[Excerpt]: The Irritable Male Syndrome
Author: Jed Diamond

Why Male Depression is Hidden:
My Personal Experience

There have been a number of times in my life when I have been concerned that my irritability and anger might be related to depression. As a professional therapist, I was well aware of the official symptoms of depression according to the Diagnostic and Statistical Manual of Mental Disorders -- Fourth Edition (DSM-IV), the main diagnostic reference of mental health professionals in the United States.

Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.
(1) Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful).
Note: In children and adolescents, can be irritable mood.
(2) Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others).
(3) Significant weight loss when not dieting, or weight gain (e.g., a change of more than 5 percent of body weight in a month), or decrease or increase in appetite nearly every day.
(4) Insomnia or hypersomnia nearly every day.
(5) Psychomotor agitation or retardation nearly every day.
(6) Fatigue or loss of energy nearly every day.
(7) Feelings of worthlessness or excessive or inappropriate guilt nearly every day.
(8) Diminished ability to think or concentrate, or indecisiveness, nearly every day.
(9) Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

Every time I checked my own feelings and behavior against these criteria for depression, I concluded I was not depressed. I rarely experienced depressed moods as the official manual defined them. I didn't feel sad or empty or appear tearful. I didn't feel a markedly diminished interest or pleasure in all, or almost all, activities. I noted that irritable mood is considered an indication of depression only in children and adolescents.

Whenever my wife or a close friend suggested I might want to "see someone," I could easily brush them off. "Look, I'm a mental health professional. I've been in practice for more than 30 years. Don't you think I would know if I had a problem? And listen, you don't have to take my word for it. Here, look at this." I'd whip out the professionally accepted, official manual as a reminder that according to the standard guidelines, I wasn't depressed. I didn't qualify. Case closed.

It took me a long time to believe that there might be something going on with me despite what the official manual said. It took me even longer to wonder if the manual might be wrong. As a psychotherapist, I saw a lot of depressed people -- primarily women. The criteria in the DSM-IV seemed to fit the majority of the depressed women. Though it fit some of the men, it seemed to miss a lot of those whom I believed were depressed.

Furthermore, I couldn't understand why the DSM-IV would recognize irritability as a symptom of depression in children and adolescence but fail to recognize it in adults. I finally acknowledged that my own unhappiness generally expressed itself through worry, anxiety, hypersensitivity -- and irritability.

I also remembered my work with people suffering from substance abuse problems. We used to believe that heroin addicts "got well" if they survived to age 40, because we didn't see them showing up in treatment programs after that age. The problem was that they were showing up in alcohol treatment programs. Since the two types of programs didn't communicate well with each other, we often didn't notice that the spontaneous cures were anything but that. In fact, most of the addicts who had not fully recovered simply switched to a different drug. I wondered if a similar thing occurred with depressed men. In my work with men who used and abused alcohol and other drugs, I found that many were depressed. Their depression had rarely been recognized or treated because it was covered by their alcohol use. In some ways, the men were self-medicating. Many depressed men use alcohol as a way to deal with their painful feelings.

Depression Unmasked: His and Hers
I think of male depression as being masked. Millions of men are depressed but don't know it. Millions more know it but are afraid to show it. It isn't "manly" to be depressed. Many of us consider emotional problems to be "feminine." Mental disability also makes us feel helpless and out of control. So those of us who live with depression wear masks that hide our real feelings from others and even from ourselves. People don't know we are depressed because what they see doesn't look like the kind of depression they are familiar with.

"Because men are raised to be independent, active, task-oriented, and successful, they tend to express painful feelings by blaming others, denying their feelings, and finding solutions for their problems in places outside of themselves," say John Lynch, Ph.D., and Christopher Kilmartin, Ph.D., authors of The Pain behind the Mask: Overcoming Masculine Depression. Those around us tend to see us as "bad" rather than "sad." This isn't surprising -- our behavior seems more aggressive than passive, more wounding than wounded. We cover our unhappiness with drink, drugs, excessive exercise, overwork, and angry moods. "Hidden depression drives several of the problems we think of as typically male: physical illness, alcohol and drug abuse, domestic violence, failures in intimacy, self-sabotage in careers," says psychotherapist Terrence Real, author of I Don't Want to Talk about It: Overcoming the Secret Legacy of Male Depression.

As a result, we don't usually associate the idea of "male" with the idea of "depression." Male aggression, yes. Male depression, no.

The view that depression is more common in women is supported by a number of major research studies. Susan Nolen-Hocksema, author of Sex Differences in Depression, found that depression is about twice as common in women as in men.

Similar results were found in two large-scale studies, the Epidemiological Catchment Area Study (ECAS) and the National Comorbidity Survey (NCS). Both studies are noteworthy in that they interviewed people in the general population rather than people who are already in treatment for depression. The ECAS, sponsored in part by the National Institute of Mental Health, used trained interviewers to survey samples from five population centers (New Haven, Connecticut; Baltimore; Raleigh-Durham, North Carolina; St. Louis; and Los Angeles). A total of 19,182 persons were interviewed. The study reported lifetime prevalence estimates of psychiatric disorders by gender. In rates of depression, bipolar disorders, and dysthymia (a milder yet chronic form of depression), women outnumbered men two to one. Interestingly, men outnumbered women five to one in alcohol abuse and dependence and antisocial personality disorders.

The NCS was designed, in part, to minimize gender bias in the reporting of symptoms of mental disorders, including depression. This study sampled a total of 8,098 men and women between the ages of 15 and 54. Although considerably more females than males reported symptoms of depression, the ratio was 1.6 to 1.0 rather than 2.0 to 1.0. It was believed that more men reported symptoms of depression in this study than in the ECAS because the NCS interviews were done in such a way as to counteract the male tendency to forget or underreport symptoms.

Neither the ECAS nor the NCS looked at the possibility that the symptoms of depression may be quite different in men than in women.

So although the generally accepted view is that women are much more likely to be depressed than men, these findings may be biased in the following ways:

Men tend to be less in touch with feelings than women and less likely to discuss feelings when asked. In addition, we often view being "down" as being "unmanly," and hence we are less likely to discuss these specific kinds of feelings.

Since men don't seek professional help as often as women, there tends to be a bias that women are more likely to be depressed.

When depressed, women often ruminate and replay situations and feelings in their minds. This makes them more likely to remember and report them. Men tend to project their feelings onto others and avoid or deny problems. They are, therefore, much less likely to describe themselves as depressed.

Male role conditioning is such that we see ourselves as independent. When we have problems, we are action-oriented and solve them ourselves. We don't focus on our feelings or share them with others. Women are more conditioned toward sharing what is going on inside them, whether or not there is a solution. Tom Golden, Ph.D., an expert on male emotions and the author of Swallowed by a Snake: The Gift of the Masculine Side of Healing, recognizes that the ways men and women deal with their emotions, particularly feelings of loss, may be quite different. Women often express their emotions through talk and tears. Men often express them through action and reflection.

Finally, symptoms that characterize female depression may be quite different from symptoms of male depression. Problems that are more common in men, such as alcohol dependence, personality disorders, or acting out sexually, may mask depression.
*endnotes have been omitted

Reprinted from: The Irritable Male Syndrome: Managing the 4 Key Causes of Depression and Aggression by Jed Diamond © 2004 by Jed Diamond. Permission granted by Rodale, Inc., Emmaus, PA 18098. Available wherever books are sold or directly from the publisher by calling (800) 848-4735 or visit their website at www.rodalestore.com.

For more information, please visit www.menalive.com or www.writtenvoices.com.








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Jed Diamond, a licensed psychotherapist for 38 years and director of the health program MenAlive, is the author of seven books, including the international bestseller Male Menopause. He is on the board of advisors of the Men's Health Network and also serves on the international scientific board of the World Congress on Men's Health. He lives in Willits, California.

For more info visit www.menalive.com

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