May is the month of family barbecues and holiday weekends. It’s also Mental Health Awareness Month — because it happens to be the month with the highest suicide rates in the United States. As a family physician, a large part of my job is recognizing depression and preventing the consequences of unchecked mental health in my patients. Sifting through the emotional turmoil of depression and identifying people who will actually pursue suicide is a challenge, but there is one patient population that has consistently demonstrated an increased risk for suicide: men.
Men are four times more likely than women to die of suicide, but are less likely to be diagnosed with internalizing disorders such as depression. The devastating effects of depression in men have been well documented in scientific literature, but it wasn’t until late 2018 that the American Psychological Association released new guidelines that articulated how masculinity affects mental health — along with recommendations on how to tailor treatment to the specific needs of men.
The term “toxic masculinity” has arisen in mainstream media as of late, but there’s some confusion on its meaning. Toxic masculinity as a scientific, medical term is meant to represent masculine traits that have been found harmful to the health of men specifically. However, the term has taken on a different meaning in popular culture, often referring to a specific set of negative characteristics associated with “locker room behavior” that induce acts of violence, aggression, and sexism. Masculinity, toxic or not, seems to have a different meaning for everyone, and it is largely shaped by the men we encounter in our lives.
When I think of what it means to be a man, the first person who comes to my mind is my father. He came from humble beginnings and lost his own father at the age of 12. He quickly had to become self-reliant, taking on odd jobs to help support his family. He grew to become a muscular, 6-foot-2 gentle giant, but his work ethic was his defining characteristic and earned him the respect of the men around him.
The face of depression is not always a frown, but often a smile.
At 60 years old, he was still working as a contractor, lifting heavy bags of concrete mix and racing up and down ladders faster than men a third of his age. He never complained and would effortlessly complete a two-man job in half the time of his younger counterparts. Then he was diagnosed with cancer. Initially, my father astounded his doctors, showing no signs of slowing down at his physically demanding job while battling stage 4 metastatic colon cancer, but like many advanced cancers do, it eventually caught up with him. Reluctantly, he had to modify his daily activities as the tumors in his lungs produced a low level of fluid that made him too winded to maintain the pace he was accustomed to. Once the tumors in his liver and lungs reached a certain size, he was forced to stop working altogether and eventually had to give up his other physically active pastimes like biking and bowling.
That is when he changed. He was reluctant to leave the house. He would grow increasingly frustrated with his pain and the medications that never made him fully comfortable. He often complained to me that the medication wasn’t working and that his doctors just didn’t get it. Why couldn’t they fix his pain? As his son and a physician, I was quick to consider the myriad possibilities for his discomfort, questioning both his medication’s efficacy and the care he received. In time, I realized that the reason for his pain was far simpler than I expected: He wasn’t taking his medication. My father never took pills for pain, and he didn’t want to start then. He would suffer silently, never asking for help and only opting to medicate when the pain became truly too much to bear. It took time to realize that the cancer wasn’t killing my father — depression was.
As his son and a physician, how could I have missed that my father was depressed? When we think of depression, we often imagine a sad, mopey individual dragging their feet — the human version of Eeyore. But that is a misconception. The face of depression is not always a frown, but often a smile. Depression is far more prevalent than we realize, affecting one in 13 Americans. And for men, masculine social norms encourage restrictive emotionality; they often have greater difficulty expressing their feelings and finding words to express basic emotions. Restrictive emotionality is associated with greater depression and can worsen the effect that stress has on a man’s mental health.
For men who are able to understand and express their emotions, another hurdle to overcome is the perceived stigma of having a mental health problem. Weekly and sometimes daily, I encounter men with depression who confide in me as their doctor about their private struggles and feel they have no one to share their feelings with. This is not because they are alone, although social isolation is a growing health concern. It is usually the opposite. These are men with small- to moderate-sized social networks who are well-liked by their friends and family, but they don’t want to shift the burden they have been carrying on to their loved ones. I frequently encounter men who take on the role of a “protector,” displaying traits of self-reliance and stoicism, but these characteristics are strongly associated with depression.
I often wonder if I should have approached things differently back then and confronted my father about his mood directly, but I suspect it would have made him more uncomfortable and withdraw from me even more. That is what I see happen with my patients.
If I push my patients too hard to confront a challenging reality, they are more likely to deny it and further isolate themselves from care. What tends to work better is if I meet them at their level of emotional acceptance. For men with restrictive emotionality, they may have difficulty recognizing depression, but we may be able to agree on something more specific, such as their decreased energy or that they are not interested in things they used to enjoy. By working with men at their level of emotional expression, we can make inroads on the factors influencing their mood and develop a strategy to improve their physical and mental well-being.
For men who have disclosed to me that they are feeling depressed, the next challenge is helping them overcome the stigma associated with depression. There is a fear among men that if they reveal their true feelings, their identity will change and they will be considered a burden to their peers instead of a reliable source of support. To lose that sense of respect would be to add salt to a very exposed wound, encouraging men to isolate themselves emotionally. To confront this fear, I often ask, “If the situation was reversed and your loved one was suffering from depression, would you view them as a burden?” The answer is typically no, they would want to do anything possible to help them. I try to push them further by asking, “How would you feel if your loved one didn’t come to you for help and tried to confront their depression on their own?” This reframing helps assuage fears of judgment, and in some scenarios, dispel the stigma enough to help my male patients discuss their feelings with a loved one. These are some of the strategies I use as a health care provider, but to see a change in how men are affected by mental health, we need to do more. We need to change the social environment we live in.
What it will take to make this happen are male role models to demonstrate healthy expression of emotion and how to receive care when a mental health issue arises. Men are influenced by the stigma of mental health and how they perceive other men will judge them, but might be more willing to engage in health-promoting behavior if they feel other men are doing it. The people needed on the forefront of this battle are fathers. The American Psychology Association highlights fatherly involvement as a critical component on improving long-term emotional and psychological health for both children and fathers. Father involvement has been associated with higher self-esteem, less delinquency, fewer depressive symptoms, less violent behavior, better grades, less substance use, and lower internalizing problems for both sons and daughters. Fathers are often our first archetype of masculinity, and we need them to lead by demonstrating what it means to confront and express difficult emotions in a healthy way.
There has been a shift in our conception of masculinity over the past few years, and we currently have the opportunity to redefine what masculinity represents in society. Men will need to let go of toxic traits to improve their well-being, but critiquing the demands of masculinity does not mean we are condemning masculinity as a whole. The challenge we are faced with is identifying masculine characteristics that also promote healthy expressions of emotion and behavior. To create this societal change, we need to meet men at their level of emotional expression and make an intentional effort in creating a safe space for men to share their feelings. Men must also reflect on the barriers keeping them from discussing their mental health and the fear of stigma attached to it. The strength we need now is the strength to be vulnerable and show others that it is okay to be open with their emotions. By embracing this revamped masculinity and having men lead by example, we can make that change. These changes won’t happen overnight, but we can start now to help build a better future for the next generation. So I ask any man reading this: Are you man enough to help?