Real Men Do Cry
Depression has no gender bias
By Susanne J. Pavlovich-Danis, RN, MSN, AMP-C, CDE
September 20, 2004
‘Don’t be a wimp” ... “Buck up” ... “Keep your problems to yourself — nobody wants to hear them” 85 “You’re the Man” ... “We’re counting on you.”
In the not so distant past, boys learned from toddlerhood on to suppress their emotions, project strength and confidence, and grin and bear it through all kinds of pain and sorrow. Parents, teachers, relatives, and peers reinforced the message. On the other hand, women were portrayed as the weaker sex needing the protection of strong, unwavering men. Not true today, we say, but beliefs and behaviors may not have changed as much as we think. Some of the major barriers to diagnosis and treatment of depression among men still include denial, social conditioning, family influences, and gender or cultural biases.1,2,3,4
Men who’ve experienced childhood abuse or neglect, for example, are just as likely as their female counterparts to experience depression and other disorders in adulthood. Unfortunately, they are less likely to be screened and treated for it.4 Women are much more likely than men to be diagnosed with and treated for depression.
Family conditioning may significantly affect the reluctance of men to acknowledge or seek treatment for depression. Although family members may play an important role in encouraging male relatives with symptoms of depression to seek help, this happens more frequently with women.3
Compounding the problem, the media consistently portray depression as uncommon among men. When advertisements from 1981 to 2001 journals that targeted to prescribing professionals were examined for gender bias, the face of depression was predominantly white and female. Fifty-seven percent of advertisements for psychotropic drugs examined featured women, and 88% of depressed individuals portrayed were white. The lack of male representation and cultural diversity in advertisements may contribute to reduced awareness of and screening for depression among men and minorities of both genders.5
Once men and women begin treatment, research shows both similar and different responses to antidepressants. For example, one study of 385 patients with major depression (139 men and 246 women) revealed gender differences in the prevalence and presentation of depressive symptoms, but no difference in the response to antidepressant medications.6 However, pharmacokinetics research also shows that culture and gender are associated with differing metabolic actions and tolerance for many antidepressants.2
Unipolar depression is less common among men than women. Likewise, hormonal changes at the onset of puberty are believed to be a significant factor for the gender variance in depression incidence.1
Outcomes, health conditions
Depressed men, unlike depressed women, experience more favorable outcomes after coronary artery bypass grafting (CABG) surgery7 and after admission for other cardiac conditions, such as acute myocardial infarction or congestive heart failure.8 Obesity is also less likely to be associated with major depression among men than women.9 However, the findings that men with comorbidities fare better than women should not diminish the importance of screening for and treating depression among men. Open dialogue with men and women is needed to facilitate diagnosis and treatment of depression. Another study of 460 patients with heart failure revealed depressive symptoms to be the strongest independent predictor of short-term decline in health status in men and women.10
Nurses must also pay close attention to male caregivers who, like women, have a high depression potential, especially when they are caring for someone with Alzheimer’s disease. Interventions that include counseling and support groups can reduce depressive symptoms among caregivers of either sex.11
Unexplained fatigue in men may be one way depression manifests itself. However, if the symptom persists after medication therapy is under way, evaluation for obstructive sleep apnea is warranted, especially in those with hypertension.12 Poor-quality sleep can result in psychological and physical manifestations that look like depression, and restoring a more healthy sleep pattern may help rule out that diagnosis. In addition, depression is an independent risk factor for ischemic heart disease and is often found among men after myocardial infarction.13,14
Sexual concerns
Erectile dysfunction and depression often occur together, possibly as a result of common risk factors, including age, diabetes, obesity, cardiovascular disease, and sedentary lifestyle. Without these or other physical problems, depression alone can be the cause of erectile dysfunction.
With three phosphodiesterase-5 inhibitor (PDE-5) oral agents for erectile dysfunction available and widely marketed in the media — sildenafil (Viagra), vardenafil (Levitra), and taldalafil (Cialis) — men are now seeking treatment for erectile dysfunction in record numbers. A reciprocal relationship is emerging in which treatment for erectile dysfunction improves underlying depression scores.15
Yet the reverse must not be overlooked. Thorough screening by clinicians before prescribing PDE-5 medications may reveal underlying depressive disorders that need to be addressed.
Treatment for depression, however, doesn’t always result in improved erectile function. Some medications used for depression actually interfere with sexual function and may ultimately lead men to refuse or discontinue treatment.14 Impotence and abnormal ejaculation have been reported with mirtazipine (Remeron) or venlafaxine (Effexor), and men who take trazodone (Desyrel) or nefazodone (Serzone) have experienced priapism. Men who take any of the SSRIs may experience decreased libido.16 Wellbutrin and other atypical antidepressants can affect libido less than Prozac, Paxil, and Zoloft, the commonly prescribed SSRIs. For anyone taking an antidepressant, careful monitoring with an eye toward the need for medication adjustment is the rule.
Desperately seeking ...
Instead of turning to a health care professional, some men who feel depressed will self-medicate with alcohol or illicit drugs. Excessive marijuana use is closely associated with a high incidence of depression.17 In others, impulsivity, violence, and problems with anger may signal depression, especially in youth: Angry young men may be seriously depressed young men — just undiagnosed.
Some men turn to alternative or complementary therapy to relieve their depression, and these choices have become increasingly more acceptable. Many fitness gyms and personal trainers also sport a variety of fitness-related supplements and services.
Some biological agents commonly used for depressed mood include hypericum perforatum (Saint-John’s-wort), s-adenosyl-l-methionine (SAMe), and 5-hydroxytryptophan (5-HTP).18 (See sidebar for precautions related to each of these biological agents.)
Other methods men may use to combat depression include exercise, relaxation therapy, yoga, tai chi, and biofeedback.18 Exercise promotes the release of natural mood-elevating endorphins. The benefits of yoga in reducing depressed mood and fatigue have been associated in one clinical study of 28 mildly depressed individuals with the development of higher morning cortisol levels.19
Nurses can help
Suicidal ideation presents a higher risk for men than for women. When men talk about suicide, pay close attention and seek immediate assistance, particularly if they have previously attempted suicide.
While women may talk about suicidal ideation more often, men use more violent methods and are more likely to complete suicide than women.20
It’s important to remember that depression is a treatable disease, and nurses must be vigilant and ready to intervene. Men may be less inclined to recognize, disclose, or seek treatment for the emotional and psychological components of depression and may be more inclined to complain of or seek treatment for physical symptoms that often accompany depression.
It’s crucial that nurses foster therapeutic relationships that encourage men to open up when telltale signs are present and encourage primary care providers to seriously consider the possibility of depression among their male patients.
Precautions with biological agents used for depression
Saint-John’s-wort
- Interacts with selective serotonin reuptake inhibitors (SSRIs) — fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), fluvoxamine (Luvox), citalopram (Celexa), escitalopram (Lexapro) — and causes lower levels of these drugs and the potential for a serotonin syndrome reaction
- Lowers serum levels of protease inhibitor drugs like indinavir (Crixivan), ritonavir (Norvir), nelfinavir (Viracept), and saquinavir (Invirase), potentially causing an increase in HIV viral load
- Lowers serum levels of warfarin (Coumadin), reducing the international normalized ratio
- Lowers the level of immunosuppressive agents like cyclosporine (Sandimmune), tacrolimus (Prograf), sirolimus (Rapamune), and daclizumab (Zenapax)
- Lowers serum levels of digoxin (Lanoxin)
- Lowers serum levels of certain anticancer drugs, including etoposide (VP-16) and teniposide (VM-26)
SAMe
- Potential for agitation
- Risk for mania in patients with bipolar disorder
5-HTP
- Potential for a serotonin syndrome reaction
- Sedative effect, which risks injury while driving and operating machinery. Dosing at bedtime is recommended to avoid daytime sedation.
References 16, 18
Susanne J. Pavlovich-Danis , RN, MSN, ARNP-C, CDE, maintains a private adult health practice in Plantation, Fla. She is also professor and area chair for nursing at the University of Phoenix in Fort Lauderdale, Fla.
References
1. Parker GB, Brotchie HL. From diathesis to diamorphism: the biology of gender differences in depression. J Nerv Ment Dis. 2004;192(3):210-216.
2. Harris PA. The impact of age, gender, race, and ethnicity on the diagnosis and treatment of depression. J Manag Care Pharm. 2004;10(2 Suppl):S2-S7.
3. Brommelhoff JA, Conway K, Merikangas K, Levy BR. Higher rates of depression in women: role of gender bias within the family. J Women’s Health. 2004;13(1):69-76.
4. Batten SV, Aslan M, Maciejewski PK, Mazure CM. Childhood maltreatment as a risk factor for adult cardiovascular disease and depression. J Clin Psychiatry. 2004;65(2):249-254.
5. Munce SE, Robertson EK, Sansom SN, Stewart DE. Who is portrayed in psychotropic drug advertisements? J Nerv Ment Dis. 2004;192(4):284-288.
6. Scheibe S, Preuschhof C, Cristi C, Bagby RM. Are there gender differences in major depression and its response to antidepressants? J Affect Disord. 2003;75(3):233-235.
7. Lindquist R, Dupuis G, Terrin, ML, et al. Comparison of health-related quality-of-life outcomes of men and women after coronary artery bypass surgery through 1 year: findings from the POST CABG Biobehavioral Study. Am Heart J. 2003;146(6):1038-1044.
8. Cheok F, Schrader G, Banham D, et al. Identification, course, and treatment of depression after admission for a cardiac condition: rationale and patient characteristics for the Identifying Depression As a Comorbid Condition (IDACC) project. Am Heart J. 2003;146(6):978-984.
9. Onyike CU, Crum RM, Lee HB, et al. Is obesity associated with major depression? Results from the Third National Health and Nutrition Examination Survey. Am J Epidemiol. 2003;158(12):1139-1147.
10. Rumsfeld JS, Havranek E, Masoudi FA, et al. Depressive symptoms are the strongest predictors of short-term declines in health status in patients with heart failure. J Am Coll Cardiol. 2003;42(10):1811-1817.
11. Mittleman MS, Roth DL, Coon DW, Haley WE. Sustained benefit of supportive intervention for depressive symptoms in caregivers of patients with Alzheimer’s disease. Am J Psychiarty. 2004;161(5):850-856.
12. Farney RJ, Lugo A, Jensen RL, et al. Simultaneous use of antidepressant and antihypertensive medications increases likelihood of diagnosis of obstructive sleep apnea syndrome. Chest. 2004;125(4):1279-1285.
13. Roose SP. Depression: links with ischemic heart disease and erectile dysfunction. J Clin Psychiarty. 2003;64 Suppl 10:26-30.
14. Rosen RC, Marin H. Prevalence of antidepressant-associated erectile dysfunction. J Clin Psychiatry. 2003;64 Suppl 10:5-10.
15. Webster LJ, Michelakis ED, Davis T, Archer SL. Use of sildenafil for safe improvement of erectile dysfunction and quality of life in men with New York Heart Association Classes II and III congestive heart failure: a prospective, placebo-controlled, double-blind crossover trial. Arch Intern Med. 2004;164(5):514-520.
16. Physicians’ Desk Reference. Thompson: Montvale, NJ; 2004.
17. Arendt M, Munk-Jorgensen P. Heavy cannabis users seeking treatment — prevalence of psychiatric disorders. Soc Psychiatry Psychiatric Epidemiol. 2004;39(2):97-105.
18. Lake J. The integrative management of depressed mood. Integrative Med. 2004;3(3):34-43.
19. Woolery A, Myers H, Sternleib B, Zeltzer L. A yoga intervention for young adults with elevated symptoms of depression. Altern Ther Health Med. 2004;10(2):60-63.
20. Skogman K, Alsen M, Ojehagen A. Sex differences in risk factors for suicide after attempted suicide — a follow-up study of 1,052 suicide attempters. Soc Psychiatry Psychiatr Epidemiol. 2004;39(2):113-120