Men are a numerical minority group receiving a diagnosis of, and treatment for, depression. However, community surveys of men and of their mental health issues (e.g. suicide and alcoholism) have led some to suggest that many more men have depression than are currently seen in healthcare services. This article explores current approaches to men and depression, which draw on theories of sex differences, gender roles and hegemonic masculinity. The sex differences approach has the potential to provide diagnostic tools for (male) depression; gender role theory could be used to redesign health services so that they target individuals who have a masculine, problem-focused coping style; and hegemonic masculinity highlights how gender is enacted through depression and that men’s depression may be visible in abusive, aggressive and violent practices. Depression in men is receiving growing recognition, and recent policy changes in the UK may mean that health services are obliged to incorporate services that meet the needs of men with depression.

Men and depression is a complicated and contentious issue and many will even disagree about whether clinicians should concern themselves with it, because the prevalence of depression is greater in women. Although the work of the mythopoetic men’s movement in using fairy tales such as Iron John (Bly, 1990) to explore archetypes of gender, for example, may be overzealous and naive, it does not mean that we have to be equally overzealous in ignoring men with mental health issues. Despite the greater prevalence of depression in women, there are three important reasons for exploring depression in men.

First, even if men represent a numerical minority group among patients with depression they still require effective interventions.

Second, although healthcare services find that they are diagnosing and treating many more women with depression than men, community surveys suggest that this disparity is disproportionate. In the UK, for example, figures from general practice for 1994–1998 show a male-female ratio of 0.4-1.0 for depression (Office of National Statistics, 2000), and data from a national household survey in 2000 show a ratio of 0.8-1.0 for depressive episode and disorders (Singleton et al, 2000). The greater prevalence of depression in women might, for example, be an artefact of how depression is recognised and treated or of how men self-diagnose and seek help. Third, mental health issues such as alcohol dependency (Alcohol Concern, 2005) or being subject to compulsory detainment and treatment (Healthcare Commission, 2007), which predominantly involve men, might be related to emotional distress and depression. Worldwide, the rate of suicide mortality for men is four times higher than that for women (White & Holmes, 2006) – China is the only country where women’s suicide mortality is greater than men’s (Hawton, 2000) – and research by Mo"ller-Leimku"hler (2003) argues that suicide is linked to depression in men.

Current approaches to men and depression draw on theories of sex differences, gender roles and hegemonic masculinity explored in this article.

Sex differences -  ‘male’ depression

When introducing sex differences it is important to define the term ‘sex’ and its relation to the term ‘gender’. However, providing definitions is difficult because the research that we have drawn on here uses these terms in different ways. It is therefore perhaps better to outline the general approaches to these terms. Broadly, ‘gender’ denotes the sexual distinction between male and female that is an amalgamation of biological, cultural, historical, psychological and social factors, although the word is often used deliberately to exclude biological factors. In terms of gender, ‘sex’ refers to just those biological factors that distinguish male and female, and ‘sex differences’ are factors (biological, cultural, etc.) related to sex. It is important to emphasise that a sex difference is not necessarily biological, although it does rest on an assumed common understanding of a biological distinction between men and women.

Establishing sex difference in research is simple and powerful (perhaps because of its simplicity), particularly in depression. As with epidemiological studies on depression, more specific studies on symptoms have found that women experience more symptoms of depression than men but that there are no sex differences in the quality of symptoms. A 15-year prospective community study found no sex differences in the number or duration of depressive episodes but, importantly, women reported more symptoms per episode (Wilhelm et al, 1998). In clinical samples, however, sex differences in the number of symptoms are less marked and show similar functional impairment and global severity (Young et al, 1990), but women are more likely to have a history of treatment for depression (Kornstein et al, 2000).

The reduction in sex differences from community to clinical samples seems to suggest that diagnostic procedures or self-care practices are resulting in a population of depression that is not representative. More specifically, there might be underdiagnosis of men, overdiagnosis of women, or systematic misdiagnoses of both men and women, which could be explored by looking at what happens in routine clinical practice. It is interesting to note that where studies have found a symptom to occur more frequently in one sex, it is the symptoms for women that appear in diagnostic criteria. In depressed women, symptoms that have been found to occur more frequently are worry, crying spells, helplessness, loneliness, suicidal ideas (Kivela” & Pahkala, 1988), augmented appetite and weight gain (Young et al, 1990). Non-diagnostic symptoms found more frequently in depressed women are bodily pains and stooping posture (Kivela” & Pahkala, 1988). However, symptoms that have been shown to occur more frequently in depressed men are slow movements, scarcity of gestures and slow speech (Kivela” & Pahkala, 1988), non-verbal hostility (Katz et al, 1993), trait hostility (Fava et al, 1995) and alcohol dependence during difficult times (Angst et al, 2002), which are not common to diagnostic criteria for (adult) depression. Increased hostility might be indicative of a conduct disorder mixed with depression (ICD–10 F92.0; World Health Organization, 1992), but is limited to onset in early childhood. International diagnostic criteria and non-diagnostic symptoms for depression are listed in Box 1Go, with footnotes showing which symptoms the sex differences research shows to be more prevalent in men or women. These criteria may not be entirely representative of contemporary mental health practice – for example, aggression may be recognised as part of adult depression by many practitioners – but the list at least provides a useful summary of this body of research.

Although differences in symptom presentation may be explained as different behavioural patterns of depression or dimensions of distress, it is not entirely implausible that there might exist a form of depression that has hitherto remained absent from international diagnostic criteria. Indeed, this possibility has led some to theorise a ‘male depressive syndrome’ (Rutz et al, 1995; van Pragg, 1996) that is characterised by sudden and periodic irritability, anger attacks, aggressive behaviour and alexithymia. The Gotland Scale of Male Depression (Zierau et al, 2002) has been developed with such a syndrome in mind. In an out-patient clinic for alcohol dependency, standard diagnostic criteria identified major depression in 17% of male patients, whereas the Gotland Scale found depression in 39%. In a clinical sample, the Gotland Scale could find no gender differences (Mo"ller-Leimku"hler et al, 2004). However, the Gotland Scale looks for signs that are not usually understood as symptomatic of depression so it is not surprising that there is little difference between men and women diagnosed with depression using this scale. Nevertheless, in the clinical sample there was a greater intercorrelation of symptoms of male depression in men, which is something that could be explored in community samples. This scale, when utilised in a study of 607 new fathers, identified a prevalence of 6.5% suffering what could be classed as post-natal depression and of these, 20.6% were not identified by the use of the Edinburgh Post Natal Depression Scale alone (Madsen & Juhl, 2007).

The sex differences approach to depression in men has the potential to provide the diagnostic tools to allow psychiatric services and clinicians to recognise and treat a new form of (male) depression. Nevertheless, it is unclear how such an approach might be used to inform treatment, for example whether antidepressants will be appropriate or effective. In addition, focusing on sex differences can mean that differences between men, such as socio-economic status, are ignored.