Men and depression

Content provided by the Faculty of the Harvard Medical School

Men and depression

In treatments, attention must be paid to sexual and other issues.

Depression is sometimes called the common cold of mental health, but it's unlike the common cold in at least two important respects: It doesn't go away in a week without treatment, and it doesn't affect men and women equally or in the same ways. Although attention is rightly paid mainly to the causes and consequences of women's high rate of depression, the disorder also presents special problems for men.

At every age, men have worse health than women and a higher death rate. They also have a higher — often much higher — risk of many psychiatric disorders, including schizophrenia, alcoholism, drug addiction, and autism. So it is remarkable that the rate of diagnosed depression is much lower in men almost everywhere in the world. In the United States, about half as many men as women become seriously depressed at some time in their lives. Men suffer less major depression, less dysthymia (chronic mild to moderate depression), and probably less bipolar depression (although the rate of bipolar disorder is the same in both sexes).

The reasons for this difference are not entirely clear. The main risk factors for an episode of depression are the same in both sexes: certain personality traits, drug and alcohol abuse, acute and chronic stress, traumatic experiences including child abuse, a family history of depression, and a previous depressive episode. Twin and adoption studies show that depression is equally heritable in both sexes; a depressed man and a depressed woman are equally likely to have a depressed parent. But a study published in the American Journal of Psychiatry indicates a few gender differences in risk factors. In men but not in women, a genetic risk for depression accompanies a genetic risk for anxiety and conduct disorders. Low self-esteem and loss of a parent in childhood are more closely linked to depression in men than in women.

Depressing hormones?

The most important clue to the mystery of gender differences in depression is that women are more susceptible than men only in their childbearing years, from puberty to menopause. The question is how to interpret that clue, and an obvious suspect is female hormones. One theory is that women are more vulnerable to depression because of problematic interactions between stress hormones and reproductive hormones in women. In a person who is under stress, estrogen promotes anxiety and depression and testosterone does the opposite. That might account in part for the fact that men are apparently less physically sensitive to their emotions than women. According to some research, the rate of depression would be the same in the two sexes if only symptoms like sadness, hopelessness, and guilt were counted. The difference results from the excess of physical symptoms in women — fatigue, agitation, insomnia or oversleeping, and appetite loss or overeating.

An animal experiment provides evidence of a hormonal influence on gender differences in depression. To produce a state analogous to human depression, rats were repeatedly forced to swim and provided with what looked like plausible ways to escape. The apparatus was arranged so that their escape attempts would always be frustrated, so most of them eventually gave up and stopped trying. This state of apathy or learned helplessness, which resembles depression, was slower to develop if the rats were given antidepressants. Males tended to keep trying longer than females, and gave up sooner if they were given estrogen. Females kept trying longer if they were given testosterone.

But these differences do not appear in all animal experiments, and the relationship of such experimentally induced states to human depression is disputed. Besides, hormonal changes are not the only ones affecting humans in adolescence and young adulthood. Cultural influences and social demands are also important. The "cost of caring" and its accompanying emotional risks fall mainly on women. In adolescence, girls begin to show less self-confidence and more guilt than boys. Some believe that depression rates are converging as the social status of women changes. And in some groups, equality may already have been achieved. One study found that among Orthodox Jews in England, men and women had the same rate of depression — a suggestion of the importance of cultural and religious values. Other research has found no gender differences in depression among college students of the same social class living in the same dormitories.

Never is heard a discouraging word

The relatively low rate of depression in men could be an illusion. It's often said that men don't like to admit, even to themselves, that they are depressed. They may feel that it is weak or unmanly to show despair or self-doubt; they may fear what might happen if employers or colleagues found out. So they withdraw into silent misery or develop a "male depression syndrome" in which the disorder masquerades as anger, irritability, alcoholism, or drug abuse. Because they do not seek treatment, the story goes, their depression is never diagnosed or recorded.

It's doubtful, though, whether male reluctance to acknowledge feelings can account for all of the gender difference in depression; for example, surveys show that women have a higher rate of depression than men even among people who are not seeking professional help.

In two ways, both related to the high male death rate, depression can be said to be an even more serious matter for men than for women. Depression is a key risk factor for suicide, and men commit suicide four times more often than women — up to 10 times more often in old age. 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 affects blood pressure, blood clotting, and the immune system. It's a well-known risk factor for coronary heart disease, heart attacks, and stroke. Men are especially vulnerable because they develop these diseases at a higher rate and at an earlier age than women. After a heart attack or bypass operation, some research shows that depression and anxiety are, paradoxically, less common and serious in men than in women. But one large study found that this advantage lasted only for the first two years.

Treating depressed men

The most important thing others can do for a man who shows signs of depression is to help him contact a physician or mental health professional and if necessary accompany him to treatment and encourage him to continue until his symptoms begin to improve. Many authorities are recommending that physicians routinely screen adult patients for depression by asking two standard questions: Over the past two weeks, have you felt depressed or hopeless? Over the past two weeks, 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.

The treatment itself is the same for both sexes — talking with a therapist about problems and taking antidepressants for symptoms. The talk may take the form of psychotherapy, mutual support groups, or marital counseling.

Antidepressants are equally effective and have similar side effects in both sexes, but one of those side effects, occurring in up to 50% of users, has special implications for men. The most widely used antidepressants, the selective serotonin reuptake inhibitors (SSRIs), tend to diminish sexual interest, desire, performance, and satisfaction and the capacity to reach an orgasm. In men, that often means the drugs prevent or delay erection or ejaculation.

Sexual side effects, like other antidepressant side effects, may fade with time. So one solution is to wait awhile. Other options are reducing the dose and switching to a different kind of antidepressant, often bupropion (Wellbutrin). Switching is generally not recommended unless the patient's depressive symptoms are not improving. The changeover should be gradual to avoid a discontinuation syndrome.

Another solution for sexual dysfunction is to add a second medication. Many of the drugs tested for that purpose have turned out to be no better than a placebo. A couple of studies suggest that adding bupropion may help. Sildenafil (Viagra) has been found effective in three studies and is probably the best choice in most cases.

Testosterone and depression

Depression itself has damaging effects on sexual function. About 40% of men in their 40s to 60s have some difficulty achieving or sustaining erections, and depression is one common cause of the problem. Another common cause is low testosterone levels, which occur in 25% to 55% of men over age 50 and 75% of men over age 70.

Testosterone deficiency may also result in mild to moderate depressive symptoms, so there can be a complicated cause-and-effect cycle between depression, low testosterone, and erectile dysfunction, which is sometimes further complicated by medical illness and the drugs used to treat it. Diabetes and blood pressure medications, for example, have sexual side effects.

For some men, testosterone treatment may help with both depression and sexual functioning. In one study, adding testosterone to an antidepressant in depressed men with testosterone deficiency relieved depressive symptoms. In another study, testosterone alone, without antidepressants, relieved symptoms of depression in older men with normal testosterone levels. A few controlled studies also suggest that dihydroepiandrosterone (DHEA), an adrenal hormone needed for the synthesis of both testosterone and estrogen, may help relieve depression in men.

Testosterone can be taken orally, by injection, or in the form of a skin patch or gel. It's easier to use in pill form, but there is a risk of impaired cholesterol metabolism and liver damage. Scientists are working on safer oral preparations. Injections (usually every two to three weeks) raise the risk that testosterone levels will fluctuate and cause mood swings. That problem is avoided with a skin patch or gel providing gradual and steady release of the hormone.

The risks of long-term testosterone use include headaches, acne, and possibly heart disease, liver damage, prostate enlargement and prostate cancer. Another problem is that synthetic testosterone suppresses the production of natural testosterone, which may be in short supply when the synthetic hormone is withdrawn.

A reasonably safe treatment for erectile dysfunction, whether caused by depression itself, antidepressant drugs, or testosterone deficiency, is sildenafil and its cousins vardenafil (Levitra) and tadalafil (Cialis). Taken an hour before sexual activity, these drugs promote and sustain erections by increasing blood flow to the penis. The main side effects are flushing, headaches, indigestion, and heartburn. Men taking nitrates for angina may run the risk of a dangerous drop in blood pressure. There are some reports of sildenafil improving depressive symptoms — indirectly, since it does not affect the brain — even in some men who are not taking antidepressants.

Last updated:	September 05, 2008