The role of masculinity in shaping men’s approach to depression

Is male companionship the answer?

It was Monday morning, I had researched and prepped the day’s patients. Most new, some complicated.

Working in an underserved clinic, there is vastness in the clinic variability, and to preemptively time is usually unsuccessful. It is tough for a primary care physician to tackle everything in the allotted time slot. And then there are the non-physical ailments, those conditions I cannot just treat with a script pad.

It was 11 a.m. and Mr. Jones, a 28-year-old with a history of hypertension presenting for a wellness visit, was my next patient. I might even have time for a lunch break (I thought to myself). I entered his room, ready to formalize the visit and discuss hypertension medications and lifestyle modifications.

“Hey, Mr. Jones. How are you?”

He responded, “life sucks,” and broke down.

As I sat there, mute, he unraveled stressors that have been bottled up for years. He touched on the separation with his wife, the trouble of weight gain, the inability to see his child every day and the lack of support from friends and family. He expressed concern about pushing his friends away. While he sought a listening ear, his friends alienated him, claiming his depressive talk and grim outlook brought the moral of any gathering down. They advised him to bottle it up and keep it to himself. What other alternatives did Mr. Jones have except to open up to a stranger he had just met?

Mr. Jones is just one example of the many male patients I have seen who ostensibly come in for a blood pressure check but are in need of so much more. Most of them are not able to open up like my patient did. Many do not recognize that their difficulty sleeping or their anger may be symptoms of a mental health problem. Our society is deeply entrenched in gender stereotypes, a disservice to all genders, which furthers the epidemic of loneliness in this country. Masculinity has its foundations in stoicism, self-reliance and restrictive emotionality. To show too much emotion is not “manly.” To depend or rely on others is not “manly.” To show vulnerability is not “manly.”

Conformity to traditional masculine norms has correlated with less help-seeking behavior and more negative cogitations toward seeking psychological treatment. In the United States, prevalence ranges from 5% to 10% but can be as high as 40% to 50% in certain primary care or specialty settings. In 2020, the prevalence of major depressive episode was higher among adolescent girls (25.2%) compared with boys (9.2%). The lower rates of male depression may not reflect better mental health compared with women, given that men exhibit higher rates of substance use, physical violence and account for higher rates of suicide deaths. Common depressive symptoms such as fatigue, low mood, restlessness and irritability are often attributed to physical illness and less frequently interpreted as signs of mental illness — like Mr. Jones, who saw his chronic fatigue, insomnia, backache and weight gain as signs of untreated pain from a past motor vehicle accident. While I started my patient on antidepressants and gave him a referral to behavioral health, I reflected on the issues we have in America with masculinity, one that exacerbates our epidemic of loneliness. After youth, when grade school recess, clubs and afterschool activities offer ample opportunities for social interactions, male companionship is tough as you age, and social isolation is common amongst men. While I cannot write a script to abolish loneliness, maybe I can write a script to join a social group, to call one person a day or get out into nature. There is not a simple solution, but small steps can add up. Relationships can be energizing and feeling alone can be the fast track to depression.

Certainly, women experience more depression, and we need to improve our detection of mental illness among all our patients, not just men. Gender differences in depression is an area in need of more research and funding. Our mental health resources are woefully inadequate to the task, especially given the increasing rates of depression and anxiety, even before the COVID-19 pandemic. The gender gap in depression notwithstanding, depression in males should not be overlooked.

Physicians should provide opportunities for men to share and create a safe environment with normalization of the stress and emotions that our patients experience. We need to pick up on those subtle cues of anger, noncompliance and despair, and treat them as we treat the blood pressure. And we need to continually advocate for a society and a medical system that supports us and our patients.

References:

• Cohen R, et al. Guys, we have a problem: How American masculinity creates lonely men. https://www.npr.org/2018/03/19/594719471/guys-we-have-a-problem-how-american-masculinity-creates-lonely-men. Published March 19, 2018. Accessed Aug. 29, 2022.
• Kondo MC, et al. Int J Environ Res Public Health. 2020;doi:10.3390/ijerph17124213.
• Major depression. https://www.nimh.nih.gov/health/statistics/major-depression. Accessed Aug. 29, 2022.
• McCarron RM, et al. Ann Intern Med. 2021; doi:10.7326/AITC202105180.
• Piccinelli M, Wilkinson G. Br J Psychiatry. 2018;doi:10.1192/bjp.177.6.486.
• Salk RH, et al. Psychol Bull. 2017;doi:10.1037/bul0000102.
• Seidler ZE, et al. Clin Psychol Rev. 2016;doi:10.1016/j.cpr.2016.09.002.
• Sloan DM, Sandt AR. Womens Health (Lond). 2006;doi:10.2217/17455057.2.3.425.
• Suicide. https://www.nimh.nih.gov/health/statistics/suicide#:~:text=In%202020%2C%20the%20suicide%20rate,females%20(5.5%20per%20100%2C000). Accessed Aug. 29, 2022.
• This former surgeon general says there’s a ‘loneliness epidemic’ and work is partly to blame. https://www.washingtonpost.com/news/on-leadership/wp/2017/10/04/this-former-surgeon-general-says-theres-a-loneliness-epidemic-and-work-is-partly-to-blame/. Published Oct. 4, 2017. Accessed Aug. 29, 2022.