Harvard Mental Health Letter

Recognizing depression in men

Physical complaints, substance abuse, and other stealth symptoms may mask the problem.

In many respects, men fare worse than women when it comes to health problems. Men are more likely to have heart attacks than women, for example, and more likely to die of cancer. But men are only half as likely as women to develop one of the most disabling disorders worldwide — major depression. Men are also less likely than women to develop dysthymia (chronic mild to moderate depression) and may be less likely to experience bipolar depression (even though the rate of bipolar disorder is the same in both genders).

It is unclear what underlies this gender difference. The leading theory is that some combination of genes, hormones, and environmental stress contributes to it.

Still, although men are less likely than women to develop depression, it remains a significant mental health problem for them. About 10% to 17% of men will develop major depression at some point in their lives. Moreover, depression may be more deadly for men than for women. Depression is a key risk factor for suicide, and four times as many men compared with women die from suicide. One reason may be men's reluctance to convey their feelings and seek help when they are in despair.

Another mortal concern for men with depression is cardiovascular disease. Depression is a well-known risk factor for coronary artery disease, heart attack, and stroke. Men are especially vulnerable because they develop these diseases at a higher rate and at an earlier age than women.

Given the toll depression takes on men, it's important that those who need help receive it. But often the symptoms of depression are different in men than in women — partly because of cultural pressures for members of each gender to behave in certain ways — a factor that may contribute to missed diagnoses.

Stealth symptoms

An analysis of the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study, one of the largest investigations of depression in "real world" settings, found that while men and women shared some symptoms of major depression (such as low mood), the overall pattern of symptoms varied by gender. Women were more likely to gain weight when depressed; men were more likely to lose weight. Women reported symptoms overlapping with anxiety disorders; men reported symptoms more typical of obsessive-compulsive disorder. Women felt less energetic; men became agitated. Men were also more likely than women to develop alcohol or substance abuse in conjunction with major depression.

Other research has found that because of cultural pressure to act "manly," men may feel that it is weak to show despair or self-doubt. As a result, symptoms of depression may masquerade as anger or irritability. Research by the National Institute of Mental Health revealed that many men were not aware that physical problems such as headaches, stomach problems, and chronic pain might be symptoms of depression.

Men also may be reluctant to admit to depression because they are worried about how their boss, co-workers, or neighbors will react. Because of these concerns, when men develop depression they may actually work longer hours or engage in more volunteer activities — all in an effort to avoid confronting or revealing symptoms of depression.

Possible protective factors

The research suggests that several factors help buffer men against depression. Men — and women — who integrate these protective strategies into their lives may improve their odds of avoiding this mood disorder.

Physical activity. Men engage in more moderate to intense physical activity on a regular basis than do women. It's not clear whether this is because men are more likely to be employed in occupations that involve activity (such as construction work) or whether they are more likely to exercise for recreation. No matter how men get this exercise, the research suggests it has a positive impact on their mental health.

Psychology. Men are less likely than women to ruminate over past events, are more likely to feel in control of their lives, and more likely to feel positive about themselves and their situation. Men with these psychological traits may have a mental buffer against depression.

Getting help

The most important thing others can do for a man who shows signs of depression is to help him contact a primary care physician or mental health professional. Taking that first step is often the hardest. If necessary, accompany him to an appointment.

Clinicians can routinely screen adults for depression by asking two standard questions:

  • Over the past two weeks, have you felt depressed or hopeless?

  • In the same period, have you felt little interest or pleasure in your usual activities?

Screening can be especially important for men because they are less likely than women to bring up the subject of depression themselves. Just keep in mind that men may have other symptoms as well, and it may be worth asking about them (see "Symptoms of major depression").

Symptoms of major depression

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) describes symptoms of major depression, but some are more common in men.

Classic symptoms (in men and women)

Symptoms men are more likely to experience than women

  • Depressed mood, feeling sad or empty

  • Less interest in or pleasure from daily activities

  • Significant weight loss or gain, or appetite changes

  • Insomnia or excessive sleepiness

  • Physical agitation or lethargy

  • Fatigue and lack of energy

  • Feeling worthless or excessively guilty

  • Inability to think or concentrate

  • Recurring thoughts of death or suicide

  • Irritability

  • Loss of interest in work or hobbies

  • Sleep problems

  • Physical problems such as headaches, digestive disorders, and chronic pain

  • Alcohol or substance abuse to self-medicate for depression

  • Changes in behavior, such as becoming abusive, controlling, or violent

  • Taking physical risks, such as aggressive driving or unsafe sex

Treatment is the same for men and women — talking with a clinician about problems, taking an antidepressant for symptoms, or both. If symptoms of depression are mild or moderate, it is often reasonable to start with either medication or psychotherapy alone. Generally, if symptoms are more severe, it is more important to consider medication earlier in treatment.

Improvement takes time. Although some patients experience symptom relief within one or two weeks after beginning a medication, for example, more often it takes from four to eight weeks for antidepressants to take effect.

Selective serotonin reuptake inhibitors (SSRIs) are the medications most often prescribed for depression. Although in general, the side effects of SSRIs may be quite manageable, one drawback is that they frequently dampen sexual response, delay orgasm, or lead to erectile dysfunction. These side effects may subside in time on their own. It's also possible that lowering the dose of a medication may help.

Switching to a new drug may also make sense. Mirtazapine (Remeron) and some older antidepressants — tricyclic antidepressants and monoamine oxidase inhibitors — are less likely to cause sexual side effects than SSRIs.

If erectile dysfunction remains a problem, men may obtain relief with an erection drug such as sildenafil (Viagra), tadalafil (Cialis), or vardenafil (Levitra). Another option is adding bupropion (Wellbutrin) to an SSRI, as this medication sometimes counters SSRI-induced sexual dysfunction, boosts sexual drive and arousal, and increases the intensity or duration of an orgasm. Another drug, buspirone (BuSpar), can restore the ability to have an orgasm and increase libido.

Sticking with treatment

Following a treatment plan can be a challenge, not only because medications can cause side effects and psychotherapy takes time — but because of stigma. Men with depression may feel at times as though they are all alone in their struggle. Support groups may be of help in this regard. (To find more information about support groups, contact the National Alliance on Mental Illness at www.nami.org, or the Depression and Bipolar Support Alliance at www.dbsalliance.org.)

And if a first depression treatment doesn't provide sufficient help for a man, it's important to explore alternatives. Perseverance, a trait that many men are proud to embrace, may be the most important characteristic when it comes to finding relief.

Leach LS, et al. "Gender Differences in Depression and Anxiety Across the Adult Lifespan: The Role of Psychosocial Mediators," Social Psychiatry and Psychiatric Epidemiology (Dec. 2008): Vol. 43, No. 12, pp. 983–98.

Lehti AH, et al. "The Western Gaze — An Analysis of Medical Research Publications Concerning the Expressions of Depression, Focusing on Ethnicity and Gender," Health Care for Women International (Feb. 2010): Vol. 31, No. 2, pp. 100–12.

Liu RT, et al. "Stress Generation in Depression: A Systematic Review of the Empirical Literature and Recommendations for Future Study," Clinical Psychology Review (July 2010): Vol. 30, No. 5, pp. 582–93.

Marcus SM, et al. "Gender Differences in Depression: Findings from the STAR*D Study," Journal of Affective Disorders (Aug. 2005): Vol. 87, No. 2–3, pp. 141–50.

Miller M, editor. Understanding Depression (Harvard Medical School, 2011).

National Institute of Mental Health. Men and Depression (2005).

Pitychoutis PM, et al. "Of Depression and Immunity: Does Sex Matter?" International Journal of Neuropsychopharmacology (June 2010): Vol. 13, No. 5, pp. 675–89.

Surveillance Epidemiology and End Results (SEER). "SEER Stat Fact Sheets: Cancer," 2011.

For more references, please see www.health.harvard.edu/mentalextra.