Senior Men: The Issue
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 retirement-loss of an important role, loss of self-esteem that 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. 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 men may be reluctant to discuss feelings of sadness or grief, or loss of interest in pleasurable activities. They may complain primarily of physical symptoms (National Institute of Mental Health, 2009).
Suicide in older men is strongly associated with depression, physical pain or illness, living alone and feelings of hopelessness and guilt (Statistics Canada, 2008). Older men also experience some specific hormonal and physiological changes, sometimes referred to as the male menopause, and also known as the viropause or andropause. These changes generally begin between the ages of 40 and 55 years, though they can occur as early as 35 or as late as 65, and can affect all aspects of a man’s life, including his mental health.
The greatest evidence of male vulnerability is in suicide statistics. Among Canadians of all ages, four of every five suicides are male. In the UK, men are around three times more likely to kill themselves than women. In New South Wales, Australia, suicide has overtaken car accidents as the leading cause of death in males since 1991. (NIMH 2013; Statistics Canada, 2008)
The Social Context of Men’s Mental Distress
All of us live with social pressures and expectations relating to our sexual and gender identity. These pressures and expectations can have adverse effects on health and well-being for both men and women. However, men are frequently brought up not to talk about their problems or express their emotions. Emotions are often associated with femininity, which boys define themselves against. An effect of this conditioning is that men may be less able than women to express or interpret their emotions. They may be unwilling to admit to emotions they associate with weakness, such as fear, sadness and disappointment. Many men live with social expectations to be – or to appear – powerful, strong and self-reliant. This concept of masculinity can be detrimental to men’s mental health and has wide-reaching personal and social effects (White, 2006). The social factors in men’s mental health are evident in family life, employment and education, contact with the Criminal Justice System and use of health services.
Barriers to seeking help
According to the Toronto Men’s Health Network (TMHN), even the concept of “men’s health” is relatively new in Canada. Dr. Don McCreary, co-chair of TMHN, associate editor of the International Journal of Men’s Health and one of a small handful of men’s health researchers in Canada, says there are a number of reasons for this.
One reason is the low priority given to men’s health issues in the research community. More funding and more specialists in this area will encourage ongoing research into male mental health.
Male and societal attitudes have fostered the silence. “The women’s health movement was very self-directed,” says Dr. McCreary. “Women banded together to work on problems with health delivery. Men don’t want to do that. We have inculcated a culture in our society that men have to be tough, men have to be strong. Our society is very good at punishing gender deviation in men. Weakness is not considered to be masculine.”
The “code” governing men’s behaviour is one of the prime barriers preventing men from seeking help. According to UK-based MaleHealth.com, men may feel it’s “weak and unmanly to admit to feelings of despair.” Because it’s easier for men to acknowledge physical symptoms, rather than emotional ones, their mental health problems can go undiagnosed.
Beliefs about masculinity also encourage men’s general lack of interest in health issues; many men simply don’t believe they are susceptible to depression, so why bother learning about it? Similarly, risky behaviour, seen especially in younger men – including abuse of alcohol and/or drugs and violence – can mask their emotional problems, both from themselves and their physicians.
Western society’s view of the value of men is seen as an important factor affecting men’s mental health. An Australian study suggested that “there is a strong element of negativity in our culture about men which cannot contribute to positive mental health…”.
Greater recognition of the significance of men’s roles as fathers and partners would help men cope with the difficult feelings that accompany a breakup and the loss of full access to their children. The social isolation experienced by many men at such a time is believed to a factor in the high rate of suicide amongst divorced men.
Men and depression
What do a firefighter, police officer, US Air Force First Sergeant, college graduate and publisher have in common? They are all male and they have all suffered from serious depression. They told their stories for the National Institute for Mental Health “Real Men. Real Depression.” campaign.
It’s estimated that up to 6 million American men have depression each year – about half the figure for women. But this gender disparity is being questioned, in the US and elsewhere. In focus groups conducted by the NIMH, “men described their own symptoms of depression without realizing they were depressed.” They made no connection between their mental health and physical symptoms, such as headaches, digestive problems and chronic pain.
Dr. Michael Myers has noted the same thing, saying, “I couldn’t do my job as a psychiatrist if I didn’t listen to women describe their concerns about men.” A psychiatrist and clinical professor in the Department of Psychiatry at the University of British Columbia, Dr. Myers says, “In men, mental illness can be masked. We’ve known for decades that women are more apt to recognize illness of any sort and go to their doctor. This doesn’t mean women are healthier, but that some men just repress it. We believe a lot of somatization [symptoms] in men, for example, migraines, back pain, irritable bowel syndrome, is rooted in depression.”
The consequences of masked depression can be devastating. “Too many men out there are suffering,” says Dr. Myers. “They’re acting out the depression.” Acting may take the form of hostility and irritability; verbal violence and abusiveness; drinking to excess; or womanizing. Canadians can obtain more information about depression by contacting your local branch of the Canadian Mental Health Association or visiting the following website to find a crisis line in your area.
“In cases of marital breakup, there is a very important link between the man’s mental health and how the divorce goes,” continues Dr. Myers, who is the director of the Marital Therapy Clinic at St Paul’s Hospital in Vancouver. He says that when children are involved, and an ongoing relationship is maintained, the father better adapts to his changed circumstances. “If there’s a complete severing, then men can become suicidal.”
Along with genetics and stress, MaleHealth.com points out that social and psychological factors can contribute to men’s depression. Men’s focus on competition and feeling powerful can be adversely affected by unemployment and the presence of women in the workplace. Physical illness, in particular a life-threatening condition, is another trigger for depression, since it directly impacts a man’s sense of strength and status.
Above taken from: The Canadian Mental Health Association, 2013. Retrieved from: http://www.cmha.ca/public_policy/men-and-mental-illness/#.Unrw7hDjUX8
Causes of suicidal ideation
Deaths by suicide are often overlooked because coroners have difficulty distinguishing between self-inflicted and natural or accidental death in equivocal cases, Heisel says. That’s true across the age spectrum but particularly so among the elderly, whose deaths can often be attributed to other causes, he adds. “Perhaps they forgot they had already taken their medication, didn’t quite understand how to take it, maybe they were confused.”
Equally problematic is that the problem of senior suicide is often overlooked by health professionals and even family and friends as there’s a false notion within society that mental health issues are just par for the course when it comes to the elderly, says Michael Price, manager of the Communities Addressing Suicide Together program, an Nova Scotia-based initiative of the Canadian Mental Health Association. “Feeling hopeless or purposelessness, or thinking a lot about death — those are all warning signs for suicide, but they’re also things we tie closely with the elderly,” he says. “We expect a level of depression because they’re losing loved ones and dealing with more chronic illnesses.”
There’s also a tendency to treat mental health problems within seniors with less alacrity, says Sharon Moore, associate professor at the Centre for Nursing and Health Studies of the Faculty of Health Disciplines at Athabasca University in Alberta.
“Some people say, well, people who reach the end of their lives have lived a good life so why bother,” Moore says. “Sometimes there’s this almost fatalistic attitude of why should we bother.”
By dint of time, alone, the elderly are also more likely to have risk factors typically associated with suicide: a history of suicidal behaviour or thinking, social isolation and death of a friend or family member. That can contribute to a loss of hope and increase the risk of suicide, Moore notes. “Lots of times what we see is not so much one particular event, but an accumulation of things that seem to contribute to that overall sense of despair — the feeling that nothing in life is worth living for.”
Other seniors simply have difficulty handling late-life transitions, such as forced retirements, particularly for men, who often lack a social network to fill the void, says Heisel.
But ageism is also a factor, he adds, noting that society often devalues the experience of seniors and relegates them to life’s sidelines. “As we age, if we’re raised in a culture that devalues older adults, then we get to a point where we devalue ourselves.”
Heisel says that there’s evidence that senior citizens who are contemplating suicide respond well to treatment. But the trick is identifying them as seniors are less likely to acknowledge depressive symptoms or other health problems, he adds. As a consequence, they are less likely to reach out for help; “They may have more stigmatizing views of mental health care, and don’t see it as something that’s as reasonable a course of action as trying to deal with one’s problems on one’s own.”
Part of that is generational, says Kimberly Wilson, executive director of the Canadian Coalition for Seniors’ Mental Health. “I think right now we’re really in an era where mental health is coming out of the shadows, but perhaps for our current cohort of older adults, there still was a lot of stigma about mental illness and it may not be something they’re comfortable talking to their physicians about.”
There’s also a societal perception that it’s entirely normal for an elderly person to experience a certain degree of hopelessness and sadness, Price argues. “Right now society is accepting a lot of things as being a normal part of aging, suicide being one of them maybe, and we need to change that thinking. We’re all going to be seniors one day and we’re going to want those protections for ourselves if nothing else.”
Above taken from: Canadian Medical Association Journal. (2012). Senior Suicide: An overlooked problem. Retrieved from: http://www.cmaj.ca/site/earlyreleases/15oct12_senior_suicide.xhtml
A number of studies suggest that depression occurs as often in men as in women (Royal College of Psychiatrists, 2008) but women get diagnosed and treated twice as often as men (Real, 2007).
‘Hidden’ or ‘covert’ depression is sometimes a factor behind problems that are sometimes thought of as being typically male – such as the misuse of drugs and alcohol. It can also be manifested in behaviours such as social withdrawal, unexplained physical symptoms and relationship problems. Men are often unwilling to admit to being depressed and it has been suggested that, for some men, ‘midlife crisis’ can be a euphemism for depression.
One in nine adult men is dependent on alcohol; men are three times more likely than women to be alcohol dependent. Men are more likely than women to use illegal drugs and to develop a drug addiction or dependency. (Statistics Canada, 2013)
Physical and Sexual Violence
Violence against men exceeds violence against women in every category apart from sexual assault and domestic violence. The risk of being involved in a violent incident caused by a stranger is significantly higher for men than women. (Statistics Canada, 1998)
There is a common myth that all domestic violence is committed by men against women. Although this is the most common form of domestic violence, men do experience violence, from family members of both sexes. For men, as for women, the experience of domestic violence is associated with high levels of mental distress. However, the extent of male experience of domestic violence is unknown. Estimates are likely to understate the true scale of the problem, as men are less likely than women to report their experiences. The myth that men cannot be the victims of domestic violence is an additional barrier that prevents men from seeking help and can increase feelings of low self-esteem, helplessness and isolation.
The effect of childhood sexual abuse on the adult health of male victims is under-researched. However, marked associations between the experience of childhood sexual abuse and a range of adult problems have been shown. Issues that have been by identified include feelings of powerlessness, a lack of trust in authority, and problems with anger, aggression, sexual identity and sexual offending. Male survivors of childhood rape and sexual abuse are more likely than female survivors, or males in the general population, to receive a diagnosis of a psychotic illness, such as schizophrenia, schizoaffective disorder or bipolar disorder. Negative experiences of mental health and other health services reported by male survivors are similar to those reported by female survivors; problems include a lack of awareness and empathy among staff, and insufficient services to meet survivors’ needs. (Nelson, 2005)
One of the biggest differences between men’s and women’s health is their respective use of health services. The following patterns have been identified (Kazajian, Morettin & Cho, 2005):
- Fewer men have health care providers; consequently men are more likely to have first contact with a health care provider in an emergency context.
- Men wait longer than women to access a mental health specialist.
- Far fewer men than women enter the health and social care professions. The lack of male visibility in health and social care environments has been put forward as a reason for lower levels of service use among men.
Physical Factors in Men’s Mental Distress
Physical illness can be a major contributory factor to emotional problems. Physical illnesses, particularly long-term conditions, and hospital stays can lead to depression in men.
Cholesterol and Depression
A study in Finland of 30,000 men over an eight-year period has established a link between cholesterol levels and depression. (Partonen, T. et al., 1999) Men with low cholesterol levels were at nearly twice the risk of depression and suicide compared with men with high cholesterol levels. A link was established between low cholesterol and poor mental health among the 280 men who were treated for depression in hospital, and researchers found a ‘significant association’ between low cholesterol and severe depression in a further 111 men who committed suicide.
Heart Disease and Depression
Researchers from the Queen’s Medical Centre in Nottingham have found that men who are depressed are three times more likely to develop heart disease. (Hippisley-Cox, 1998). These findings have been confirmed by research in America. (Ford, 1998) The researchers suggest a number of possible explanations for the link. Depression may lead to unhealthy lifestyles, such as lack of exercise or an increase in smoking, which could increase strain on the cardiovascular system. Being depressed also affects the nervous system, with a knock-on effect on the heart, and can alter the balance of hormones and neurotransmitters in the body.
The link between depression and heart disease appears to exist only in men, but the reasons for this are unclear, although men appear to be more sensitive to biochemical changes in the body. Men also have an increased risk of developing depression after being diagnosed with heart disease. (Hippisley-Cox)
Erectile dysfunction (impotence) is one of the most common chronic medical disorders in men over 40 years of age. One study found that 52 per cent of men aged 40–70 years reported some degree of erectile dysfunction, and 35 per cent reported experiencing moderate or complete erectile dysfunction. (Feldman et al., 1994)The prevalence and severity of this disorder increases with age, and is a major quality-of-life issue for older men. Erectile dysfunction can lead to depression and relationship problems.
Raising awareness about men and their vulnerability to depression is a rising trend and “may help in terms of reducing the stigma attached to mental health,” says Dr. McCreary.
Some focused steps are being tested. A study in Australia reports that a men-only prompt list for physicians and patients, designed to overcome male reticence and low mental health literacy, assisted 60% of male patients in raising issues with their doctor.
National men’s health organizations in the United States, Australia, the United Kingdom and Europe are growing focal points for men’s health research. The acknowledged lack of data on male health is leading to calls for a needs-driven rather than a gender-based approach to health care.
Promotional campaigns, web sites, journals and networking groups targeting men and their mental health awareness are breaking the silence that has long surrounded this topic. But there is a long way to go before the depth and breadth of knowledge about men’s mental health issues approaches that relating to women.
Above taken from: The Canadian Mental Health Association. (2013). Men and Mental Illness. Retrieved from: http://www.cmha.ca/public_policy/men-and-mental-illness/#.Unrw7hDjUX8
Feldman H. A., et al. (1994). Impotence and its medical and psychosocial correlates: results of the Massachusetts Male Aging Study, Journal of Urology, vol. 151: 54–61.
Ford, D. et al. (1998). Depression is a risk factor for coronary artery disease in men: the precursors study, Archives of Internal Medicine, vol. 158: 1422–1422.
Hippisley-Cox, J. (1998). ‘Depression as a risk factor for ischaemic heart disease in men: population based case control study’, British Medical Journal, vol. 316:1714 – 1719.
Kazajian, A., Morettin, D. & Cho, R. (2005). Health Care utilization. Retrieved from: http://www.ciqss.umontreal.ca/Docs/Seminaires/PresentationResultats/2005-01-28_HealthCareUtilization.pdf
National Institute of Mental Health. (2013). Older Adults and Depression. Retrieved from: http://www.nimh.nih.gov/health/publications/older-adults-and-depression/index.shtml
Nelson, S. (2005). Torn up with anger, Mental Health Today, March, pp. 29–31.
Partonen, T. et al. (1999). Association of low serum total cholesterol with major depression and suicide. British journal of psychiatry, vol. 175: 259–262.
Statistics Canada. (2013). Canadian Community Health Survey – Mental Health.
Statistics Canada. (2008). CANSIM Table 102-0561. Leading causes of death, total population, by age group and sex, Canada, annual.
Statistics Canada. (1998). Violence committed by strangers. Retrieved from: http://www.publications.gc.ca/Collection-R/Statcan/85-002-XIE/0099885-002-XIE.pdf
Real, T. (1997). I don’t want to talk about it: overcoming the secret legacy of male depression, Fireside/Simon & Schuster: New York.
White, A. 2006, Men and mental wellbeing – encouraging gender sensitivity, The Mental Health Review, vol. 11(4): 3–6