Depression’s machismo mask

YOU might call it melancholy on steroids -- a muscular mixture of fast-driving, heavy drinking, hard-charging cussedness. For perhaps 3 million American men yearly, that’s the plotline for depression.

For almost 24,000 men yearly, the final scene is suicide. Often, there is no cry for help, no river of tears, no abyss of sadness. Just a violent, tragic bolt from the blue.

In the United States, a man is four times more likely than a woman to commit suicide, according to government statistics. Yet, he is only half as likely to be diagnosed with depression. That stark disconnect underscores a simple fact about depression in men: It often does not look like the mixture of sadness, guilt and withdrawal that dominates diagnostic descriptions and popular perception of the disease. As a result, a man’s depression is often missed -- by loved ones, by physicians, by the sufferer himself.

The costs are steep: in lives hobbled, jobs lost, relationships ruined. Some professionals even tally the toll in prison terms, substance-abuse statistics and shattered communities.

But today the diagnosis of depression is in the midst of a long-overdue makeover, as medical and mental health professionals have come to recognize that in at least half of depressed men, the recognizable litany of symptoms don’t really fit.

‘Their way of weeping’

Some depressed men may be plagued by impotence and loss of sexual interest, but others may become wildly promiscuous. Many complain of depression’s physical symptoms -- sleep troubles, fatigue, headaches or stomach distress -- without ever discerning their psychological source. Compared to women suffering depression, depressed men are more likely to behave recklessly, drink heavily or take drugs, drive fast or seek out confrontation.

Instead of acting like they are filled with self-doubt, depressed men may bully and bluster and accuse those around them of failing them. For many men, anger -- a masculine emotion that one “manages” rather than succumbs to -- is a mask for deep mental anguish.

“That’s their way of weeping,” says psychologist William Pollack, director of the Centers for Men and Young Men at McLean Hospital in suburban Boston and an expert on depression in men.

Dr. Thomas Insel, director of the National Institute of Mental Health, likens the shift now taking place among psychologists and psychiatrists to one that is taking hold in other areas of medicine. In the diagnosis of, say, heart disease, physicians have come to recognize that men and women can have the same illness, but their symptoms often look very different.

In any given year, says Insel, 6.4 million men will be diagnosed with depression -- and many health professionals think that number may be far too low. Insel’s institute has launched a broad campaign to raise awareness of the depression that affects men.

Steve Klepper is one of those men. For almost two decades as an aerospace machinist in San Diego, a coffee-fueled Klepper worked so much overtime that he was able to buy a family home by himself. At work, he says, he was short-tempered and had little patience for his co-workers’ blather about friends and family.

At home, he would drink himself numb virtually every night. By his own admission, he “acted very much like a jerk” to women and friends, and suffered constant stomach problems and skin rashes. He thought frequently of suicide.

Today, Klepper manages his condition with medication, and leads a San Diego support group for those suffering depression and bipolar disorder. He finds it hard to fathom why no one ever called his evident depression what it was. But he knows why it’s a hard diagnosis for a man to admit to himself.

“It’s embarrassing to be sad,” he says. “And the difference between being sad and lazy is hard to distinguish.”

Neither tears nor indolence, it seems, are manly virtues.

“Depression equals vulnerability and shame and lack of functioning. That takes away the man’s masculinity -- and for men, that takes away the sense of self,” says Pollack, author of “Real Boys: Rescuing Our Sons from the Myths of Boyhood.” In the American ethos, Pollack says, “a man who’s vulnerable is not even a man any more.... It’s the equivalent of being psychologically castrated.”

Pollack and a small but growing number of depression experts say it’s time for the mental health profession to expand its definition of depression so it is better recognized in men. They are pushing for a new category of depression -- Pollack calls it “male-based depression” -- to be incorporated into the new “Diagnostic and Statistical Manual,” the bible of the mental health profession that is being updated.

The reformers could easily cite Bill Maruyama as male-based depression’s Exhibit A.

As a Japanese-American kid growing up in Inglewood after the Watts riots, Maruyama outwardly nurtured a demeanor that was all “swagger and bravado” but in reality it was a veneer hiding the torment of rising depression.

Alone, in secret, he often cried.

Years later, as a young Los Angeles lawyer, Maruyama spent his paychecks as quickly as they came in. Driving along the winding cliff-side roads of Mulholland Drive, he would thrill at the fantasy of driving off the edge, and speed up, just to tempt fate. Behind the wheel, in the line at a coffee shop or at home with a romantic partner, he would fly into a rage at the least provocation.

The death of both his beloved parents within the span of three years sent him finally falling into the abyss of depression and spurred him to seek professional help. It was no easy move. Among tradition-bound Asian Americans of his parents’ generation, “depression is a sign of weakness and that weakness is a shame on the family,” says Maruyama. “And to bring shame on the family, you may as well just commit suicide.”

Maruyama, instead, sought out a psychotherapist -- a decision “that saved my life,” he says. While he does not take medication, he stays in touch with a therapist, mindful that “you’re like a recovering alcoholic, you can always slip back.”

As they work to overhaul the long-held view of depression as a predominately “women’s disease,” mental health reformers are following a growing trend of openness among depressed men. In the worlds of business, sports and politics, a few influential sufferers have broken their silence in recent years, helping to put a male face on the disease.

One of them is business mogul Philip E. Burguieres, once the youngest chief executive of a Fortune 500 company. In the early 1990s, Burguieres says he was an outwardly successful workaholic problem-solver. But he never slept more than a few hours at a time -- and inside, worry gnawed at him so furiously, “I almost wanted to peel my skin off,” he says.

In 1991, after wrestling for weeks with a particularly intractable business challenge, Burguieres passed out in his office. A psychiatrist bluntly told him he was clinically depressed and prescribed medication, psychotherapy and participation in a mental health support group. Burguieres dismissed her recommendations out of hand.

By 1996, his depression was back with a vengeance, and at age 53 he bowed out as chief executive of an energy services company, citing “health reasons.” For almost a year before doing so, he had fantasized obsessively about committing suicide.

But “almost to the day I committed myself, I could fake it,” says Burguieres. “I could put on my blue suit and my red tie and look good for a couple of hours, then come home and collapse.”

In recent years, Burguieres, now owner of the NFL’s Houston Texans, has spoken to many business groups about his depression. And so many fellow businessmen have confided their own, similar stories that Burguieres believes the disease is “chronic and widespread in the executive office,” and growing harder to ignore.

More visible still are the athletes who have gone public. In November 2002, Milwaukee Bucks power forward Jason Caffey announced he needed time away from basketball to get treatment for his depression, prompting sympathetic attaboys from crusty Milwaukee fans and sports columnists.

In May 2003, four-time Superbowl quarterback Terry Bradshaw embarked on a multi-city campaign sponsored by GlaxoSmithKline, maker of the antidepressant Paxil, to discuss his own lifelong depression and urge sufferers to get help. “Taking the first step toward a diagnosis and treatment was one of the bravest thing I’ve ever had to do,” said Bradshaw.

Bravery, indeed, is a central theme of the National Institute of Mental Health’s campaign, now entering its third year. Featuring a series of national radio, television and print advertisements called “Real Men, Real Depression,” it urges those who may suffer from the disorder to get treatment. A firefighter, a former Air Force sergeant, a lawyer and others talk about their symptoms and how they finally broke their silence and, with help, got relief. The advertisements stress to men that “It Takes Courage to Ask for Help.”

Cultural stigma

This month, the campaign will begin distributing a new series of public service announcements aimed at some of depression’s most underserved sufferers: Latinos. The Spanish-language ads are expected to begin airing in large, Spanish-speaking markets such as Los Angeles by the end of this year.

Latino cultural taboos against depression run deep, says Rodolfo Palma Lulion, one of the men profiled in the campaign.

As a Latino man, Palma found it hard to confront the notion that depression had seized hold of him, and he found it even harder to talk to his family. “My mom was a social worker, so she knows about depression,” says Palma. “But it was always demonstrated as weakness, or as a phase. It wasn’t something you deal with with a professional. It was something that stays in the family.”

Latinos certainly are not alone in that view. A 1996 survey by the National Mental Health Assn. found that 63% of African Americans said they considered depression “a personal weakness,” compared with 54% of all those who responded.

John Head knows that stigma well. In the 1990s, Head was a rising reporter with the Atlanta Journal-Constitution, an African American man with a lovely home and family. He ran every day -- sometimes twice a day -- in a frenetic bid to outrun his sadness. But he could not outrun the feeling that he was a fraud, undeserving of his growing recognition. He ruminated that affirmative action may have given him an unfair advantage.

From the time he was small, “I was told that I had to be a man” -- and that meant no crying, no admission of the sadness he could not escape. His family, he believed, would think less of him if he sought treatment; his employer and co-workers would think him less capable of doing his job.

Even physicians and mental health professionals who have come to recognize depression’s unexpected manifestations in men are careful to avoid what psychologist Pollack calls “the D-word” when they first suspect it. Dr. Kevin Brown, a family physician in the Crenshaw district, says that with men in general -- and his predominantly African American and Latino patients in particular -- he reaches for other words to open a conversation about depression.

“I tend to use the words ‘under stress’ more often than not, and people can definitely relate to that,” Brown says. A referral to a mental health counselor or a psychological support group “is definitely almost a no-no,” he says, because “there’s usually more machismo or bravado about men’s ability to handle whatever emotional problems they might have.”

Brown says that in men who do not appear to have reached a state of crisis, he may first prescribe an antidepressant. Only after a few follow-up visits, when he has gained a patient’s trust, would he suggest counseling. Brown, who is African American, suspects that among males in the population he serves, depression is quite common and largely unrecognized. Most of it, he suspects, plays itself out on the streets, in gangs and behind the tinted windows of cars. “I can only guess the numbers of those who do not get help, and I think we see the effects of this in the criminal justice system,” he says.

This view of young male African Americans’ behavior has gained resonance in the last two decades, as suicide rates among black males from age 10 to 19 have risen steeply. In his 2000 book, “Lay My Burden Down,” Harvard Medical School psychiatrist Dr. Alvin F. Poussaint writes that an epidemic of suicide among young black males is only part of hopelessness and self-hate among African American men: Drug use, alcoholism and violent behavior have their roots in depression too.

But admitting to depression, says Head, is “something that men don’t do, and especially black men don’t do.”

Head did seek help for his depression. But he first moved out on his family, convinced that his wife and sons would be better off without him. Alone in his apartment, he conducted what he calls “a dress rehearsal” for suicide, tying off a rope, checking a chair for its height, ensuring that he could kick it away.

Head did not kick the chair away from under him that day. He went to his wife, who, horrified by his admission, helped him plot a quiet search for help. Many in his family first learned of the depths of his despair -- and of his climb back to mental health -- with the publication of his book, “Standing in the Shadows: Understanding and Overcoming Depression in Black Men.”

Now, as he crisscrosses the country talking about his book, Head see signs of change upon the landscape of American men. There once was a time when mostly women would come to hear him. Their concern for their secretly depressed male friends, relatives and partners were evident in their urgent questions.

Today, says Head, “I’m seeing more men who’re willing to come to these forums, and who stand up and say, ‘This is the first time I’ve ever stood up,’ ” and acknowledged their mental anguish, says Head. “That kind of thing gives me hope that things are changing.”

*

(BEGIN TEXT OF INFOBOX)

Talking about the ‘D-word’

It is a refrain heard so commonly by psychologists and psychiatrists that it could be the opening to an inside-the-profession joke: “This guy trudges into my office, collapses into the chair and says, ‘My wife/partner/friend sent me. She says I’m depressed.’ ”

The man seldom believes it himself. But as the symptoms are coaxed from the patient -- changes in appetite, fitful sleep, low energy -- resistance often drops away. And a willingness to get treatment can emerge.

But the first step for many men, is to hear, “I think you’re depressed” from someone close to them -- someone who has seen first-hand his anxiety, mood swings, sleep problems.

If you suspect depression in your friend or partner, do not downplay the changes you see or criticize his behavior harshly.

Instead, say you’re worried about his mood or behavior. Tell him that depression is common in men, and doesn’t always look, or feel, like sadness. Explain that treatments -- “talk therapy” and/or antidepressants -- bring relief in four of five cases. Next, urge him to talk about his behavioral changes with his physician, a community health clinic worker or a trusted religious advisor. They can make referrals to psychiatrists or psychologists.

If your friend, spouse or partner talks about suicide -- even in jest -- do not dismiss it, and do not shrink from probing his intentions and getting help for him. A suicide-prevention hotline should be your first call.

*

(BEGIN TEXT OF INFOBOX)

Where to find help

* The National Institute of Mental Health has launched a public awareness campaign on men and depression, with lots of personal stories, advice and resources: www.menanddepression.nimh.nih.gov.

* The federal Substance Abuse and Mental Health Services Administration maintains a large database of places to seek help for any mental illness: (800) 789-2647 or www.mentalhealth.samhsa.gov/databases.

* The Depression and Bipolar Alliance, at www.dbsalliance.org, has information about support groups across the country.

* The National Alliance for the Mentally Ill offers information, support and referrals to those with depression and their families. It maintains affiliates across the country, including crisis numbers by county. Go to www.nami.org or www.namicalifornia.org.

* Suicide-prevention hotlines are available around the clock, including the National Hopeline Network at (800) 784-2433 and the National Suicide Prevention Lifeline at (800) 273-8255. Or check for local listings and agencies on suicidehotlines.com/california_south.html.