The Presenting Problem
When Mindy got into trouble, her mother, Sharon, came to me for help. Sharon took off from work to come to the appointment but her husband did not come. That in itself was not unusual. But Sharon reported that he was not interested in dealing with the problem and she was afraid to push him.
I kept these facts in the back of my mind as I explored the family history and listened to Mindy's hesitant description of her life at school and home. I wondered what role her parents played in her current problems. As I got to know the family better, I was finally able to convince her father to come with his wife for the benefit of their child.
Mr. P was a physically large man, with a quick smile and laid back attitude. He contrasted sharply with his wife, who was thin and tense. Mr. P denied any problems at home but a quick glance at his wife told me otherwise. Over time I learned that Mr. P was unemployed and had not worked consistently for many years. His wife worked full-time and was afraid to cut back because of the loss of benefits and the fear that they would need her salary to survive. Mr. P often overslept and left the morning routine to his wife, who was under pressure to get to work on time. She tried to get him moving but was afraid of his anger, especially in front of the children. He refused to meet with their Rabbi, although she had spoken privately to the Rabbi more than once about their situation.
Meanwhile, the P's maintained a charming social front. They attended family events, sent their children to mainstream schools and told no one outside of the tuition committees of their financial situation. Their families worried but expressed their belief that the situation would improve soon.
The P's started coming on a regular basis to aid in the treatment of their daughter and to discuss issues at home. They were caring, loving parents. But they struggled with more than financial problems; Mr. P was suffering from years of untreated depression.
Causes of Depression in Men
Mr. P's illness and the resultant family issues are unfortunately a common occurrence. Men are taught from a young age to suffer in silence. They are supposed to be strong and self-reliant, with their wives and children leaning on them for support. Their sense of duty compels them to produce at work, then come home and pitch in where needed.
What if a man cannot meet these expectations? The pressure to succeed may overwhelm him and engender feelings of low self-esteem and helplessness.
Joel heard through the grapevine that his company was merging with its competitor and that there would be massive layoffs. No one knew who would stay and who would be dismissed. He didn't want to worry his wife so he didn't say anything. But he would often awaken in the middle of the might feeling anxious and unable to sleep.
There are times when a man feels vulnerable or scared but does not want to admit it. He may feel unproductive or insecure at work; he may question his competence as a husband and father; or he may compare himself to his peers and find himself wanting. Nevertheless -by dint of his nature or societal expectations - he is unlikely to talk about his feelings. He feels that he should be able to solve all of his own problems. Needing help is viewed as a sign of dependency which, in turn, is seen as a weakness. If he has a problem, he tries to hide it.
Meanwhile, no one - not even his wife - understands what is happening. While she may want to talk about the situation, her husband avoids the discussion and resents being nagged about it. He is physically uncomfortable when pushed to discuss these emotional hotbeds. He dreads the possibility that the light will be shined on him and he'll be "found out." Indeed, trouble in marriage is consistently linked to depression in one or both partners.
Aging, in particular, challenges a man's feelings of self-sufficiency and can lead to depression.
Max was doing very well in retirement until his wife passed away. Then he began to withdraw. He didn't answer phone calls or invitations from old friends and began to lose interest in attending family celebrations. He neglected his hygiene and clothes, didn't care what he ate and became reticent and withdrawn.
Depression, it is important to note, is not a normal part of aging. On the other hand, the significant losses that occur in the twilight years are keenly felt and may trigger depressive symptoms. Hence, when an older man seems to lack energy or lose his appetite, he may be exhibiting signs of depression.
Finally, a man might think that he's just "in a bad mood" and will soon snap out of it. While it is true that everyone has times in their lives when they feel irritated or unhappy, depression is deeper and lasts longer. It becomes a thick cloud that darkens one's entire life. If the depression persists or intensifies, a man can be at risk for more serious complications.
Symptoms of Male Depression
Men who are depressed are more likely to talk about their physical state than their emotional or psychological one. They may visit their family physician, who focuses on their high blood pressure and unhealthy life style, but may not ask the questions that will yield clues to their emotional suffering. Their mental illness remains undetected.
Actually, the term "mental" or "emotional" illness is a misnomer. Depression is a medical disorder - just like diabetes and high blood pressure are medical disorders - that affects a person's thoughts, feelings, physical health and behaviors.
To complicate the picture, depression is often viewed as a "woman's disease." According to the Wall Street Journal (4/24/07), "twice as many women as men are diagnosed with depression, fueling the belief that depression is a woman's health issue." This imbalance in rate of identification may occur not because there is a difference between the genders in the prevalence of depression but rather in its manifestation. Early on, men who are depressed do not appear weepy and sad. Only in the more severe stages of clinical depression do men and women display similar symptoms.
How dare you wake me up! Don't you know that today is the only day that I can rest? Don't I work hard enough the rest of the week to give you everything that you want?
Unpredictable bouts of explosive anger are telltale signs of illness. These symptoms may or may not be signs of depression; only a licensed professional can properly diagnose the cause. But psychologists have observed that "(depressed) men are more apt to be irritable and angry - moods that aren't included in the classic diagnostic tests. Their sadness and helplessness are hidden behind a mask of anger." (Readers' Digest, January 2007, p. 132)
For this reason, many physicians now routinely screen their patients, both male and female, for depression. For example, one effective screen for depression consists of only two questions, as follows:
1. During the past month, have you often been bothered by feeling down, depressed or hopeless?
2. During the past month, have you often been bothered by little interest or pleasure in doing things?
A response of "yes" to either of these questions indicates the need for further exploration and possible referral to a mental health professional. Responses of "no" to both questions, without any conflicting evidence, significantly reduce the likelihood that the person is depressed.
Thus there are tools to detect depression in men. But, as with most illnesses, the signs that there is a problem often appear before a visit to a professional.
Increased education and awareness about its symptoms are the key to preventing the consequences of depression. A man's friends and relatives are in the best position to notice that something is wrong.
They may observe that he seems anxious and irritable, or unusually quiet and unable to talk about things. He may complain about vague physical symptoms or report that he is performing less well at work. He may feel tired all the time, appear unable to concentrate or make decisions, and express disinterest in being with his family and friends. He needs help.
Consequences
The risks of untreated depression are very serious. When a man is depressed his personal and professional lives suffer. In his quest for relief he may turn to other means to help himself. He'll plunge into his work, take an extra drink or two at meals and in-between, or look to food or drugs as a source of comfort. These ad hoc remedies lead to worse troubles. He may destroy the very relationships that he seeks to protect and cause irreparable damage and pain. He will also jeopardize his health.
A man who is depressed may have difficulty with concentration or memory. In a study published this month in the scientific journal of the American Academy of Neurology, those individuals who most often experience negative emotions such as depression were 40 percent more likely to develop mild cognitive impairment (MCI). MCI, which is characterized by short-term memory loss, can be a predictor of Alzheimer's disease.
Depression has also been linked to heart disease and strokes even when controlling for all other risk factors, such as cigarette smoking. Depressed men are at 80% higher risk of having "sudden cardiac death." Overall, men with depression are more than twice as likely as men without depression to die of any cause.
Equally frightening is the fact that suicide rates are four times higher for men than for women. Older men, age 65 and beyond, have higher rates of completed suicide than older women.
Hence it is crucial that men receive treatment for their illness. It is the job of our society to change its view of mental illness as a character flaw, sign of personal weakness, or lack of faith. Depression is not the same as sadness and a person cannot will himself or herself out of it. Depression is an illness that is real, that is treatable and that can be fatal.
Treatment
Do not ignore your spouse's moods and behavior. If he seems to exhibit any of the symptoms outlined above, be sure to discuss your concerns with a trusted health professional.
A referral to a mental health professional will lead to an evaluation as to whether the person is indeed suffering from depression as well as its level of severity. Either or both therapy and psychotherapeutic medication may be recommended. It has been found that certain types of therapy, such as cognitive-behavioral and interpersonal therapy, are highly effective means of treating depression. When medication is used as an adjunct, the patient is able to utilize all of his resources to learn coping skills that will strengthen him in the present and minimize or prevent future bouts of depression.
The sooner that a person obtains help, the better the outcome. This applies not only to each individual instance of depression, but also to the long-term prognosis. In general, the younger the person and the fewer the number of depressive events, the greater the likelihood that his treatment will be successful. Even when there is not a complete recovery, however, both medication and therapy are invaluable tools to minimize the suffering from this illness.
Finally, there are very important self-care strategies that men can undertake to help themselves. Many men are saddled with responsibilities. They are under constant pressure to perform - at work, at home, in their learning and in their relationships. As they continue to produce, day after day and year after year, it is not surprising that they end up neglecting their health.
So encourage your husband to set aside time regularly to engage in mental and physical activities that enhance his well-being. If possible, put the younger children to bed before he sits down to eat so that you may be able to join him. At the very least take walks together. Protect your time with each other; it is precious and too easily lost.
Increase your husband's awareness about the importance of healthy eating and sleeping habits. Persuade him to set realistic goals in all areas of his life. Then acknowledge and applaud him as he achieves each objective along the way.
Educate yourselves about depression; read and listen to the widely available material about this illness. Finally, seek treatment for him and, if needed, for yourselves as a couple. Don't allow depression to overshadow the joy of living.
Mona attended Barnard College and then continued on at Columbia University, where she earned two Masters degrees and a Doctorate in Psychology. Mona publishes the MFC Newsletter and contributes articles to family magazines, both online and in print. She speaks to women’s groups all over the country, introducing them to the benefits of coaching. Mona is a member of the International Coach Federation and the American Psychological Association. Visit her at http://www.myfamilycoach.com
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