The Depression Gap Is Smaller Than You Think
"And so we came forth, and once again beheld the stars."
Note: This post deals with mental health. If you’re not in the right headspace now, please return to it later.
William Styron was an award-winning American writer and essayist. Lewis Wolpert was a South African-British biologist who provided crucial insights into embryonal development. Abraham Lincoln was, and remains, one of the most well-known presidents of the USA.
These three men have something in common beyond being giants in their respective fields: they all suffered from lifelong depression. Styron wrote Darkness Visible about it; Wolpert detailed his experience in Malignant Sadness. And here’s a great account of Lincoln’s struggles.
But those guys are exceptions, right? After all, women are over twice as likely to suffer from depression as men, popular media tells us.
Only, what if we’re missing something?
Here’s another number I’d like you to take into account. Compared to women, men are around two to four times more likely to take their own lives1. An article on the perceived gender gap in depression2 puts it bluntly: Women seek help — men die! There are a few reasons for this suicide discrepancy. The use of more lethal methods by men for one, but also the ‘boys don’t cry’ phenomenon. Men are told to hide their pain every day of their lives, from a very young age. After all, big boys don’t cry.
What if those increased suicide rates in men reflect a higher proportion of men with undiagnosed depression3? Should we change the twice as likely observation to: women are over twice as likely to be diagnosed with depression as men?
Let’s do some digging.
Here’s a 25-year-old report that makes an interesting case:
The gender difference in depression may result from a difference in a specific subtype of anxious somatic depression.
What does that mean? First and foremost, depression is not a monolith. Everyone who deals with it experiences a unique constellation of symptoms. Right now, most diagnoses rely on a checklist for the presence and severity of those symptoms. Put bluntly: check enough boxes and you’ll ‘qualify’ for a diagnosis of depression.
Depending on which boxes you tick, you’ll fall into a different ‘subtype’ of major depressive disorder. To go back to the earlier quote: in an anxious somatic subtype, you’ll experience, among others, fatigue as well as appetite and sleep disturbances.
Here’s the kicker: the symptoms on the current checklists are more prevalent among female depression patients. Men suffering from depression tend to - on average(!) - display different (combinations of) symptoms which include sudden aggression, substance abuse, and high-risk behavior. Kicker number two: many of the more typically ‘male’ symptoms of depression are not included in the usual diagnostic checklists.
A 2013 study looked into this average difference between male and female depression symptom constellations and its effect on diagnosis rates. The findings are eye-opening:
Analyses using the scale that included alternative, male-type symptoms of depression found that a higher proportion of men than women met criteria for depression. Analyses using the scale that included alternative and traditional depression symptoms found that men and women met criteria for depression in equal proportions…
So if we use a ‘male-symptom’ checklist, more men than women would be diagnosed. Obviously. But the real finding here is that with a diagnostic checklist that included both typically male and typically female symptoms… the depression gap between the two main genders disappeared!
‘Male inclusive’ diagnostic lists for depression are still not standard of care. To illustrate that, let me jump to a 2021 review, which looks at the evidence and concludes (emphasis mine):
For effective diagnoses and timely treatment of male depression, it is critical to incorporate symptoms of depression in males into the relevant diagnostic criteria, encourage males to express negative emotions, and increase awareness of suicidal behavior in males.
Medicine (including psychology) continues to be blatantly biased against women. Almost every treatment, every medication, and every diagnostic criterion is based on a white male template.
Depression, though, seems like it could be the odd one out4.
While I remain cautious about hope as a matter of principle, here is how Styron finishes his personal account of depression, Darkness Visible:
…whoever has been restored to health has almost always been restored to the capacity for serenity and joy, and this may be indemnity enough for having endured the despair beyond despair.
E quindi uscimmo a riveder le stelle.
And so we came forth, and once again beheld the stars.
Women are more likely to undertake an attempt or admit to suicidal ideation, but that number might be inflated due to people with multiple attempts (which, by definition, is proportionally rarer in men because of the relatively higher number of ‘completed’ attempts). This is also called the gender paradox in suicide.
Of course, I’m assuming a simple gender binary here only to make my point. We know that gender minority groups (trans and non-binary) have even higher rates of depression and anxiety than cisgender women and men, in large part due to various stigmas and social as well as healthcare discrimination.
This meta-analysis additionally suggests that, even after diagnosis, depression is more likely to be lethal in men.
An important topic to raise awareness to and discuss more frequently! I hope you are doing well in this regard.
A friend of mine here is a psychologist who worked at the suicide hotline for a while as he was getting experience in the early days. He told me about when he would lose people on the other side of the line. It was pretty intense. He always said the adage, “Anger is depression turned outward.” Occasionally, that's rephrased as “Anger is fear turned outward.” Clinicians must separate the possible diagnoses or decide if they're concurrent (comorbid). Often, men will be diagnosed with something else, narcissistic personality, for example, because, as you say, violent outbursts aren't a part of the diagnostic criteria. But you have to wonder where one ends and the other begins. At the end of the day, what matters most in mental healthcare is getting the patient well and while diagnosis is a crucial part of that process, it's not the only part. If the treatment works, it doesn't matter what the diagnosis is on paper.
One big problem, here in America, is economic. We have great access to mental health treatment, contrary to popular belief, arguably better than the rest of the world, but we live in a ruthless, cutthroat economic environment of dog-eat-dog capitalism that's not conducive to healthy, balanced, comfortable living. I've also heard sayings like, “Women turn to therapy, men turn to alcoholism,” and I think that's true and a pretty rigid gender difference we see across cultures and across the animal kingdom, especially if we add a little bit onto the end, “…men turn to alcoholism and, or violence.”
Regarding suicide, testosterone certainly must play a role. Males evolved complex physiology that make some of us rush into battlefields even in cases of near-certain death, to take unbelievable risks, and to hold things like honor in high esteem, high enough to die and kill for. No doubt, this plays a role in the far more successful male suicide rate, just as it plays a role in the more successful male homicide rate, and I think it's not analyzed or discussed enough for fear of being labeled sexist. But it holds true across all cultures that men tend to be more violent by far, committing far more violent crimes and suicides. The discrepancies aren't small. That simply can't be cultural.