Diagnosing and Treating Male-Type Depression

Tracy, 18, called his parents to say he was not doing well in college. “I can’t take it,” he said, “I have to get out.” After insisting he keep trying, his parents did finally relent: they sent him a ticket to come home and he did. Three days later, in his bedroom, he hung himself.

“We missed the signals,” his parents told me, years later, still grieving. “But all along, he was such a normal kid. He was beautifully sensitive, a real talker. We thought once he came home, he would be okay.” Tracy’s parents and community—all well attached to this boy–missed his gender-specific, male-type depression.

Cory, 15, took his girlfriend’s break up with him very hard. His mother, as most parents would, assumed his puppy love was part of his maturation. And he, like Tracy, was a “good talker” (his mother’s words to me at a social gathering as she told me Cory’s story). “He said he was okay and he seemed to be okay.” Gradually, though, she said, he became increasingly angry. One day, after being suspended from school for fighting, he told his mother he wanted to “really f—k up Mr. Halliday” (English teacher who set his suspension in motion). A month later, he attacked another boy with a knife.

Nearly 1 in 5 Americans struggle with a mental health issue and many of those are depressed males. Male suicides exceed 30,000 per year and depressed males are publicly violent in ways that shock our nation, including school and workplace shootings. The accused school shooter in Parkland, Florida, Nicholas Cruz, had shown signs of mental illness; he had allegedly been in and out of the mental health system, but still his condition was not fully understood, and necessary intervention did not occur. With accessibility to weapons, he appears to have concocted and refined his plan and finally, carried out his slaughter of children and adults.

Boys, Girls, and Depression

Most research on depression, like “Why is Depression More Prevalent in Women?” Paul R. Albert, The Journal of Psychiatry and Neuroscience, points out that women and girls are nearly twice as likely as boys and men to experience depression (at approximately a 5.5 to 3.2 ratio respectively). Girls and women do struggle with depression more than boys and men, but the statistic does not tell the whole story.

The depression measured in these studies are, generally, “overt depression” and “reported depression.” Overt and reported depression can be seen mainly because women and girls (and boys and men who have this kind of depression) present with its symptoms, often verbally (they talk about it).

“Covert depression,” favored by males, is a somewhat different animal. Once covert depression is factored into statistics, the statistical female/male gap closes somewhat. And whether the gap never closes—indeed, it is likely that female depression data will always at least slightly outnumber male—that still leaves millions of males around the world who are depressed.

This blog will ask and answer three essential questions. I believe these have become civilization-crucial.

Will we admit that there is something called “male-type depression” and that its incidence-rate is reaching crisis proportions in America?

Will we allow ourselves to see beyond our culture-based approach to what causes male depression, i.e. the “pressures of masculinity”?

Will we invest in training parents, teachers, mental health workers and policy makers in male-specific depression assessment and treatment modalities?

Is A Child in Your Care Depressed?

First, to ascertain whether your someone in your care is depressed, look for these symptoms across the gender spectrum:

• excessive rumination (constantly thinking and talking about negative thoughts, especially about a recent occurrence or trauma)
• expressed feelings of guilt, sadness, shame, perhaps about a trauma (e.g. being bullied or hurt and expressing the hurt to others)—the expression can happen in person or via social media)
• headaches or other physical pain noticed by or brought to the attention of parents or friends
• relatively constant irritability and/or overreaction to others in social interactions
• noticeable lethargy, ennui that becomes relatively impossible for loved ones to ignore
• insomnia on the one hand or too much sleep on the other
• suicidal thoughts or attempts—the attempts will likely bring attention to the problem and generally, lead to treatment.

If you or anyone you know fits these symptoms, it is essential to get help immediately.

Simultaneously, did you notice that all or most of those symptoms emerge into a diagnostic framework because they are communicated by the depressed person? They fit under the category of “overt depression” and/or “reported depression.” It may take a while for parents, teachers, or counselors to realize this child or teen is depressed, but thankfully, the realization does often occur, and help, hopefully, is forthcoming.

Notice, too, that boys and men often do not fit the pattern of communication inherent in the list I just gave. In fact, sometimes, even when they do communicate their feelings—as did Tracy, Cory, and the Parkland shooter–our social systems, including parents who are intimately bonded with a child; teachers and other caregivers who know the child relatively well; and mental health professionals who are tasked with reading psychological signals—miss the extent of what is going on in the male.

If We Could Just Get Males to Talk About It….

We have, for a few decades now, chosen to culturally assess what I will argue is a natural male under-reporting of their own hurt and sadness as the result of the emotion-erasing pressures of masculinity.

A recent headline in Harpers Bazarr reflects this position: It’s Time to Let Boys Be Girly https://www.harpersbazaar.com/culture/politics/a19046540/how-to-stop-toxic-masculinity-raise-boys-to-embrace-femininity/ . The author says, “We’ve taught men to reject traits like gentleness, empathy and sensitivity. But if men don’t have the means to deal with their anger and frustration in a healthy fashion, it can have deadly consequences.”

On the Today Show, March 25, 2018, https://www.today.com/video/how-do-we-help-today-s-boys-before-they-turn-to-gun-violence-1194547779598, five boys, one author, and one expert posit that males kill people because they have been indoctrinated to not cry or show feelings of kindness and friendship. The pressures of masculinity, the guests said, cause male suicide and homicide.

On NPR’s Hidden Brain episode (March 22, 2018), “The Lonely American Man,” https://www.stitcher.com/podcast/national-public-radio/hidden-brain/e/53767481?autoplay=true&refid=asi_eml, “Boys get the message at a young age: don’t show your feelings. Don’t rely on anyone. This week, we take a close look at misguided notions of masculinity in the United States.”

Promundo, an international organization focused on gender justice, published a report in 2017, https://promundoglobal.org/resources/man-box-study-young-man-us-uk-mexico-key-findings/, with this abstract: “The research, conducted with a representative, random sample of young men aged 18 to 30 in the US, UK, and Mexico, reveals that most men still feel pushed to live in the “Man Box” – a rigid construct of cultural ideas about male identity. This includes being self-sufficient, acting tough, looking physically attractive, sticking to rigid gender roles, being heterosexual, having sexual prowess, and using aggression to resolve conflicts.”

The report is presented as a “study” but, like the pieces in Bazarr, on Today, and on NPR, it is more of an opinion piece created from anecdotal interviews with a small sample of individuals who agree with the ideological principal of masculine/male defect. Like so many reports of this kind, it is well meaning, but it is soft science, at best.

I can find no scientific way to prove that males who are depressed, suicidal, and violent have become that way because of “the Man Box” or “the pressures of masculinity.” Depression and violence against self and others are biochemical and neural conditions; they are distresses and diseases with etiologies that correlate with an ideological construct, but the Man Box does not cause the neural condition. We have to look deeper, into the male brain.

Deepening the Conversation About Boys and Depression

The masculine-defect conception of males, depression, and violence is what I have called in Saving Our Sons the “Dominant Gender Paradigm” (DGP). This concept rises in some part from awareness among all of us that people miss the signals of male distress much more than we do female distress.

While there is no doubt that some people teach boys to repress tears and not talk about feelings, and while some boys are raised with masculine norm pressure, to mainly or only emphasize an outdated culture construct to assess and treat male depression is to abandon our males by misreading male signals and then blaming males for it.

Is a Boy in Your Care Depressed?

If not only through the lens of DGP/toxic masculinity idea, what is the best way to look at male depression, suicide, and violence?

Just as with every other physical or mental illness, sex differences impact nature, nurture, and culture, especially the prevalence of covert depression among males. Many of the males participating right now in the opioid abuse epidemic are covertly depressed. They have male-type depression, but we don’t realize the depression because the males don’t tell us how they feel, and, they feel better when they self-medicate.

Are there brain-based and genetically linked reasons males tend more toward male-type/covert depression than females?

Yes.

Brain differences, pre-set in utero by gene markers on the X and Y, provide a nature-base for male/female differences in neuro-chemistry and blood flow in these parts of the mid/lower-brain that involve feeling/emotion experience and expression: insula, anterior cingulate cortex, amygdala, hippocampus, caudate nucleus, nucleus accumbus, cerebellum. Similarly, the male/female differences exist in activity to executive function and verbal/word areas of the upper brain, e.g. the orbito- and pre-frontal cortices, and Broca’s and Wernicke’s areas.

Two overall male/female brain differences significantly impact the way depression is experienced and expressed by males.

First, the male brain utilizes up to 7 times more gray matter activity for its mental processing of intelligence and emotion while the female brain utilizes up to 10 times more white matter activity. Gray matter concentrates activity in one or more “splotches” of the brain (areas of activity) while white matter spreads activity throughout the brain.

Second, the female brain has verbal (word) centers throughout the brain in both hemispheres while the male brain lateralizes/compartmentalizes verbal activity mainly on the left side of the brain with heavy concentration in the front left. In part, also, because of heightened white matter activity, the female brain connects its various and multi-lateral verbal centers to feeling/emotion centers in the mid-brain with more quality and quantity of word-use (verbal expression of feelings/emotions) than males tend to do.

Researchers have found this difference to hold true for most males/females with a 1 in 5 to 1 in 7 exception rate. This means, as psychologist Joann Deak, author of Girls Will Be Girls, has put it: around 10 – 20% of males may verbalize more feeling at any given moment than females. To her point, and as research has shown us over the last twenty years, while the male and female brain are robust phenomena across cultures, gender differences happen in the brain on a gender spectrum.

Meanwhile, the exceptions prove the rule. In a majority of cases females will outperform males at any given moment in verbally processing what they feel.

This fact is a baseline for understanding male-type depression. Even neuro-scientists at the National Institute of Mental Health have begun to look at the phenomenon from a research viewpoint, inspired by the number of men returning from war with severe depression. It is clear to the scientists looking at the phenomenon that male depression does not necessarily present, express, or even terminate in exactly the way that female depression does.

Moving Toward A New Paradigm for Assessing Male Depression

In the late 1990s, I changed my clinical paradigm for helping boys and men in large part because I saw that male- and female-type depression often needed sex-specific differences in understanding three areas:

Presentation

Assessment

Treatment.

I could see that some men (and women) won’t talk about how they feel, what they feel; many men put up a stoic front and won’t admit verbally that they are hurting–this is all true–but it seemed to me that both boys and girls and women and men are, actually, all quite expressive of their sadness—we just expect (and want) boys and men to express it in words the way girls and women do, and thus we miss a lot of what males need us to see.

Two of my books, How Do I Help Him, a clinician’s guide to working with boys and men in counseling and psychotherapy, and Saving Our Sons, a book on healthy male development for general readers, look in depth at strategies for working with males in distress. The first is to re-assess our assessment of male-type depression.

Specifically: relying the standard of words-for-feelings is not enough when assessing or helping males in any sphere. The verbal-emotive differences between female and male brains require us to pull back on putting all our eggs in the “if he would just talk about it” basket.

Better is to learn and understand the brain differences between females and males and adapt our protocols to them. Here are two interconnected tools I use. These come from a brain science perspective and assume that boys and men will not be able to express depression as well in words as girls and women will, even integrating a 1 in 5 exception rate.

The Ten Questions Life-Story Assessment Tool

If a parent, teacher, or provider feels even a whiff of intuition that a silent boy may be depressed, your assessment might be assisted by answering these questions about his life-story (i.e., his present and past daily living).

*Is the boy absorbing environmental neuro-toxins that can trigger lowered testosterone/hormonal imbalance?

*Has the boy experienced significant trauma, e.g. abuse or bullying, or perhaps divorce trauma?

*Does the boy have a head injury? Has he suffered concussions in the past?

*Has your son witnessed homicide or other acts of significant violence?

*Is the boy engaged in excessive social media use and screen time?

*Even if he is on social media, is he otherwise isolating himself from friends and family?

*Is your son spending too much time with substances, alcohol, video games, gambling, or pornography?

*Does the boy perceive himself as a social, academic, financial, or physical failure?

*Is your son obese or significantly overweight, and/or does he suffer from insomnia?

*Does the boy lack attachment to necessary caregivers and mentors—often, especially, a lack of father or father figure in his daily life?

Both females and males can experience these issues but male physical, hormonal, emotional, and cognitive systems experience and, quite often, act out these sufferings in male-specific ways. Assessing the potential for depression by assessing the life-story of the boy can be crucial, especially with males who will simply never tell us in words what they feel when we want them to.

Ultimately, I suggest acting from this position: if a “Yes” is the appropriate answer for two or more of these, your son may be depressed even if he does not tell you he is. By using this tool among parents, teachers, and counselors, you can decide if “may” should be more definitive, and intervention on behalf of your son needs to occur.

The Reading Male-Signals Tool (aka, Seeing Through the Masks)

While using this second tool, we can and should certainly ask a boy what he feels. We should ask him constantly.

At the same time, this tool, like the previous one, assumes:

1. boys and men will not talk to us about their feelings as much as females do in the aggregate, ever, even accepting a 1 in 5 exception rate;
2. they will not do so mainly for neuro-biological reasons rather than cultural constructs (though cultural constructs can have some sway in some cases, of course); and
3. talking is just one way of expressing feelings of sadness and depression. Boys show us their emotions, quite often, by “doing” or “not doing” (action or withdrawal).

The Male-Signals or Masks Assessment Tool asks you to become a Citizen Scientist in the boy’s life. If you even suspect the boy or man might be depressed, study his life with these assumptions and then decide what is accurate:

If he is angry a lot, especially more than he was previously, he may be depressed.

If he has just lost a significant peer attachment, e.g. girlfriend/partner, he may be situationally depressed.

If he has just lost an adult attachment, e.g. contact with Dad, Mom, parent-like mentor, he is likely depressed.

If he has been humiliated out of (ostracized from) his crew/best friend/peer group, he may be depressed.

If he is unemployed and unable to find work, he is very likely depressed.

If he is unmotivated in school and under-performing academically without compensating mission, purpose, or focus, he is likely at least mildly depressed.

If he has become obese and/or unable to self-motivate and perform at something useful physically, he may be depressed.

If he is addicted to or abusing porn, substances, alcohol, video games, or involved in another addiction, he is likely also somewhat depressed.

If he is becoming increasingly lonely, isolated, and not relating to primary attachment assets (e.g. parents, team members, friends) he is likely depressed.

If he is only or primarily relating to others via online and social media rather than in person, he is likely depressed.

If he is obsessed with weapons, revenge plots, or extreme ideologies, he is very likely depressed.

If he is not sleeping, not exercising enough, eating poorly (eating junk food but little nutritional food), he is likely depressed.

If he has absorbed head traumas, he may be depressed.

If he has engaged in the performance arms race in school (grades, test scores) or as an athlete and failed (failed to get into the college of his choice, kicked off the team), he may be at least temporarily depressed.

If he is living in poverty, especially an ongoing cycle of poverty, he may be depressed.

If he has been sexually or physically abused, witnessed the murder or a parent and felt powerless to save her/him, or has been significantly bullied, he is likely depressed.

If he has been humiliated in school via cyber-bullying or being outed or sexually compromised, he is likely depressed.

If on top of two or more of these, he says he is fine, he may well be depressed. This model overlaps with the Life-Story model, and purposely so. It is in some ways an echo, giving the parent, educator, or counselor an echoing wall on which to study the boy. Again, a boy may not be depressed even if he fits some of these categories. And yet, too, erring on the side of “he may be depressed” is rarely a wrong move.

For many males, increased anger and/or withdrawal are clear signals of sadness, hurt, and potential depression. We don’t need this guy to talk at length with us to tell us he is sad or hurt; instead, we need to accept that the anger or withdrawal is already the expression of hurt, sadness, and potential depression: they are way of talking. The boy’s stress hormone level may be constantly high; his serotonin may not re-up-take as it should; axons and neurons in the brain are not transmitting correctly–he may well be depressed.

How to Treat Male-Type Depression

As it is with so many other parts of our educational, mental health, and social systems, if we do not train professionals and parents in sex-specific developmental signals, many people will miss the real and actual signals our males are already sending. Missing those signals because of our own lack of knowledge of male-specific development, we will concomitantly blame “masculinity.” This neglect and blame constitutes a systemic abandonment of male development that we don’t even realize we are involved in.

To treat a male who is depressed:

*Make sure he is in the care of a psychiatric professional and counselor—get him any help he needs, from psychiatric to supplements to lifestyle changes to social interaction.

*Use brain scans if affordable and possible to look at the exact parts of the brain involved in the depression.

*Use gene and blood testing to discover exactly which medications might be most useful for treating the depression, given his individualized genetic structure.

*If you discover that he is allergic to a certain food, keep that food away from him, e.g. gluten is well known to trigger or amplify depression.

*Connect him with other males who have been depressed and come through it, let them mentor him.

*Keep him away from weapons, guns, etc.

*In safe and reasonable intervals, confirm that he has not set up a plan for suicide or homicide.

*Remove the substances that are co-morbid with the depression (drugs, alcohol, etc.).

*Limit screen, Smart Phone, video games, and Internet Use.

*Increase social contact with two or more well-attached adults and two or more well-attached peers.

*Give him purpose, mission, a cause, and meaning through service-work such as visiting elders in nursing homes, caring for pets, caring for others.

*Allow no locks on bedroom doors, always know where he is and what he’s doing (as much as possible) for at least a one-month trial period from the day of intervention.

*Increase his exercise time to at least two hours of healthy and, at times, intense exercise per day.

*Cut out junk food, plastics, non-organic food (or at least some of these) to reduce environmental neuro-toxins.

Remember that studies have shown consistently the power of exercise: individuals who exercise report fewer symptoms of anxiety and depression and lower levels of stress and anger. As neuro-scientist Daniel Amen recently put it, “Exercise appears to affect, like an antidepressant, particular neurotransmitter systems in the brain, and it helps patients with depression re-establish positive behavior. Exercise helps keep your psyche fit. It’s an effective, cost-efficient treatment for depression and my help in the treatment of many other mood disorders.”

Meanwhile, Getting Him to Talk to You

I have argued that male-type depression does not always come with words-for-feelings attached to it. Saying this, however, does not mean we shouldn’t keep pursuing “getting him to talk about it.” In fact, my research has shown these eight strategies to be successful in getting difficult males to open up. These are not a substitute for treatment for depression but practicing them can up your chances of male words-to-feelings ratios increasing on average.

*Avoid too much eye-to-eye contact when asking him about his feelings; do more shoulder to shoulder contact, if possible.

*Use parallel play, i.e. play a game of chess, poker, etc. while talking about how he feels.

*Say “What do you think about that?” as much as or more than “How did that make you feel?”

*Ask him to analyze what motivated him or another person to do a specific thing, e.g. “Why do you think Allan attacked you on social media?”

*When talking with him, remember that fear and courage are deep themes for males and targeting them can help him express himself verbally, i.e. “What are you afraid will happen if you _______________?” and “I see you as really courageous and brave, do you see yourself that way?”

*Use peripatetic interaction and counseling, i.e. talk with him while walking together, side by side, rather than sitting.

*Do something physical together before getting into deep work, e.g. shoot hoops, throw a ball together, even play a video game as preamble.

*Ask him to draw what he is feeling, make an audiotape of himself talking about what he’s feeling, or make a video on his phone to illustrate how he is feeling.

With the new consciousness rising in our culture about how much our males of all colors are now struggling in American society (and, indeed, throughout the world), I believe we will need to turn away from these two inadequate DGP obsessions:

1. Sex and gender sameness (“there’s no real difference between boys and girls except reproductive anatomy”); and
2. Masculine defect is causal of male distress (“if we cure boys of masculinity, their problems will go away, and then so will ours”).

It is indeed true that masculinity, like femininity, can have its problems. Awareness of them can’t hurt us, and the anti-masculine folks will keep showing us problems with masculinity, and we will keep listening. But masculine defect is just not enough.

It is also true that we are all human, not “just” female, male, and/or transgender. At the same time, as David C. Page, M.D., professor of biology at MIT recently pointed out: “Our genomes are 99.9% identical from one person to the next as long as the two individuals being compared are two men or two women. But if we compare a woman and a man, the genetic differences are 15 times greater than the genetic differences for two males or two females.”

Marianne J. Legato, M.D., in Eve’s Rib: The New Science of Gender-Specific Medicine, warns us to be careful about pretending this is not so. “Everywhere we look,” she writes, “the two sexes are startlingly and unexpectedly different, not only in their internal function but in the ways that they experience illness. To care for them, we must see them as who they are: female and male.”

Male-type depression is a very real phenomenon. Twenty-seven years of clinical experience, to say nothing of thousands of research studies in the field, have taught me that when it comes to this depression, we can and must now choose–culturally and globally–to recognize it and treat it correctly.