Data on suicide attempts and completions clearly paint a grim picture for depressed men: depressed men complete suicide in very high numbers. Even if it is true that there are fewer men who suffer from a diagnosable clinical depression, there are many men who take their own and others’ lives and who must be in the throes of some kind of depressive disorder. This is especially troubling since men visit therapists’ offices less frequently than do women, and often will mask their depression through alcohol and substance abuse and other dangerous or distracting behaviors. This indirect or masked expression of depressive symptoms, including suicidal thinking and behavior, obscures the issue of suicide in a host of apparently unrelated concerns and complications.

Most persons with major depression who are at risk for suicidal behavior are undertreated. This is especially of concern when taken together with findings from one investigation that found that men who committed suicide had received less treatment than had women. Clearly, in addition to depression’s being undetected and untreated in men, suicide risk is underestimated and undertreated in men. Such a situation results in large numbers of depressed men being at greatly increased risk for suicide.

Data from suicide attempts and completions enables us to identify a number of risk factors, both historical and immediate, that increase the likelihood that a given man at a given time will commit suicide. This information, combined with the knowledge that depressed men are, by virtue of their sex, at increased risk for suicide, can assist in careful assessment of suicide risk in men.

Clinician Query — “I wish I had known.” The therapist mulled it over again and again. “What could I have done? Why didn’t I see this coming? Why didn’t I get him into a hospital? Why didn’t he tell me he was going to do this? I wonder if I should be practicing therapy?” All of these questions go through the mind of anyone who has been treating a patient who has successfully committed suicide. Even if it was known that a person had made previous attempts, that the problems were longstanding, and that one could not sit watch 24 hours a day with a patient, it is difficult not to find fault with yourself when it happens to you.

Drew was a ruggedly handsome 33-year-old married man who had struggled most of his life with identity difficulties. He had recently gotten married for the third time. Drew had dropped out of college in his sophomore year and never returned, though he often repeated that he wished he had. He had grown up in an affluent area but now lived in a lower middle-class neighborhood. In the past three months, he had lost another job and had again been bailed out by his father, a successful chief financial officer at a large corporation. His father had given him a large sum of money to pay his bills and “hold him over” until he was back on his feet again. This had been a typical pattern since he had dropped out of college. Drew described his wife during sessions as “really nagging” him about finding a good job so they could “get out of this dump” they were living in. His younger brother had recently become an executive with an established company, buying a house in the same affluent area in which his family had lived. Drew often commented that his life felt like a lot of pressures.

The following interchange occurred in the last session before he committed suicide by asphyxiation in the garage of his house.

“I wish I could finish something. I never seem to be able to hang onto jobs or relationships. It’s really discouraging.”

“This sounds like a broken record. You really want to do life differently, but somehow it’s hard for you to see yourself as other than a failure,” his therapist commented, having known Drew for four years in their therapy relationship.

“I know you’ve told me many times that life begins today and that I seem to sabotage myself with the negative self-talk. But it seems like I’m running in place. Dad bails me out as I look for another job. My wife is already getting on my case and we’ve only been married for six months.”

Drew paused and let out a deep sigh.

“You seem overwhelmed. Be honest with me. Are you having any of those suicidal thoughts or feelings?” his therapist inquired, knowing that Drew had a history of suicidal ideation and two attempts, one as a teenager and another in his midtwenties.

“I’m definitely feeling low. I don’t know if I’d call it suicidal. I do imagine that it would be easier for my family and my wife to live without me. I’m really tired of my own excuses for my lame life.”

“That sounds pretty desperate to me. Have you thought about how you might kill yourself?”

“Wow! I can’t believe you are asking me this. I haven’t given it much thought. I don’t think I have the guts to follow through with it. I can’t finish anything else, so I’m not likely to finish my own life in that way.”

“I’m still uncomfortable with the fact that you are feeling so low right now. Would you be willing to spend some time at the hospital for a few days voluntarily until some of these feelings pass?”

“I don’t think so. I’m not suicidal, just a bit depressed. Nothing worse than it has ever been,” Drew said, trying to convince his therapist that he could take care of himself.

“Okay. Would you promise me that you will call me if you feel like you want to take your life so we can talk? I’ll be here for you.”

“Don’t worry. I can take care of myself.”

As Drew left the office after his session, his therapist recalled that he felt uneasy but that Drew had sounded this way before and had always faithfully returned for his weekly therapy session. When Drew missed his next session, his therapist became alarmed and called his home. His wife told him that she had found Drew dead in their car in the garage. His therapist tried to keep his composure and strained to help her process her own feelings, but he was internally devastated. He resumed his own psychotherapy to sort out his competency issues that had been stirred up by his patient’s suicide.

•  What are the most serious risk factors for men who commit suicide?

•   How can a therapist minimize the probability that a patient will successfully commit suicide?

In light of men’s higher risk for suicide, careful assessment of suicide risk is essential when treating men for depression. This assessment of risk in men focuses on specifying the level of risk and identifying the contribution of any comorbid conditions that increase suicide risk in the context of male depression. These comorbid conditions include alcohol and other drug abuse, personality disturbances, and other serious psychiatric disorders, such as schizophrenia or bipolar disorder. After assessment of suicide risk is completed, appropriate interventions to minimize the likelihood that a man will commit suicide can be planned and implemented.

The foundation of accurate suicide risk assessment is the clinical interview. A number of authors have outlined various approaches to the assessment of suicide risk with adolescents and adults. Hendren (1990) offers specific interviewing and assessment strategies that are geared to the patient’s developmental level. Chiles and Strosahl (1995) recommend contextualizing the assessment process, depending upon whether the clinician is working within an assessment of risk context or within a treatment context in which suicidal risk arises. Within each of these contexts, Sommers-Flanagan and Sommers-Flanagan (1995) recommend five foci for assessment: severity of depression, suicidal ideation, suicide plans, capacity for self-control, and suicidal intent.

In addition to these considerations, assessment of both distal and proximal risk factors contributes to refinement in understanding the context of a given suicide risk assessment. Distal risk factors decrease the threshold for containment of suicidal action. These include depression, alcoholism, personal vulnerability to abandonment or loss, history of family violence, and an impulsive response tendency. Proximal risk factors act as precipitants for a suicidal act. These can include stressful life events, isolation, medical disorders, accessibility to firearms or medications, and alcohol or drug intoxication. Hall, Platt, and Hall (1999) found that severe anxiety, acute depression, recent relationship loss, alcohol or substance intoxication, hopelessness, insomnia, and medical illness, in descending order, were recent stresses or events most predictive of suicide attempts. The contribution of these and other proximal risk factors must be carefully assessed in any discussion of suicide with depressed men.

Table Assessment of Suicide Risk in Men outlines the essential elements of assessment of suicide risk in depressed men. A prerequisite for effective assessment is the rapid establishment of rapport with the patient. This is accomplished by a calm approach to the task at hand, an attitude of respect toward the patient, and an acknowledgement of the psychological pain and suffering of the patient. Establishing rapport with depressed, potentially violent, men may prove challenging for many therapists. Therefore, a thorough grasp of counter transference dynamics that might be activated when working in this context is important for any therapist to have.

TABLE  Assessment of Suicide Risk in Men

These symptoms include depressed mood; diminished interest or pleasure in daily activities; changes in weight and sleep patterns; psychomotor retardation or agitation; fatigue; feelings of worthlessness or excessive guilt; decreased concentration; and finally, thoughts of death and suicide. Coverage of each of these nine symptoms is best woven into an interview that ebbs and flows as the clinician inquires into the current life circumstances of the patient and the implications of thoughts of death and suicide.

Brief self-report inventories, such as the Beck Depression Inventory or the Beck Hopelessness Inventory, may be utilized for the purpose of obtaining a simple evaluation of the severity of the patient’s current mood disturbance. A patient-generated rating scale may also be utilized by asking the patient to rate, on a scale of 1 to 10, or even 1 to 100, the severity of his depressed mood. A rating of 1 would indicate minimal depression, while a rating of 10, or 100, would represent the most extreme feelings of depression that might cause the person to commit suicide. The self-rating gives both a quantitative and a personally meaningful self-assessment of how close the patient may be to a psychological state in which suicide would be not only thinkable but preferred.

The ninth criterion for assessing a depressive episode, thoughts of death and suicide, provides a convenient link to more direct and explicit exploration of these thoughts with the patient. It is common for persons suffering from depression to think of death and suicide. The clinician can evaluate the specificity of these thoughts. This will lead to an exploration of the patient’s contemplation of the method for committing suicide as well as the availability of the means to carry out the plan. In evaluating suicide risk, greater specificity of the method and availability of the means greatly increase the extant risk of the patient committing suicide. For men, as well as women, the use of a firearm is a significant risk factor. For men, the use of rope for hanging, the use of a car for asphyxiation, or the use of other means by which to poison or gas oneself are significant risk factors.

The assessment of the patient’s capacity for self-control examines current and past efforts to inhibit impulsive acting out as well as previous suicide attempts. The ability to inhibit self-destructive impulses and tolerate painful affective states is of paramount importance in the patient’s ultimate decision to choose to stay alive. Past suicide attempts, whether designed to end life or simply to call attention to the patient’s suffering, indicate an inability to inhibit the self-destructive impulse and are a significant risk factor. This is especially true if the patient reports that he was disappointed that his attempt to end his life had failed.

In addition to specific suicide attempts, the utilization of other acting out behavior to ward off painful affective states signifies difficulty in managing painful affect and may also signify increased risk. Examples of such behavior include going on a drinking binge after being rejected by a romantic partner, driving recklessly after being informed of a demotion at work, or getting into a fight at a bar after losing a sports event. These behaviors, while not directly intended to end one’s life, signify a weakness in the patient’s ability to contain and manage disturbing and painful affective states — a key capacity in weathering suicidal feelings.

Finally, within the context of suicidal feelings and thoughts, it is important to assess suicidal intent. Suicidal intent refers to the specific intent to act on a suicidal plan with the expected outcome that the patient would end his life. After questions regarding suicidal thinking and feeling have been explored, and as the interviewer is formulating a specific assessment of suicidal risk, a direct inquiry into the patient’s intention to follow through on the plan is recommended. This may take the form of a question such as, “Since we have been discussing the thoughts you have about ending your life, and the way in which you would do this, how likely do you think it is that you will actually act on these thoughts?” Such a question invites the patients to clarify for himself and for the interviewer the extent of his self-control and the degree to which the interviewer must be concerned about the patient’s safety. It is not unusual, in the context of evaluating suicidal intent, for a patient to exclaim, “Oh, I would never actually do it; it would be simply devastating to my wife and kids.” Such statements must be evaluated carefully and considered in the context of the interview and the patient’s involvement in his therapy. A statement such as this may actually refer to the inner capacity to resist such impulses and may lead the clinician to conclude that, at least for now, the patient is relatively safe. Such a statement may also be designed to deflect further inquiry into the area due to the patient’s serious and unresolved ambivalence about these feelings.

Clinician Query — “I feel like I’ve never been wanted in my life.”

Jerry was a large, 53-year-old divorced man with long hair, a beard, and prominent tattoos covering most of his body. He had been admitted to the Veteran’s Hospital because of a suicide attempt. Police had arrested Jerry for assault following an altercation at a rock concert in which Jerry had punched a security guard. While in jail, he had cut his wrist on a scrap of metal he had twisted from a spring of the bunk, and he had announced to the jailers that he was going to kill himself. Jerry was transferred to the Veteran’s Hospital after the jailer had discovered that he had been an ongoing patient in the outpatient psychiatry clinic and had been frequently admitted to the inpatient unit over the past 20 years.

Jerry had served in a combat unit in the Vietnam War, and had been the lone survivor of a platoon that had been ambushed. He came from an abusive family in which he and his two siblings were moved into group homes during adolescence. Jerry was married for a brief time, and has remained isolated since he was divorced. He was interviewed by a new therapist at the Veteran’s Hospital who had not had previous contact with him.

“What happened the other night, Jerry?” he asked.

“I just flipped out. I felt like a caged animal, and didn’t have any way to get out of there.”

“At the concert or the jail?”

“First, it was at the concert. I was just enjoying myself, smoking a doobie, when this security dude shined his flashlight at me. I smiled at him but he seemed really determined to get me so I tried to take off out of my seat. He must have called some other guys, because before I knew it there were two or three of them on me. I fought them but I got tried and the next thing I know I’m down at the city jail.”

“What were you thinking and feeling when you got to the jail?” his therapist inquired.

“I really thought I was going to die. I hate lockup. It’s so degrading. I just wanted to get it over with.”

“So you tried to kill yourself?”

“Yeah. I began cutting myself with this piece of metal I found sticking out of the bunk. I started bleeding, and the other guys in the cell started calling for the guards.”

“How does it feel to be here? Do you still feel like killing yourself.”

“It’s okay, to be here. I feel pretty safe. I always feel like there is a part of me that wants to die. Do you know what I mean?

“No, tell me about it,” requested his therapist.

“Well, it’s a long story. It’s like I never felt like I have ever really been wanted, so I’ve had to pretend my whole life that there was some meaning to things,” Jerry started.

“Never felt wanted by who?” his therapist followed.

“My parents. My teachers. My friends. Nobody. I thought that joining the army during the war would give me some purpose. I felt like I had nothing to lose. Man, was I wrong. Those frigging gooks killed all the guys I knew. It was like I finally had some friends. You had to trust these guys with your life, and then in a split moment, they were chopped liver.” Jerry stopped abruptly, stared straight past the therapist, and became mute for several minutes.

“What just happened?” his therapist asked when Jerry’s gaze returned.

“Oh. I can remember that day like it was yesterday. I still don’t know how I live through it. I really wished I hadn’t,” Jerry responded.

“Like you don’t deserve to be alive?”

“Yeah. I just wished God or somebody would get this over with already. Life is too much for me. Just put me out of my misery.”

•  What effect does early trauma and repetitive trauma have on the development of depression and suicidality in men?

•  What is the role of suicidal ideation in the psychodynamics of male trauma survivors?

Assessment of suicide risk invariably directs clinician attention to the management of suicide risk. Goals and strategies for management of suicide risk may vary, depending upon the context in which the clinician is functioning. Chiles and Strosahl (1995) outline two contexts in which management of suicide risk occurs: an assessment context and a treatment context. In an assessment context, specification of the level of suicide risk and the implementation of more immediate, shorter-term strategies to contain emergent suicide danger are emphasized. In a treatment context, analysis of the level of suicide risk is balanced with the strength of the therapeutic alliance and active decision-making regarding whether treatment would be best served in an outpatient or inpatient setting.

TABLE  Management of Suicide Risk in Men

Management of suicide risk will require the clinician to balance an ongoing assessment of the degree of immediate suicide risk with planning and implementing interventions designed to decrease immediate risk. A number of authors offer guidelines and recommendations for decreasing immediate suicide risk in the context of both assessment and treatment.

Several common factors are important as the clinician engages in managing suicidal risk (see Table Management of Suicide Risk in Men). First, therapeutic interventions to increase tolerance of depressive and painful affect are helpful in decreasing the intrusive and burdensome nature of severe depression. Second, strategies designed to limit access to means of committing suicide may interrupt the patient’s plans for committing suicide. Third, clinician activities that address other aspects of danger related to proximal risk factors, such as acute intoxication or active psychosis, minimize the negative impact of these risk factors. Fourth, the clinician can make efforts to increase environmental support systems where appropriate. And finally, bolstering the therapeutic alliance by increasing session frequency, offering between-session access, and the use of no-suicide contracts or agreements may increase the level of support felt by the patient.

In working with men, a number of therapeutic interventions may be geared toward increasing tolerance of painful depressive affect. Direct empathy and explicit affirmation of the therapeutic alliance may decrease feelings of isolation and palliate depressed mood. Cognitive therapy interventions that might be used include monitoring and rating level of depression, graded task assignments designed to alleviate depressed mood or increase positive mood states, and analysis and re-framing of cognitions related to depression.

At times, direct reality-testing or education-oriented interventions may be helpful. Such strategies are designed to undo the negative effect of male gender-role socialization and to assist in helping the man develop perspective on his emotional life. Male gender-role socialization views sadness and any display of depressive affect as unmasculine and undesirable. Direct statements that support the depressed man in his specific situation while “normalizing” his experience of depression may be helpful in increasing his capacity to tolerate depressed mood. The significance of simply responding directly to the man’s affective state can never by minimized when working with men in therapy. Existential approaches to treatment often will help engage the man in a frank and open discussion about his current predicament. This perspective also provides a linkage to direct assessment and discussion of the meaning of life and the option of suicide as a solution to the patients’s problems.

Another crucial aspect of therapeutic activity when managing suicide risk is effort designed to decrease access to means of committing suicide. Direct questioning has already helped the therapist gain information about the specificity of the patient’s plan and his access to the means of carrying out the plan. Empirical studies show that access to firearms is one of the most dangerous proximal risk factors that significantly increases the immediate probability that a man will commit suicide. Offering to hold a weapon or identifying other persons who might be enlisted to assist in such an intervention would be one appropriate therapeutic strategy to decrease or eliminate access to lethal means. It is generally not useful for the therapist to engage in a debate or power struggle with the man over who will assume custody of a weapon or how such risk will be managed. At times, the impossibility of resolving such debates signifies a level of danger that cannot be managed in the context of a typical outpatient treatment regimen. Such power struggles are often a means by which the patient externalizes his own ambivalence about staying alive. By engaging in such a struggle the patient is expressing his preference for the therapist to take action and help resolve his indecision.

While these strategies are helpful in the context of an established therapeutic relationship with the depressed man, additional therapeutic activity may be directed toward decreasing or diffusing the potential impact of proximal risk factors. In addition to decreasing access to lethal means by which to commit suicide, these activities include efforts to decrease social isolation, efforts to eliminate alcohol or drug use, interventions to manage emergent symptoms that might signify decompensation or psychosis, and continuing focus on treatment of the underlying mood disorder.

Additional clinician activity that might be directed to strengthening environmental supports includes enlisting family or friends to assist in the treatment plan as appropriate. Although often family relationships, or disrupted intimate relationships, may be a root cause of the man’s distress, identification of persons the man perceives as supportive will often decrease the intensity of immediate suicidal ideation or intent. Arranging for reduced work or school schedule until the suicidal phase has passed may also be an appropriate support for the clinician to offer.

Within the context of a therapeutic relationship in which suicide risk management emerges, a number of strategies may be enlisted by the clinician to strengthen and bolster the therapeutic bond with the patient. First, the therapist can increase the frequency of session contact. Moving session frequency from one time per week to twice or thrice weekly will often assist in containment of suicidal impulses between sessions. In extreme cases, daily sessions may be required until an immediate crisis has passed. In addition, the therapist can invite extra-session phone contact, or “check-in” calls if extra sessions are not possible. Electronic mail could also be considered as a short-term means of checking in with the therapist. Finally, simply allowing the patient to come to the office and sit in the waiting room if this would result in a greater sense of connection to the therapist would be warranted. Of course, the extent to which such strategies might provide untoward disruptions in the therapeutic framework must be considered. However, it is always important to balance a rigid adherence to the “ground rules” of therapy with those compassionate efforts designed to help a patient “over a hump,” so that he can continue and benefit from the ongoing therapy relationship. After all, a dead patient is a treatment disaster in any orientation to therapy.

If a man is unable to cooperate in creating conditions that will assure his own safety, hospital treatment may be warranted. This is always a difficult decision for a clinician to make, since it creates disruptions in the man’s life and is often extremely costly financially. However, there are often situations in which the safety of a controlled hospital environment is required to assure the patient’s safety. Several factors must be taken into consideration when assessing a depressed man for hospital versus outpatient treatment. First, and foremost, is the level of suicide risk. Obviously, the risk must be high and immediate. Often, this involves strong suicidal ideation, the presence of a plan, the means to carry out the plan, and the intent to take action.

Other factors that increase the immediate risk of suicide and that should be taken into consideration when making decisions about hospital treatment include absence of social support networks, acute intoxication with alcohol or other mood-altering substances, active psychosis, and inability or unwillingness to cooperate with a treatment plan. Each of these factors, taken in isolation, may not trigger the decision to utilize a hospital environment. However, more than one in conjunction with a high level of suicide risk should alert the clinician to the possibility that hospital management might be more appropriate than outpatient management.

I could feel the tears within me, undiscovered and untouched in their inland sea. Those tears had been with me always. I thought that, at birth, American men are allowed just as many tears as American women. But because we are forbidden to shed them, we die long before women do, with our hearts exploding or our blood pressure rising or our livers eaten away by alcohol because that lake of grief inside us has no outlet. We, men, die because our faces were not watered enough.

Biological factors have long been known to play a role in depression in both men and women. Spurred primarily by the recent development of antidepressant medications with relatively few side effects, psychopharmacologic treatments for depression have become the norm for men presenting with complaints of depression. This increased use of medication for depression has also been driven by two additional forces. First, insurers believe that providing antidepressant medication is more cost effective than providing psychotherapy, either alone or in combination with medical treatment. Second, the frequent prescribing of antidepressant medication by family physicians and internists, who actually treat the majority of cases of depression, also contributes to the increased use of medications to treat depression.

Psychopharmacologic treatment of men is generally considered less complicated than similar treatment of women for several reasons. First, with males, there are no concerns regarding possible medication effects on pregnancy or breastfeeding. Though it is possible that psychotropic medications may be teratogenic in the sense that they may increase the risk for chromosomal abnormalities in the sperm of men exposed to them, there have been no data supporting this conclusion. At present, there are no antidepressant medications which are considered to be teratogenic when used by males.

Second, though there is some controversy about the possibility that men may experience clinically meaningful hormonal cycling, there is as yet no evidence supporting this position. Thus, treatment issues which might parallel those involved in treating women at various phases during their menstrual cycles are not present. There is as yet no validated male equivalent to what the Diagnostic and Statistical Manual of Mental Disorders has labeled “Premenstrual Dysphoric Disorder” in women. Additionally, though there is some evidence that there are changes in male sexual hormones that may be associated with aging and depression, there are no clinical phenomena in males that are similar to the climacteric in women.

Though depression is diagnosed more frequently in women, men are typically overrepresented in drug treatment trials for depression, particularly in the early phases of testing, in large part because there are fewer factors which may complicate treatment response and because of the lack of potential for teratogenicity. Empirical data supporting the efficacy of antidepressant medication in men is, therefore, abundant and compelling.

There are two facts that serve as the foundation upon which the pharmacologic recommendations in this chapter rest. First, there is no evidence that there is any differential treatment response to pharmacologic interventions when men and women are compared. In other words, men and women respond at equal rates across all antidepressant medication treatments. Given the extensive literature regarding antidepressant medications, it is unlikely that any differences will be detected in the future.

Second, despite the claims made by different pharmaceutical companies, there is no evidence that any of the antidepressant medications is superior in treating depression. Head-to-head comparisons of antidepressants and parallel comparisons to placebo treatment across studies have all demonstrated approximately equal response. As a caveat, it is important to realize that there is also a relatively large placebo response rate for patients with major depression.

Clinician Query — “I’m concerned about my sexual performance.”

Jon, a 35-year-old male, presented with a 4-week history of depressive symptoms, which had worsened over time. Prominent among his symptoms were insomnia, decreased appetite, anhedonia, and poor concentration. He denied suicidal ideation. He reported a decrease in libido that had also worsened over the last month. No other sexual dysfunction was reported. He reported no previous psychiatric history, but had been in counseling for ongoing marital problems intermittently in the past.

Family history was significant for alcohol abuse and depression in the patient’s father, though the patient denied any substance abuse himself. He reported that his father had been successfully treated with fluoxetine several years ago, though his father had been only sporadically compliant with the medication after recovery. The patient reported no medical problems and he was not taking any other medications. On exam, he appeared depressed in mood and affect, but did not appear to be particularly anxious or have any psychomotor disturbances.

Because of the positive family history of response to fluoxetine, he was started on a dose of 20 mg per day. The patient returned two weeks later stating that he was experiencing some improvement in mood and concentration and noted that, as his mood had improved, he had experienced some increase in his sexual interest. He noted that on one occasion, however, he had experienced some difficulty in achieving orgasm. Both the patient and his clinician agreed to continue with the same dose of fluoxetine.

Two weeks later, the patient reported that his mood had returned to near normal levels. Despite the improvement in sleep, appetite, and mood, however, he noted that his libido had decreased to pretreatment levels, and that he continued to have ejaculatory problems that were worsening. In particular, he noted that, on two occasions, he had been unable to come to climax during intercourse, and appeared to be quite distraught about this. He also reported that his wife was dissatisfied with their sexual relationship.

Several options were discussed, including switching medications and adding another medication on an as-needed basis to counteract the effects of the fluoxetine. Since he had a good response to the fluoxetine, it was agreed that he would attempt a reduction in dose with close monitoring of any sexual side effects. At his next appointment two weeks later, the patient reported that though his sexual functioning appeared to be improving, his depression had worsened, with a decline in sleep and appetite once again.

A decision was made to switch to a different medication at this point. Buproprion was chosen because of the evidence suggesting that it likely has fewer sexual side effects. After a week of continued decline, the patient noted improvement in his depressive symptoms thereafter. His sexual dysfunction also continued to diminish, and four weeks after switching medications, he reported no sexual problems. He continued on buproprion for another six months without sequelae.

•  What are some of the common sexual side effects associated with antidepressant treatment for depression in men?

•  What considerations should be given to decision-making regarding choice of antidepressant medication for men?

Antidepressants And Depression In Men

Testosterone And Depression In Men

Summary

Studies that examine the efficacy of psychopharmacological treatments for depression indicate that men, as well as women, respond well to all classes of drugs. Recently developed antidepressants, the selective serotonin reuptake inhibitors, have demonstrated efficacy when used to treat depression in men. Clinical reports of possible sexually related side-effects that include decreased libido and erectile dysfunction make careful assessment of sexual functioning important. Matching of possible side-effects with desired symptoms targets is often useful in deciding on a medication to prescribe for treating depression in men.

In addition to the use of the common antidepressant medications, the use of testosterone to treat depression in men has been studied and shows some potential. However, clear indications for the use of this and other hormones in the treatment of depression are not clearly defined. Therefore, the use of testosterone or other sex hormones for the treatment of mood disorders in men must be considered very carefully in light of the fact that other efficacious psychopharmacological treatments are available.

Though the population-based data demonstrate equal response to antidepressant medication, there are, of course, compelling reasons to choose a particular medication for a given individual. Primary among predictors of depression remission is previous response to a medication — if a patient has done well before with particular medication, then it should obviously be the first choice should a new episode of depression occur.

A family history of response to a specific antidepressant medication is also a response predictor, and a reason to make that agent a first-line choice for the treatment of depression.

In most cases, however, notably those of new onset depression, there is often no history of either personal or familial response. In these instances, considerations such as ease of administration and potential interaction effects with other medications or medical conditions are important in rational prescribing. The next section of this chapter, however, will be devoted to what is probably the most compelling factor in making a prescription decision: the side-effect profile of the medication.

Numerous texts have been written regarding the side effects of antidepressant medications, and much of the advertising of pharmaceutical companies focuses on the lack of side effects of their particular medication. Though side-effect profile in general should obviously be considered when choosing an antidepressant, there are several side effects that are specific to men, which should be considered by both clinicians and their patients. With males, these are related to sexual functioning, and include changes in libido, erectile dysfunction, and anorgasmia or delayed ejaculation. Table Antidepressant-induced Changes in Sexual Functioning in Males summarizes the potential antidepressant-induced side effects related to sexual functioning in men.

Antidepressant-induced Sexual Side Effects: General Considerations

Untreated affective disorders have long been known to be associated with impaired sexual functioning. Successful treatment of the depression has been shown to result frequently in improvement in or a return to normal sexual functioning.

TABLE  Antidepressant-induced Changes in Sexual Functioning in Males

Because of this, differentiating sexual impairment due to depression from that which may be caused by medication is often very difficult. The clinician is obligated to take a very careful history. Often, the time course of changes in sexual functioning can help determine whether it is a primary symptom of depression or due to medication. Cases in which sexual functioning is initially impaired, and continues to be so even after medication treatment has brought about resolution of other neurovegetative symptoms, may also make determination of the cause of impairment difficult. In addition to depression, many other factors that may cause sexual problems which must also be considered. Table Antidepressant-induced Changes in Sexual Functioning in Males outlines some of the potential causes of sexual dysfunction in depressed men.

Another factor that profoundly affects the diagnosis and treatment of sexual dysfunction during depression is the effect of the source of the report of the symptoms. The incidence of sexual problems spontaneously reported by patients during clinical encounters is dramatically less than that reported when patients are directly questioned about sexual problems. Monteiro, Noshirvani, Marks, and Lelliott (1987), in a study evaluating the sexual side effects of clomipramine, a tricyclic anti-depressant used for both depression and obsessive-compulsive disorder, found that while only about one-third of patients with obsessive — compulsive disorder spontaneously reported sexual problems, 96% of patients reported becoming anorgasmic on the medication when directly queried about sexual side effects. Similarly, Montejo, Liorce, and Izquierdo (1996) reported that sexual dysfunction was spontaneously reported by about 2-7% of depressed patients treated with selective serotonin reuptake inhibitors as compared to 55% of patients who reported such symptoms on direct questioning.

It is also extremely important when considering sexual side effects to recognize that patients who are receiving placebos in medication trials typically report significant rates of sexual dysfunction.

TABLE Causes of Sexual Dysfunction in Depressed Men

Though sexual functioning is multidetermined, and is highly correlated with many psychological factors, reports of changes in sexual functioning may be widely reported by patients receiving placebo because of the subjective nature of many of the complaints. Thus, the calculation of rates of sexual dysfunction due to medication should include the rate reported by patients taking the medication less the placebo rate. Most calculations are simply estimates based on small, retrospective series. The bias towards reporting adverse effects of medication also influences the estimates of incidence rates adversely. In sum, the rates of sexual dysfunction induced by antidepressant treatment are unknown.

Antidepressant-Induced Changes in Libido

Almost all of the antidepressant medications have been reported to have an effect on libido in males. These include the monoamine oxidase inhibitors (MAOIs — phenelzine and tranylcypromine), tricyclic antidepressants (TCAs — amitriptyline, imipramine, desipramine, clomipramine, nortriptyline), the selective serotonin reuptake inhibitors (fluoxetine, paroxetine, sertraline), as well as the newer generation antidepressants such as venlafaxine and citalopram. Both buproprion and trazodone have been reported to increase libido above predepression levels, in some cases. However, the prescribing information for buproprion indicates that libido was reported as decreased in about 3% of patients receiving the medication and in about 1.5% of patients receiving placebo, while the reported rate with trazodone was about 1% with a less than 1% report by patients receiving placebo. It has been the experience of the author that, although rare, depressed males treated with the selective serotonin reuptake inhibitors may also report increased libido.

The incidence of sexual side effects in comparison to placebo are typically reported for all phase III medication efficacy trials, along with information about all other side effects which are spontaneously reported. The prescription inserts for most antidepressant medications report decreased libido in approximately 2-5% of patients, and a placebo rate of about 1%. There have been very few placebo controlled studies comparing the sexual side effects of antidepressants. In one study comparing imipramine and phenelzine, Harrison, and Morris (1986) found that decreased libido was reported on direct inquiry in about 30% of patients taking phenelzine and about 20% of patients treated with imipramine, as compared to 10% who were taking a placebo.

With the data that is available at present, the incidence of antidepressant-induced changes in libido is not clear. Based on efficacy trials of antidepressants, the incidence appears to consistently be in the range of 2 — 5%, with an incidence of about 1% related to treatment with placebo. In contrast, studies in which sexual side effects are specifically evaluated have reported much higher rates. What is clear is that for some patients, decreased libido is a substantial problem that warrants either a change in medication or some other type of intervention.

Management of antidepressant-induced decreased libido requires close clinical consultation with the patient being treated. During the evaluation, close attention must be paid to the time course of the development of the dysfunction — libido problems which develop after the initiation of the medication and which persist for several weeks during treatment can be considered to be due to the medication. It is also crucial to work collaboratively with the patient regarding possible treatment options. Some patients, despite a decrease in libido, will opt to continue the antidepressant medication if it has otherwise been effective rather than risk the return of depressive symptoms with a drug holiday or a switch to another medication. Patients who opt to continue with the same medication should be assured that all data suggests return of sexual functioning to baseline once the medication is stopped.

There are several options for those patients who do not wish to continue the same antidepressant. The most obvious is to switch from the antidepressant suspected of causing the libido problems to one in another class. There is some evidence that buproprion may be associated with a lower incidence of decreased libido, making it a reasonable choice in such cases. Two open-label studies involving a switch from either a variety of antidepressant medications or from fluoxetine to buproprion noted an increase in libido with buproprion for those patients who had complaints on their initial antidepressants. Another small study of patients switched from sertraline to nefazodone also noted improvement in libido, suggesting that nefazodone may be associated with fewer libido problems.

Several other recommendations have been made regarding treatment of the decreased libido. The use of 7.5 to 15 mg of neostigmine prior to coitus has been reported to restore libido in some cases, and yohimbine has also been recommended and has been shown to be of benefit in an open trial.

One last option is to plan a drug holiday. However, careful consideration should be given to stopping antidepressant medication given the morbidity associated with depression. In addition, the rather lengthy half-life of many of the newer antidepressants would suggest that a rather long drug holiday would be required before sexual functioning normalized. Moreover, the provision of drug holidays may undermine the physician’s message to the patient that daily compliance with medication is needed to treat depression. Given these risks, the weight of evidence at present would suggest that, for those patients who cannot tolerate a change in libido, a switch to another category of antidepressant medication, particularly buproprion or nefazodone, is indicated. Table Management of Antidepressant-Induced Sexual Side Effects summarizes recommendations for the management of medication-induced sexual side effects.

Antidepressant-Induced Erectile Dysfunction

Historically, the TCAs have been anecdotally associated with reports of erectile dysfunction in depressed males. As with changes in libido, however, case reports abound for nearly all of the antidepressant medications, including imipramine, desipramine, nortriptyline, amitriptyline, fluoxetine, paroxetine, sertraline, trazodone, doxepin, and venlafaxine. As with impairment of libido, erectile dysfunction can also be a symptom of depression, making it difficult to distinguish drug effects. A careful review of the time course of the problem will usually identify the cause.

TABLE  Management of Antidepressant-Induced Sexual Side Effects

The incidence of antidepressant-induced erectile dysfunction is not known. Data from efficacy trials of antidepressant medications suggest that it is fairly infrequent — while case reports are found frequently, erectile dysfunction is rarely reported as a side effect in efficacy trials, meaning that it does not surpass the threshold of 1% incidence during either antidepressant or placebo treatment. Data from the few studies that have specifically examined erectile dysfunction also suggest that the incidence is low. A double-blind, placebo-controlled study of imipramine and phenelzine found minimal evidence that either medication interfered with erectile function. In a double-blind study using nondepressed volunteers, amitriptyline and mianserin (the latter is not currently available in the United States) were found to slightly decrease the magnitude and duration of nocturnal erections as measured by penile tumescence, but there was no reported difference in waking sexual functioning in the exposed subjects.

Treatment options for patients experiencing antidepressant-induced erectile dysfunction are similar to those for decreased libido. There is some evidence that buproprion may be a reasonable alternative antidepressant: a clinical series found that patients who were receiving a variety of antidepressant medications who reported erectile problems reported resolution of the problems with substitution of buproprion. Bethanechol taken prior to intercourse has been reported to be of benefit, though its use has not been empirically evaluated. The available evidence suggests that switching to a different class of antidepressant medication is the best course, and that buproprion may be associated with a lower incidence of erectile dysfunction than other antidepressants (see Table Management of Antidepressant-Induced Sexual Side Effects).

Antidepressant-induced Anorgasmia and Delayed Ejaculation

Although anorgasmia can certainly be induced by antidepressant medication, it is probably more accurate to speak of delayed orgasm, or more specifically in men, delayed ejaculation, than of complete absence of orgasm. Much attention has been given to this issue in the medical press — the selective serotonin reuptake inhibitors in particular have been associated with this side effect. As with other antidepressant-induced sexual side effects, the true incidence of delayed ejaculation is not known. Rates vary greatly, depending on the method by which reports about side effects are elicited. Anecdotally, however, delayed ejaculation does appear to present a greater clinical problem than either loss of libido or erectile dysfunction.

Case reports have suggested all of the selective serotonin reuptake inhibitors are associated with delayed ejaculation. From these case reports, it has been estimated that up to 30% of patients taking an selective serotonin reuptake inhibitor will experience problems with ejaculatory delay. The validity of establishing incidence from retrospective cases, however, makes the estimates of side effect incidence with the selective serotonin reuptake inhibitors suspect. In contrast, the Physician’s Desk Reference (1999), reporting information from efficacy studies in which patient self-report was used to determine the incidence of treatment-emergent side effects, reports an incidence of less than 1% (comparable to placebo) for depressed patients and 7% for obsessive-compulsive patients treated with fluoxetine; 7% for depressed patients and 17% for obsessive — compulsive patients treated with sertraline, and 1.6% for depressed patients and 2.1% for obsessive — compulsive patients receiving paroxetine. Though it is likely that the selective serotonin reuptake inhibitors are associated with a much higher incidence of ejaculatory problems than the TCAs, case reports of such side effects have also been published regarding the use of amitriptyline, desipramine, and nortriptyline. Doxepin and trazodone have also been implicated.

Two additional lines of evidence exist, however, which strongly suggest that the selective serotonin reuptake inhibitors are associated with delayed ejaculation The TCAs (with the exception of clomipramine) have not been systematically studied in the same fashion. In addition to controlled studies of sertraline, several of the selective serotonin reuptake inhibitors have been evaluated as treatments for premature ejaculation, lending credence to their ability to induce delayed orgasm.

Several controlled studies have been conducted in which the sexual side effects of antidepressant medication were evaluated. Harrison and colleagues compared imipramine and phenelzine over six weeks. Questionnaires about sexual functioning were administered prior to treatment and at the end of the treatment trial. Delayed orgasm was reported by 21% of the men taking imipramine, and by 30% of the men taking phenelzine; none of the men taking placebo reported problems.

Sertraline was compared to nefazodone in a controlled double-blinded study of depressed patients. Sixty-seven percent of the men taking sertraline reported emergence of delayed ejaculation with treatment on direct questioning, while there appeared to be no increase in incidence with nefazodone. There was no difference, however, in the reported incidence of changes in libido or erectile functioning. Another study of men with orgasmic problems while taking sertraline assigned patients in double-blinded fashion to either sertraline or nefazodone for eight weeks. Seventy-one percent of patients who continued on sertraline reported continued delayed ejaculation, while only 30% of those who switched to nefazodone reported such problems. Sertraline has also been used to treat premature ejaculation. No controlled trials examining the sexual side effects of fluoxetine and paroxetine have been conducted; however, both have been reported to be beneficial in the treatment of premature ejaculation.

While the true incidence of ejaculatory delay with antidepressant treatment is unknown, it is clearly a clinically significant side effect of the selective serotonin reuptake inhibitors and may occur, though likely less frequently, with other anti-depressant medications as well. In the author’s experience, it is a significant, though not highly prevalent, problem which is spontaneously reported by male patients much more frequently than either decreased libido or erectile dysfunction.

In addition to switching antidepressants, several other treatment strategies have been reported in the literature. There have been some reports of tolerance developing with some of the antidepressants and the effect on ejaculatory dysfunction may be dose related. Several reports have noted that decreasing the dose of medication may be effective in relieving anorgasmia.

There have been several medications that have been used to counteract the delayed ejaculation associated with antidepressant medications. Cyproheptadine at 4 — 8 mg prior to coitus has been reported to be of benefit for patients taking clomipraine, nortriptyline, imipramine, tranlcypromine, fluoxetine, fluvoxamine, and citalopram. Yohimbine at 5.4 to 10.8 mg 1 — 32 hours prior to coitus has also been reported to reverse anorgasmia associated with use of selective serotonin reuptake inhibitors and with clomipramine. Bethanechol given 1 to 2 hours prior to coitus has been reported to reduce ejaculatory dysfunction when used with impramine. Case reports describing successful treatment of selective serotonin reuptake inhibitor-induced anorgasmia have also been published regarding amantadine, buproprion, dextroamphetamine, and buspirone. A small open trial of buproprion also suggests that it may be effective in the treatment of delayed ejaculation induced by other antidepressants.

Based on the available evidence, it appears that delayed ejaculation and anorgasmia are relatively common side effects of antidepressant treatment, particularly with the selective serotonin reuptake inhibitors and clomipramine. A trial of a decreased dose or a switch to another class of antidepressants is usually indicated. There is some evidence that buproprion is associated with a lower incidence of sexual dysfunction, and switching to buproprion, from selective serotonin reuptake inhibitors in particular, may be effective in relieving the dysfunction .

Other Sexual Side Effects Induced by Antidepressant Medications

Among other antidepressant-induced side effects, priapism, though apparently quite uncommon, is the most serious. Trazodone has been reported to be associated with priapism, though the incidence is unknown. A single case report also describes priapism associated with paroxetine. Painful ejaculation has been reported with imipramine and clomipramine. Penile anesthesia has been reported with fluoxetine.

In sum, there are a variety of sexual side effects which may result from use of antidepressant medication in males. The incidence of these dysfunctions is unknown, but it does appear that they may be more common during treatment with the selective serotonin reuptake inhibitors and that delayed ejaculation is the most clinically significant of the reported side effects. The incidence is not great enough, however, that it should outweigh other considerations noted above which are associated with a positive response, namely, previous response to a particular antidepressant or a familial response to a particular antidepressant.

In those cases in which intolerable sexual side effects do develop, rational prescribing suggests either a trial of a reduced dose of medication or a switch to a different class of antidepressant. For males, buproprion and nefazodone appear to be associated with a lower incidence of sexual side effects. Other strategies, such as the addition of medications to counteract the sexual dysfunction caused by the antidepressant, may also be tried, but there is a lack of compelling empirical data supporting their use.

Another issue which is unique to the assessment and treatment of depressed men is the potential role played by testosterone in the genesis and maintenance of low mood. There is some evidence that reductions in testosterone levels may be associated with depression, particularly in elderly men, and it has been speculated that testosterone may be useful in the treatment of depression in those cases in which testosterone levels are low. Several hypotheses have been proposed. First, depression that occurs in the setting of hypogonadism may remit or improve with testosterone replacement therapy. Second, some depressive subtypes that occur in males with normal testosterone levels may respond to testosterone. Third, depression which occurs in hypogonadal males, though not responding to testosterone directly, may be more difficult to treat with conventional antidepressants. Finally, testosterone, though not an efficacious primary treatment for depression, may benefit some male patients when used as an adjunct to antidepressant treatment.

Association of Depression and Testosterone in Men

Several lines of empirical evidence provide some support for the hypothesis that testosterone is associated with depression. First, several cross-sectional studies have examined the relationship between depressive symptoms and testosterone levels. The gonadotropin levels of depressed and nondepressed cohorts have also been compared cross-sectionally. Second, there are several longitudinal studies examining the testosterone levels of men during an episode of depression and following recovery.

Though several studies have provided data regarding the relationship between testosterone and depression, none of them was designed to examine the prevalence of psychiatric symptoms specifically Additionally, the instruments used to assess depressive symptoms are variable, as are the criteria (if any) used to determine cases of depression. These methodologic limitations make it difficult to determine if any relationship exists between testosterone levels and major depression.

Two epidemiologic studies assessing the cross-sectional relationship between testosterone and depressive symptoms have been conducted. Both were population based. Due to random sampling, each contained some depressed men, but the vast majority of subjects were nondepressed. The first, the Massachusetts Male Aging Study, was a cross-sectional population-based survey of about 1700 men, aged 40-70, designed to examine the correlation between depression and erectile dysfunction. Morning levels of testosterone were measured and compared to self-reported levels of depression, which were obtained using the Center for Epidemiologic Studies Depression Scale (CES-D). Though there was a significant correlation between depression and erectile problems, there was no correlation between CES — D scores and testosterone level in these men.

The second study, the Veteran’s Experience Study, surveyed over 5000 veterans between the ages of 33 and 42. Morning testosterone samples were compared to depressive symptoms obtained by structured interview using the Diagnostic Interview Schedule (DIS).Testosterone levels were only very weakly associated with depression (r=.04), a level which, though significant at p<.01, has little clinical relevance. The study did not disaggregate men with low testosterone levels for further analysis, though the weak correlation between testosterone levels and depressive symptoms would suggest that further analysis would have little yield.

There have also been a number of studies examining the cross-sectional testosterone levels of men who are depressed with men from a nondepressed cohort, and studies which compare the testosterone levels of men during an episode of depression and after recovery. Most of the studies that have examined the relationship between depressed and non-depressed men have shown that there are no detectable differences in testosterone, though one study reported that depressed men have slightly lower levels. Two studies reported a negative correlation between testosterone level and age among depressed men, but not among age-matched controls. The significance of this finding may be that older men with low testosterone levels may be more susceptible to depression than are their younger colleagues. Other studies have demonstrated a negative correlation between testosterone levels and severity of depression and melancholia. Davies, Harris, Thomas, Cook, Read, & Riad-Fahmy (1992) found no significant difference between a cohort of men with melancholic depression and age-matched controls, but did find that, in the depressed group alone, the testosterone level was negatively correlated with depression severity.

Studies that have examined testosterone levels during and after depression have also reported inconsistent results. Of the five longitudinal studies, testosterone levels were lower during depression in three studies, higher in one, and no different in one.

The role of testosterone in depression is unclear, based on the available data. Most of the studies are limited by small sample sizes or methodologic problems, and the results across studies are contradictory. It is unclear what the significance of subnormal testosterone levels may be, particularly when they occur in the presence of depression. It is also unclear whether hypogonadism has differential effects on mood in older cohorts of men. Consequently, it is difficult to make recommendations to clinicians. However, testosterone levels can be easily measured, and consultation with an endocrinologist may be advised for those depressed men with subnormal levels.

Treatment of Male Depression with Testosterone

There have been several trials of testosterone or testosterone derivatives for depression in men. I til, Hermann, and Blasucci (1978) conducted several treatment trials with mesterolone. In the first of these, they treated 17 depressed men for 3 weeks in an open trial, finding that 8 were improved after treatment. A second placebo-controlled double-blind study included 38 men who were treated with mesterolone or placebo for 4 weeks. Treatment was reported to be associated with improvement in such symptoms as lack of motivation and anhedonia. In the last of these trials, mesterolone was given over 6 weeks to men with major depression, dysthymia, or bipolar depression, who were randomized to mesterolone or placebo. Both the treated group and the placebo group improved significantly, and no difference was found between the two with respect to depressive symptoms. Interestingly, those patients with higher testosterone levels appeared to benefit more from treatment than did those who had lower levels.

Vogel, Klaiber, and Broverman (1978) conducted an open trial in which 13 men with refractory depression and normal testosterone levels were treated with mesterolone for 7 weeks. Eleven of the patients responded to the treatment, with a decrease in mean Hamilton Rating Scale for Depression  scores, decreasing from 21.1 to 5.6. A second randomized double-blind trial compared mesterolone to amitriptyline in 34 depressed, eugonadal men.They were found to be equal in reducing depressive symptoms. Another study of the effects of testosterone on refractory depression was conducted by Seidman and Rabkin (1998), who treated 5 men with selective serotonin reuptake inhibitor refractory depression in an open trial over 6 weeks. All five of the patients achieved remission of depression, with mean Hamilton Rating Scale for Depression scores decreasing from 19.2 to 4.0 over the 8-week trial. Three of the four patients who were withdrawn from testosterone relapsed after discontinuation.

In the only study that focused specifically on the treatment of hypogonadal men, Rabkin, Rabkin, and Wagner (1995) administered testosterone to hypogonadal depressed HIV-positive men. Mean Hamilton Rating Scale for Depression scores decreased from 13.6 to 4.1 over the 8-week trial, with 64% of patients achieving remission of depression.

Several tentative conclusions can be drawn from these studies. There is some evidence that depression which occurs in some males with normal gonadotropin levels may respond to treatment with testosterone, though one well-controlled study did not find any differences between treated men and those receiving placebo. There is, as yet, no information about which men might benefit from such treatment. Testosterone may also be a beneficial  treatment  for  eugonadal  men  who  have  not responded to traditional antidepressants, though further study is clearly needed in this area. The treatment of depression with testosterone in hypogonadal men and the use of testosterone as an adjunctive treatment for depression have not been adequately studied. Particularly given the dearth of information regarding efficacy, clinicians are well advised to consider the risks that are posed by testosterone, including potential adverse effects on cholesterol and the prostate. Without further evidence of benefit, the use of testosterone as a treatment for depression should be considered with great caution.

He who conceals his disease cannot expect to be cured.

Ethiopian Proverb

The title of Whybrow’s (1997) popular treatise on mood disorders, “A Mood Apart,” anticipates the difficulty clinicians encounter when attempting to accurately assess depressive conditions. What “sets apart” those mood states that we know as depression, which require medical and psychological treatment, from the normal spectrum of human emotions? How are we to know that a deeper sadness or an extended period of elation is truly the beginning of a mood disorder and not just a peak or valley in the human experience? What signs and symptoms might we look for in men, whose moods may be obscured or blunted by cultural conditioning and shame-induced repression? Do men’s depressed moods become intertwined in physical or psychosomatic phenomena that further complicate accurate assessment of depression in men? These questions form the basis for our exploration of the assessment of depression in men.

Assessment of depression is accomplished using several different strategies. These include clinical interviewing designed to identify the extent to which a man meets established criteria of depression. The use of self-report depression checklists and assessment questionnaires may also be used to gain information about depressive symptomatology. Objective and projective psychological assessment techniques have a long history of use in the assessment of depression. And finally, the use of clinician ratings to assess an individual’s mood state is a popular strategy that is used both in clinical and research settings. Each approach to the assessment of depression views the person’s experience and symptoms through a window designed to illuminate the symptomatology from a particular vantage point. Each has advantages and disadvantages, especially with regard to assessing depression in men. For example, men may respond differently than women do to an interviewer of a particular sex. Men may be less likely to report certain symptoms when questions are couched in terms of assessing specifically for depression, but may be more likely to admit to symptoms when assessment is phrased in terms of “hassles” or difficulties in managing daily life. Men may respond differently than women do to certain objective or structured measures of depression, and this response bias may vary with age as well as gender. These findings remind any clinician interviewing men that specific attention must be given to the clinical process of the assessment as well as methods used for the assessment.

Evidence that men may mask or hide depressive moods as a result of the complex interplay of cultural conditioning and internal psychodynamic processes requires clinicians to look carefully not only at the obvious overt symptoms of depression but at ways a man may submerge or “camouflage” his pain and suffering. Masking of depression may occur through use of mood-altering substances such as alcohol or other drugs. Other addictive processes men may favor as a consequence of their cultural conditioning include over-involvement in work, sexual conquests, gambling, or other high-risk or self-defeating behaviors. To be sure, these behaviors should never, in isolation, be taken to indicate that a given man is suffering from depression. However, when assessing men’s moods, it is important for the clinician to look beyond the presence or absence of symptoms traditionally associated with depression and consider the meaning of all aspects of the man’s life, including those aspects that may serve a containment function for dysphoric, depressed mood states.

Clinician Query — “Everybody does it; what’s the problem?” Bill sought therapy  after having been  reprimanded  at work for irregularities in his expense account records. He had been adding mileage to his monthly expense account and altering receipts for his meal expenses. After these irregularities were uncovered, he was put on probation and strongly encouraged to seek therapy to help him prevent further recurrences of this problem. He opted to seek help for his difficulties. However, his presentation to his therapist was characterized by excuses and rationalizations for his behavior, as he struggled to avoid taking responsibility for what had happened.

“What’s the big deal? Everybody does it. I don’t get it,” Bill lamented as he told his story to his therapist. Bill was a big, friendly man, and chuckled a lot as he talked. As the interview progressed, his therapist realized that his sense of humor covered up his unhappiness with his employment and his life in general. Interspersed in his protests and excuses, the therapist detected feelings of discontent and frustration with his work and life. Bill had been divorced for five years and lived alone. He had kept the same sales position after his divorce, but was having trouble making ends meet with the alimony and child support payments each month, combined with his own increased living expenses.

“No one will ever notice this extra little bit in the expense account. Besides, they owe it to me for sticking me with this crummy job,” he rationalized as he completed his expense account each month.

“I see what you’re saying,” his therapist commented, “but what I don’t understand is why you decided to solve your tight financial situation in this manner. It seems awfully risky to me.”

For the first time in the session, Bill paused and reflected on this confrontation. “It is risky,” he said with a lowered tone of voice. “I don’t know. A lot of the time I just don’t think about what I’m doing or why I’m doing it. It’s that way with the expense accounts. I just don’t think about it. It’s automatic. It’s what Sarah used to complain about a lot of the time. That I just didn’t seem to think about what I did. I guess it keeps my mind off me.”

“Keeps your mind off you?” his therapist repeated. “I think we better take a look at that one, Bill. What exactly do you mean by that?”

“I guess I’ve just never really felt very happy since I got divorced. I miss Sarah and the kids so much.” Bill looked down at his shoes and rubbed his hands together. He looked up with a sheepish smile, and said, “It’s all I had.”

Bill and his therapist sat for several seconds in silence, just looking at each other.

“How do you feel talking about this right now, Bill?”

“Pretty lousy. I just want to get up and get going,” Bill replied. “What a mess I’ve gotten myself into here. I might lose my job. I’ve already lost my family. What would I do?”

•  How does the typical, traditional male role in our culture encourage men to deny or to avoid awareness of depressed mood states?

•  What are the main symptoms of depression that men and women experience, and what are some symptoms that men appear to experience more than women?

Symptom Profiles In Mood Disorders

Interviewing Men For Depression

In light of the evidence indicating that men underreport specific symptoms of depression, careful clinical interviewing and assessment is necessary. The foundation of any careful clinical assessment of depression is the clinical interview. Practice guidelines and formats for the clinical interview designed to assess the symptoms and severity of depression are described by a number of authors. In addition to a review and assessment of symptoms present and the severity of these symptoms, the assessment of suicidal and homicidal ideation and plans is of crucial importance when assessing depression in men. A complete chapter is devoted to this important topic.

In parallel with the epidemiological surveys and diagnostic nomenclature schemes developed over the last 20 years, structured interview formats and interview schedules have been developed to increase reliability of assessment and diagnosis of depression. These include the Diagnostic Interview Schedule, the Composite International Diagnostic Interview; the Schedule for Affective Disorders and Schizophrenia and its revised cousin the Structured Clinical Interview for DSM-III-R; and the Hamilton Rating Scale for Depression. These structured, clinician-directed interview protocols provide a guide for the specific assessment of depression, in the case of the Hamilton Rating Scale, and for depression as well as other DSM Axis I conditions, in the case of the Structured Clinical Interview for the DSM and the Composite International Diagnostic Interview.

The most frequently used of these clinician-rated instruments is the Hamilton Rating Scale for Depression. This scale was developed to assess severity of depression in patients already diagnosed with depression. It is composed of 21 items. A clinician rates the patient’s level of depressive symptomatology after an interview with the patient. The items are used to guide the give-and-take of the assessment interview and the clinician establishes ratings based on patient responses to the items. This instrument has advantages in that it is widely used, mainly by researchers but also by clinicians. It is easy to complete, and can be used in situations in which completion of a self-report instrument would be difficult (e.g., reading level, intoxication, combativeness, etc.).

The next most frequently used instruments are the Diagnostic Interview Schedule, the Schedule for Affective Disorders and Schizophrenia, and the Structured Clinical Interview for DSM-III-R. The Diagnostic Interview Schedule was developed for use by lay interviewers gathering information for the Epidemiological Catchment Area study. The Schedule for Affective Disorders was an early effort to standardize interviewer assessments of psychiatric diagnoses and to increase inter-rater reliabilities when assessing these conditions. Similar to the Diagnostic Interview Schedule, the Schedule for Affective Disorders and Schizophrenia is used to diagnose conditions besides depression. The Structured Clinical Interview for the DSM-III-R is a somewhat revised and updated version of the Schedule for Affective Disorders and Schizophrenia, and was specifically designed to be used as an aid to diagnose DSM-III-R disorders. It, too, covers conditions in addition to depression, including anxiety disorders, psychoses, eating disorders, and substance use disorders.

These instruments have been used extensively in both clinical and research settings, and are the foundation of many empirical investigations of mood disorders. Gotlib and Hammen (1992), Sholomskas (1990), and Shaw et al. (1985) summarize the psychometric properties and use of these instruments. All have demonstrated good reliability and validity when used for the assessment of depression, although none has been shown to offer special value when teasing out any possible differences between men’s and women’s symptom profiles in depression. Seller, Blascovich, and Lenkei (1981) suggest that sex stereotyping, and not objective criteria, may play a more important role in how clinicians diagnose depression in men and women. They found that, despite similar symptom profiles of depression, women were diagnosed more frequently with depression than were men in a study that used a sample of family practice patients. Even though this investigation used family practice residents as the clinicians, other studies have found similar biases in mental health clinicians.

Instruments To Assess Depression

Masculine-Specific Assessment Of Depression

Summary

Since men will often suppress overt expression of depressed mood in conformity with cultural norms, a clinician assessing depression in men must carefully balance direct inquiry into traditional symptoms associated with depression with sensitivity to the ways in which men conceal depressive symptoms. Thus, assessing depression in men requires knowledge of the common symptoms of depression, the various comorbid conditions associated with male depression, and the unique ways that men often conceal depressed mood from themselves and others.

The foundation of assessment is based on interviewing that is designed to identify the presence of symptoms enumerated in the Diagnostic and Statistical Manual of Mental Disorders the symptom profiles of depressed men typically parallel those profiles found in depressed women. However, since many depressed men may be missed in a quick or superficial questioning about their symptoms, a clinician must often carefully probe not only for the typical symptoms of depression but for other related symptoms and conditions. The clinician must carefully assess for the presence of alcoholism and drug abuse, since these conditions are commonly related to depression in men. In addition to these conditions, many men who are depressed exhibit a constellation of externalizing defenses and symptoms that are typical of antisocial traits. These include increased interpersonal conflict, prominent anger and aggressive outbursts, and other self-destructive or self-defeating behaviors. The presence of any of these common symptom clusters in the absence of a specific complaint of depression should immediately alert the interviewer to the strong possibility that depression may exist.

Clinician rating scales and patient self-report instruments are helpful in assessing male depression. Men may respond differently from women to some scales and instruments. Research has indicated that responses to some items of the Beck Depression Inventory and the Center for Epidemiologic Studies — Depression Scale may be influenced by the sex of the patient. It is important for a clinician to review how men might respond to a chosen instrument and to be prepared to incorporate such findings into her or his assessment regimen.

A primary consideration in the assessment of depression is a careful review of the individual’s symptoms. A diagnosis of depression, as defined in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association (1994), is built on a foundation of those symptoms that constitute a depressive episode. The length and intensity of such an episode plays an important part in the diagnosis of a depressive disorder. We may all experience a depressed mood from time to time, but what distinguishes a normal deflated mood from a depressive episode? According to the Diagnostic and Statistical Manual of Mental Disorders a depressed mood that persists beyond two weeks and that represents a departure from a person’s usual mood state warrants attention. In addition to this temporal criterion, there are a number of specific symptoms that an individual must endorse that would confirm the diagnosis of a depressive episode. These symptoms include, in addition to the presence of a depressed mood, loss of interest or pleasure in most activities, weight change, difficulties with sleep, fatigue and loss of energy, restlessness or feeling slowed down, trouble concentrating, feelings of worthlessness or guilt, and thoughts about death.

One aspect of research in the area of sex differences in depression has been the study of symptom profiles of men and women. Might men endorse different symptoms of depression than do women? Could this possibly account for the discrepancy observed between rates of depressions reported for men and women? What are the baseline data when we look at the occurrence of symptoms in depressive episodes in men and women?

The Epidemiological Catchment Area survey included in its design a thorough assessment of all subjects’ depressive symptoms. The Diagnostic Interview Schedule was designed to assess a number of signs and symptoms of mental disturbance, including depressive episodes experienced in the past 12 months and at any point in the subject’s lifetime. Table Lifetime prevalence of depressive symptoms reported by men and women age 18-65+ summarizes the data from this study for both men and women with regard to the prevalence of depressive symptoms experienced over the individual’s lifetime.

In all categories, fewer men than women reported depressive symptoms at any time during their lives. However, the specific symptoms endorsed most frequently by men and women do not differ. In fact, the most frequently reported symptoms (e.g., dysphoria, death thoughts, changes in appetite and sleep, fatigue, difficulties with concentration) are identical for both men and women. The National Comorbidity Survey similarly found that a greater percentage of women than men endorsed a query involving depressed mood in general, as well as items asking about an increasing number of specific symptoms. However, the percentages of women compared to men who endorsed these criteria and the ratio of women-to-men who would be diagnosed as depressed using such criteria was consistently less than similar ratios from the Epidemiologic Catchment Area survey. One possible reason for this is that men may tend to “forget” symptoms of depression. In order to obtain accurate symptom reports for the determination of lifetime prevalence estimates of the various disorders, a Life Review Section of the assessment process was utilized in the National Comorbidity Survey to assist respondents in focusing on symptoms that may not have been available for immediate recall. The investigators believe that this may have tended to stimulate recollection of depressive episodes or symptoms for the men, thus accounting for the almost fourfold increase in prevalence estimates for men between the Epidemiological Catchment Area study and the National Comorbidity Survey.

TABLE  Lifetime prevalence of depressive symptoms reported by men and women age 18-65+

In studies involving clinical populations, the identification and reporting of symptoms by men appear to parallel that of women. Young, Scheftner, Fawcett, and Klerman (1990) found that the clinical symptom profiles of men and women with unipolar depression were very similar. Only weight gain and appetite problems were reported more frequently among women than men. Other symptoms, including insomnia, fatigue, somatic concerns, and difficulties with concentration, were reported at similar levels between men and women. Two additional investigations conclude that there are minimal differences in severity of symptoms among depressed men and women when their symptoms are rated by clinicians. However, self-report measures such as the Beck Depression Inventory tend to reveal that women report more symptoms, different symptoms, and may endorse more severity in the symptoms that are reported. In general, women tended to endorse symptoms related to weight gain, appetite loss, and anxiety. In a related investigation, Williamson (1987) performed factor analyses of the responses of men and women who were seen in a general medical practice clinic to the Beck Depression Inventory. She found sex differences in the factor structure of the responses, indicating that men and women tend to report different patterns of depressive symptoms. Dysphoric mood and performance difficulties were found in both men and women, but a unique component, interpersonal behavior changes, was found in the men in this study. This finding is consistent with other reports of changes in interpersonal behavior, such as an increase in interpersonal conflict and anger for men who are depressed.

Although men and women are generally comparable in their overall symptom profiles in depressive episodes, there are important masculine-specific differences in these profiles that can be used as a guide for the assessment of depression in men (see Table Clinical Features Associated with Depression in Men). Some of these differences include the findings that men have a greater incidence of comorbid drug and alcohol dependence in depression, may present with associated anxiety disorders and antisocial traits as well as compulsive personality traits, may be experiencing overt strains in gender-role expectations, may be responding with depressed mood to perceived threats to self-esteem or self-respect, may present with a loss of sexual interest rather than decreased sexual activity per se, and may present with exaggerated or defensive assertions of autonomy. Such symptom constellations are consistent with the male tendency to externalize problems, discharge uncomfortable dysphoric affective states through anger and aggression, and self-medicate mood difficulties with mood-altering substances.

TABLE  Clinical Features Associated with Depression in Men

In addition to the presence of overt depressed mood, men presenting for evaluation or treatment for depression may exhibit some or all of the features detailed in Table Clinical Features Associated with Depression in Men. Although many men may not express overt symptoms of depressive disorders initially, many men will exhibit tearfulness, guilt, sadness, and concerns about weight and sleep that are characteristic of depressive symptoms in women. However, unlike women, many men may also display anger and overt defensiveness at initial points in the evaluation of depression, which often complicates assessment of classical depressive symptoms.

Clinician Query — “It runs in the family.”

James had seen a therapist for four sessions. He met diagnostic criteria for severe recurrent major depression, with primary symptoms including depressed mood, guilt, insomnia and loss of appetite, suicidal thinking, and feelings of persecution with ideas of reference. James was single, 28 years old, and worked as a convenience store manager. He had finished college with a degree in sociology and had continued working at the same store where he had worked part-time to help pay his college bills. He lived alone, did not socialize, and did not have many friends. He was, though, a hard worker and had a lot of energy when he was at work. He had been promoted to his current position as store manager three months prior to the development of his current depressive episode. His first episode occurred when he was 18 years old and a first-year student in college. He had struggled off and on with depression through college and had been helped somewhat with imipramine that was prescribed by a psychiatrist at his campus’ health service. He occasionally obtained short-term support through his campus’ counseling services.

James’ general approach to life was bitter, aggressive, and hostile. He was often argumentative and held himself aloof. As long as “things” were fine, he was “fine.” When things weren’t fine, he looked for someone to blame. His employees didn’t work “hard enough” and this meant that he had to spend extra time at the store. His suppliers didn’t make deliveries on time, and thus he couldn’t plan the activities of the work day because of their likely interruptions. His supervisor didn’t give him “enough backing” in handling a difficult employee he had to reprimand. He had many problems, none of them of his own making. In his fifth session with his therapist, he was describing his deepening depression.

“I just don’t give a shit anymore about anything. Who cares?”James moaned dramatically. “What’s the point? You get born, you live, you die. There’s nothing for me to really look toward. I’m just sick of it. I gotten to the point where I don’t really care what happens to me anymore. It’s too much.”

James’ therapist struggled to maintain empathy. “Yeah. You’ve had a difficult couple of months getting settled into this new job and the new responsibilities. But it sounds like it’s more than that, James. You sound today like you’re really at the end of your rope.”

James tapped his foot and looked impatiently out the window. His eyes moved from the window to the desk to the therapist’s face to the floor. “I don’t like this job. I’m sick of working so hard. For what? I don’t like this town. I don’t like anything. I feel like ending it sometimes.”

“You feel like ending it sometimes?” his therapist followed.

“Yeah.” James paused. “Like my old man. He just offered himself when he couldn’t deal with his life. That bastard. That’s what I should do.”

“I remember you said you father had killed himself when you were a boy. It sounds like you’re thinking about him today. What happened?”

“I don’t even really know. He was always mad about something. He was a rageaholic. He would stomp around, pissing and moaning, all the time. Just like me, huh? Then one day when I came home from school, there were police and an ambulance there. Mom just took me aside and said dad had been hurt and would have to go to the hospital. I knew right then what had happened. He used to threaten to kill us all the time. What an asshole.”

James paused after describing the day his father had committed suicide and looked out the window. He was quiet. Then he looked at the therapist but did not say anything.

“That sounds terrible, James. What a terrible trauma for a little boy. And now you’re feeling like doing the same thing?”

“I just don’t feel like dealing with this. I’m tired of working so hard and getting nowhere. I’m tired of not having any friends. I’m tired of being alone.” James began sobbing. “I should just kill myself. It runs in the family.”

•  What assessment issues should James’ therapist explore with James in this interview?

•  What is the relationship between a man’s expression of anger and hostility and underlying feelings of depression?

In addition to structured clinical interview methods for assisting the clinician in assessing depression, there are a number of popular self-report measures that can also be used to supplement the clinical interview. These include the Beck Depression Inventory, the Zung Self-Rating Depression Scale, the Minnesota Multiphasic Personality Inventory Depression Scale, the revised Minnesota Multiphasic Personality Inventory Depression Scale, and the Center for Epidemologic Studies Depression Scale .

The Beck Depression Inventory is the most widely used self-report instrument for assessing depression. This is most likely due to its short length and ease of administration and scoring. The Beck Depression Inventory consists of 21 items designed to assess the extent to which a patient has experienced or exhibited various aspects of depressive symptomatology over the past week. Results indicate the extent of depressive symptoms and the severity of these symptoms, ranging from normal mood range through mild depression, moderate depression, and severe depression. A similar self-report scale used in assessing depression is the Zung Self-Rating Depression Scale. This scale, like the Beck Depression Inventory, is a self-report scale composed of 20 items. The Zung Self-Rating Depression Scale is self-administered and also requires minimal time for the patient to complete. The items are scored on a scale from 1 to 4, and a depression index is derived as the final estimate of depressive severity by dividing the raw score by 80, the total possible score. This results in a depression index that ranges from 0.25 (minimal) to 1.00 (maximum).The Center for Epidemiologic Studies Depression Scale was developed to measure depressive symptomatology in the general population. This scale, like the Zung Self-Rating Scale for Depression, consists of 20 items. The patient responds to each item by indicating how much each symptom had troubled him or her over the past week, with 0 corresponding to very little or none of the time, and 3 corresponding to most all of the time. The resulting sum of scores indicates the severity of the person’s depressive symptoms, with 0 being the lowest score an individual can obtain and 60 being the highest. The Minnesota Multiphasic Personality Inventory, and its revised successor, the Minnesota Multiphasic Personality Inventory-2, was developed to assess a range of psychiatric and psychological syndromes and conditions, including unipolar depression. Scale 2, the depression scale in both the original and the revised Minnesota Multiphasic Personality Inventory, consists of 57 items designed to reliably differentiate normal control subjects from depressed patients. As part of the complete Minnesota Multiphasic Personality Inventory, the individual responds “yes” or “no” to a number of items that describe their feelings, thoughts, and behaviors. Scoring is empirically derived, based on the extent to which groups of items consistently differentiate the clinical group (in this case, depressed patients) from the normal control groups. Higher raw scores translate to higher standard scores, with clinical cutoffs established at t = 70 for Minnesota Multiphasic Personality Inventory, and t = 65 for the Minnesota Multiphasic Personality Inventory-2.

Psychometric properties for the Beck Depression Inventory, including Cronbach alpha values ranging from .86 through .90, are summarized by Beck, Steer, and Garbin (1988). Guidelines for the use of the Beck Depression Inventory are detailed by Kendall, Hollon, Beck, Hammen, and Ingram (1987). Since the Beck Depression Inventory is used widely in both research and clinical settings, a number of studies have reported sex-related differences in responses to items on the inventory. A number of these reports are consistent with a model that emphasizes the social conditioning women and men experience around depressive symptom expression, and have consequently yielded findings of differential response patterns for men and women. Ham-men and Padesky (1977) found that men and women reported similar severity of depression on the Beck Depression Inventory, but men were more likely to report an inability to cry, a loss of social interest, somatic complaints, and a sense of failure. This finding is consistent with Vredenburg, Krames, and Flett (1986), who found that men tended to endorse symptoms on the Beck Depression Inventory that were consistent with aspects of the male gender role, such as somatic problems and work performance-related difficulties. Oliver and Toner (1990) found that men reported more withdrawal and somatic symptoms on the Beck Depression Inventory than did women, supporting the hypothesis that symptom expression is shaped by cultural norms. In addition to these findings, Nolan and Willson (1994) found that the item concerning tiredness was most discriminating between men and women. Page and Bennesch (1993) found that men were more likely to report more symptoms of depression when items from the Beck Depression Inventory were phrased in terms of “hassles,” instead of in terms of symptoms of depression.

In addition to these findings, which may be interpreted as confirming the importance of gender-role conditioning in responses to the Beck Depression Inventory, Wallace and Pfohl (1995) reported that scores for men on the Beck Depression Inventory were negatively correlated with age. In contrast, scores for women did not vary with age. The older the men in the study, the lower their obtained scores on the Beck Depression Inventory. However, in this investigation, the Hamilton Scale did not demonstrate this age-related correlation.

Gumbiner and Flowers (1997) reported sex differences in Minnesota Multiphasic Personality Inventory-2 profiles from a population of outpatient community mental health clinic patients. They found that men consistently elevated subscales related to antisocial behavior, authority problems, addiction problems, amorality, and Type A behavior patterns. Women, in contrast, elevated clinical scales measuring depression, hypochondriasis, hysteria, and paranoia and subscales related to depression, need for affection, health concerns, and somatic complaints. Maffeo, Ford, and Lavin (1990), using the Minnesota Multiphasic Personality Inventory as well as other measures of depression, found that depressed men tended to have greater difficulty with concentration and motivation than did depressed women.

Schaefer, Brown, Watson, Plemel, DeMotts, Howard, Petrick, Balleweg, and Anderson (1985) reported a study that compared the validity of the Beck Depression Inventory, the Minnesota Multiphasic Personality Inventory depression scale, and the Zung Self-Rating Depression Scale. Subject ratings on each of these three scales were correlated with clinician-derived DSM-III diagnostic ratings. The Zung Self-Rating Depression Scale produced the best validity coefficients when related to these clinician-based ratings of depression.

Studies that have utilized the Center for Epidemiological Studies — Depression scale have not typically reported sex differences found when using this scale. Clark, Aneshensel, Frerichs, and Morgan, however, did report sex differences in item correlations and factor loadings and concluded that the scale may measure different phenomena in men and women.

Overall, it is incumbent upon any clinician assessing male depression and who is planning to utilize any of the common self-report depression inventories to be familiar with the research on various sex differences in these instruments. Considerable research with the Beck Depression Inventory has suggested that men may respond to this instrument in ways consistent with gender-stereotyped symptom expression. For example, men may endorse items related to crying less, and may endorse items related to concentration difficulties, work difficulty, or somatic concerns more frequently. Minnesota Multiphasic Personality Inventory-2 subscales and the Center for Epidemiological Studies — Depression scale may similarly be prone’ to such variations. One investigation found the Zung Self-Rating Depression Scale demonstrated the best external validity compared with the Minnesota Multiphasic Personality Inventory Depression Scale and the Beck Depression Inventory when used with male inpatient psychiatric ward and chemical dependency ward patients.

Clinician Query — “I didn’t mean to hurt her.” Greg was a 27-year-old married man with one child who was referred for therapy by the court after he was charged with assault of his wife following a domestic dispute. Greg was employed by the telephone company. Because this was his first prosecuted offense, he was given the option to receive counseling and be placed on probation rather than serve time in jail. Greg arrived for therapy with a smile on his face. It was later found out that he uses his charm to make positive impressions in social situations, especially first meetings.

Greg was relatively open about his behavior but spent a good deal of the first session describing how much better he was than his own father, who had beat him, his brother, and his mother mercilessly Greg also stated that his wife’s father was abusive and that she had learned how to set him off. What was apparent was that Greg did not want to take much responsibility for his aggressive behavior. In his fourth session, his therapist confronted Greg about what his aggression meant.

“So you say that you have only hit your wife a few times, and that usually she had provoked you. I wonder what was going on inside of you when you heard her words?”

“You mean what was I thinking?”

“Thinking and feeling,” added his therapist.

“The last time this happened, she had just told me that I was stupid for not having stopped for baby formula and diapers on my way home from work.”

“How did this feel when she said it?”

“I hate being called stupid. She knows that will piss me off,” replied Greg.

“So what was going on in your body? What were you feeling?”

“I could feel myself get hot. I had an impulse to want to grab her neck,” Greg responded, squirming somewhat in his chair.

“Can you remember ever being called stupid or made to feel stupid when you were growing up?” his therapist queried.

“My old man used to call me that all the time.”

“What did that feel like, when he would call you stupid?”

“It felt lousy. I already felt stupid, and when he said it, it validated how I felt about myself. I never got really mad at him because he would beat the shit out of me if I talked back to him or showed any defiance in my face.”

“So you felt helpless or hopeless when he did this?”

“I don’t know what I felt,” Greg answered, his smile gone from his face.

“Sounds to me like you were feeling pretty sad,” replied his therapist, offering some emotional vocabulary.

“I hate to be sad. I’ll do anything to get a smile back on my face. What I want to do right now is tell you a joke,” Greg responded.

“So you avoid feeling sad as much as possible?”

“Yeah. I don’t want to cry or act like I can’t take it. My dad would call me a girl or a fag if I showed any tears. He was harsh.”

“So instead of feeling sad or hurt, you either crack a joke or get angry.”

“Yeah. I’d rather joke around. But sometimes if someone catches me off guard, I get angry.”

“Like your wife?”

“Yeah. She can be a bitch.”

“So with the big world, you’re a joker. But with her you get angry?”

“I guess. I think she should know better,” Greg retorted.

“She should know that you are really hurt by her comments?” his therapist asked.

“Yeah.”

“So why can’t you say ‘that hurts me’ instead of raging at her?” asked his therapist.

“I don’t know,” Greg replied, his eyes cast downward.

“It looks like we have some work to do, Greg,” his therapist suggested.

“You’re probably right,” Greg finally admitted.

•  To what extent do men who batter conceal an underlying mood disorder or depression?

•   How might therapy help impulsive or aggressive men by encouraging expressions of sadness, loss, or grief?

Pollack (1998a) has proposed a change in the way clinicians assess male depression. This new approach to assessing depression in men emphasizes the important role covert or masked depressive phenomena, as well as the role that comorbid conditions, play in men’s mood disorders. This assessment model de-emphasizes the traditional diagnostic criteria that are viewed as biased toward feminine means of expressing emotional distress. By proposing diagnostic criteria for “major depressive disorder-male type” (see Table Proposed Criteria for Major Depressive Disorder-Male Type) Pollack directs clinicians’ attention to a number of often seemingly unrelated symptom, that often signify the presence of a mood disorder in men.

This important recommendation, that clinicians focus on male-specific symptom clusters when assessing men for depression, has implications for clinicians. Interviewing men for depression requires balancing knowledge of the typical symptom profiles seen in depressive episodes with an awareness of the ways in which men might be likely to conceal, obscure, or otherwise hide these symptoms of depression. Table Masculine-Specific Assessment of Depression outlines areas for assessment when interviewing men. As noted, when asked directly about symptoms of depression, men and women report the same symptoms with remarkable consistency. Men report dysphoria most, as do women. Thoughts of death, problems with sleep, appetite, and fatigue are next in frequency for both men and women. In addition, many men will reveal long suppressed feelings of sadness, guilt, shame, and inadequacy that have built up over the years but have been suppressed in conformity to gender-role restrictions.

TABLE Proposed Criteria for Major Depressive Disorder-Male Type

TABLE  Masculine-Specific Assessment of Depression

Since many men may not directly reveal a sad mood to an interviewer, consideration of the context of the man’s presenting situation often reveals important information. Examining the circumstances surrounding the initial visit to the therapist is important. Specific questioning of these circumstances often reveals a pattern of emergent depressive symptoms that may have become too intrusive or problematic for a man to manage. Examination of the precipitating circumstances will also yield valuable insights into the psychodynamic meaning and implications of many of the depressive symptoms that may have led to a man’s seeking help. An important aspect of the circumstances precipitating a man’s visit to a therapist is whether he has experienced a recent narcissistic wound. Rejections in significant relationships, loss of role status in employment or leisure activity pursuits, and other symbolic losses represent failure in many men’s eyes and often are associated with significant depressive sequelae. Left to smolder, many such wounds and losses often emerge later as precipitant in acts of homicidal and suicidal violence perpetrated by disgruntled, depressed men. Kahn (1990) emphasizes the importance of narcissistic injury and the activation of envy and rivalry issues in assessing depressed men for suicidal risks.

In addition, it is important to note to what extent a man might have been coerced into seeing a therapist. Such coercion may be in service of forestalling one of the previously mentioned narcissistic injuries, such as an opportunity to preserve a job if he enters treatment. Such coercion may also occur after some aspect of the patient’s behavior has exceeded the limits that important persons in his environment, such as a spouse or employer, are willing to tolerate. Whatever the circumstances, it is important in the context of coerced therapy to balance a desire to challenge the implications for motivation such a presentation suggests with a recognition that many men may need a “problem,” often imposed externally, to sanction a first visit to a therapist. Conveying empathy to the male client and the recognition of his frustration at having been “given a problem” will often lay a foundation of acceptance that ensures continuation in treatment.

As noted, many men present for help with the typical constellation of depressive symptoms. These include sad mood and guilt feelings, difficulties in eating and sleeping, withdrawal from most activities, physical and health complaints, and thoughts of death and suicide. In addition to these common symptoms, many men will also exhibit anger, irritation, frustration, and increased conflict in interpersonal relationships. Such symptoms are characteristic of a pattern of managing depressed mood that is based on withdrawal, externalization, and distraction. Any time the clinician encounters a pattern of such behaviors and symptoms she or he should look further for an underlying depressive condition.

The clinician must also carefully assess the presence of any comorbid clinical conditions, which frequently complicate the clinical picture. Different patterns of comorbidity are associated with clinical samples of depressed men and women. Men are more likely to exhibit comorbid alcohol abuse and dependence, other substance use and dependence, and antisocial personality traits. Since these comorbid conditions are common in men and because they contribute significantly to increased risk of violence and suicide, especially in younger men, they must be addressed directly and completely in assessment.

Finally, since depressed men are at such increased risk for suicide at all ages, a careful inquiry into the presence of suicidal ideation, suicidal plans, and suicidal intent is crucial any time a clinician establishes the existence of depression in a male patient. Specific recommendations for this assessment are offered elsewhere in this volume, but the importance of such inquiry in the complete assessment of depression in men is impossible to overstate.