Mental Health in Men

Everyone experiences episodes of low mood and anxiety depending on certain situations.  This is called situational depression or situational anxiety and is completely normal.  However, when symptoms extend beyond two weeks or beyond the time we would normally anticipate, then clinical depression or anxiety may be an issue.

Incidence

 

A U.S. National Health Survey[i] performed from 2010-2013 found that 8.5% of American men have daily feelings of depression and anxiety.   7.7% of men suffer from anxiety and 3.8% suffer from depression (2.2% overlap and suffer from both anxiety and depression).  Only about one-third (33%) of those men sought medication treatment, and only one-fourth (25.7%) sought the help of a mental health professional. 

Another study[ii] found that nearly one-third (30.6%) of men will suffer from a period of depression over the course of their lifetime.  Most sources have indicated that men experience depression less often than women because women seek help for depression twice as often as men.  However, this study found that men and women experience depression at about the same rate when we correct how depression is diagnosed in men using symptoms that men may exhibit more often.  For example, men are less likely to have decreased mood and more likely to have symptoms such as anger, aggression, addictive behaviors (substance abuse, pornography, gambling), and risk taking behaviors.  Since these more male predominant symptoms are often left out of depression screenings, this often leads to male depression often going undiagnosed.  In addition, men often externalize their depressive feelings rather than internalizing them, so they may be less likely to recognize that the feelings they are having are coming from within, not due to outside an event.  Gender expectations also expect men to be “less emotional” than women.  This also makes it more socially difficult for men to “open up”.

Symptoms

 

The name “depression” can be misleading since some people with depression really don’t have a depressed mood.  In fact, depressed mood is only one symptom out of the many symptoms that can be triggered in clinical depression.  So having depression doesn’t always mean having a depressed mood.

 

In addition, a large portion of people that experience depression also experience anxiety, so it’s not uncommon for these two conditions to go hand in hand.  Like depression, anxiety can manifest as symptoms that we don’t often think of with being anxious, such as racing thoughts or troubles “turning the mind off” in order to fall asleep.

There are multiple symptom scales used for depression.  However, few are geared specifically towards men.  Two depression tools that help identify depression in male patients are the Gotland Male Depression Scale (GMDS) and Masculine Depression Scale (MDS). 

Men with depression can have the following symptoms:

  • Prolonged stress

  • Irritability

  • Anger attacks/aggression

  • Loss of vitality/feelings of emptiness

  • Tiredness/fatigue

  • Indecisiveness

  • Sleep problems (too much or too little)

  • Anxiety/uneasiness

  • Alcohol/drug abuse

  • Addictive behaviors (gambling, pornography, sexual addiction)

  • Social withdrawal

  • Depressed mood

  • Worthlessness

  • Risk-taking behavior

  • Hyperactivity

 

Other symptoms that men may experience are:

  • Appetite changes

  • Loss of self-confidence

  • Suicidal thoughts

  • Over-focusing on school/work

  • Blunted affect (being numb or emotionless – neither happy nor sad)

  • Over-exercising

  • Aches and pains

  • Lack of displaying emotions

  • Changes in sexual desire (libido)

  • Need for independence/autonomy

  • Feeling overburdened

  • Externalizing rationale (turning feelings outwards on events or others rather than internalizing feelings)

 

Symptoms of anxiety often overlap with depression symptoms in men.  Anxiety symptoms can include:

  • Constant pressure, worrying, or tension

  • Restlessness (always feeling “keyed up”)

  • Worries that float from one problem to another

  • Difficulty concentrating

  • Racing thoughts/can’t turn mind off

  • Fear that something is going to go wrong

  • Fatigue

  • Irritability

  • Sleeping difficulties

 

WHAT'S GOING ON IN THE BRAIN

People who have not experience depression often wonder why those who do struggle can’t simply “pull themselves up by their bootstraps”.  However, situational depression and clinical depression are two completely different events. 

Everyone experiences situational depression and anxiety.  It’s natural to feel sad at the loss of a loved one, stressed out from work, overwhelmed by a big examination at school, worried about bringing home a paycheck, etc.  These are natural stressors that motivate individuals to address and appropriately overcome obstacles that stand in the way of happiness and success. 

In the past, depression was often referred to as a chemical imbalance.  This is actually accurate in many instances.  The nervous system uses electrical signals as well as chemical signals to coordinate communication between different parts of the brain.   Clinical depression and anxiety are actually disorders of a part of the brain called the limbic system.  The limbic system is found on the inside of the brain just above the spinal cord.  It governs our emotions, memories, and responses to situations.

 

[i] Blumberg SJ, et. al. Racial and Ethnic Disparities in Men’s Use of Mental Health Treatments, NCHS Data Brief (206), 2015.

[ii] Martin LA, et. al. The Experience of Symptoms of Depression in Men vs. Women, JAMA Psychiatry. 2013; 70(10):1100-1106.

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There are three main structures in the limbic system.

  • The amygdala is responsible for internal emotions such as joy, fear, anger, and anxiety.

  • The hippocampus is responsible for memory storage as well as internal emotions like the amygdala.

  • The hypothalamus is responsible for external emotions such as crying, laughing, sweating, and heart rate.  The hypothalamus is the master control center of the body, regulating sleep cycles, appetite, temperature, physical drive/energy, and sex drive.  It also controls the pituitary gland which controls hormone release throughout the body. 

 

Sometimes individuals can have depression that is focused in one area of the limbic system more than another.  For example, an individual whose depression is focused more in the amygdala and hippocampus may feel sad but cannot cry.  On the other hand another individual whose depression is focused in the hypothalamus may be tearful, but doesn’t necessarily complain of being overly saddened.

The limbic system has no “thought” process, but is the more “instinctive” part of the brain.  For example, we don’t have to think about what our heart rate is or if it’s hot enough that we need to start sweating.  We do our “thinking” in the cortex of the brain.  For this reason, our cortex receives information from the limbic system that we need to interpret appropriately.  When chemical imbalances occur, the signals from the limbic system often don’t match what’s going on in our environment, so we feel things that aren’t necessarily accurate.  For example, someone may feel afraid when there’s nothing to be afraid of or feel sad when there’s nothing to feel sad about.  Since we often don’t feel an emotion without there being a reason, many individuals with anxiety and/or depression will try to figure out why they’re feeling a certain way.  They may blame their feelings on an event that is long in the past as a way to “explain” why they feel the way they do.  For example, a man may blame his depressed mood or feelings of worthlessness on the loss of a job that occurred months or even years ago, even though he’s found a new job.  Or individuals can create scenarios that aren’t true – for example, a man may blame his anger on a situation at work rather than depression.

 

Neurotransmitters

 

Neurotransmitters are chemical signals the limbic system uses to communication within itself and with different parts of the brain.  The main neurotransmitters are:

  • Serotonin

  • Norepinephrine

  • Dopamine

 

Serotonin has a calming effect in the central nervous system.  We often refer to serotonin as the “mom” – balancing and calming things out.  In fact, many individuals who struggle with anxiety symptoms often have a decrease in response to serotonin.  Serotonin causes a sense of well-being.  In men, a flood of serotonin is released during orgasm and ejaculation.  Serotonin is responsible for the intense feeling of calm and pleasure in the minutes after ejaculation.  Serotonin is also involved in the sleep cycles, so this flood of serotonin at ejaculation also explains why men often fall asleep right after intercourse.  Serotonin also affects the male reproductive system by causing an erection to subside after ejaculation.  As long as serotonin levels are relatively high, it can be difficult for a man to get another erection.  For some men with depression caused by serotonin, they may engage more frequently in sexual activity, masturbation, and/or pornography as a means of self-treatment for depression since on a subconscious level the brain realizes that ejaculation and orgasm cause serotonin release, thus “correcting” the imbalance for a short period of time.

 

Norepinephrine on the other hand has a motivating or energizing effect in the nervous system.  We often refer to norepinephrine as the “dad” – creating a “kick in the pants” and getting us up and going and motivated to accomplish tasks and have energy.  In fact, norepinephrine is very closely related to adrenaline and is sometimes referred to as “noradrelanline”.  In individuals who have fatigue and lack of energy as a symptom of their depression, norepinephrine may be the neurotransmitter out of balance.  Side effects of norepinephrine can include increased sweating, heart palpitations, and in some cases agitation (think of how you’d feel when your adrenaline is pumping). 

 

Dopamine is actually structurally similar to norepinephrine.  The body can take dopamine and create norepinephrine or it can take norepinephrine and create dopamine.  We often refer to dopamine as the “fun uncle” – creating a sense of joy, excitement, and anticipation.  It is also responsible for focusing and good judgement.  Lack of dopamine can cause lack of focus while excessive dopamine can overwhelm our focus (created a “stoned” or “drunken” state).  Dopamine is a chemical that creates high motivation for certain activities.  In fact, dopamine is released during times of high excitement and is a reinforcing chemical that motivates us to return to that activity over and over.  Dopamine is released in response to endorphins – so eating food, exercising, accomplishing something great, and sexual activity are all activities that increase dopamine and reinforce that behavior or cause us to want to “accomplish” something again.  In men, dopamine increases sexual desire and sexual functions.  It increases our desire for sex and enhances a man’s ability to get an erection and ejaculate more quickly.  It is released in large quantities while anticipating and engaging in sexual activity.  Unfortunately, dopamine is also why pornography and masturbation addiction so difficult to overcome.  In fact, all addictions are disorders of dopamine.  A good example is gambling – the anticipation of winning the jackpot can cause enough dopamine release to keep someone coming back to the betting table over and over again.  Since dopamine is involved in focus, men who are suffering from addiction frequently lose focus during recovery which leads to diminished self-control and lack of thinking things through when faced with a trigger or temptation to act out on their addiction again (especially those with pornography/masturbation addiction).

 

The final neurotransmitter we will discuss is GABA.  This is often not associated with depression, but can be associated in men who have anxiety, especially panic attacks.  We often refer to GABA as the “grandma” or “grandpa”.  GABA is the nervous system’s way of slowing everything down.  In people who have panic attacks, it is thought that GABA isn’t released appropriately causing an over-reaction to an event.  It is associated with helping to calm seizures and bring an overly active nervous system back to a reasonable level.

 

CAUSES OF ANXIETY/DEPRESSION

 

The imbalances of neurotransmitter can intensify the feelings of anxiety and depression beyond what they should be.  In addition, these feelings of anxiety and depression do not resolve when the stressing situation has passed.  In fact, these symptoms may make every subsequent situation or event feel overwhelming and stressing.  These imbalances can occur for a few different reasons – namely genetics, stress, addiction, and other medical conditions. 

 

Genetic factors may cause genes to be passed from one generation to the next that code for inappropriate production or release of these neurotransmitters.  So it’s not uncommon for depression and anxiety to run in families.

 

Stress is perhaps one of the leading causes of depression and anxiety.  A severe or prolonged stress event can cause our nervous system to become depleted or low on neurotransmitters.  In addition, stress prevents our bodies from creating new batches of neurotransmitters efficiently.  This is why depression is often caused by a situational event (death of a loved one, divorce, lost job, etc.).  In normal situations, the stress would be short-lived and neurotransmitters would remain balanced.  However, in some individuals the stress decreases the amount of neurotransmitter produced thus causing a prolonged episode of depression and/or anxiety that extends beyond the normal “mourning phase”. 

 

Addiction often causes profound depression, especially when individuals try to overcome the addictive behavior or drug.  During addition, the body gets used to dopamine only being released when acting out on the addiction.  In addition, the amount of dopamine released during an addictive episode is much higher than would occur naturally.  This leads to a depletion of dopamine that requires more and more addictive encounters to release enough dopamine to keep emotions level.  When individuals try to stop acting out on their addiction, there is often a huge deficiency in dopamine which causes depression, numbness, lack of focus, poor judgement, and regular relapses with the addiction.

 

Other medical conditions that affect the nervous system as well as the endocrine (hormone) system can also cause depression.  Disorders of the nervous system such as chronic pain and sleeping disorders/lack of sleep can upset the balance of chemicals in the brain, thus leading to depression and/or anxiety.  Changes in the hormone levels in the body can also loop back and affect the hypothalamus, thus triggering an imbalance in the limbic system.  These can include:

  • Hypothyroidism (decreased thyroid hormone)

  • Puberty (increase in testosterone)

  • Low T (decreases in testosterone)

 

TREATMENT

Treatment for anxiety and depression includes both medication therapy as well as psychotherapy. 

 

Forms of psychotherapy can include talk therapy and counseling. 

Medication treatments are also highly effective.  The treatments for anxiety and depression are often quite similar since they involve balancing the same neurotransmitters.  It’s important to understand how antidepressants work so that individuals give them enough time to do their job.

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Medication therapy is typically focused on balancing neurotransmitters.  As previously stated, nerves communicate with one another through chemical messengers called neurotransmitters.  At the end of a nerve cell, a bulge called the axon terminal.  Inside the axon are packets of neurotransmitters (serotonin, norepinephrine, and dopamine).  When the nerve wants to communicate a signal to another part of the brain, these neurotransmitters are released into the space between the nerve cells called the synapse.  On the other nerve cell, there are receptors that the neurotransmitters can fit in to – kind of like a key in a lock.  When enough receptors have been stimulated, the next nerve becomes excited and sends a signal (norepinephrine or dopamine) or calms down and doesn’t send a signal (serotonin or GABA).  This prevents an inappropriate signal from being sent from one part of the brain to the other.  Neurotransmitters are then recycled by re-entering the axon through a reuptake channel.

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In depression and anxiety, either the number of neurotransmitters (keys) are insufficient or the number of receptors (locks) are insufficient.  This leads to nerve communication that occurs either too often or not often enough depending on the neurotransmitter.  This inappropriate firing or lack of firing is what causes feelings of depressed mood, fatigue, lack of sleep, lack of appetite, aggression, etc. to occur.  If neurotransmitter levels have been low for a prolonged period of time, then the body responds by reducing the number of receptors (locks).  If there aren’t enough receptors, then not enough locks can be opened to start or stop the second nerve from firing.

Antidepressant medications primarily focus on increasing the number of neurotransmitters staying in the synapse by closing the reuptake channels.  In essence, antidepressant medications help the body use the neurotransmitters it makes naturally more efficiently.  If there are enough receptors on the second nerve, then antidepressants can often begin working right away since the nerves only needed increased neurotransmitter in the synapse in order to communicate effectively.  However, if receptor counts are low, then it can take anywhere from 4-12 weeks for the body to “grow” new receptors in response to normal amounts of neurotransmitters in the synapse.  This is a main reason why many individuals with depression have to take medications for a few weeks before they start feeling the beneficial effects on their mental health. 

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There are multiple drug classes that treat anxiety and depression, but the most common are the SSRI’s, SNRI’s, and NDRI’s.

SSRI’s (selective serotonin reuptake inhibitors) work by increasing the amount of serotonin in the synapse.  These medications include fluoxetine (Prozac®), citalopram (Celexa®), escitalopram (Lexapro®), and sertraline (Zoloft®).  Healthcare providers often choose these medications in individuals that have anxiety as it is thought that lack of serotonin can cause nerve signals to over-fire (thus causing the anxious symptoms).  These medications are also highly effective in helping individuals that have issues with sleep.  The one drawback to these medications for men involves their effects on sexual function.  SSRI’s are often a cause for delayed ejaculation since they slow down the firing of nerves in the penis and spinal cord that lead to ejaculation.   Sometimes providers use this side effect to their advantage when treating men who have premature ejaculation (ejaculate too quickly.  Another side effect of SSRI’s is diminished erectile function.  As stated previously, when men experience orgasm, they release a large amount of serotonin.  This causes a sense of well-being, but it also is one of the key reasons erections subside or go away.  Some men on SSRI’s find that they have difficulties attaining or maintaining an erection.  This occurs because chemically their body may chemically be in a state of have “just ejaculated” due to the higher serotonin levels.  In addition, in men who are not sexually active, SSRI’s may inhibit or reduce wet dreams by reducing nocturnal erections.  This often goes away with time; however, other medications such as cyproheptadine may sometimes be prescribed by a healthcare provider to block the serotonin effects for a few hours when sexual activity is desired.

SNRI’s (serotonin norepinephrine reuptake inhibitors) work by increasing both norepinephrine and serotonin.  These medications include duloxetine (Cymbalta®) and venlafaxine (Effexor®).  These medications are often useful in treating the same individuals that we use SSRI’s for, but they have the added benefit of stimulating norepinephrine which can help individuals who are feeling fatigue or lethargic.  For some reason not fully understood, the combination of serotonin and norepinephrine make these medications highly effective in treating certain types of nerve pain.  So these medications are often chosen in men who experience pain as a part of their depression.  The sexual side effects with SNRI’s are the same as they are for SSRI’s which can create difficulties with erections, delayed ejaculation, and in sexually inactive men, decreasing wet dreams.  In addition, the norepinephrine component can cause men to sweat more.  This is called hyperhidrosis.  Men using these medications may need to reapply antiperspirant or be prepared to changes clothes after strenuous work or exercise. 

NDRI’s (norepinephrine dopamine reuptake inhibitors) work by increasing both norepinephrine and dopamine.  This class of medications includes bupropion (Wellbutrin®).  This is one of the only antidepressants that increases dopamine levels.  This class is used oftentimes in men who are having difficulties with concentrating since concentration is linked to dopamine levels.  It is also used frequently in men who have depression in conjunction with an addiction such as smoking, pornography, masturbation, or gambling.  Not only can this class help men with addictions who are experiencing depression, but it can actually help reduce the cravings to act out on the addiction.  In fact, bupropion is approved by the FDA to help individuals quit smoking.  Some providers also find that it is helpful in individuals trying to overcome pornography and masturbation addictions.  The sexual side effects of NDRI’s are more favorable.  Men find it easier to attain erections.  In fact, NDRI’s can be added to an SSRI to balance out the sexual side effects.  Men often find that ejaculation occurs more quickly on NDRI’s and bupropion can help men with delayed ejaculation.  Although not proven, bupropion may actually increase the likelihood of wet dreams in men who are sexually inactive and could be used to help male patients with difficulties in having wet dreams.  NDRI’s can however increase agitation and aggression, so men who have strong symptoms of aggression are often tried on other antidepressants first.

Buspirone is a medication that is sometimes used to treat men who have anxiety that sometimes breaks through their anti-depressant medication.  This medication can be taken as needed and can help alleviate symptoms. 

Other medications are available to treat depression and anxiety if a provider feels that the above medications are not good option for a particular individual.

 

 

TYPES OF DEPRESSION & ANXIETY DISORDERS

There are a few different types of depression and anxiety disorders.  These can range from mild dysthymia to major depressive disorder.  Some types of depression are seasonal and other types last for years on end.  In this section we will discuss the different types of depression and anxiety disorders.

Dysthymia

Dysthymia is a milder form of long term depression that doesn’t go away on its own.  There can be ups and downs in mood and other symptoms but there is rarely if ever a break of more than 2 months from feeling down most of the time.  This commonly occurs before the age of 21 and can follow an individual throughout adulthood.  These individuals are often thought of as being “gloomy”, “complainers”, or “unmotivated”.  One of the main symptoms of dysthymia includes a loss of pleasure in doing certain things that were once pleasurable.  However, having low self-esteem, lack of productivity, and feeling hopeless are also common.  People with dysthymia can often benefit from medication and/or counseling.

Seasonal Affective Disorder (SAD) is a type of dysthymia that worsens with lack of light.  We know that light helps trigger neurotransmitter release, especially serotonin.  The thought is that less bright light (less sunshine or shorter days) can reduce the amount of serotonin in the brain leading to worsening symptoms of dysthymia and depression.  SAD is most often seen when days get shorter.  Symptoms typically set in or worsen in the autumn then peak during the winter.  Symptoms often start to diminish by springtime, and often go away in the summer.  SAD can also occur when moving from sunny climates like the desert to a more overcast or rainy climate.  SAD is also seen in individuals that start working graveyard shifts and are awake when it’s dark and are asleep when it’s light outside.  It can also occur in individuals who work in buildings that don’t have many windows.  Treatment can involve bright light therapy.  These bright lights stimulate the brain to increase the production of serotonin.  However, for many individuals with SAD, medications taken during the part of the year with the shortest days is often very beneficial.

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Major Depressive Disorder - MDD

Major Depressive Disorder (MDD) is a more severe form of depression.  It actually affects not only how people feel, but also how they behave.  Many individuals with MDD have difficulties with some day to day functions in their life.  This can range from excluding themselves from events with friends and family, to difficulties focusing on work/homework, or simply having difficulties handlings certain high stress situations.  MDD often manifests with multiple symptoms and can include sleep disturbances, appetite changes, anger, sadness, guilt, difficulties concentrating, and trouble thinking clearly.  Individuals with MDD may also have suicidal thoughts or start planning how to commit suicide.  MDD can occur once during someone’s life or there can be repeated episodes.  Medication and/or therapy are often the recommended treatments for MDD.

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Generalize Anxiety Disoroder - GAD

Generalize Anxiety Disorder (GAD) is a disorder where individuals have symptoms that are more anxiety driven.  People with GAD often complain of having a constant, pent up feeling of worry or tension, feeling restless, difficulties concentrating, worries drifting from one concern to another, fatigue, racing thoughts, and irritability.  In GAD, there are few symptoms of depression.  Lack of serotonin can cause feelings of anxiousness, so GAD often responds well to serotonin agents.  Cognitive behavioral therapy (a form of psychotherapy that deals with how individuals respond to stressors) is also very helpful for men with GAD. 

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Mixed Anxiety & Depressive Disorder - MADD

Mixed Anxiety and Depressive Disorder (MADD) is perhaps the most common form of depression.  This occurs when patients have symptoms of both major depressive disorder (MAD) and generalize anxiety disorder (GAD).  In fact, over half of people with MAD are thought to actually have MADD.  So it is more common that not for people with major depression to also have anxiety symptoms.  Medications and psychotherapy are both effective in the treatment of MADD.

Obsessive Compulsive Disorder - OCD

 

Obsessive Compulsive Disorder (OCD) is a form of anxiety disorder where obsessive thoughts and worries lead to compulsive actions in order to decrease the anxiety they feel.  A good example is individuals that have a compulsion around cleanliness.  Obsessive thoughts about germs can lead to compulsive behaviors such as constantly sanitizing, excessive handwashing, prolonged showers, monitoring others’ cleanliness, or creating elaborate routines to ensure that they or their environment stays clean.  As you can see from this example, individuals with OCD not only feel anxious about a particular event, but they change their behavior in an effort to control that event.  Other examples can include obsessions with accuracy (compulsive number counting), discarding objects (compulsive hoarding), safety (constantly checking doors/windows repeatedly), etc.  OCD occurs in about 1% of individuals and is thought to be either genetic, induced by stress, or a learned behavior.

WHEN TO SEEK TREATMENT

Many individuals with depression or anxiety put off getting help for their symptoms, thinking that there depression or anxiety is situational and will just go away.  Normal situational feelings of depression or anxiety typically are worst at the time of the event and the two weeks following the event.  Although not all symptoms go away within two weeks, symptoms associated with situational depression typically improve over time.  If there have been feelings of depression that last for more than two weeks or worsen over a two week period, it can indicate an imbalance in the neurotransmitters that control emotion. 

 

The sooner depression and anxiety are treated the easier and faster it is to return to a state of good emotional health and lack of symptoms.  The longer the neurotransmitter imbalance persists, the more likely that receptors on nerves will change as well.  This can lead to longer time to respond to treatment.  Also, changes in our perception of the world change as we become accustomed to inappropriate emotional responses, which can often require more talk therapy or psychotherapy to change our perception of our emotional world.  Earlier treatment typically results in a faster recovery.

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