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Urban Suffering Studies Center



Gender differences in depression: Societal background, causalities, consequences, clinical findings, challenges and suggested solutions

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Wolfgang Rutz


Professor of Social Psychiatry
Senior Consultant of International and Public Mental Health,
WHO European Regional Advisor for Mental Health 1998-2005

Coburg / Stockholm / Uppsala

Introduction: Male vulnerability


During times of dramatic social change, such as in the 90s in Eastern Europe and today in Southern Europe, men seem more vulnerable and women more protected (1-5). European men's premature mortality, including suicide, rose in the 1990's Eastern European transitional societies 5-9 times, compared to that of women, whose mortality rose on average by a factor of 1.5 [3, 4]. Thus, men's suicide rates mirror in times of change almost "seismographic" the stress load in a society. This can be viewed as a "community syndrome", consisting of patterns of morbidity and mortality, particularly due to violence, risk taking, abuse, accidents and other stress-related causes including cardiovascular diseases, cerebral events and diabetes II (8-10). An important risk factor for men's sensitivity to the stress of social change seems to be their vulnerability caused by loss of predictability, status and dignity (6.7).
Thus, it was found in a Danish study of more than 800 suicide victims that mental illness was the strongest risk factor for suicide in both sexes. In men, however, unemployment, retirement, being alone, and sick were the most significant
risk factors, while caring for children at home was an important protective factor for women. An excessive mortality in Danish groups of newly divorced men and a Swiss group of widowers underlines these findings (7).

It is also known from animal experiments that stress reactions appear different among the sexes. [14]. Male individuals are often more sensitive to hierarchical downgrading, while female individuals react strongly to social marginalisation and loss of family cohesion. (14) Here, men appear particularly sensitive to an experienced loss of identity and dignity due to work loss and the resulting lost ability to be breadwinners. Women, however, seem even in times of crisis and transition preserve a protective ability to maintain health by creating social networks, take family responsibilities and keep up control and meaning in life (6, 7).

Some gender related paradoxes in Public Health


Men in Europe are reported to seek therapeutic support and consume medical care only half as often as women do, but die 5 (EU) to 15 years (Russian Federation) earlier than women (9). We also believe to know that between 70-90% of all suicides are committed in a clinical state of depression, where the cognition is psychologically influenced by a depressive distortion of reality and by an emotional and cognitive misperception. This in turn often leads to perceiving suicide as an apparently "logical" consequence of the present melancholic life experience regarding the past as well as the present and the future situation (15-17). Here it seems unexpected and paradoxical, that men commit suicide 3-10 times more often than women, but that only half as many men are diagnosed as depressive (16, 18-23).On the other hand, attempted suicides are more common in women, whose suicidal acts are usually less aggressive and often characterized by a "de facto" suicide preventive "cry for help" .behavior, signalizing helplessness and a plea for shelter and protection.

Part of the explanation of men's higher suicide rates is due to their more frequent use of violent suicide methods, which can be seen as a sign of their depressive determination. A plausible explanation for the gender paradox with regard to suicide and depression, is therefore that male suicidal and depressive states are more likely to be undetected due to their proneness for aggressiveness and acting out. This lack in detecting men's suicidality together with men's alexithymic lack of help seeking behavior, frequent choice of violent methods and more resolute, violent suicide intention lead to the overrepresentation of men's suicide rates (24).
Related to this, another surprising and paradoxical finding is the epidemiological and clinical observation, that the prevalence of depression seems inversely correlated to the frequency of suicide, despite our knowledge regarding specific and causal links between depression and suicide (16, 19, 25). In other words, it has been noted that the higher the suicide rate is in a community or population, the lower the reported incidence of depression seems to be. This paradox can only be explained by the assumption that adequately diagnosed depression leads to adequate treatment and follow-up of depression in a population, which in turn prevents depression-related suicides (25-26). Several studies support this observation, which shows that a lower incidence of (diagnosed) depression in a population is correlated to a higher suicide rate, and that a large number of diagnosed depression probably reflects a better treatment and proper follow up of depressions, which in turn may lead to decreasing numbers of depression-related suicides (23, 25-36).


Symptoms of depression and suicidal tendencies - are they gender specific?


Nowadays, depression is still often considered to be a "women's disease" - twice as frequent in women as in men. Recently, however, there are increasing indications that men are just as often depressed as women, though in a different way. There are also indications that men's depression is under diagnosed and the gender difference regarding the frequency of depression overemphasized. One of the reasons for this may be that male depression is not identified due to concurrent substance abuse with alcohol or drugs as well as poor impulse control and / or aggressive and violent acting out. These features lead often to diagnoses of personality disorder, character disorder or addiction problems instead of a diagnosis of depression. Consequently, the focus in diagnostics and therapy often gets distracted from the underlying depression and its distinctive bio-psycho-social and/or existential background (32, 37) to more instrumental or solely medicalized approaches.

In contrast, the symptoms reported by women who feel depressed often differ from those reported or non-reported by men in those situations of helplessness and the collapse of function and coping ability that we call depression. Men feel and report themselves rarely as depressed. Since diagnostic criteria in conventionally used depression diagnostic instruments usually are developed on the basis of reported
symptom variables these depression scales become inadequate when it comes to men. The background is men's inability to verbalize feelings and depression, often with unrealistic traditional masculinity ideals that often also become the reason for men's inability to seek and get help in time. (32)

Two large-scale population-based epidemiological studies showed that untreated depressive men reported fewer affective and other symptoms than women (22, 38). Moreover, it was found that marked gender differences in stress management strategies exist: men coped with depressive dysfunction by increasing sports and the consumption of alcohol and tobacco, while women tended more to use emotional relaxation, religious activities and reading (38). Also, the high level of addiction and alcohol abuse in men in connation to depressive helplessness suggests self-medication in the absence of specific help. This may be explained by the fact that alcohol consumption has an immediate anti depressive effect but later on increases depression in a vicious circle (38, 39).

Lower incidence of depression among men - an artifact?


In the "Amish" - population in the US is aggressive behavior, violence and abuse strictly stigmatized [40]. Stigma is also associated with alcohol abuse in the Israeli Jewish Orthodox communities. In both populations, depressions occur less frequently than in other ethnic and religious groups. [41] In parallel depression is diagnosed
in these populations as often in men as in women and suicide figures are equally low in both sexes. On the other hand in EU countries where alcohol abuse is relatively frequent and relatively little stigmatized the prevalence of depression is 2-3 times higher in women than in men. Men instead are often diagnosed with personality disorder and/or addiction and have a suicide frequency which is 2-3 times higher than that of females (16, 19 to 22, .38, 42). In addition, alcoholism, which can mask depression, is in Russia 9 times more common among men than women. Men are, however, rarely diagnosed as depressed - with the result that men's suicide figures in Russia are approximately 5-7 times higher than women's, and that depression is in some Russian male populations almost never diagnosed (15, 20, 42).

The need for better diagnosis and treatment of depressive men The "Gotland Study" - an Example


In the years 1984-1985 an educational program was developed in order to prevent, improve and monitor a dramatic suicide and depression situation on the island of Gotland. The program was given to all general practitioners (GPs) (31-32) on the island. At that time in the 1970s - and early 80's a situation of dramatic social changes resulted in a high suicidality with the highest suicide figures in Sweden, that primary GPs no longer felt able to manage. Following a request from the island's GPs and supported by the County Council of Gotland, psychiatrists launched a comprehensive training program in collaboration with the Swedish Committee for the Prevention and Treatment of Depression.


Gotland Study - Results


The program resulted in a significant improvement of general practitioners' ability to detect, treat and monitor depressive disorders. Another result was a strong reduction in the number of completed suicides and violent suicide attempts on the island, along with a reduction in depression-related morbidity, absenteeism at the workplace and health care consumption due to depression related conditions. Even the seasonal fluctuation of suicides mainly disappeared and Gotland showed in the years consecutive to the educational program Sweden's lowest suicide rates. However, the program affected almost exclusively the figures of depression related female suicides (23). Men's suicide rates remained unchanged at a high level (32, 37). To examine the reasons for this, a "psychological autopsy" study reviewed the life situations of all male suicide victims during the 80ies on Gotland by interviewing their relatives, next of kin and contact persons on the conditions before suicide. Here we found that the suicide victims in principle were not known to the medical system, neither in primary care nor in specialized psychiatric care. They suffered heavily and felt uncomfortable, even in the company of family members and friends. Yet they denied depression and needs for help. They had usually more or less voluntary contact with other social structures - not the medical system but police, tax authorities, substance abuse treatment organizations and the social welfare system. They were often self-pitying, acting out, blaming everything and everyone, including themselves, sometimes with verbal or physical aggression, irritation, "psychopathic" behavior and poor impulse control. Also abuse or abuse equivalents such as workaholic and risk taking behaviour and a general negativism could be described. They often behaved indecently and in the few cases where they had asked for help - a rejection of offered therapies and a non-compliant attitude to any treatment trials could be noticed (24.32 to 37). These men's insight into their depression was rare, and - as the outcome showed - they were highly suicidal. Frequently there was also a heredity for both substance abuse and suicide.

Based on these findings, together with our knowledge of the clinical picture of stress-related disorders and their relation to serotonin metabolism in men, we formulated a "male depressive and externalizing serotonin syndrome". Moreover, a diagnostic screening instrument was elaborated in order to identify, to prevent and to treat male depression and suicidality. This instrument was called the "Gotland Male Depression Scale (GMDS)" and was based on specific male characteristics of depression described in our study. The Items in the GMDS include reduced stress tolerance, reduced impulse control, feeling of exhaustion, fatigue, irritability, indecision, sleep disturbances, morning-anxiety, abuse or abuse equivalents, antisocial behavior, depressive perceptual distortion, regressive self-pity, and a genetic hereditary predisposition to depression, alcoholism and / or suicide (24, 44).

We noted that this clinical picture of male depression included features of "pseudo-psychopathy", which are in contrast to a stable and personality rooted behavioral disorder of psychopathy. Of note is that these features could be related to a distinct point in time of personality change which came as a surprise to both the affected individuals and their relatives. This change was from being predominantly socially adapted and decisive to features of the described male depression syndrome.

Gotland Study - Evaluation

A scientific evaluation of the initial training program in 1994 showed that mainly female suicide levels had dropped dramatically in the three years period after the educational intervention. After several years without repeated educational training, however, the effects of the program diminished. A renewed program was therefore set up in 1994 to restore and maintain the original educational effect. In this follow-up educational program the Gotland Male Depression Scale was presented and discussed, and considerable time was dedicated to the male, suicidal depression, its prevention, diagnosis, treatment and follow-up. Moreover, this information was presented at lectures to other medical specialties, other health care providers and the public as well as in the mass media.

The public response was astonishingly positive but came mostly from women who asked for help for their male family members and friends, as they clearly recognized features of the male depression and suicidality that had been described in the media (24, 32). Even if men rarely took contact directly they got often indirectly motivated to seek help and get their depressive and suicidal condition treated. A motivational trigger was often the threat for divorce, a destructive family atmosphere, a risk to lose a working place, the driving license, economic hardships etc. The result of this extended follow up education to all GPs as well as the public relation activities to extended sectors of the community was that the male suicides rates decreased for the first time on Gotland during the mid and late 1990s (32). Today, however, suicide rates on Gotland are again among the highest in Sweden. This is likely due to the discontinuation of the educational efforts due to lack of resources and personal as well as political engagement. Here, "the costs of doing nothing" become obvious and the need for continuous education in order to maintain the effects of such educational projects become evident.

The design and results of the Gotland study have initiated locally adapted successors e.g. in Jämtland and Stockholm (36), in the German "Nuremberg Alliance Against Depression" (NAAD/DAAD) (46), in a Hungarian training for general physicians in a high-risk area (Bács-Kiskun county), (47) and in suicide prevention projects in the UK, Ireland, Norway, Iran, Australia, the Philippines, Taiwan, Slovenia, Austria, Iceland, Russia and the Baltic countries. Thus, the Gotland Study today is recommended by the EU and WHO as a model in order to get locally adapted to suicide endemic environments in suicide preventive country work. Moreover, the GMDS is scientifically validated, translated into several languages and enjoys growing interest both nationally and internationally. It is used with good results as a screening instrument in both primary care, and in other healthcare facilities for detecting masked depression in addicts, among young acting out male and female youngsters, as well as in "Postpartum Depression" (9, 48-51).

Lessons learned: Male depression - Early Detection


In a WHO Study on 'Psychological Problems in General Health Care ", that was conducted including more than 25,000 primary care patients in 14 countries, it was found that only 15% of the patients with a diagnosis of major depressive disorder were recognized by their physicians (55). Although recent studies report an improvement regarding diagnostic knowledge regarding typical depression (56), the problem of identifying and treating the atypical male depression in health care still remains high. The challenge is to find these depressive and suicidal men, where they are and who they are, i.e. outside the usual supportive structures, not seeking help, dismissive, obstructive and denying. Features include also aggression and
self-medication through substance abuse or addiction equivalents, such as gambling, violence, sensation seeking, destructive and excessive exercise or being a workaholic or sexually hyperactive (32, 38, 49, 57, 59).

Even the design of our health care and support structures is rarely outreaching and motivational enough for these kinds of non-compliant and denying clients. Thus, treatment is often not practicable to these men that are hardly capable of living up to the routinely demanded criteria of insight, motivation, compliance and willingness to change that usually are the presupposed intake criteria to supportive and therapeutic outpatient services.
This also applies for these men's suicide proneness where after all windows of opportunity seem to exist. An extensive literature study in 2002 showed that people who committed suicide had significantly more contacts with primary care during the last year before their death (77%), than they had with the mental health services (32%) (60). Women sought hereby contact to a somewhat greater extent than men. If one only looked at the contacts with the health care during the last month before the suicide, the corresponding figures were 45% regarding primary health care and 19% for psychiatric care. Generally elderly people had more often contact with health care before their suicide, than younger people did. This applied for both sexes. Thus, the importance of addressing and involving primary health care in the diagnosis and treatment programs of depression and the prevention of suicides, again, is underlined.

What can be done?


By improving early diagnosis, intervention and follow-up of male suicidal depression, and by adequately applying the GMDS in addition to conventional diagnostic instruments in primary health care, the high suicide rates among men can be reduced. The use of the GMDS should go hand in hand with information to the patient and by the involvement of families, friends, partners and colleagues who are committed to the persons afflicted and their suicide problem. Because of the difficulties men often have to reporting depression, depressive feelings or depressive symptoms, an additional use of "the WHO 5 Wellbeing Scale" as a first useful screening instrument can be helpful. This scale is not asking for depressive symptoms but for criteria indicating more or less wellbeing in a way that even men with difficulties to verbalize feelings can answer. The WHO scale has been used in several large studies, and is a useful first step in identifying male depression, even in non-medical arenas (39, 50, 51).

Furthermore, a psychosocial therapeutic effort should be to challenge the often unrealistic self-image of conventional masculinity and self-determination, e.g. "always being strong", "always in control", never "crying or complaining" and "not showing emotions". Here, men's ability to develop the strength to ask for help in time could be increased by cognitive or other psychotherapeutic strategies that focus on this. Especially important seems to create therapeutic alliances initiated by specifically trained and motivated therapists that can support men with broken or lost identity, lost in the failure to cope with prevailing traditional masculine responses like showing strength and non-help seeking, captured in a weakness, that is not acceptable for them and losing their self-respect and dignity. These men need therapists who can respond with sympathy and understanding, empathetically accepting these men's rejection, denial, and sometimes aggressive, indecent and non-compliant behavior and a lack of gratefulness. Therapists may find it easier to help female clients, particularly as it is not always easy or possible to understand helplessness behind an aggressive and indecent male behavior.

New arenas of detection and support


Depressive men, often feeling narcissistically insulted and sometimes (self-) destructive and violent often generate huge problems for themselves and their next of kin. Due to their lack of help seeking ability they should be actively sought for, in order to prevent accidents, suicide, violence and risk-taking negligence. Conventional platforms for offering care and support are not enough. Other arenas for reaching this men, diagnosing them, treating them and get them motivated and compliant should be looked for. Potential venues are working places, social networks, friends and families, parishes, trade unions, social media, sports clubs and political organizations, but even aid organizations for veterans, drug addicts and e.g. the re- socialization of e.g. criminals. Strategies should mainly focus on motivation, awareness raising, training and capacity building outside the medical system.



Men's often suicidal depression is a huge societal problem due to its direct and indirect harmful consequences, but can- like that of women - be prevented and coped with. Early detection, treatment and follow-up is possible. The perceived unpredictability, helplessness and loss of self-determination associated with male suicidal depression can be dealt with. Moreover, deficiencies in existential and social cohesion and loss of status and respect experienced as a narcissistic humiliation can strategically be met. Person centered prevention, focusing on both individuals at risk as well as risk populations can be developed and good examples are existing.
In individual cases even an addition of active anti-depressive pharmacological interventions seems to have an effect on male depression and suicidal tendencies, if given in an empathic way and integrated in a holistic therapeutic approach. By this, a solution for one of our main public health problems could be found, with adherence, trust and therapeutic alliance, created in a person centered individually and locally adapted way embedded in a holistic and respectful approach.



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