Men’s depression often passes unnoticed in healthcare
Depression is a major cause of sick leave and a growing threat to public health. Twice as many women as men are diagnosed, yet many researchers believe that men’s depression often passes through the healthcare system unnoticed. In addition, it is more difficult for men to ask for help.
‘Men do not call the doctor to the same as extent as women. Asking for help is often associated with weakness and is not compatible with the male gender role, as being a man generally implies that you are supposed to be strong and persistent,’ says Mats Hilte, Docent (Reader) in Social Work at Lund University.
He feels that the male norm is grossly simplified and that the view of masculinity should be problematised to a larger extent.
‘The discussion about men is largely focused on power and dominance, but many men have a sense of powerlessness, which is a sense that is hard to admit and formulate in words.’
Despite the fact that men are diagnosed with depression less often than women, their suicide rate is twice as high.
‘This supports the hypothesis that men tend to endure their depression in silence, until they simply cannot take it anymore. There are also studies that show that significantly fewer men than women who have attempted to commit suicide have been in contact with healthcare professionals,’ says Hilte.
And men in particular show links between depression and alcohol abuse.
‘The burden of disease for depression and alcohol addiction combined is about the same for women and men,’ says Anne Hammarström, district doctor and professor at Umeå University.
Studies also show that the gender differences in mental ill-health disappear when controlling for life conditions. When Hammarström compared unemployed women and men who were 21 years old, she did not find a difference in mental ill-health – they all feel equally bad.
Many diagnoses and treatments are based on research on men. However, the diagnosis for depression is an exception, as it is based on research on women with typical symptoms of depression.
‘If the research on depression had been done differently in the 1960s, then the diagnoses would have been broader today,’ says Hammarström.
She says that medical research is increasingly focusing on biomedical explanations – mainly sex hormones – to depression among Western women.
‘This may be due to commercial influences. If you can find hormonal or other biological mechanisms behind depression, then drug treatments might be a simple solution.’
Research on women in parts of the world where such commercial agendas are lacking instead tends to emphasise cultural factors and poverty.
Pressured to perform
Ulla Danielsson’s dissertation is titled Struck by lightning or slowly suffocating: gendered expressions of depression in a primary health care context. She is a district doctor, psychiatrist and researcher at Umeå University and has interviewed depressed patients in primary healthcare. The title of her dissertation refers to the gender-coded stories that the patients conveyed.
‘One thing that the adult patients shared was that they felt pressured to live up to high standards. The women talked a lot about shame and guilt, whereas the men talked more about physical symptoms such as chest pains and headaches.’
The stories told by the adolescents were influenced by the ideas of depression that are commonly portrayed in media. Girls thought of depression as a lonely, crying woman, while boys did not have any crying men to relate to. Rather, they tended to refer to male ideals such as those promoted by for example Rambo, Sylvester Stallone’s movie character.
‘Asking for help was a gigantic step to take for the boys, but once they showed up at the health centre it was like opening a floodgate – they had this incredible need to talk.’
There were many exceptions to the typical stories of men and women – women who talked about physical symptoms and men who perceived shame and guilt.
‘It’s important not to give in to stereotypes and reinforce gender differences, but instead encourage other ways to relate to gender-coded norms,’ says Danielsson.
She sees a tendency in healthcare to psychologise mainly women and girls and thus disregard the importance of gendered life conditions.
‘It may be helpful for girls in particular to know that everything is not their fault and that various conditions in society affect their situation.’
The need for a diagnosis was created in connection with the development of the first anti-depressants in the 1950s and 1960s. The depression diagnosis was introduced in the DSM, the U.S. classification system that is used across the world, in 1980. The diagnosis is based on a description of symptoms that the patient must have experienced for at least two weeks. Strictly applied, the estimated symptoms comprised the actual diagnosis, but today the need for a more general assessment is discussed.
‘It used to be that the internal and external causes of depression were addressed. If the patient was going through a tough time, it was common to refer to depression as a normal reaction. But today the talk about a cause-and-effect relationship is gone,’ says Arja Lehti, general practitioner and senior lecturer at Umeå University.
As part of her research she interviewed district doctors with extensive experience with depressed women and men of both Swedish and non-Swedish origin. She found that the doctors had problems using the symptom-based criteria.
‘The patients expressed their symptoms differently depending on not only gender but also social class and ethnicity The doctors therefore used the older criteria, which take the causes of a depression into account.’
Another difficulty is due to the universal nature of the diagnosis criteria. They are meant to be used for all types of individuals, in all countries and in all cultural contexts.
‘Some cultures don’t even have a word for depression. The displayed symptoms and expressions of emotions vary with the context. For example, there’s a big difference between being stoic and not showing emotions, which is a common ideal in Japan, and being expected to talk openly about emotions, as is common in North America,’ says Lehti.