By Stephen J. Johnson, Ph.D.
In Part I of my threepart series on depression titled, When Depression Turns Deadly: The Mask Men Wear, I focused more specifically on the hidden depression in men and how to recognize it before it ravages your life. The tragic loss of a loved one by suicide is often the end result of a life long battle with unremitting depression. Learn how to recognize the signs and treat the problem before it’s too late. In the second part, Depression in Men and Women: Recognizing and Understanding the Condition, I discuss the two main forms of depression, the causes and common symptoms of Major Depressive Disorder as distinguished from Persistent Depressive Disorder (Dysthymia), its occurrence in men and women, how depression can turn violent and what needs to be done to weatherproof your life as a hedge against the condition. In the third part of the series, The Ups and Downs of Depression: Treating the Disruptive Cycle that Turns Your Life Upside Down, I provide information on childhood Disruptive Mood Dysregulation Disorder, Bipolar and Cyclothymic Disorders, a self evaluation depression checklist, standard medical and alternative treatment modalities, and how to help yourself and others heal from the condition.
With an intention to provide some of the salient features of depression to help the reader to more readily recognize and distinguish the condition, I am synthesizing in some information from the Diagnostic and Statistical Manual of Mental Disorders (DSM) that is essentially the clinical bible that mental health practitioners utilize. The fifth edition of the DSM was published in 2013 and is a vital resource for understanding and diagnosing mental disorders. Since it is not my intention to provide a complete clinical analysis of the conditions mentioned herewith I recommend that for further and more in depth clinical information please refer to the DSM5.
Eleven million people are estimated as struggling with depression each year. The combined effect of lost productivity and medical expense due to depression costs the United States over 47 billion dollars per year a toll on a par with heart disease. And yet the condition goes mostly undiagnosed. Somewhere between 60 and 80 percent of people with depression never get help.
The National Institute for Mental Health reports that in the U.S. somewhere between 6 and 10 percent of our population close to one out of every ten people are battling some form of depression. Even allowing for increased reporting, each successive generation has doubled its susceptibility to depression.
Current estimates are that, with a combination of psychotherapy and medication, between 80 and 90 percent of depressed patients can get relief if they ask for it.
We all go through brief periods of depressed mood lasting from minutes to hours. It can be caused by any number of conditions or triggers i.e. illness, PMS, postpartum or menopause, lack of sleep, overindulgence, loss, hurt feelings, etc. We need to characterize whether the depressed state is one that will pass naturally or one that will hang around and even tend to recycle periodically. We need to determine whether the depressed state has arisen out of a reaction to something external or Exogenous or something internal or Endogenous.
Two Main Forms of Depression
An Exogenous Depressive State, for instance, may be triggered by an incident in which someone hurts your feelings. If you felt angry regarding the injustice and yet you don’t express the anger then you may be left feeling depressed. We would say that suppressed or repressed anger is essentially anger turned inward on the self and, therefore, the cause of the depression. Suppression is when one makes a conscious decision to withhold, while repression is when the decision is made unconsciously or below conscious awareness.
In the case of Exogenous Depression, when one gets clear as to what the issue is that caused the reaction and then determines the best way to remedy the problem and then takes action to solve it, the symptom of depressed mood typically lifts. This may require counseling or psychotherapy to facilitate one’s being able to learn to recognize the triggers and learn nonbelligerent ways of expressing oneself authentically.
Where depressed mood arises from an illness, partying too much or bereavement, for example, it usually passes within a normal amount of time following the onset of the stressor.
In the case of Endogenous Depression we must understand that it is a “whole body” illness. It affects the way you eat and sleep, the way you feel about yourself and the way you think. A depressive disorder is not the same as a passing blue mood. It is not a sign of personal weakness. People with depressive illness cannot merely “pull themselves together.” Without treatment, symptoms can last for weeks, months or years. Appropriate treatment, however, can help most sufferers.
Causes of Endogenous Depression
Several factors can contribute to the onset of Major Depressive Disorder (MDD). Often a depressive disorder is triggered by a combination of the following:
A. Genetic/biological factors: Some types of depression run in families, indicating that a biological vulnerability can be inherited. And major depression, whether inherited or not,
is often associated with an imbalance of certain chemicals in the brain called neurotransmitters. When there is a genetic predisposition to acquire the illness at some point in one’s life it is because typically one or more family members has experienced the disorder.
B. Psychological factors: People who are prone to depression often have low self esteem, consistently view themselves and the world with pessimism or are readily overwhelmed by stress.
C. Environmental factors: Depression can also be triggered by a serious loss, chronic illness, difficult relationship, financial problem or any unwelcome change in a life pattern.
The most recognizable symptoms include:
1. Persistent sad, anxious or “empty” mood
2. Feelings of hopelessness, pessimism, guilt, worthlessness or helplessness
3. Loss of interest or pleasure in activities that were once enjoyed, including sex
4. Insomnia, earlymorning awakening or oversleeping
5. Loss of appetite and/or weight, or overeating and weight gain
7. Thoughts of death or suicide; suicide attempts
8. Restlessness, irritability
9. Difficulty concentrating, remembering or making decisions
10. Physical symptoms that do not respond to treatment, such as headaches, digestive disorders or chronic pain
Occurrence of Major Depressive Disorder
MDD occurs as a combination of disabling symptoms that interfere with your ability to work, sleep, eat and enjoy activities. Episodes can occur several times in a lifetime, or
only once or twice. The essential feature of a Major Depressive Episode (MDE) is a period of at least 2 weeks persisting for most of the day during which there is either depressed mood or the loss of interest or pleasure in nearly all activities. An untreated episode typically lasts 6 months or longer, regardless of age at onset. In children and adolescents, the mood may be irritable rather than sad. The individual must also experience at least four additional symptoms drawn from the previously mentioned list.
The mood in a MDE is often described by the person as depressed, sad, hopeless, discouraged, or “down in the dumps.” Some individuals emphasize somatic complaints
(e.g. bodily aches and pains) rather than reporting feelings of sadness. Many individuals report or exhibit increased irritability (e.g., persistent anger, a tendency to respond to events with angry outbursts or blaming others, or an exaggerated sense of frustration over minor matters). In children and adolescents, an irritable or cranky mood may develop rather than a sad or dejected mood.
A familial pattern of MDD is 1.5 3 times more common among first degree biological relatives of persons with this disorder than among the general population. There is evidence for an increased risk of alcohol dependence in adult first degree biological relatives, and there may be an increased incidence of AttentionDeficit/Hyperactivity Disorder in the children of adults with this disorder.
Persistent Depressive Disorder (Dysthymia)
Persistent Depressive Disorder (PDD) is effectively an amalgam of DSMIV DysthymicDisorder and chronic Major Depressive Episode (MDE). The essential feature of this
type of depression is that it occurs for most of the day more days than not for at least 2 years. Individuals with PDD describe their mood as sad or “down in the dumps.” In children, the mood may be irritable rather than depressed, and the required minimum duration is only 1 year. During the 2 year period (1 year for children or adolescents), any symptom-free intervals last no longer than 2 months.
When symptoms rise to the level of a MDE, they are likely to subsequently revert to a lower level. However, depressive symptoms are much less likely to resolve in a given
period of time in the context of PDD than they are in MDE. Several studies suggest that the most commonly encountered symptoms in PDD may be feelings of inadequacy; generalized loss of interest or pleasure; social withdrawal; feelings of guilt or brooding about the past; subjective feelings of irritability or excessive anger; and decreased activity, effectiveness, or productivity. In individuals with PDD, vegetative symptoms (e.g. sleep, appetite, weight change, and psychomotor symptoms) appear to be less common than for persons in a MDE. In children, PDD may be associated with Attention Deficit/Hyperactivity Disorder, Conduct Disorder, Anxiety Disorders, Learning Disorders, and Mental Retardation.
In children, PDD seems to occur equally in both sexes and often results in impaired school performance and social interaction. Children and adolescents with this disorder
are usually irritable and cranky as well as depressed. They have low self-esteem and poor social skills and are pessimistic. It is traditionally believed that in adulthood,
women are two to three times more likely to develop PDD than are men. However, given the phenomenon of masked or “covert” depression in men, the incidence may more accurately be evenly experienced by both genders. It is more common among first-degree biological relatives of people with MDD than among the general population. In comparison to individual with MDD, those with PDD are at higher risk for psychiatric co-morbidity in general including anxiety disorders and substance use disorders in particular.
Uncovering Depression in Men and Women
Though there has been a common belief that depression affects women more than men, Terrence Real, in his book “I Don’t Want to Talk About It,” (Scribner) believes that depression affects men and women equally.
Until recently, there has been no formal clinical description for the numbing desperation that drives many men into what were once dismissed as midlife crisis. Real calls the “dark, jagged emptiness” that has plagued men for generations: covert depression. Refer to Part I of the series on Depression, When Depression Turns Deadly: The Mask Men Wear.
One possible reason that attention has been focused more on the lifelong illness of depression impacting men and women is that American baby boomers are now in the 48-68 year old age range. Issues of menopause, mood disorders and other midlife conditions are being given a closer look due to the fact that this generation has always been in the forefront of exploration and discovery.
For years, such leaders of the men’s movement as Robert Bly, Michael Meade, James Hillman and Robert Moore have warned men of the high price they pay for withholding their feelings. Whether the depression is expressed as a sleeping disorder, irritability, indecisiveness, a sense of worthlessness or recurrent thoughts of death, experts say the condition can be especially difficult to diagnose and treat in men.
By providing opportunities for men to be more open through therapy and with such consciousnessraising gatherings that contain rituals such as American Native Sweat Lodges, workshops, drumming circles, large and small group communication opportunities men can weatherproof themselves from debilitating conditions. Bly’s “mythopoetic men’s movement” has forged a trail for many men. The Sacred Path men’s retreats that the Men’s Center of Los Angeles has put on for 28 years have provided help and healing for many men and the women in their lives. Having a community of men to meet with can mitigate against the tendency for men to isolate, lose friends, suffer estrangement and wind up alone and lonely.
Studies at Stanford University of coping styles in men and women suggest that men are far less likely to handle depression by ruminating. That is, they focus less on their symptoms and tend not to try to understand or analyze them, says Dr. Susan K. Nolen Hoeksema.
For decades, students of human behavior have recognized that depression in men is often masked by other antisocial behaviors drinking, drugs, domestic abuse, workaholism. The sadness stays hidden. Unlike women and girls, who tend to internalize their pain and blame themselves for what’s wrong with their lives, men and boys are more likely to feel victimized by others, some psychologists contend.
“This is one major reason depressed men may strike out at their wives, their children, their coworkers,” Real says. “And if they can’t, they’ll find addictions to soothe the pain, selfmedicating with sex, gambling, booze, whatever.”
As far back as Aristotle, who reasoned that the coldness of life could be warmed by the heat of drink, poets and other writers have often penned the feelings they cannot articulate any other way. Henry David Thoreau was certainly in tune with the feelings of many of his gender, then and now, when he observed, “The mass of men lead lives of quiet desperation.”
Almost a century later, T.S. Elliot described another generation of numb men – men isolated even from themselves, men who needed understanding: “Remember us – if at
all – not as lost, violent souls, but only as the hollow men, the stuffed men.”
When Depression Turns Violent
Robert Bly has long supported the theory that men “inherit depression” from their fathers and, like Real and other therapists, believes that the rising incidence of domestic violence may reflect a similar increase in undiagnosed depression among men. A history of domestic violence has gone on under the radar for years but is finally being exposed now that the prevalence of hidden cameras and social media has proliferated.
Even though statistics reveal that the incidence of domestic violence among players for the NFL within the 24-29 age range is significantly less than for the general population within that age group, recent events have brought it out of the closet and into our living rooms for discussion. As the game becomes more physical and injurious the incidence and scope of domestic violence within the NFL has garnered our attention and now expanding to a wider vantage point. Within any context, it seems evident that depressed and battered women become trapped by their own depressed condition in nightmare relationships they cannot awaken from or escape. The cycle of violence perpetuates.
As an aside, it’s prudent to consider that with the preponderance of disenfranchised and depressed adolescent and young men in their 20’s around the world, those most
vulnerable to psychological, mental and physical harm including homicide and suicide, is it no wonder that the ranks of terrorist groups are filled and recruiting from this age group. Without a sense of meaning and purpose that one can accomplish something positive to enhance one’s own life and in turn, Humanity, it’s tempting to transform one’s depressed state into violent outrage against a perceived source or imagined cause of one’s despair. I wrote an article published in 1998 that you may find edifying: When Depression Turns to Anger.
Current research confirms that a vulnerability to depression is most probably an
inherited biological condition. With the right mix of chromosomes, any man – or woman – is susceptible. It is also wellknown that people with heart disease are more likely to be depressed than others. Robin Williams went through open heart surgery and then was diagnosed with Parkinsons, both carry their own collateral consequences constituting a depressed state. In the case of Williams, an exacerbation of an inveterate Bipolar condition.
Without treatment, it can be deadly. Statistics show that men kill themselves at least four times as often as women do. For too many, that is the first ~ and last symptom of their depression.
Weatherproofing for the Condition
Just as our weather patterns are growing more intense and unpredictable, the storms of lifecircumstances can also catch us off guard. Similar to the need to protect our external homes from potential onslaughts, it’s equally important to do the same with our internal abodes. Life is more demanding, if not daunting, presenting increasingly more urgent matters to consider, deal with and resolve. It’s time to be bold in the actions we take to weatherproof our lives.
“Thanks to a host of new therapies and cures … ” states biopsychiatrist Mark S. Gold in his book, The Good News About Depression (Bantam), “you couldn’t have picked a better time in human history to feel miserable. With a combination of psychotherapy and new psychiatric medications, between 80% and 90% of depressed patients get relief.” For men and women, getting an evaluation and appropriate treatment is most important. The first step in finding help is to undergo a thorough physical and psychological evaluation. The evaluation should include a complete history of symptoms when they started, how long they last, how severe they are, whether they have appeared before and what treatment has been given. The evaluation also should include a family medical history, including whether other family members have had a depressive illness and what treatments they received.
Recent research at the University of Houston has confirmed that marriage, for example, can protect many men from depression. The assumption is that close, reliable relationships are needed more by men than by women, who are more comfortable expressing pain and asking for help. Women maintain and sustain relationships and typically have a female support system through their entire life span. Men on the other hand tend to leave and lose relationships over time only to wind up with their marital partners and whatever family members that are present as they grow older. Single men are quite vulnerable as they age and at risk of becoming depressed or more depressed once into their 60’s. Men are 10 times more likely to commit suicide after age 65, especially following a divorce or death of a spouse.
“Depression in men,” Real proposes, “is in itself seen as unmanly and shameful. That can make it difficult for a therapist or physician to pronounce the diagnosis, to slap a patient with such an insult. Yet, once it is diagnosed, depression is the most treatable of all behavioral disorders.”
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