mental health AIDS

Winter 2006 Newsletter / Volume 7, Issue 2

Men Misunderstood: Straight Talk About HIV & Depression

"The tendency for women to signal distress and to expose their need for help or support seems to be inversely matched by men's internalized avoidance of, or aversion to, showing signs of weakness or vulnerability. Thus, gender differences in depression appear to lie not in the 'experience' of depression per se (both men and women experience depression similarly), but in the 'expression' of depression. What men 'do' has (unfortunately) been associated with 'men behaving badly' ... rather than associated with men being depressed."

–– Brownhill, Wilhelm, Barclay, & Schmied, 2005, p. 928

Over the past decade, portions of edited volumes (e.g., in Good & Brooks, 2005; in Pollack & Levant, 1998), and even entire books (Cochran & Rabinowitz, 2000), have been dedicated to "the problem of undiagnosed and untreated depression in men" (Cochran & Rabinowitz, 2003, p. 132). Particular emphasis has been placed on "[d]epression in men [that] seems to be hidden in antisocial and risk-taking behaviours[,] including drug and alcohol abuse, deliberate self-harm, suicide, road rage, sexual encounters, gambling, binge drinking, aggression and violence[,] often referred to as 'depressive equivalents' or 'masked depression'" (Brownhill, Wilhelm, Barclay, & Schmied, 2005, p. 926). Furthermore, "constrained emotional distress ... is likely to make depression even more difficult to detect or measure in men because of its latent or arbitrary nature beyond the '2-week' period established by DSM-IV criteria ..." (Brownhill, Wilhelm, Barclay, & Schmied, 2005, p. 927).

On the HIV front, in recent reports that evaluated depressive symptoms in gay and heterosexual men living with HIV who were African American (Coleman & Hummel, 2005) or Chilean (Vera-Villarroel, Pérez, Moreno, & Allende, 2004), heterosexual men were found to have higher levels of depressive symptoms than their gay counterparts.

In another recent report, investigators in London (Orr, Catalan, & Longstaff, 2004) conducted a retrospective case-controlled study and found that heterosexual men who engaged in HIV primary care services were "almost three times less likely to be referred for specialist mental health care than HIV-positive gay men" (p. 592) and "were less likely to be given a diagnosis of a depressive illness, but ... were more likely to have a substance misuse diagnosis" (p. 592). Of note as well was the finding of "no differences ... in terms of problems and social difficulties except, rather surprisingly, that heterosexual men, who are HIV-positive, had more problems with bereavement than gay men" (p. 592).

In discussing the differential pattern of referral, Orr and colleagues point to the large proportion of black African heterosexual men in this study. The investigators suggest that "it is possible ... that differing social and cultural expectations of the roles of doctors and patients will influence the presentation of psychological distress, and adverse emotional experience, leading to different interpretations on the part of medical practitioners" (p. 593) and, presumably, different types of referral. An alternative explanation hinges on the presentation of "depressive equivalents" (i.e., substance misuse) that medical practitioners accepted at face value, even among men experiencing problems with bereavement.

Because "depression in men can often be hidden, overlooked, not discussed or 'acted out'" (Brownhill, Wilhelm, Barclay, & Schmied, 2005, p. 921), "efforts to enhance clinicians' sensitivity and skills in assessing and treating depression in men are warranted" (Cochran & Rabinowitz, 2003, p. 132).

"[C]ultural prohibitions placed on men against the experience of mood states directly related to depression (e.g., sadness) and the behavioral expression of these mood states (e.g., crying) make clear and simple descriptions of male depression difficult ... . Furthermore, racial, ethnic, and social class norms concerning emotional expression add to this difficulty."

–– Cochran & Rabinowitz, 2003, pp. 132-133

Knowing Depression When You See It

Although the primary symptoms and eventual course of depression are similar in both men and women, a number of researchers have identified important masculine-specific modes of experiencing and expressing depression. ... Many of these ... modes ... do not conform to criteria used to diagnose depression detailed in the DSM-IV ... . In general, these masculine-specific features of depression are consistent with a tendency for men to use externalizing defenses ... , to engage in ruminative responses that may lead to alcohol abuse ... , and to express irritation, anger, and withdrawal in response to narcissistic vulnerability or injury ... . These externalized symptom clusters may be the outward manifestations of a covert or hidden mood disorder in men sometimes referred to as masked depression ... . When a clinician encounters any of these symptoms in a male client, she or he should carefully assess for the presence of a coexisting mood disorder. (Cochran & Rabinowitz, 2003, p. 133)

Defining depression broadly to encompass "the full range of depressive disorders as well as the spectrum of emotions including grief and sadness that are often triggered by loss" (p. 132), Cochran and Rabinowitz (2003) offer the following guidelines for the gender-sensitive assessment of depression in men:

Review established DSM-IV criteria for major depression. "Men who meet formal diagnostic criteria ... for depression exhibit the following symptoms, in descending order of frequency: (a) dysphoria, (b) thoughts of death, (c) appetite disturbance, (d) sleep disturbance, (e) fatigue, (f) diminished concentration, (g) guilt, (h) psychomotor change, and (i) loss of interest in typical activities ..." (Cochran & Rabinowitz, 2003, p. 133).

Evaluate masculine-specific modes of experiencing and expressing depression "derived from empirical reports, qualitative inquiry, and clinical case reports" (Cochran & Rabinowitz, 2003, p. 133). These can include:

o An increase in conflict/anger in interpersonal relationships (substituting for sadness), with expression ranging from social withdrawal to violence;

o An increase in the use of alcohol/mood-altering substances as a form of self-medication;

o An increase in somatic complaints (e.g., headaches, digestive disorders, and chronic pain; Rochlen, Whilde, & Hoyer, 2005, p. 189);

o A decrease in concentration and motivation tied to school, employment, or leisure activities;

o An increase in worries over productivity and level of functioning in school or work;

o A decrease in sexual interest without a corresponding decrease in sexual activity; and

o An increase in the tension between gender-role-related expectations and performance, particularly with regard to emotional expression and conflict between commitments to work and family.

Assess culturally salient features of depression. These often include:

o Familial norms and expectations related to the expression of emotions;

o Cultural norms related to the expression of depressive affect; and

o Within-group (e.g., social class) expectations related to the expression of depressive affect.

Assess and manage the risk of suicide , including:

o Client's level of ideation, the specificity of plans, the availability of means, and the intention to act;

o Client's capacity for self-control and his ability to cooperate with the therapist; and

o The strength of environmental supports (e.g., family, friends, employer, therapist) in comparison with conditions exacerbating suicidality (e.g., relationship conflict, drug or alcohol use).

Cochran and Rabinowitz (2003) conclude that "[a] clinician using gender-sensitive assessment strategies ... will be more likely to detect depression ... by linking ... anger, hostility, alcohol use, concern with work performance, and isolation to the client's mood disturbance. Moreover, careful history and evaluation of symptoms will frequently reveal a more complete symptom picture, including sad mood, tearfulness, sleeping difficulties, withdrawal, and suicidal thoughts" (p. 135).

"[C]linicians who can appreciate the contribution of gender role socialization to men's cognitive distortions will be better able to understand contributing factors to men's presenting problems, respond more empathically to their male clients, and anticipate the types of messages male clients internalize that may contribute to their depression, anxiety, and rigid self-defeating interpersonal relationships ... . Such gender informed interventions might help reduce gender role strain in clients, and break some of the connections between societal gender role stereotypes and men's feelings of adequacy and self-worth."

–– Mahalik, 1999, p. 339

Empirically Supported & Innovative Interventions

When depression is detected, Cochran and Rabinowitz (2003) advise clinicians to employ "empirically supported treatments as well as innovative psychotherapies developed specifically for men[, as these approaches] show great promise in treating depression in men" (p. 135). While granting that group therapy and marital/couples therapy are modalities that have a place in the clinician's treatment repertoire during work with men who are depressed, Cochran and Rabinowitz focus their recommendations on models for individual psychotherapy. Two empirically supported individual psychotherapeutic interventions for mild-to-moderate unipolar depression that they highlight are cognitive-behavioral therapy and interpersonal therapy; each was found to work equally well with men and women. They also describe three innovative, gender-sensitive, masculine-specific treatment approaches. These include:

o Mahalik's cognitive-behavioral approach (1999), which

integrates aspects of masculine gender role strain into a description of maladaptive cognitions that a therapist would expect to encounter when working with depressed men. ... The [cognitive] distortions Mahalik proposed (e.g., "I must be successful to be happy and fulfilled" or "If I can't do it myself, people will think I'm inept") relate specifically to men's vulnerability to episodes of depression when certain gender role expectations are not fulfilled. ...

This approach focuses on a review of the validity of each masculine-specific cognitive distortion, a weighing of the costs of the distortion in terms of emotional health, and development of a behavioral strategy designed to challenge the validity of the distortion. Because cognitive-behavioral approaches to treating depression have been verified as effective with men, the benefit of a perspective that is sensitive to the masculine gender role is likely to enhance the effectiveness of this particular approach. Although untested as a specific component of therapy, the gender role strain from which these cognitive distortions are assumed to arise has been related in a number of empirical investigations to increased levels of both depression and psychological distress ... . (Cochran & Rabinowitz, 2003, p. 135)

o Pollack's psychodynamic/self-psychology model (in Pollack & Levant, 1998), which

focuses on identifying and working through present-day derivatives of a discontinuity in a man's early childhood emotional "holding environment." This discontinuity, derived from a cultural tendency to eschew dependency and maternal connection in little boys, produces a masculine-specific vulnerability to relational abandonment and narcissistic wounding. Current-day life experiences of loss, rejection, or abandonment recapitulate this early experience of loss and thus render a man vulnerable to feelings of abandonment and the development of an acute depressive episode. In utilizing this approach, a gender-sensitive therapist would work with a male client toward repairing this underlying vulnerability to abandonment depression by providing a sustained therapeutic holding environment in which the male client can develop and strengthen his own capacity for self-soothing while integrating split-off or repressed experiences of grief. (Cochran & Rabinowitz, 2003, p. 135)

o Cochran and Rabinowitz's psychodynamic/self-psychology model (2000), which

emphasize[s] how men are culturally programmed to repress the affective aspects of loss experiences. Gender-sensitive therapists utilizing this model would work with a male client to identify these frequently repressed experiences of loss that have accumulated across the life span. Some common experiences of loss include early maternal disconnection, boyhood experiences of rejection by peers on the playground, experiences of rejection and loss in relationships, failure in occupational achievement, and loss of physical health due to the aging process. This particular conceptualization of psychotherapy with men allows for an expanded view of loss (beyond interpersonal loss or bereavement) that encompasses loss experiences of men at all stages in the life span and of all sexual orientations and cultural backgrounds ... .

Often, men may find that historical experiences of loss resonate with a current triggering event. If left unresolved, accumulation of these losses may render a man vulnerable to a full-blown depressive episode. Empathic responding to these experiences of loss may help identify the source of a depressed mood and lay the groundwork for more adaptive ways to manage depressed moods. (Cochran & Rabinowitz, 2003, p. 136)

"[S]ome men who are depressed can experience a trajectory of emotional distress manifest in avoidant, numbing and escape behaviours which can lead to aggression, violence and suicide."

–– Brownhill, Wilhelm, Barclay, & Schmied, 2005, p. 921

Taking Control ("in a tragically masculine fashion") 1

According to Cochran and Rabinowitz (2003), "[m]anagement of suicide risk in depressed men is a significant issue for therapists who treat men for depression" (p. 138).

[M]asculine-specific risk factors for suicide in men ... have been identified in various empirical studies of attempted and completed suicides. These include active alcohol or drug abuse, a coexisting antisocial personality disorder, and a co-occurring psychiatric disorder (schizophrenia, panic disorder, or major depression). In addition, a family history of conduct disorder, sexual abuse, violence, or suicide further increases suicide risk. Finally, in older men, physical illness is a significant risk factor for suicide. Any male client who is being treated for depression and who fits into any of these categories should be considered at increased risk for suicide.

Even though a male client may deny ongoing suicidal ideation or intent, if he fits into any of these empirically derived categories of elevated risk, responsible risk-management strategies should be considered. Typical risk-management strategies may include removal of the means for committing suicide, increase in frequency of sessions, practical strategies for increasing client tolerance for depressed mood, elimination of influence of alcohol or other drugs that reduce impulse control, activation of external support systems that might include family members or friends, and psychiatric consultation with the option of brief hospitalization. Applied in the context of a strong therapeutic alliance, one or more of these strategies may ultimately make the difference between life or death for a male client who is suffering a severe depression and who may be contemplating ending his life by committing suicide. (Cochran & Rabinowitz, 2003, p. 137)

References

Brownhill, S., Wilhelm, K., Barclay, L., & Schmied, V. (2005). 'Big build': Hidden depression in men. Australian & New Zealand Journal of Psychiatry, 39(1), 921-931.

Cochran, S.V., & Rabinowitz, F.E. (2000). Men and depression: Clinical and empirical perspectives. San Diego: Academic Press.

Cochran, S.V., & Rabinowitz, F.E. (2003). Gender-sensitive recommendations for assessment and treatment of depression in men. Professional Psychology: Research & Practice, 34(2), 132-140.

Coleman, C.L., & Hummel, D.B. (2005). Sexual orientation a predictor of depressive symptoms among HIV-infected African American men: A descriptive correlational study. Archives of Psychiatric Nursing, 19(5), 236-241.

Good, G.E., & Brooks, G.R. (Eds.). (2005). The new handbook of psychotherapy and counseling with men: A comprehensive guide to settings, problems, and treatment approaches, revised edition. San Francisco: Jossey-Bass.

Mahalik, J.R. (1999). Incorporating a gender role strain perspective in assessing and treating men’s cognitive distortions. Professional Psychology: Research & Practice, 30(4), 333-340.

Orr, G., Catalan, J., & Longstaff, C. (2004). Are we meeting the psychological needs of heterosexual men with HIV disease? A retrospective case controlled study of referrals to a psychological medicine unit in London, UK. AIDS Care, 16(5), 586-593.

Pollack, W.S., & Levant, R.F. (Eds.). (1998). New psychotherapy for men. New York: Wiley.

Rochlen, A.B., Whilde, M.R., & Hoyer, W.D. (2005). The Real Men. Real Depression campaign: Overview, theoretical implications, and research considerations. Psychology of Men & Masculinity, 6(3), 186-194.

Vera-Villarroel, P.E., Pérez, V., Moreno, E., & Allende, F. (2004). Diferencias en variables psicosociales en sujetos VIH homosexuales y heterosexuales. International Journal of Clinical & Health Psychology/Revista Internacional de Psicología Clínica y de la Salud, 4(1), 55-67.

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1 Cochran & Rabinowitz, 2003, p. 137

– Compiled by Abraham Feingold, Psy.D.

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