning signs and a lack of communication make male depression something of an invisible epidemic; according to a survey in 2016 by the National Institute of Mental Health, nearly 5 percent of men in the United States have major depression, but that may underestimate the actual numbers.

If someone has family members with histories of depression or substance use, they are at higher risk. Early history plays a role in other ways, too: A childhood with exposure to significant loss or trauma could mean higher risk, and a number of medical conditions and medications are also associated with higher risk.

Major depression involves at least two weeks of symptoms such as:

• changes in eating and sleeping patterns
• impaired focus and concentration
• reduced energy and motivation
• excessive guilt and self-blame
• irritability and negative mood
• suicidal thoughts

When major depression keeps coming back, it’s described as major depressive disorder.

The Problem Isn’t Always Obvious

There’s also “masked depression” — more typical in men — when instead of acknowledging depression, a sufferer displays numbed or detached emotions, physical complaints, behavioral problems, substance abuse, reduced productivity, and problems relating to other people.

They may think of depression as being sad, weepy, and weak, and not perceive themselves as being depressed; they’re more likely to feel flat, numb, detached, or “neutral.” Some are unable to describe or name feelings beyond a very superficial level, a condition known as alexithymia. Without a language to talk about variations in feeling states, they have few ways to understand their own internal state or describe it to others. In other cases, men may have learned to override feelings rather than respond to them, including many men in the military and first responder roles who have learned to suppress fear or panic.

Finally, for some men, there may be simply a sense that their happiness is unimportant, that they exist to perform a duty, not to seek fulfillment.

Depression In Men Often Presents As Physical Symptoms …

Exhaustion and fatigue are commonly named by men as the most significant feature of their depression, but sleep disorders, particularly insomnia, also occur, as well as stomach complaints, headaches, back pain, and muscle weakness. Depression also increases pain perception, resulting in chronic pain.

Physical problems also result from the effects of depression and poor self-care. Weight gain is a frequent problem as men consume more fast food, drink more alcohol, stop exercising, and watch more television.

In a recent study of suicides, many men saw a doctor for physical complaints in the six weeks before they killed themselves, but weren’t in therapy— and a clinician isn’t going to be able to do what a therapist can. There are significant challenges in treating men for depression, which relies on patients to initiate treatment and be a willing participant in it.

… or As Anger And Aggression

Anger can be expressed toward loved ones through criticism, blame, negative attitudes, suspicion, and chronic irritability, and a low tolerance for frustration can lead to road rage, angry outbursts, domestic violence, and assault. The irony of constricted feelings is that there is a tendency to seek release through big actions: Speed and power become intoxicating releasers and antidotes to pervasive feelings of helplessness and flatness.

Watch Out for Substance Abuse and Escapism …

Alcohol can be relaxing at first, reducing muscle pain, lowering inhibitions, and relieving anxiety. But as it is metabolized, alcohol levels in the blood drop, resulting in more anxiety, irritability, and depression — downsides that may not be apparent to many who drink to help manage emotional and physical pain. Alcohol is a particular risk factor for men who are depressed. Roughly 20 to 25 percent of men who are depressed abuse alcohol.

The recent rise in opiate-related overdoses has also been called “deaths of despair.” The escape from pain through self-medication and anesthesia never lasts long enough, and must be repeated again and again. Behavioral forms of escapism can also occur through workaholism, gambling, binge-watching television, sports, and pornography.

… Reduced Productivity and Endurance …

Men often measure their worth, competence, and effectiveness in terms of success at work and financial performance, and depression can worsen work performance. There are issues with poor concentration, impaired memory, and problems making decisions; absences can occur as a result of exhaustion and injury; and chronic pain may make it impossible to accomplish as much.

When men perceive themselves as less effective, they may simply work harder, which can be exhausting and cut back on recreation and relationships — both the result of depression and cause of deeper distress.

Similarly, since men are taught to value strength, endurance, and physical stamina, it can be hard to grapple with expectations of physical strength and endurance being challenged by depression and the natural aging process.

… and Relationship Problems

Relationships deteriorate as depressed men express irritation and frustration and tend to withdraw, becoming isolated instead of seeking help or support. The most significant impact is likely to be on their closest relationships.

Depression also causes sex drive to wane, and those problems deepen relationship problems. One estimate is that 75 percent of depressed patients experience low libido, which can be an unfortunate effect of many antidepressants.

The Risks Include Suicide

Masked or unacknowledged depression poses serious risks, especially considering that without intervention and treatment, episodes can last as long as two years.

The risk of suicide is also significantly higher for men, who tend to use more lethal methods than women, such as guns or hanging, and often do not communicate their intentions to others, meaning less opportunity for intervention.

White men are at the highest risk for suicide of any ethnic group. Veterans and first responders also have elevated suicide rates. Other risk factors include men who are unemployed, live alone, and use alcohol or other drugs to self-medicate physical or emotional pain.

How to Help: Begin by Gathering Information …

One of the most powerful motivators for men to get help is support and encouragement from trusted friends, partners, and family. Spend time with him and look for behavior that indicates depression. In a relaxed moment, ask open-ended questions about how he has been, and listen carefully. Indicate that you have been concerned about him and describe how his attitude and behavior appear to you. Use words such as “frustrated,” “unhappy,” “preoccupied,” “irritable,” “discouraged,” or “shut down.” Wait for a response.

… Exploring Ideas and Plans …

Ask what he thinks would help him feel better, and listen to his ideas. If he can identify a plan and set of goals, check back on progress for those goals within a few days. If there is no progress or no ability to define a plan, ask if you can offer some resources. Suggest a doctor’s visit and ask him to tell the doctor about your conversation. Ask if he has considered therapy to look for solutions. Tell him that feeling better is worth the time and cost, and that there is a real risk of feeling worse if he does nothing. Ask directly about feeling hopeless and suicidal. Listen carefully. Offer immediate options that might include the 24-hour suicide hotline number (1-800-273-TALK or 8255), or the option of 911.

… and Maintaining Regular Contact

Offer to spend time hiking or engaging in some other kind of physical activity, which has antidepressant benefits. Try to plan time together without alcohol, since it increases depression. Check back over time to see what has changed.

If You’re Depressed, Help Yourself

If you are recognizing your own symptoms of depression, take action now. If you have seen your role with others as provider and protector, think about extending some of that same attention to yourself.

Providing for yourself can mean exercising and sleeping regularly; eating a healthy diet; building in social and recreational time; and getting support from close and trusted partners, friends, and family.

Protecting yourself can include reducing pressure to act like everything is normal; postponing major life decisions until you feel better and clearer; breaking large tasks or projects into small, manageable goals; gauging whether you’re up to major commitments before making them; and avoiding alcohol and other street drugs.

Start Therapy

A tendency to be action-oriented challenges men in therapy, which can feel like so much sitting and talking rather than doing, and takes time to produce results — a tall order for an impatient man in pain. Also, men who are prescribed medication may dislike the early side effects and stop taking it before it can take effect. But once men are in therapy, they benefit like anyone else.

Getting professional treatment can include individual and group therapy, medication, and additional resources such as 12-step meetings. Since depression is recognized as a medical condition, many people find that a combination of medication and therapy works the fastest to change mood. But when it comes to depression, the most important aspect is time. Don’t wait until it’s too late.

If you or someone you know is suicidal or in emotional distress, contact the National Suicide Prevention Lifeline online or by calling (1-800-273-TALK or 8255), available 24 hours a day. If the situation is potentially life-threatening, get immediate emergency assistance by calling 911.

Carol Povenmire, Ph.D., is a licensed psychologist with a practice in Pasadena, California.