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Beyond Blue

I often focus on women’s issues with regard to depression–hormonal triggers, people-pleasing, guilt, motherhood, and so forth—because, statistically speaking, more women than men suffer from depression. But, as you can read from the message boards, Beyond Blue has many male readers.
So today I focus on men’s depression, and in particular, on older men’s mood disorders.
For today’s feature of my “How Do You Move Beyond Blue?” series, I’m excerpting an interview published in the Fall 2007 issue of the “Johns Hopkins’s Depression and Anxiety Bulletin” with Peter V. Rabins, M.D., M.P.H., who is Co-Director of the Division of Geriatric and Neuropsychiatry at the Johns Hopkins University School of Medicine, as well as a professor of psychiatry with a joint appointment in the Department of Medicine and the Department of Mental Health at the Johns Hopkins Bloomberg School of Public Health. Dr. Rabins has published extensively in such journals as the “American Journal of Psychiatry” and the “Journal of the American Geriatrics Society.” He also serves on the editorial board of numerous journals, such as the “Journal of Mental Health and Aging” and the “International Journal of Geriatric Psychiatry.”
1) How common is depression in older men? Why is it difficult to diagnose?
Depression affects 6 million American men and 12 million American women each year. But these numbers don’t tell the story of older men in particular.
Depression is actually less common in older men than in middle-aged men. Estimates range from 2 to 5 percent of men over age 65 in a given year, though it’s unclear how reliable those estimates are because older men are more likely to deny sadness as a symptom, making diagnosis more complicated.


We know that, overall, about one-third of older people suffering from depression do not experience sadness as a symptom, but that percentage rises to 50 percent among elderly men. The lack of sadness makes it more challenging for primary care physicians to make the diagnosis of depression.
Sometimes called “depression without sadness,” this form of clinical depression has severe anxiety, physical discomfort, sleep disorders, and diminished energy and self-confidence as some of its primary symptoms.
Men are particularly prone to this type of depression as they age. Men—more commonly than women—are likely to feel angry, irritable, and frustrated rather than sad when depressed.
Men also tend to cope with depression differently than women. Instead of withdrawing from the world, men may act recklessly or develop a compulsive interest in word or a new hobby. Instead of crying, men may engage in violent behavior.
Men also are more likely to abuse drugs and alcohol when in the midst of a depression, perhaps to find relief from the pain of depressive feelings. This can make it difficult to determine whether a problem is specifically alcohol-or drug-related or whether it is primarily depression.
Changes in sleep habits, such as insomnia or feelings of exhaustion, and appetite changes are often recognized as signs of depression in both men and women, but it’s less well known that headaches; joint, back, or muscle pain; dizziness; chest pain; and digestive problems also may be symptoms. Men report these physical symptoms more often than women, although they are often unaware the symptoms are linked to depression. These physical symptoms are not imagined: Chemical imbalances that cause depression also affect other part of the body.
2) Do older men have a unique set of triggers or risk factors for depression?
It’s true today (but may change in the future) that some of the triggers for depression and risk factors for suicide—retirement or loss of a job, lack of social supports, and the availability of firearms—are more common in men than in women.
Regarding job stress and retirement, speaking purely from my clinical experience, I think men are more likely to primarily define themselves in light of their work role. Women who work seem less likely to do that. They continue to define themselves in terms of their roles as a family member or as part of a social network, making retirement or job loss less of a stressor for them. When men lose their work role, in their eyes it is the main contribution that they have been making. The adjustment can be very difficult.
This view is not grounded in science; it is simply my observation. And it may change with the next generation as the roles of men and women in the workforce and at home continue to evolve.
3) What role does age play in male depression?
Too many people believe that depression is an inevitable part of aging, so let me say this very directly: Almost every study finds either lower rates of depression in old age compared to middle age or equivalent rates of depression. Moreover, the majority of studies find less clinical depression in older people.
Depression does not become more common as we move from midlife to late life, and it is certainly not a normal part of aging that people should resign themselves to. Indeed, a majority of older men never experience depression.
That said, it is true that depression is still underdiagnosed and undertreated in the elderly. Older people with depression tend to suffer from other medical illnesses, complicating treatment. And part of the reason depression is underdiagnosed in the elderly is that their depressive symptoms are often attributed to those co-existing medical illnesses, instead of depression.
Where age does become a major risk factor in male depression is suicide. There is a common misconception that suicide rates are highest among the young, but it is older white males who suffer the highest rate.
When elderly men make suicide attempts, they are highly likely to be lethal. They are more likely, for example, to use guns and less likely to use pills (which, overall, tend to be less lethal and are a more common choice for women attempting suicide).
Attempted suicide rates and methods of suicide vary by culture. One example is that, in Singapore, where suicide rates are highest among elderly women, the most common method of suicide is jumping off the balcony of a high-rise building—obviously, a highly lethal method that raises the rate of completed suicides.
4) What is your advice for men who think they might be experiencing late-life depression?
If you’re experiencing some of the mental and physical symptoms described previously, tell your physician! Don’t be timid about mentioning depression.
Your primary care physician can treat you or refer you to a mental health care professional. Psychologists, social workers, and licensed counselors can all provide therapy. Psychiatrists can prescribe antidepressants. A number of well-conducted studies have demonstrated that combining counseling with antidepressant medications is the best treatment for depression.
It is worth mentioning that years of psychoanalysis are no longer the standard form of therapy. Short-term therapies, such as cognitive-behavioral therapy, take only weeks or months. Cognitive-behavioral therapy teaches you to recognize and change thought patterns that lead to depressed feelings.
The challenge in treating older people, whether male or female, is the fact that physical illness (e.g., stroke, heart disease, and cancer) becomes more common as we age. The challenges of treating a person who is medically ill AND depressed are significant at any age. It requires close cooperation between the doctors providing the patient’s medical care and the mental health care provider.
5) Erectile dysfunction (ED) can be an issue for men suffering from depression, both as a physical symptom of depression and as a side effect of antidepressant medications. What should men know about ED as it relates to depression?
One of the general symptoms of depression is a loss of interest in activities that the individual usually enjoyed, and so many men—and women—experience a diminution in sex drive and a diminution in the pleasurable aspects of all kinds of intimacy, not just sexual intimacy. ED is just one manifestation of that.
The other aspect of ED as it relates to depression is that almost all the antidepressants, particularly the commonly-used selective serotonin reuptake inhibitors (SSRIs), can cause ED. Moreover, it’s not just ED or loss of “sexual performance” that’s the problem; the drugs can actually impair sex drive itself—in both men AND women.
“Sexual dysfunction” is a good umbrella term. It includes diminished libido, inability to orgasm, decreased sensation in the genitals, erectile dysfunction (in men), and vaginal dryness (in women). It is better to discuss sexual dysfunction as it relates to depression, rather than just ED. And the advice about what a person suffering from depression and sexual dysfunction can do applies to both men and women.
First and foremost, raise the issue with your physician. The first thing your doctor will do is a thoroughly medical workup to rule out any possible physical problems. Hypertension, diabetes, urological problems, and neurological problems can all cause sexual dysfunction.
If depression is indeed the source of the problem, the right antidepressant might help renew your interest in sex. If you’re already on antidepressant medication and you and your doctor believe the antidepressant is the likely cause, several possible remedies exist.
First, you and your doctor may consider switching to an antidepressant with a low rate of sexual side effects, such as Wellbutrin (bupropion). This must be done carefully to minimize the risk of a relapse of depression.
As an alternative, your doctor may suggest adding Wellbutrin to your current antidepressant regimen. Research indicates that small doses of Wellbutrin (75-150 mg daily) in combination with other antidepressants can be helpful in alleviating the sexual side effects of those antidepressants.
Another remedy is to add the medication Viagra (sildenafil), which is potentially effective for combating antidepressant-induced sexual dysfunction in both men and women.
There is no good evidence that adding testosterone replacement therapy (in men or women) is beneficial, even though this is something that is commonly done.
A slight decrease in your antidepressant does may be helpful. If you want to try this approach, however, it’s important to develop a plan with your doctor to decrease the dose slowly and in small increments to avoid a recurrence of depressive symptoms.
Sometimes a “drug holiday” is an effective remedy. This involves taking a short respite from your medication. Evidence shows that periodic two-day breaks from antidepressant therapy can lower the rate of sexual side effects during the “drug holiday,” without increasing the risk of a recurrence of depressive symptoms. For example, in one study, taking medication Sunday through Thursday and skipping it Friday and Saturday allowed participants to enjoy improved sexual functioning 50 percent of the time on weekends, with no overall worsening of mood.
6) What can be done to prevent late-life male depression?
What seems to work is training physicians, mental health care professionals, and the public about the very early signs of depression. Early recognition of depressive symptoms appears to lower suicide rates or at least rates of suicidal thoughts, and may prevent depression from becoming chronic.
Doctors call this secondary prevention. Primary prevention is preventing the disease itself; secondary prevention is preventing a recurrence or exacerbation of the disease. An example of secondary prevention is treating high blood pressure so that a person doesn’t suffer a stroke. Identifying and treating the very early signs of depression would be akin to screening for and treating high blood pressure.
Doctors need to be better educated about recognizing and treating depression in later life. Over 70 percent of older suicide victims visit their primary care physician within the month of their death. Many of these patients have a depressive disorder that goes undetected during these visits.
Fortunately, to change this dismal statistic, research and educational efforts to improve physicians’ abilities to detect and treat depression in older adults are under way.
7) Have you noticed a change in social attitude toward male depression in recent years?
I do think, particularly compared to 20 to 30 years ago, that there is a greater appreciation for the fact that depression can overtake people in the way that many diseases do. I also think that this is a view that’s probably less common among older people than younger people, and particularly among older men. I hope that this will change over time.
But I think the fact that suicide rates are still high in elderly males, particularly white males, says something about the culture we live in and how men perceive loss of function loss of relationships, etc. Men are less about to reach out others for help in adapting to life’s upheavals.
Suicide is usually an indication that a person feels hopeless and doesn’t think anything can be done. Depression at any age—in 10-year-olds just as in 80-year-olds—can cause that. But most people, even when they’re hopeless, fortunately don’t turn to suicide.
The fact that suicide rates are so high in elderly, white men probably means that this group of people still sees depression as a personal failure and something that they can’t turn around or talk about with their doctor or loved ones. Hopefully, we can change those attitudes and dispel the myths associated with depression in older people (and older men in particular) through public education such as this interview.
Improved recognition, acknowledgement, and treatment of depression in later life can truly make those years more enjoyable and fulfilling, not just for the depressed older man, but for his family, friends, and caregivers as well.

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