The unexpected signs of depression in men

Sometimes depression, especially male depression, doesn’t look like what you think. If you have an image in your mind of someone who’s sad all the time, you’re only getting part of the picture. Depressed men are often angry, aggressive, or bored just as often as they’re melancholy—and they often fail to view such symptoms as signs of mental illness. For that reason, and others related to our public conception of manliness, male depression frequently goes undiagnosed and can be a serious problem for men of all ages.

Depression, also called major depressive disorder or clinical depression, is characterized by feelings of sadness or despair, suicidal thoughts, restlessness, and a loss of interest in things like work and family. But everyone’s situation is unique, and men and women can have very different-looking types of depression. Although depression affects 8.4% of adults in the U.S., according to the National Institute of Mental Health, for women, the rate is 10.5%. For men, who are less likely to seek help, it’s just 6.2%, a number that healthcare providers believe doesn’t reflect the true number of cases.

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Signs of depression in men vs. women

Depression for men and women can vary for a number of reasons. Women, in general, are more willing to talk about physical and mental health problems and express their emotions than men, so many women with depression seem sad. Men, on the other hand, are more likely to hide their emotions and may seem angry instead of depressed. Men may also be more likely than women to have difficulty sleeping. And while women who live with depression account for more suicide attempts, men are more likely to die by suicide because they use more lethal methods.

Common symptoms of depression in men and women 

To receive a diagnosis of depression, a person must show symptoms for at least two weeks. Common signs of depression include:

• Feelings of sadness or worthlessness
• Loss of interest in activities you once enjoyed
• Weight loss or gain
• Trouble sleeping or sleeping too much
• Fatigue and feeling tired
• Feeling worthless or hopeless
• Problems with concentration
• Suicidal thoughts or preoccupation with death
• Withdrawing from family and friends or becoming isolated

Male-specific symptoms of depression

“The major symptom of male depression is low mood. That can be explained away because it could be covered over by angry mood or irritable mood,” says Steven Korner, Ph.D., a licensed psychologist in New Jersey specializing in neuropsychological evaluations, depression, and other mood disorders. “Trouble sleeping or eating can be covered over very easily. So can trouble concentrating. And a lot of these symptoms can be covered over by people using substances. People may use a substance and then think that these symptoms are not a big deal.”

These additional symptoms of depression in men can be common:

• Anger, irritability, or aggressiveness
• Feeling anxious, restless, or on edge
• Problems with sexual desire and performance
• Engaging in risky behavior
• A need for alcohol or drugs
• Inability to meet the responsibilities of work, family, or other obligations
• Physical aches, back pain, headaches, cramps, or digestive problems

Ironically, physical symptoms can sometimes be a good thing, as men are more likely to seek medical attention for a physical ailment than they are for anything having to do with mental health.

RELATED: The link between mental and physical health

Types of depression

There are several different kinds of depression. For men, the most common ones are: 

• Major depression: Characterized by an all-consuming dark mood and a loss of interest in activities, family, and friends, major depression is the classic depression type. Symptoms can be so severe that they disrupt a man’s ability to work, study, sleep, eat properly, or enjoy life.
• Psychotic depression: In some cases, severe depression may be accompanied by delusions (fixed, false beliefs) or hallucinations (hearing or seeing things that aren’t really there). Usually, these psychotic symptoms have a depressive theme.
• Persistent depressive disorder: Also called dysthymia, persistent depressive disorder is a depressed mood that lasts for more than two years. People with this disorder may have episodes of major depression along with periods where symptoms are less severe.
• Seasonal affective disorder: People with seasonal affective disorder show symptoms in the winter months, when there is less natural sunlight. They may also sleep more, gain weight, or withdraw socially. This mental health condition usually gets better in the spring and summer but returns each winter.
• Minor depression: Someone with minor depression has symptoms similar to those of major depression or persistent depressive disorder, but the symptoms may be less severe or may not last as long.
• Bipolar disorder: The National Institute of Mental Health includes bipolar disorder as a type of depression, even though it differs from standard depression. Men with bipolar disorder have episodes of extremely low mood. This bipolar depression, however, may alternate with periods of mania, when they can experience extremely high moods that can be euphoric or irritable. 

What causes male depression?

Depression is one of the most common mental disorders in the world. According to the American Psychiatric Association, about 1 in 6 people (16.6%) will experience depression at some point in their lives, and physicians believe there are a variety of risk factors. 

Men with a family history of depression are more likely to develop depression themselves, suggesting genetic factors may have something to do with it. In older men, in particular, depression can often set in as a result of other health issues like diabetes, cancer, heart disease, or Parkinson’s disease, and the depression can often make the symptoms of those medical conditions worse. Medications taken for other health issues can sometimes cause depression as a side effect. 

Stress, trauma, major life changes, the loss of a loved one, or a difficult relationship can bring on depression for men and women alike, but financial problems and work problems may affect men more than women because of the stereotypes we often associate with each gender.

“The old cultural myth is that men are supposed to be the breadwinners,” says Korner. “They’re not supposed to have any weaknesses, and going to talk to a therapist is a way to show you’re not making it.”

Why is male depression often undiagnosed?

Research suggests that rates of undiagnosed depression are substantially higher in men than women, according to the American Journal of Men’s Health. A big part of the reason for that has to do with the way society sees men. That societal image of what a man is supposed to be—strong, stoic, able to deal with things on his own—can affect a man’s ability to recognize depression and seek help for it.

“Men are less likely to come forward about depression because there’s more stigma for men,” says William S. Pollack, Ph.D., director of the Centers for Men and Young Men and assistant clinical professor of psychology at Harvard Medical School. “Even with our more androgynous, spectrum idea of gender, we still have fairly dyed-in-the-wool views of masculinity, which include, in general, seeing depression as not just another medical illness, but also as a weakness.”

As a result, men are much less likely to talk to anyone about their low mood, let alone a complete stranger. It’s not considered “manly” or “masculine” to talk about your feelings, although this attitude has been changing in recent years. 

“It’s definitely gotten better,” says Pollack. “Oddly enough, during the pandemic it’s gotten better in a split way. A certain percentage of men are much more likely to come for help, and another percentage of men are less likely.” 

Attitudes about manliness can also make it harder for men to recognize that what they’re going through is, in fact, depression. Because sadness may not be their primary symptom, men often fail to make the connection between the symptoms they’re experiencing and their mental health. Headaches, digestive problems, and long-term pain could be physical signs of depression, as could fatigue, irritability, or overeating, but since they don’t involve being sad, they might not seem like depression. Men also tend to downplay their symptoms or cover them up with drug or alcohol use rather than seek proper treatment, which can lead to more severe problems, like substance abuse, over time.

When men do seek treatment for their symptoms, doctors often misdiagnose the condition. “Women are more over-diagnosed with depression. Men tend not to get help for depression, and when they do, they’re under-diagnosed,” says Pollack, “which is to say that, unfortunately, many of my colleagues in physical medicine, psychology, psychiatry, and mental health tend to under-diagnose depression even when men come for help with it.”

If you have any symptoms of depression that last for more than two weeks, talk to a healthcare professional, and they can give you a referral to a therapist. If you don’t want to bring it up to your doctor, talk to a family member or friend, but make sure you talk to somebody about how you’re feeling.

“Just talking to someone else can improve someone’s mood for a while,” says Dr. Pollack.

 If you are having thoughts of suicide or hurting yourself, call the National Suicide Prevention Lifeline at 800-273-8255 (TALK), or just dial the three-digit hotline at 988 to be connected with a mental health professional. Or, go to the nearest emergency room.

Treatment for depression in men

There is no complete cure for depression, but there are a number of effective treatments that can help reduce or eliminate symptoms. The most important thing is to start looking for help. That doesn’t necessarily mean immediately going to a therapist or getting a prescription. Often, a lifestyle change, more mindfulness, or simply getting regular exercise might be enough to improve your well-being.

“Exercise isn’t just to avoid depression,” says Pollack. “Exercise enhances endorphins, and endorphins enhance serotonin levels, and that’s exactly what happens when you take an SSRI (selective serotonin reuptake inhibitor, a class of commonly prescribed anti-depression drugs).”

“Self-help wellness techniques or strategies like meditation or relaxation exercises can be tried first, and those are things that most therapists will use in addition to talk therapy,” says Korner. “You do the most conservative thing first, and if that works, great. If it doesn’t, then, in a stepwise fashion, you ratchet up the degree of intervention.”

The right treatment plan for depression depends on the type of depression, how long it’s been present, your other health information, and, in the case of medications, your tolerance of side effects. Common depression treatments include:

Psychotherapy

Also known as talk therapy, psychotherapy can be an effective depression treatment. Common types of psychotherapy include:

• Cognitive behavioral therapy (CBT): Works to help an individual change negative thought patterns and provides practical steps for managing symptoms
• Interpersonal therapy: Looks at external factors, such as relationships, and their role as contributing factors to depressive symptoms. The therapist works with you to improve personal relationships and find ways to resolve conflicts.
• Psychodynamic therapy: Places emphasis on resolving past issues that might be contributing to negative behaviors and feelings
• Psychoeducation: Teaches you about depression symptoms, how to recognize early warning signs and steps to take before a relapse occurs
• Support groups: Can be led by a therapist or by someone who also has depression. During group therapy sessions, you can talk freely about your feelings and share experiences as well as practical ways to overcome negative emotions. 

Brain stimulation therapies

Your provider might suggest brain stimulation therapies if other treatment methods have not provided relief from symptoms. Brain stimulation therapies include electroconvulsive therapy, repetitive transcranial magnetic stimulation, and vagus nerve stimulation. They work by stimulating different areas of the brain. 

Antidepressant medications

There are several different classes of antidepressant medications, and each works to relieve symptoms differently. It can often take two to four weeks for you to begin to feel better, and it can take up to 12 weeks for the medications to be fully effective. Finding the right treatment may require trying a few different dosages and medications before you find the one that works for you.

Medications for depression target specific brain chemicals, called neurotransmitters, such as serotonin, norepinephrine, and dopamine. The most commonly used classes of drugs are: 

Selective serotonin reuptake inhibitors (SSRIs)

SSRIs target serotonin and are the most widely used medications for depression. Common SSRIs include:

Serotonin and norepinephrine reuptake inhibitors (SNRIs)

SNRIs increase the brain chemicals serotonin and norepinephrine. Common SNRIs include:

Serotonin modulators

Serotonin modulators are a class of drugs used as antidepressants as well. They work to increase serotonin along with minimal effects on norepinephrine and dopamine.

Atypical antidepressants

Atypical antidepressants are a class of drugs that affect multiple neurotransmitters, including serotonin, dopamine and norepinephrine. The most commonly used atypicals are:

Tetracyclic & tricyclic antidepressants

Tetracyclic antidepressants and tricyclic antidepressants (TCAs) were once considered a first-line treatment for depression, but are now mostly used for hard to treat or treatment-resistant depressive symptoms. These are less commonly used since they may have more side effects and more interactions with other medications. They work to increase serotonin and norepinephrine in the brain. The most commonly used are:

Monoamine oxidase inhibitors

MAOIs can have severe side effects, so they are rarely used. They should never be taken in combination with SSRIs and many other medications, as this can cause various drug interactions. These include:

 Work with your healthcare provider to find the medication that’s right for you.