Half as many men report being depressed as women (about 1 in 16 men versus 1 in 8 women), according to the National Alliance of Mental Illness. But that discrepancy may be because many men see the condition as a sign of emotional weakness, which makes them less likely to tell anyone, seek help, or be diagnosed and treated. “Primary care physicians miss depression more than 50 percent of the time,” explains Steven Lamm, MD, medical director of the Preston Robert Tisch Center for Men’s Health at NYU Langone Medical Center.
Major depressive disorder (also known as unipolar depression) is a serious disease, which can affect every aspect of a man’s life. But depression can result from other conditions as well, including bipolar disorder, schizophrenia, substance abuse, even PTSD. It may also point to another medical issue (such as, rarely, a brain tumor), an undiagnosed attention deficit disorder, or side effects from medication. Because early diagnosis and treatment are crucial, physicians at the Center for Men’s Health routinely screen patients for signs of the disorder.
“Our specialists understand that depression can manifest itself in their area of expertise,” Dr. Lamm explains. “Cardiologists, for example, know that it can lead to chest pain and shortness of breath.” During office visits, doctors watch for telltale signs, such as being unsociable or unkempt, and take a thorough history, noting possible triggers, such as a divorce or losing a job. If they suspect clinical depression, they’ll suggest a consultation with a psychiatrist.
“I spend a lot of time explaining to men that depression is a biochemical disorder,” says psychiatrist Norman Sussman, MD, who works closely with physicians at the center. “There may be circumstances that trigger it, but there’s a genetic predisposition. It’s not a reflection of their character or strength.”
Studies show that cognitive behavioral therapy (CBT) is an effective treatment for many men. In CBT, the therapist helps the patient restructure negative thinking patterns and change behaviors that may be contributing to his depression. During therapy sessions, a man works with an NYU Langone therapist to learn how thoughts, feelings, and behaviors influence one another. The therapist explains how to test the reality of thoughts and perceptions and to manage symptoms. Dr. Lamm emphasizes that when a man is grappling with depression, overcoming the shame associated with the disorder is key to getting well. “I tell men, ‘You can’t just will yourself out of being depressed.’” Treatment with CBT typically lasts for 12 to 16 weeks, or longer in persistent cases. Doctors may prescribe cognitive behavioral therapy alone or in combination with medication.
The most common medications used to treat depression are called selective serotonin reuptake inhibitors, or SSRIs. They increase levels of the brain chemical serotonin, which regulates mood, appetite, and sleep. It can take up to 12 weeks for SSRIs to take full effect.
If the patient’s symptoms don’t respond to an SSRI, the doctor may recommend a medication from a class of antidepressants called serotonin-norepinephrine reuptake inhibitors, or SNRIs. These medications may be helpful for people with depression-related fatigue or pain. SNRIs appear to improve communication between nerve cells by making more of the chemicals serotonin and norepinephrine available in the brain, helping to boost the patient’s mood.
When devising a treatment plan, Dr. Sussman takes many factors into account. For example, SSRIs can lead to sexual dysfunction, cause weight gain, and elevate blood sugar levels. Other medications don’t have those side effects but may cause urinary issues for patients with a prostate problem. “It’s important to pick a drug based on the patient’s total health,” he stresses.
Depression is often a chronic condition that must be managed over a lifetime. People on medication typically meet with their psychiatrist regularly to discuss any side effects and review how well the medication is working.
For men who have treatment-resistant depression, or depression so severe that they may be in imminent danger of suicide, electroconvulsive therapy (ECT) may be a lifesaving option. The procedure as it’s performed today bears little resemblance to the crude “shock treatments” that were commonplace in the therapy’s infancy or as portrayed in movies such as One Flew over the Cuckoo’s Nest.
“This treatment has become safer, with fewer side effects,” explains psychiatrist Patrick Ying, MD, director of the ECT program at the Medical Center. An estimated 1 million patients worldwide undergo the procedure each year. ECT works by triggering a controlled seizure of the entire brain. Although the mechanism is not fully understood, this neural storm causes biochemical changes that can radically improve a patient’s mood. Patients are given a muscle relaxant and general anesthesia to protect them from anxiety and discomfort.
Over the past 15 years, refinements—using ultrabrief pulses of electricity, for example, and stimulating only the right side of the brain—have reduced the temporary confusion and memory loss associated with the procedure. Although special precautions may be necessary for some patients, such as those with cardiac arrhythmias or brain tumors, the risk of serious complications is generally low.
Studies show that nearly 80 percent of patients with severe depression experience complete remission with ECT. Moreover, patients who receive ECT often achieve near-total remission within two to four weeks, while those on medication typically experience only partial improvement after six to eight weeks.
Most people are able to return to work after the initial course of therapy (generally 6 to 12 treatments, administered two or three times a week). But because the effects of ECT can wear off quickly, patients usually continue taking medication, and some may have follow-up sessions about once a month. Treatment may need to continue indefinitely.
“ECT is not a cure,” says Dr. Ying. “It doesn’t mean your depression is gone forever. You still need to do some kind of maintenance. But for many, this is the thing that gets them better when nothing else has worked.”