For nearly a decade, while serving as an elected official and working as an attorney, Massachusetts state Sen. Bob Antonioni struggled with depression, although he didn't know it. Most days, he attended Senate meetings and appeared on behalf of clients at the courthouse. But privately, he was irritable and short-tempered, ruminating endlessly over his cases and becoming easily frustrated by small things, like deciding which TV show to watch with his girlfriend. After a morning at the state house, he'd be so exhausted by noon that he'd drive home and collapse on the couch, unable to move for the rest of the day.
When his younger brother, who was similarly moody, killed himself in 1999, Antonioni, then 40, decided to seek help. For three years, he clandestinely saw a therapist, paying in cash so there would be no record. He took antidepressants, but had his prescriptions filled at a pharmacy 20 miles away. His depression was his burden, and his secret. He couldn't bear for his image to be any less than what he thought it should be. "I didn't want to sound like I couldn't take care of myself, that I wasn't a man," says Antonioni.
Then, in 2002, his chief of staff discovered him on the floor of his state-house office, unable to stop crying. Antonioni, now 48, decided he had to open up to his friends and family. A few months later, invited to speak at a mental-health vigil, he found the courage to talk publicly about his problem. Soon after, a local reporter wrote about Antonioni's ongoing struggle with the disease. Instead of being greeted with jeers, he was hailed as a hero, and inundated with cards and letters from his constituents. "The response was universally positive. I was astounded."
Six million American men will be diagnosed with depression this year. But millions more suffer silently, unaware that their problem has a name or unwilling to seek treatment. In a confessional culture in which Americans are increasingly obsessed with their health, it may seem clichéd—men are from Mars, women from Venus, and all that—to say that men tend not to take care of themselves and are reluctant to own up to mental illness. But the facts suggest that, well, men tend not to take care of themselves and are reluctant to own up to mental illness. Although depression is emotionally crippling and has numerous medical implications—some of them deadly—many men fail to recognize the symptoms. Instead of talking about their feelings, men may mask them with alcohol, drug abuse, gambling, anger or by becoming workaholics. And even when they do realize they have a problem, men often view asking for help as an admission of weakness, a betrayal of their male identities.
The result is a hidden epidemic of despair that is destroying marriages, disrupting careers, filling jail cells, clogging emergency rooms and costing society billions of dollars in lost productivity and medical bills. It is also creating a cohort of children who carry the burden of their fathers' pain for the rest of their lives. The Gary Cooper model of manhood—what Tony Soprano called "the strong, silent type" to his psychiatrist, Dr. Melfi—is so deeply embedded in our social psyche that some men would rather kill themselves than confront the fact that they feel despondent, inadequate or helpless. "Our definition of a successful man in this culture does not include being depressed, down or sad," says Michael Addis, chair of psychology at Clark University in Massachusetts. "In many ways it's the exact opposite. A successful man is always up, positive, in charge and in control of his emotions."
As awareness of the problem grows—among the public and medical professionals alike—the stigma surrounding male depression is beginning to lift. New tools for diagnosing the disease—which ranges from the chronic inability to feel good, to major depression, to bipolar disorder—and new approaches to treating it, offer hope for millions. And as scientists gain insight into how depression occurs in the brain, their findings are spurring research into an array of new treatments including faster-acting, more-effective drugs that could benefit those who struggle with what Winston Churchill called his "black dog."
For decades, psychologists believed that men experienced depression at only a fraction of the rate of women. But this overly rosy view, doctors now recognize, was due to the fact that men were better at hiding their feelings. Depressed women often weep and talk about feeling bad; depressed men are more likely to get into bar fights, scream at their wives, have affairs or become enraged by small inconveniences like lousy service at a restaurant. "Men's irritability is usually seen as a character flaw," says Harvard Medical School's William Pollack, "not as a sign of depression." In many cases, however, that's exactly what it is: depression.
If modern psychologists were slow to understand how men's emotions affect their behaviors, it's only because their predecessors long ago decided that having a uterus was the main risk factor for mental illness. During the last two centuries, depression was largely viewed as a female problem, an outgrowth of hormonal fluctuations stemming from puberty, childbirth and menopause. Even the most skilled psychologists and psychiatrists missed their male patients' mood disorders, believing that depressed men, like depressed women, would talk openly about feeling blue. "I misdiagnosed male depression for years and years," says psychologist Archibald Hart, author of "Unmasking Male Depression."
Some of the symptoms of depression are so severe, like gambling addiction or alcoholism, they are often mistaken for the problem. David Feherty, the affable CBS golf commentator and former golf pro, began drinking at such a young age it became part of his personality. "I drank a bottle of whisky in order to get ready to start drinking," he jokes. By his 40s, he routinely consumed two bottles of whisky a day, and was in such physical pain, he thought he suffered from "some kind of degenerative muscle disease." During that period, he maintained a jovial front, and kept up a steady stream of on-air wisecracks during golf tournaments. "It was a problem that just, I don't know, ate itself up and got bigger and bigger and then, one day, bang, I disappeared." When he finally learned in 2005 that he suffered from depression, he felt a combination of shock and relief. "That was the most stunning thing. I just thought I was a lousy husband and miserable bastard and a drunk," says Feherty, now 48. "A mental illness? Me? I had no idea."
The widespread failure to recognize depression in men has enormous medical and financial consequences. Depression has been linked to heart disease, heart attacks and strokes, problems that affect men at a higher rate and an earlier age than women. Men with depression and heart disease are two or three times more likely to die than men with heart disease who are not depressed. Lost productivity due to adult depression is estimated at $83 billion a year. Over the past 50 years, American men of all ages have killed themselves at four or more times the rate of women, depending on the specific age range.
A general practitioner is usually the first—and often, the only—medical professional a depressed man encounters. In 1990, when Mark Totten began sleeping a lot, refusing food and acting sullen, his sister, Julie, suggested he see a doctor, but never for a moment did she think it was life threatening. "I didn't know anything about depression back then," says Julie. In November of that year, Mark, 24, lay down on an Iowa train track and ended his life. Totten learned afterward that her brother had indeed visited his primary-care physician but complained only of stomachaches, headaches and just generally "not feeling so great," she says. The doctor didn't make the connection.
Confronted with a patient making vague medical complaints who is unwilling (or unable) to talk about his feelings, the hurried primary-care physician often finds it difficult if not impossible to assess a patient's emotional state. To help clear that hurdle, researchers developed a simple screening test for doctors to use: Over the last two weeks, have you been bothered by either of the following problems: (a) little interest or pleasure in doing things? or (b) feeling down, depressed or hopeless? If a patient responds "yes," seven more questions can be administered, which result in a 0 to 27 rating. Score in hand, many physicians feel more comfortable broaching the subject of depression, and men seem more willing to discuss it. "It's a way of making it more concrete," says Indiana University's Dr. Kurt Kroenke, who helped design the questionnaires. "Patients can see how severe their scores are, just like if you showed them blood-sugar or cholesterol levels."
Depression-screening tests are so effective at early detection and may prevent so many future problems (and expenses) that the U.S. Army is rolling out a new, enhanced screening program for soldiers returning from Iraq. College health-center Web sites nationwide provide the service to their students, and even the San Francisco Giants organization offers these tests to its employees.
At Clark University in Massachusetts, where Sigmund Freud introduced his theories to America, researchers are developing new clinical strategies to encourage men to seek help. The Men's Coping Project, led by Michael Addis, recruits men for interviews and discussion groups that focus not on depression but on how they deal with "the stresses of living." At a recent staff meeting, the team reviewed the file of a middle-aged local man who described himself as stressed, angry and isolated, but vehemently denied that he was depressed. In a questionnaire, the man indicated that he preferred "to just suck it up" rather than dwell on his problems and that he believed part of being a man was "being in control." Researchers decided that rather than say "you have a problem" or "you need help," they would praise his self-reliance and emotional discipline, and suggest that meeting with a counselor might be the most effective way for him to "take charge of the situation." So far, Addis and his team have met with 50 men, some of whom said they would seek counseling, and they plan to interview another 50 before the program concludes next year.
For decades, scientists believed the main cause of depression was low levels of the neurotransmitters serotonin and norepinephrine. Newer research, however, focuses on the nerve cells themselves and how the brain's circuitry can be permanently damaged by hyperactive stress responses, brought on by genetic predisposition, prolonged exposure to stress or even a single traumatic event. "When the stress responses are stuck in the 'on' position, that has a negative effect on mood regulation overall," says Dr. Michael C. Miller, editor of the Harvard Mental Health Letter. A depressed brain is not necessarily underproducing something, says Dr. Thomas Insel, head of the National Institute of Mental Health—it's doing too much.
These discoveries have opened up broad new possibilities for treatment. Instead of focusing on boosting neurotransmitters (the function of antidepressants in the popular SSRI category such as Prozac and Zoloft), scientists are developing medications that block the production of excess stress chemicals, hoping to reduce damage to otherwise healthy nerve cells. They are also looking at hormones. In a recent study, DHEA, an over-the-counter hormonal therapy, was shown to be effective in treating major and minor midlife-onset depression. And Canadian scientists have had success with deep brain stimulation—a procedure in which two thin electrodes are implanted in the brain to send a continuous electrical current to Area 25, a tiny, almond-shaped node thought to play a role in controlling emotions. In recent trials involving patients who got no relief from other forms of treatment, all the subjects reported mood improvements within six months and, remarkably, most said they were completely cured of depression.
Researchers at the NIMH are also experimenting with the idea of fast-acting antidepressants that would relieve symptoms in a few hours instead of the eight weeks or more needed for most antidepressants to take effect. In clinical trials, scientists found that a single, IV-administered dose of ketamine, an animal tranquilizer, reduced the symptoms of depression in just two to three hours and had long-lasting effects. Because of its hallucinogenic side effects, ketamine can never be used out of controlled environments. But the success of the trial is giving scientists new ideas about drugs and methods of administering them.
The most effective remedy remains a combination of medication and therapy, but finding the right drug and dosage is still more art than science. The nation's largest depression-treatment study, STAR*D, a three-year NIMH-funded project, found that 67 percent of patients who complete from one to four treatment steps, such as trying a different medication or seeking counseling, can reach remission. The process can be onerous and frustrating, and the potential side effects, including a low libido, can be hard to take—especially for men. Stephen Akinduro, 35, an unemployed phone operator in Georgia whose mother had committed suicide, tried two different drugs over a three-year period, but both resulted in weight gain, fatigue and a diminished sexual performance. "When that happened I was, like, 'What is going on here?' " says Akinduro. Frustrated, he gave up on antidepressants. Today he gets free counseling through his church and a local support group. Twelve years after his diagnosis, he is still struggling.
Often the person who seeks treatment isn't the depressed man, but his fed-up wife. Terrence Real, author of "I Don't Want to Talk About It: Overcoming the Secret Legacy of Male Depression," says most men in counseling are what he calls "wife-mandated referrals." When depression left Phil Aronson unable to get out of bed, feed himself or even pick up the phone, his wife, Emme, the well-known model, physically helped him into the shower, found doctors and therapists, and drove him to appointments, even escorting him inside. At one point, when Phil became suicidal, doctors told Emme it was her job to make sure he continued taking his medication and keep him safe from himself. "It was such an incredibly awesome, all-encompassing responsibility," says Emme, who became the sole caretaker of Toby, their daughter, then 2 years old. Even when the depression began to lift, her husband's moodiness took a toll on their marriage and Emme's career. "I had to be caretaker, I had to be a supportive wife, I had to leave my work. I was developing a new TV show and had to drop it." Today Phil is recovered, and Emme is thrilled to once again have a partner who makes her laugh, contributes to the relationship and helps parent Toby, now 5.
Success and wealth offer no protection from the ravages of depression. At 46, Philip Burguières was running a Fortune 500 company, traveling constantly and meeting with shareholders, when, in the middle of a staff meeting on a Tuesday afternoon, he suddenly collapsed. Doctors diagnosed him with depression and encouraged him to leave his high-stress job. But after a short hospital stay, he was back in the game and by the following year was running Weatherford International, an energy-services company with $3 billion in revenues. The pressure became unbearable, and in 1996 he once again took a medical leave. "The second one was a grade-A, level-10, atomic-bomb depression," he says. In his darkest moments, he was certain the world would be better off without him, but even then, he felt enormous pressure to succeed. "I want out, but am stuck because I have never quit anything in my life," he wrote in a hospital diary. Strengthened by counseling and a friendship with a similarly depressed CEO, Burguières attained what he describes as a "full recovery" and stepped down as CEO. He found new work running a family investment company and as vice chairman of the NFL's Houston Texans, positions that permit him to delegate more responsibility and have more fun. He also found that helping other people was the best way for him to get better, and since 1998, he has been privately counseling the numerous depressed CEOs who seek him out. "You get outside yourself; you don't obsess on your own issues," he says.
Fading social stigmas are already making it easier for young men to come forward. Recently, Zach Braff, filmmaker and star of TV's "Scrubs," told a reporter from Parade magazine that he thinks he suffers from "mild depression." At colleges and universities across the nation, health officials are putting mental-health care front and center. At UCLA, the Student Psychological Services moved two years ago from a basement office to a bright building in the center of campus across from Pauley Pavilion. In January, center director Elizabeth Gong-Guy walked through the waiting room and noticed that every person there was male. "It was amazing to me," she says. "I've been doing this for 18 years and that's not something you would have seen even three years ago."
Social attitudes toward depression are changing, thanks in part to men themselves. John Aberle is a sales and marketing consultant, retired Air Force security specialist, part-time radio talk-show host, devoted husband, active father and a 6-foot-4, 250-pound body-builder who twice faced a depression so deep, he cried on his knees. He readily tells other men it's their duty to get better. "There's no crime in having a disorder, whatever it is," says Aberle, 38. "The crime is not dealing with it. It's your responsibility to be at the top of your game." Taking care of yourself physically, mentally and emotionally—maybe that's the real definition of what it means to be a man.