What Depression in Men Really Looks Like

Mad or sad?

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When we think of clinical depression, we usually think of sadness, anxiety, poor motivation, the "blahs," guilt, and negativity. These all have the negative inclination that characterizes depression. We may also think of women as they are subject to depression more often than men. Depression in adult men is frequently quite different.

As an example: A man who is usually calm and even tempered, becomes irritable, prone to anger, criticism, disparaging remarks and cynicism. He does not show emotions such as sadness, pessimism and guilt.

Or, if he already has these anger laden traits, they become clearly worse. Of course, a thorough psychiatric evaluation is in order, but in most cases the conclusion is reached quickly. This man is depressed.

The cause of this different presentation of depression in men is subject to debate. Is it genetics and testosterone? Family upbringing of boys? Or our culture’s expectation of men? The answer seems to be that all these factors contribute.

We do not know exactly what percentage of men present differently from traditional sadness symptoms. But studies and experience place it anywhere from 30% to a clear majority. It is difficult to count, as there are always people who do not come for treatment, especially with a group who are reluctant to acknowledge their depression at all.

Some research literature discusses the observation that rather than experience the core feelings of depression men often indulge in escape behaviors such as risk-taking, substance abuse, or acting out (such as extramarital affairs). These are the behavioral manifestations of feeling states like irritability and anger, which they then act out. Although this does happen, I did not see it in my practice. This may reflect negative biases about men more than the clinical reality.

The diagnosis is easy to spot for experienced clinicians or individuals close to the patient, who have seen the man through this before. Otherwise, the man in question will naturally attribute anger to problems outside of him causing him to be upset. Others will blame his temper as the problem. It is hard to be empathic when someone is yelling at you. With the help of a professional, everyone above can see through the fog of anger to the depression underneath.

A common question is: Is there really sadness or some other more typical depressive symptom beneath the anger and irritability? This is a good question without an easy answer. In practice, you will find men who eventually identify feelings under all the anger. Others just find the anger goes away with no residue or revealed underpinnings. As anger is a negative feeling, I have no trouble believing that it can be a primary symptom of depression.

Men often understand their symptoms in a way characteristic of people raised in the early part of the 20^th century. They see their emotions as perfectly proportional reflections of life situations. They are angry because something angered them. Someone screwed up, cost them time and money. Something is broken. Their team lost again. There is no internal process here. Only reactions to the world outside.

Over and above this older view of how the mind works, anger and irritability are different from sadness and negativity in one important way; they are externalizing emotions. They point outside the person for their causes and solutions. Sadness is internal as it points inside a person to understand its nature. And in externalizing, they are more masculine.

It looks masculine to be decisive, stand one’s ground, remain strong in the face of challenge. But this is not usually what’s at play. Decisiveness can be inflexibility; standing strong, a lack of openness. Black and white thinking gives the appearance of strong principles but is can also be an intolerance of gray areas that characterize so much of life. These examples of inflexibility almost always accompany the irritability of male depression. They are also expectations society places on men.

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The very idea of depression does not fit with the view of men in most cultures. Sadness in men is seen as weakness. And even when aware of their own irritability, they may feel that they must conquer it on their own.

When I saw men in my practice, it was often because the anger became excessive. Either their partner declared that they had had enough, or the man finds himself yelling at a child for a minor infraction. Whatever the case, the man sees that this is not him.

As I stated above, I do not see anger as a defense against feeling other things, such as deep sadness. But I do see rationalizing the anger as a socially acceptable way of understanding what is happening. In other words, “I am angry because of…” becomes a way of legitimizing feelings and behavior.

You certainly see this when there is a loss of a traditional male role, such as unemployment or divorce, two common causes of male depression. Some conditions predispose men to externalizing emotions like anger. The two that show up most are ADHD, especially when it went untreated during childhood and obsessive-compulsive personality. The latter can be a full personality disorder or just psychological traits.

Understanding obsessive-compulsive personality is key to understanding men in our culture. This disorder or set of traits has no relationship to obsessive-compulsive disorder. The latter has to do with feeling compelled to perform certain rituals such as cleaning, counting, or arranging things in specific ways. This is what people mean when they refer to OCD.

The personality version, which unfortunately bears the same name, has nothing to do with these rituals or their accompanied thoughts. Rather, it is a set of personality traits such as rigidity, control, a lack of showing emotion, black and white thinking, and believing in moral absolutes. Such people like to be in charge, dictate orders that they expect to be followed, and do not see gray areas in topics under discussion. Such men may be quick to anger as a part of their temperament.

These traits are often valued in leadership positions or at least perceived leadership such as head of household.

Depression often appears in these men in midlife. They find themselves without close friends, and even those close such as family members carry resentment for the poor treatment they have endured over the years. Depression treatment opens a new world to these men. They have much work to do in rebuilding relationships, but they see their abilities in an entirely new way that includes expressing emotions and is free of the tension they have carried all their lives.

In my own experience, both medication and therapy are very effective in these individuals. Medication reduces the symptoms, and therapy helps in understanding what was happening and how it affected the life they are now rebuilding. They have spent their lives in the obsessive realm as know-it-alls, always in charge, with little tolerance for mistakes or challenges. Now they are calmer, open, and importantly, aware of the change that took place in them with a strong desire not to return to that way of living.

Some may think this is about most men who live in a patriarchal society. But this is not the case. Many men show few to none of these qualities. They can be warm and affectionate, work on a team on the job, have their own flexible opinions and still feel masculine.

In my view, from both my professional and personal life, expectations held by society and men themselves keep many men out of treatment while their anger and irritability are doing damage to their lives and the lives of their loved ones. Bringing this to light is an important step as we become more psychologically aware as a society.

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