Cultural Expectations May Explain Why

Henry gets so agitated in traffic that his face turns red and he punches the steering wheel.

Marc comes home from a hard day's work and drinks a six-pack of Budweiser -- every night.

Ken, who has been on disability for six months, watches television all day long, barely speaking to anyone.

Bill smokes more marijuana now than he did when he was in high school 20 years ago.

What these men have in common was once thought of as almost exclusively a women's problem, but depression affects both sexes. Depression can just manifest itself differently in men, according to a California psychologist and author. While women may cry, become withdrawn, and gain or lose weight, men may abuse alcohol or drugs, work or eat excessively, and/or become violent to themselves or others, among other things.

Affecting approximately 19 million Americans, depression clearly takes its toll on both sexes. The toll is physical as well as mental: A recent study of Johns Hopkins medical students found that depressed men were twice as likely as their nondepressed counterparts to develop heart disease or die suddenly because of heart problems.

But even though 80% of people who seek help will get relief from antidepressant medication, therapy, or a combination of the two, just one in three people actually seek help, according to the National Institute of Mental Health in Bethesda, Md.

And most of them are women. Because many men are brought up to believe that expressing emotions is largely a feminine trait, half as many men as women seek psychotherapy or are diagnosed with depression. This may be one of the reasons that, according to unpublished CDC findings, men in the U.S. are about four times more likely than women to commit suicide.

"We are brought up with a code that says if one shows these feelings or acts in a vulnerable way, then he is weak, a sissy, or a girl," exclaims Fred Rabinowitz, PhD, professor of psychology at the University of Redlands in Redlands, Calif.

The stigma associated with male depression must be removed so men can get the help they need, Rabinowitz says. He and Sam Cochran, PhD, the director of clinical services at the University of Iowa in Iowa City, are the authors of the book Men and Depression: Clinical and Empirical Perspectives.

"Some researchers believe that women are more prone to depression biologically, more oppressed in society, and thus experience more depression," says Rabinowitz. This same thinking, he says, holds that women "tend to be more ruminating than men, and thus more likely to focus on and talk about depressing ideas, and are permitted by society to express feelings like sadness and emotional pain -- unlike men, who must keep it hidden.

"Our take on why men show up less depressed is that men are not likely to show typical depression symptoms like crying, sadness, loss of will, verbalization of suicide intent. Instead, men are likely to keep it hidden, like they do most of the time with most feelings. Thus, others are unable to tell if a man is depressed or not."

Men at risk for depression and/or suicide include those who are feeling like they aren't measuring up any more, who feel physically weaker, sense that their lives no longer have outlets for pleasure, or who have experienced a personal loss.

"One of the biggest triggers is loss, especially of a relationship that has been supportive and sustaining," Rabinowitz says. "Many men, when they lose their fathers or partners, experience a grief that is more debilitating than expected."

For example, a man going through a divorce may feel sorry for himself, drink too much, and feel isolated from friends and family. At work, he may do his job, crack jokes, and be one of the guys. But "when he gets home, he sits in front of a television, drinks and eats too much, and harbors private thoughts of anger that he can not fully express," Rabinowitz says.

Another trigger of depression is physical illness such as cancer or heart disease, he says, because illness is a direct attack on a man's sense of virility, strength, and self-definition.

Unfortunately, like depression, therapy also is often seen as feminine, he says. "It involves verbalizing emotions and talking about problems, which is more common for women to do with same-gender friends," Rabinowitz says. "On the other hand, boys and men tend to be less verbal and more uncomfortable in deep relationships."