Research and clinical evidence reveal that while both women and men can develop the standard symptoms of depression, they often experience depression differently and may have different ways of coping with the symptoms. Men may be more willing to acknowledge fatigue, irritability, loss of interest in work or hobbies, and sleep disturbances rather than feelings of sadness, worthlessness, and excessive guilt. Some researchers question whether the standard definition of depression and the diagnostic tests based upon it adequately capture the condition as it occurs in men.


“I’d drink and I’d just get numb. I’d get numb to try to numb my head. I mean, we’re talking many, many beers to get to that state where you could shut your head off, but then you wake up the next day and it’s still there. Because you have to deal with it, it doesn’t just go away. It isn’t a two hour movie and then at the end it goes ‘The End’ and you press off. I mean it’s a twenty four hour a day movie and you’re thinking there is no end. It’s horrible.”


-Patrick McCathern, First Sergeant, U.S. Air Force, Retired
Men are more likely than women to report alcohol and drug abuse or dependence in their lifetime;14 however, there is debate among researchers as to whether substance use is a “symptom” of underlying depression in men or a co occurring condition that more commonly develops in men. Nevertheless, substance use can mask depression, making it harder to recognize depression as a separate illness that needs treatment.


Instead of acknowledging their feelings, asking for help, or seeking appropriate treatment, men may turn to alcohol or drugs when they are depressed, or become frustrated, discouraged, angry, irritable, and, sometimes, violently abusive. Some men deal with depression by throwing themselves compulsively into their work, attempting to hide their depression from themselves, family, and friends. Other men may respond to depression by engaging in reckless behavior, taking risks, and putting themselves in harm’s way.


“When I was feeling depressed I was very reckless with my life. I didn’t care about how I drove. I didn’t care about walking across the street carefully. I didn’t care about dangerous parts of the city. I wouldn’t be affected by any kinds of warnings on travel or places to go. I didn’t care. I didn’t care whether I lived or died and so I was going to do whatever I wanted whenever I wanted. And when you take those kinds of chances, you have a greater likelihood of dying.”


-Bill Maruyama, Lawyer
More than four times as many men as women die by suicide in the United States, even though women make more suicide attempts during their lives.15,16 In addition to the fact that men attempt suicide using methods that are generally more lethal than those used by women, there may be other factors that protect women against suicide death. In light of research indicating that suicide is often associated with depression,17 the alarming suicide rate among men may reflect the fact that men are less likely to seek treatment for depression. Many men with depression do not obtain adequate diagnosis and treatment that may be life saving.


More research is needed to understand all aspects of depression in men, including how men respond to stress and feelings associated with depression, how to make men more comfortable acknowledging these feelings and getting the help they need, and how to train physicians to better recognize and treat depression in men. Family members, friends, and employee assistance professionals in the workplace also can play important roles in recognizing depressive symptoms in men and helping them get treatment.


Men must cope with several kinds of stress as they age. If they have been the primary wage earners for their families and have identified heavily with their jobs, they may feel stress upon retirementloss of an important role, loss of self esteemthat can lead to depression. Similarly, the loss of friends and family and the onset of other health problems can trigger depression.


Depression is not a normal part of aging.18 Depression is an illness that can be effectively treated, thereby decreasing unnecessary suffering, improving the chances for recovery from other illnesses, and prolonging productive life. However, health care professionals may miss depressive symptoms in older patients. Older adults may be reluctant to discuss feelings of sadness or grief, or loss of interest in pleasurable activities.19 They may complain primarily of physical symptoms.


It may be difficult to discern a co occurring depressive disorder in patients who present with other illnesses, such as heart disease, stroke, or cancer, which may cause depressive symptoms or may be treated with medications that have side effects that cause depression. If a depressive illness is diagnosed, treatment with appropriate medication and/or brief psychotherapy can help older adults manage both diseases, thus enhancing survival and quality of life.


“As you get sick, as you become drawn in more and more by depression, you lose that perspective. Events become more irritating, you get more frustrated about getting things done. You feel angrier, you feel sadder. Everything’s magnified in an abnormal way.”


-Paul Gottlieb, Publisher

Identifying and treating depression in older adults is critical. There is a common misperception that suicide rates are highest among the young, but it is older white males who suffer the highest rate. Over 70 percent of older suicide victims visit their primary care physician within the month of their death; many have a depressive illness that goes undetected during these visits.20 This fact has led to research efforts to determine how to best improve physicians’ abilities to detect and treat depression in older adults.


Approximately 80 percent of older adults with depression improve when they receive treatment with antidepressant medication, psychotherapy, or a combination of both. In addition, research has shown that a combination of psychotherapy and antidepressant medication is highly effective for reducing recurrences of depression among older adults. Psychotherapy alone has been shown to prolong periods of good health free from depression, and is particularly useful for older patients who cannot or will not take medication.


Improved recognition and treatment of depression in later life will make those years more enjoyable and fulfilling for the depressed elderly person, and his family and caregivers.
Only in the past two decades has depression in children been taken very seriously. Research has revealed that depression is occurring earlier in life today than in past decades. In addition, research has shown that early onset depression often persists, recurs, and continues into adulthood, and that depression in youth may also predict more severe illness in adult life.


An NIMH sponsored study of 9 to 17 year olds estimates that the prevalence of any depressive disorder is more than 6 percent in a six month period, with 4.9 percent having major depression. Before puberty, boys and girls are equally likely to develop depressive disorders. After age 14, however, females are twice as likely as males to have major depression or dysthymia.

The risk of developing bipolar disorder remains approximately equal for males and females throughout adolescence and adulthood.


The depressed younger child may say he is sick, refuse to go to school, cling to a parent, or worry that the parent may die. The depressed older child may sulk, get into trouble at school, be negative and grouchy, and feel misunderstood. Signs of depressive disorders in young people are often viewed as normal mood swings typical of a particular developmental stage. In addition, health care professionals may be reluctant to prematurely “label” a young person with a mental illness diagnosis. However, early diagnosis and treatment of depressive disorders are critical to healthy emotional, social, and behavioral development.


Depression in young people frequently co occurs with other mental disorders, most commonly anxiety, disruptive behavior, or substance abuse disorders, as well as with other serious illnesses such as diabetes.


Among both children and adolescents, depressive disorders confer an increased risk for illness and interpersonal and psychosocial difficulties that persist long after the depressive episode is resolved; in adolescents, there is also an increased risk for substance abuse and suicidal behavior.25,30,31 Unfortunately, these disorders often go unrecognized by families and physicians alike.


Although the scientific literature on treatment of children and adolescents with depression is far less extensive than that for adults, a number of recent studies have confirmed the short term efficacy and safety of treatments for depression in youth. An NIMH funded clinical trial of 439 adolescents with major depression found that a combination of medication and psychotherapy is the most effective treatment.32 Additional research is needed on how best to incorporate these treatments into primary care practice.


Bipolar disorder, although rare in young children, can appear in both children and adolescents. The unusual shifts in mood, energy, and functioning that are characteristic of bipolar disorder may begin with manic, depressive, or mixed manic and depressive symptoms. It is more likely to affect the children of parents who have the illness. Twenty to 40 percent of adolescents with major depression go on to reveal bipolar disorder within five years after the onset of depression.
Depression in children and adolescents is associated with an increased risk of suicidal behaviors.


This risk may rise, particularly among adolescent males, if the depression is accompanied by conduct disorder and alcohol or other substance abuse.35 In 2002, suicide was the third leading cause of death among young males, age 15 to 24. NIMH supported researchers found that among adolescents who develop major depressive disorder, as many as 7 percent may die by suicide in the young adult years.25 Therefore, it is important for doctors and parents to take seriously any remarks about suicide.


NIMH researchers are developing and testing various interventions to prevent suicide in children and adolescents. Early diagnosis and treatment, accurate evaluation of suicidal thinking, and limitations on young people’s access to lethal agentsincluding firearms and medicationsmay hold the greatest suicide prevention value.


“You are pushed to the point of considering suicide, because living becomes very painful. You are looking for a way out. You’re looking for a way to eliminate this terrible psychic pain. And I remember, I never really tried to commit suicide, but I came awful close, because I used to play matador with buses. You know, I would walk out into the traffic of New York City, with no reference to traffic lights, red or green, almost hoping that I would get knocked down.”


-Paul Gottlieb, Publisher
Sometimes depression can cause people to feel like putting themselves in harm’s way, or killing themselves. Although the majority of people with depression do not die by suicide, having depression does increase suicide risk compared to people without depression.


If you are thinking about suicide, get help immediately:
• Call your doctor’s office.
• Call 911 for emergency services.
• Go to the emergency room of the nearest hospital.
• Ask a family member or friend to take you to the hospital or call your doctor.
• Call the toll free, 24 hour hotline of the National Suicide Prevention Lifeline at 1 800 273 TALK (1 800 273 8255) to be connected to a trained counselor at the suicide crisis center nearest you.


The first step to getting appropriate treatment for depression is a physical examination by a physician. Certain medications as well as some medical conditions such as a viral infection, thyroid disorder, or low testosterone level can cause the same symptoms as depression, and the physician should rule out these possibilities through examination, interview, and lab tests. If no such cause of the depressive symptoms is found, the physician should do a psychological evaluation or refer the patient to a mental health professional.


A good diagnostic evaluation will include a complete history of symptoms: i.e., when they started, how long they have lasted, their severity, and whether the patient had them before and, if so, if the symptoms were treated and what treatment was given. The doctor should ask about alcohol and drug use, and if the patient has thoughts about death or suicide.


Further, a history should include questions about whether other family members have had a depressive illness and, if treated, what treatments they may have received and if they were effective. Last, a diagnostic evaluation should include a mental status examination to determine if speech, thought patterns, or memory has been affected, as sometimes happens with depressive disorders.


Treatment choice will depend on the patient’s diagnosis, severity of symptoms, and preference. There are a variety of treatments, including medications and short term psychotherapies (i.e., “talk” therapies), that have proven effective for depressive disorders. In general, severe depressive illnesses, particularly those that are recurrent, will require a combination of treatments for the best outcome.

Medications

There are several types of medications used to treat depression. These include newer antidepressant medications–chiefly the selective serotonin reuptake inhibitors (SSRIs)–and older ones, the tricyclics and the monoamine oxidase inhibitors (MAOIs). The SSRIs (and other newer medications that affect neurotransmitters such as dopamine or norepinephrine) generally have fewer side effects than tricyclics. Sometimes the doctor will try a variety of antidepressants before finding the most effective medication or combination of medications for the patient.


Sometimes the dosage must be increased to be effective. Although some improvements may be seen in the first couple of weeks, antidepressant medications must be taken regularly for three to four weeks (in some cases, as many as eight weeks) before the full therapeutic effect occurs.



Patients often are tempted to stop medication too soon. They may feel better and think they no longer need the medication, or they may think it isn’t helping at all. It is important to keep taking medication until it has a chance to work, though side effects (see section on Side Effects, pages 19 20) may appear before antidepressant activity does. Once the person is feeling better, it is important to continue the medication for at least four to nine months to prevent a relapse into depression.


Some medications must be stopped gradually to give the body time to adjust, and many can produce withdrawal symptoms if discontinued abruptly. Therefore, you should never discontinue your medication without first talking to your doctor. For individuals with bipolar disorder and those with chronic or recurrent major depression, medication may have to be maintained indefinitely.


Recently, concerns have been raised that the use of antidepressant medications themselves may induce suicidal behavior in youths. In fact, following a thorough and comprehensive review of all the available published and unpublished controlled clinical trials of antidepressants in children and adolescents, the FDA has adopted a “black box” label on SSRI medications to warn the public about an increased risk of suicidal thoughts (suicidal ideation) or behavior (“suicidality”) in children and adolescents treated with these medications.


However, studies show that there are substantial benefits from medication treatment for adolescents with moderate and severe depression, including many with suicidal ideation. Parents and children should work with their health care provider to determine the best and most appropriate treatment.
For more information, visit the NIMH website at http://www.nimh.nih.gov/healthinformation/antidepressant_child.cfm.


Medications for depressive disorders are not habit forming. Nevertheless, as is the case with any type of medication prescribed for more than a few days, doctors must carefully monitor these treatments to determine if the patient is getting the most effective dosage. The doctor should check regularly the dosage of each medicine and its effectiveness.


For the small number of people for whom MAO inhibitors are the best treatment, it is necessary to avoid certain foods that contain high levels of tyramine, including many cheeses, wines, and pickles, as well as medications such as decongestants. The interaction of tyramine with MAOIs can bring on a hypertensive crisis (a sharp increase in blood pressure) that can lead to a stroke. The doctor should furnish a complete list of prohibited foods, and the patient should carry it at all times.


Other forms of antidepressants require no food restrictions. Efforts are underway to develop a “skin patch” system for one of the newer MAOIs, selegiline. If successful, this may be a more convenient and safer medication option than the older MAOI tablets.


Medications of any kind prescribed, over the counter, or borrowed should never be mixed without consulting a doctor. Health professionals who may prescribe a medication, such as a dentist or other medical specialist, should be told of all the medications the patient is taking. Some medications, although safe when taken alone, can cause severe and dangerous side effects if taken in combination with others.


Alcoholincluding wine, beer, and hard liquoror street drugs may reduce the effectiveness of antidepressants and should be avoided. However, doctors may permit people who have not had a problem with alcohol abuse or dependence to use a modest amount of alcohol while taking one of the newer antidepressants.
Antianxiety drugs or sedatives are not antidepressants. They are sometimes prescribed along with antidepressants, but they are not effective when taken alone for a depressive disorder. Stimulants, such as amphetamines, are also not effective antidepressants, but they are used occasionally, under close supervision, in medically ill depressed patients.


Lithium has for many years been the treatment of choice for bipolar disorder, as it can be effective in smoothing out the mood swings common to this illness. Doctors must carefully monitor its use as the range between an effective dose and a toxic one is small. If a person has preexisting thyroid, kidney, or heart disorders or epilepsy, lithium may not be recommended. Fortunately, other medications have been found to be of benefit in controlling mood swings. Among these are two mood stabilizing anticonvulsants, valproate (Depakote®) and carbamazepine (Tegretol®).


Both of these medications have gained wide acceptance in clinical practice, and the Food and Drug Administration has approved valproate for first line treatment of acute mania. Other anticonvulsants that are being used now include lamotrigine (Lamictal®), and topiramate (Topamax®); however, their role in the treatment of bipolar disorder is not yet proven and remains under study.


Most people who have bipolar disorder take more than one medication. In addition to lithium and/or an anticonvulsant, doctors often prescribe a medication for accompanying agitation, anxiety, depression, or insomnia. Finding the best possible combination of these medications is of utmost importance to the patient and requires close monitoring by the physician.


Questions about any medication prescribed, or problems that may be related to it, should be discussed with your doctor.
Side Effects


Before starting a new medication, ask the doctor to tell you about any side effects you may experience. Antidepressants may cause mild and, usually, temporary side effects (sometimes referred to as adverse effects) in some people. Typically, these are annoying, but not serious. However, any unusual reactions or side effects, or those that interfere with functioning, should be reported to the doctor immediately.
The most common side effects of the newer antidepressants (SSRIs and others) are:


• Headache will usually go away.
• Nausea also temporary, but even when it occurs, it is short lived after each dose.
• Insomnia and nervousness (trouble falling asleep or waking often during the night) may occur during the first few weeks but are usually resolved over time or with a reduction in dosage.
• Agitation (feeling jittery) notify your doctor if this happens for the first time after the drug is taken and is persistent.
• Sexual problems consult your doctor if the problem is persistent or worrisome. Although depression itself can lower libido and impair sexual performance, SSRIs and some other antidepressants can provoke sexual dysfunction. These side effects can affect more than half of adults taking SSRIs. In men, common problems include reduced sexual drive, erectile dysfunction, and delayed ejaculation. For some men, dosage reductions or acquired tolerance to the medication reduce sexual dysfunction symptoms. Although changing from one SSRI to another has generally not been shown to be beneficial, one study showed that citalopram (Celexa®) did not seem to cause sexual impairment in patients who had experienced such events with another SSRI.


Some clinicians treating men with antidepressant associated sexual dysfunction report improvement with the addition of bupropion (Wellbutrin®)38 or sildenafil (Viagra®)39 to ongoing treatment. Be sure to discuss the various options with your doctor and inquire about other interventions that can help.
Tricyclic antidepressants have different types of side effects:


• Dry mouth drinking sips of water, chewing sugarless gum, and cleaning teeth daily is helpful.
• Constipation adding bran cereals, prunes, fruit, and vegetables to your diet should help.
• Bladder problems emptying the bladder may be troublesome, and the urine stream may not be as strong as usual; notify your doctor if there is marked difficulty or pain. This side effect may be particularly problematic in older men with enlarged prostate conditions.
• Sexual problems sexual functioning may change; men may experience some loss of interest in sex, difficulty in maintaining an erection or achieving orgasm. If they are worrisome, discuss these side effects you’re your doctor.
• Blurred vision – will pass soon and will not usually necessitate a new glasses prescription.
• Dizziness rising from the bed or chair slowly is helpful.
• Drowsiness as a daytime problem – usually passes soon.

If you feel drowsy or sedated you should not drive or operate heavy equipment. The more sedating antidepressants are generally taken at bedtime to help sleep and minimize daytime drowsiness.


Psychotherapies
Several forms of psychotherapy, including some short term (10 20 weeks) therapies, can help people with depressive disorders. Two of the short term psychotherapies that research has shown to be effective for depression are cognitive behavioral therapy (CBT) and interpersonal therapy (IPT).


Cognitive behavioral therapists help patients change the negative thinking and behavior patterns that contribute to, or result from, depression. Through verbal exchange with the therapist, as well as “homework” assignments between therapy sessions, CBT helps patients understand their depression and resolve problems related to it. Interpersonal therapists help patients work through disturbed personal relationships that may be contributing to or worsening their depression. Psychotherapy is offered by a variety of licensed mental health providers, including psychiatrists, psychologists, social workers, and mental health counselors.


For many depressed patients, especially those with moderate to severe depression, a combination of antidepressant medication and psychotherapy is the preferred approach to treatment. Some psychiatrists offer both types of intervention. Alternatively, two mental health professionals may collaborate in the treatment of a person with depression; for example, a psychiatrist or other physician, such as a family doctor, may prescribe medication while a nonmedical therapist provides ongoing psychotherapy.


“You start to have these little thoughts, ‘Wait, maybe I can get through this. Maybe these things that are happening to me aren’t so bad.’ And you start thinking to yourself, ‘Maybe I can deal with things for now.’ And it’s just little tiny thoughts until you realize that it’s gone and then you go, ‘Oh my God, thank you, I don’t feel sad anymore.’ And then when it was finally gone, when I felt happy, I was back to the usual things that I was doing in my life. You get so happy because you think to yourself, ‘I never thought it would leave