Traditional tools for diagnosing depression fail to include symptoms common in men, which may explain why they are diagnosed with the disorder half as often as women, a study suggested.
When researchers analyzed data from a nationwide mental health survey using a measure that included both traditional depression symptoms and alternative symptoms more common in men, they found no significant difference in the rate of depression between the two sexes (30.6% of men met the criteria for depression versus 33.3% of women; P=0.57).
Men reported significantly higher rates of anger/aggression (94.8% versus 88.9%; P≤0.001), substance abuse (61.4% versus 40.6%; P≤0.001), and risk-taking behaviors (52.7% versus 29.1%; P≤0.001), Lisa A. Martin, PhD, of the University of Michigan, Dearborn, and colleagues wrote in the Aug. 28 issue of JAMA Psychiatry.
The findings suggest that current measures for diagnosing depression may be biased toward detecting symptoms exhibited more often by women, such as sadness, crying, and sleep problems, Martin told MedPage Today.
"We generally think of depression as a women's disease, because twice as many women are diagnosed," she said. "For many decades depression researchers have been looking for an answer to the question, 'What makes women more vulnerable?', but I wanted to turn the question upside down and ask, 'Why aren't more men diagnosed with depression?'"
One theory is that traditional symptoms used to identify depression, such as sadness and crying, are at odds with the societal ideals of masculinity so men are less likely to exhibit or report them.
A hypothesis dubbed the "masculine depression framework" suggests that depressed men are more likely than depressed women to exhibit externalizing symptoms such as anger, self-destructive behavior, or substance abuse.
It has also been suggested that irritability is a key symptom of depression in men, but not in women.
In the study, which involved secondary analysis of data from the National Comorbidity Survey Replication (NCS-R), the researchers created and analyzed depression measures that combined traditional symptoms of depression with alternative symptoms.
One measure, which they called the Male Symptoms Scale (MSS) included eight symptoms associated with the hypothesis of male-type depression: irritability, anger attacks/aggression, sleep disturbance, alcohol or other drug abuse, risk-taking behavior, hyperactivity, stress, and loss of interest in pleasurable activities.
The second measure, which they named the Gender Inclusive Depression Scale (GIDS) included all these symptoms plus more traditional symptoms of depression, including sad/depressed mood, loss of vitality, tiredness, ambivalence, anxiety/uneasiness, and complaintiveness (feeling hopeless or pathetic).
Scores on the MSS could range from 0 to 8, with a score of 5 or higher meeting the researchers' criteria for depression. GIDS scores ranged from 0 to 15, with scores of 5 to 9 considered moderate depression cases and scores ranging from 10 to 15 labeled severe depression cases.
There were 3,310 (58.5%) women and 2,382 (41.5%) men included in the sample, and their mean age at the time they were surveyed was 45.2 years. Roughly three out of four (73.4%) respondents were non-Hispanic white and more than half (51.6%) had some education beyond high school.
Among the findings:
- When the MSS scale was used, men had a higher rate of depression than women (26.3% versus 21.9%; P=0.007). Men were more likely to report engaging in anger attacks/aggression, substance abuse, and risk-taking behaviors, while women reported more stress, irritability, sleep disturbance, and loss of interest in things they enjoyed.
- Women were significantly more likely to report irritability than men (94.7% versus 86.6%; P≤0.001), suggesting that while irritability may be an overlooked symptom of depression, it is not a male-specific one.
- Using the GIDS scale, the rates of mild, moderate, and severe depression were not statistically different between men and women.
- Men were more likely to report anger/aggression, substance abuse, risk-taking behavior, and hyperactivity on the GIDS measure, while women were more likely to report stress, indecisiveness, anxiety, sleep disturbance, depressed mood, and complaintiveness.
Depressed mood was the principal symptom for both men and women, and anger attacks/aggression, stress, irritability and anxiety/uneasiness were the four other top symptoms reported for both sexes.
"The current depression criteria may be biased toward detecting symptoms that are more common in women," the researchers wrote. "Our findings, however, highlight that male-type symptoms are also fairly common in women."
They concluded that further study is needed to clarify which symptoms truly best describe depression in men.
Martin said clinicians should consider asking patients of both sexes about irritability, anger, and substance abuse when assessing depression.
"We know that men are less likely than women to seek treatment, even when they recognize that they are depressed," she said. "Incorporating these symptoms may not only identify depression in more men, it may lead to ways to entice more men to get help."
No funding sources were disclosed, and the researchers reported no conflicts of interest related to this study.
- Reviewed by Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner