Men and Depression: From Masculine Norms and Gender Differences to Symptoms, Diagnosis, and Treatment

Jaime Canterbury, Sean Alan Kindt, Shannon Selander, Katie Vander Meer, Nicole Weinert, Natalie Wolfers, and Christen Wright

The study of depression amongst men leads one to discover the particular ways in which the societal norms and gendered differences play a part in the expression and experience (or lack thereof) concerning men in such a state. Gone are the days when men simply battled the elements, hunted for dinner, and guarded his dwelling from wild beasts. Today’s man must take on the ever-growing challenges the world hurls at him, all without the understanding of his own feelings, especially that of depression. The symptoms of depression may be expressed as an outright rejection of any ill-feelings at all, an abuse of substances (including alcohol or drugs), the tendency to physically strike out, as well as the internalization of depression by refusing to eat and take care of general health, withdrawal from people or activities that once proved enticing, as well as the desperate turn to a violent act against one’s self through suicide.  Diagnosis is especially difficult considering the fact that most men do not wish to even admit they need therapy, let alone need to adhere to the guidelines and words of advice provided them once they begin the arduous journey of restoring mental and emotional wellness. Treatment is also a problematic component that one encounters in the study of men and depression. Abuse of medication and the resistance to undergo treatment in the first place or to follow orders are only a few of the trappings of the road to healing. Still, there exists the hope that through diligent effort and by the support of a caring family, spouse, loved one, doctor, or therapist, men may not only identify the source of their depression, but that they might work past it.

Masculine Norms

Men are diagnosed with depression at lower rates than are women, yet men commit suicide 4 to 15 times more often. In response to these startling statistics, Mahalik and Rochlen (2006) conducted a study exploring how likely men are to utilize various options of responses to symptoms of depression. These researchers wondered if conformity to masculine norms relates to the likelihood of certain responses and which masculinity norms are associated with specific actions. The sample consisted of 153 college students with a mean age of 19 years old. The students were mostly Caucasian, all single, and predominantly heterosexual. The participants completed the Conformity to Masculine Norms Inventory as well as a survey consisting of a description of a depressive episode and likely responses. Pearson correlations were conducted. The results indicated that men’s most likely responses to depression are either turning to a support system (talking to wife, friend, etc.) or waiting to see if  a depressive episode ends on its own. The most significant finding was that men who conform to the masculine norms concerning violence, dominance, the pursuit of status, living the life of a playboy, and in the seeking of power over women are more likely to respond to depression by having a few drinks and less likely to talk to their wives or partners (Mahalik & Rachlen, 2006).

The implications of these findings (Mahilik & Rachlen, 2006) are important in helping both men and women to more clearly understand the harm that masculine norms, perpetuated by society, can cause. The masculine norms listed above are related to men responding to depression in a negative and potentially life-threatening manner. Men whose behaviors gravitate towards the norms push away those closest to them, and are potentially at risk for substance abuse. Intervention needs to occur before depression sets in, as the men at risk avoid seeking help. Changing the societal masculinity norms is the best early intervention for men who are at risk for depression. Mahilik and Rachlen’s (2006) study had some limitations, including very narrow demographics. Although the researchers did bring to light some important correlations between men’s responses to depression and masculinity norms, no practical application for dealing with depression in men with these masculinity norms was offered.

To address the problem of men and depression, Brownhill, Wilhelm, Barcley, and Schmied (2005) investigated men’s experience of depression. In their study, they hoped to find out about men’s experiences by simply asking them. The sample consisted of 77 men, broken up into ten focus groups. Each group was asked open-ended questions to help futher the discussion and to gather qualitative data. The term “down in the dumps” was used to refer to depression. Researchers used two standard measures of mood (the positive and negative affect schedule [PANAS] and the life orientation test [LOT]) to assess whether the participants were clinically depressed or not.

Results of this study (Brownhill et al., 2005) indicate that emotional distress in men is multifaceted. Responses include: avoiding ‘it’, numbing ‘it’, escaping ‘it’, ‘hating me, hurting you’, and ‘stepping over the line’. Each of these successive responses moves men away from adaptive behavior towards maladaptive behavior, which results in the constant hurting of others as well as themselves. The experience of depression amongst men is not much different than that of the experience of depression amongst women; it is the expression of depression that provides ample grounds for the analyzation of differences. Traditional masculinity norms tend to hide symptoms of depression, which may be why it is so easily overlooked in men. Brownhill et al.’s (2005) study had limitations. Researchers compared men’s data to women’s data, but used different methods to analyze both sets of gathered information. If the goal is to compare the sets of data, data from both groups should be analyzed in the same way. Also, the sample size was relatively small, possibly too small to be representative of the male population.

When men do not live up to society’s masculine norms, they experience feelings of anxiety and shame. This may occur as a result of the discrepancy between their ideal self and their actual self. In order to combat the experience of depression resulting from gender role conflict, it might be helpful to incorporate a course on emotionality for boys in school. In this course, boys experiencing gender role difficulty could learn and discuss male roles, including the negative characteristics. As boys get older and mature, masculinity roles become more complex. Because of this increasing complexity, their view of themselves continues to change. Boys need guidance at every stage of childhood through adolescence to comprehend and manage the changing views the have of themselves (Jackson, 2007).
Gender role conflict has been found to be associated with higher rates of depression among men.

In order to further study this area, Jackson (2007) conducted an analysis of data collected by 92 boys, ages 12-18, in the hope of examining the correlation between gender role conflict and psychological well-being. The boys responded to the statement, “How I am as a man”. They completed the Masculinity Across Roles Scale (MARS), the Gender Role Conflict Scale-Adolescent (GRCS-A), and the Child Depression Inventory-Short Version (CDI). Jackson’s (2007) findings indicate that a high MARS number and intensity within role conflicts were significant predictors of CDI scores. Specifically, if boys had a greater amount of masculine role conflict, they were more likely to score highly on the depression inventory. Similarly, restricted emotionality and conflict between the workplace and amongst family life were significant predictors of CDI scores.

Gender Differences

Hyde, Mezulis, and Abramson (2008) proposed a model integrating affective (emotional reactivity), biological (genetic vulnerability, pubertal hormones, puberty timing and development), and cognitive (cognitive style, objectified body, consciousness, rumination) factors as vulnerabilities to depression that, in interaction with negative life events, heightens female’s rates of depression beginning in adolescence and account for the gender difference in depression with males. Containing a sample group consisting of adolescents 13 to 17 years old (with 30 males, 40 females and 10 humans), the study postulated that in adulthood, twice as many women as men are depressed and that this pattern holds true for most of the nations on Earth. In childhood, girls are no more depressed than boys, but more girls are depressed by the time they reach 13 to 15 years of age. Although there are many influences on this particular gender difference in depression, this study was performed to provide an integrated developmental model.

The study (Hyde et al., 2008) consisted of individual questionnaires, interviews, comparative research, and literature integration. Though there have been numerous existing models before this particular study, none were fully integrated. Hyde et al. utilized numerous research studies to support their proposed ABC (affective, biological, cognitive) model. Their study included evaluation, critique, and updated research on the topic to more fully include new theories that have been put forth in recent years. They included new evidence that links pubertal processes and timing with the emergence of the gender difference in depression. Recent theories and research go far beyond the concept of body image or body dissatisfaction and specify particular cognitive processes that link body dissatisfaction to depression, primarily in girls. The key causal factors in prior reviews had individual and particular focuses whereas this study worked to bring all of the elements together for a broader picture of the complex issues of how and why depression impacts boys and girls differently. Hyde et al. proposed that important affective and biological features of development could be integrated with cognitive factors to form a developmental vulnerability-stress model of gender and depression in significant ways (Hyde, Mezulis and Abramson). They also included newer research studies as related to genetics, hormones and pubertal processes, the brain and neural processes, temperament and negative life events which provided conceptual and empirical evidence that these elements increased the interactive vulnerability factors in boys and girls at different rates and significantly affected their levels of depression. From the Hyde et al. perspective, and the research models that they presented, there are different pathways to depression. These pathways then explain the gender difference between boys and girls and how depressed they become.

Hyde et al. (2008) found and presented empirical evidence supporting their hypothesis, which stated that there are many components that affect the level of depression in both boys and girls. Their findings indicated that negative cognitive style, when paired with stressors, prospectively predicts depression. They found that gender differences in negative cognitive style are not present in childhood, but emerge in adolescence. They also found that objectified body consciousness (OBC) and the role of puberty and hormones in adolescence contribute significantly to the gender difference in depression. It was proposed that there is no single pathway, but rather multiple complex pathways, in the development of depression in both boys and girls. Their findings effectively supported the theory that different individuals with the same outcome (depression) arrive at this state through more than one pathway. Their ABC model provides a structure to support individual differences and multiple pathways.

The ABC model is also supported by attachment theory inasmuch as boys and girls are forming early emotional bonds with caregivers and there is a significant impact that continues throughout their lives. As mothers are available and responsive to infants, and as they provide a sense of security, the infant knows that the caregiver is dependable. This, in turn, creates a secure base for the child to then explore the world around them. When this attachment is not healthy, it impacts the later cognitive and emotional processes that occur in both boys and girls as related to their self-image and vulnerability to depression. This was a significant study to help understand depression in men and why it is less prevalent than in females (Hyde et al., 2008).

Hyde et al’s (2008) study provides a valid model to help sort through the complex issue of depression. Further research can identify the thought processes in girls that can be effectively modified in order to help them become less vulnerable to their high incidence of depression. The primary question that this study raised concerns the manner of how and why there is such a significant difference between the way in which males and females perceive negative events that occur in their lives. It may also be helpful to ask why it is that that there are twice as many adult women who are depressed when compared to men.

Ryan, Carriere, Ritchie, Stewart, Toulemonde, Dartigues, Tzourio, and Ancelin (2008) sought to examine the relationship between depression and mortality, using subjects from a community-based, elderly population. They also examined the influence of gender and the use of anti-depressant medication. Data for the research were the results of a longitudinal study between 1999 and 2001.  Subjects were over age 65, non-institutionalized, and were selected randomly from electoral rolls from the French cities of Bordeaux, Dixon and Montpellier. Diagnosis of depression in subjects was evaluated using the Mini International Neuropsychiatry Interview (MINI). Levels of depression were assessed using the Center for Epidemiology Studies-Depression scale (CES-D). Subjects were also evaluated to identify whether their depression manifested itself as a single episode or as recurrent in nature. Subjects were classified into three groups: severe depression, mild depression, and no depression. The use of anti-depressant medication by subjects and its influence on depression levels was also studied. Follow-up time for this study was a period of four years. A total of 7,363 subjects were studied.

 Results indicated that women had a significantly greater occurrence of depression than men, and that women were much more likely to use anti-depressants. Subjects who were depressed were likely to live alone, have a disability, and to suffer from cognitive impairment and co-morbidity. Women who were depressed were less educated and were more likely to have a recent hospitalization. When a four-year follow-up evaluation was done, subjects with mild or severe depression were found to have died at a greater rate than those who were initially assessed as being non-depressed. Nearly three times as many men not taking anti-depressants had died, compared with those who had been taking anti-depressant medication. Women who were initially assessed to be depressed were also more likely to have died compared to non-depressed women. A similar number of women taking anti-depressant medication died compared to women not taking anti-depressant medication. Only four deaths were attributed to suicide. The greatest risk for death was among men who were taking anti-depressant medication, with increasing risk each time their level of depression increased. For women, increased risk was found among those who were severely depressed and not receiving treatment. Mortality was therefore found to be associated with gender and the severity of depression. Depression is believed to make recovery from physical illness more difficult. The social isolation and lack of motivation associated with depression increases the incidence of mortality. Overall, results indicate that the mortality rate in elderly individuals is related to gender and to the severity of symptoms. Treatment with anti-depressant medication lowers the incidence of mortality for groups assessed.

Further Notes on Gender Differences

Research has shown that twice as many women than men suffer from major depression. There may be biological or psychoanalytic explanations for this ratio, such as learned helplessness or gender roles, but many hypotheses for this phenomenon have to do with the instrumentation of the diagnoses. For example, it could be that the symptoms of depression practitioners could identify were more often manifested in women than men. An alternative hypothesis explored by Sigmon et al. (2005) is that men may report symptoms of depression less often than women.

According to Sigmon et al. (2005), there are a variety of reasons depressive symptoms may go unreported by men, but one of the major theories is the response bias explanation. This explanation is twofold: Men do not want to admit to seemingly “feminine” symptoms, such as crying and weakness, and women have been socialized to recognize sadness as an emotion, resulting in higher reports of depressive symptoms. The underlying attribution of the response bias explanation is gender role socialization. Gender role socialization’s affect on the report of depressive symptoms can range anywhere from differences in perception of depressive symptoms to women’s positive experiences in the sharing of emotions with others. The goal of many in the psychological field is to create assessments void of the opportunity for response bias.

Sigmon et al.’s (2005) study focused on response bias in relation to the intrusiveness of follow-up. Research had noted that men were less likely to report depressive symptoms with the promise of follow-up. The study also explored men’s likelihood to report symptoms if depression was attributed to biological means, such as a disease. Finally, the relationship between mental health attitudes and the self-report was explored. As expected, the men’s report of depressive symptoms increased as the level of follow-up decreased. Women reported a higher level of attention to mental health problems, and men reported more incidents of avoidance in relation to mental health issues. Surprisingly, men did not attribute any depressive feelings to biological or outside factors, but rather to those of a psychological nature (Sigmon, et al., 2005).

Sigmon et al.’s (2005) findings are significant as the study shows how men avoid attending to depressive feelings as well as disengaging from reporting with the promise of follow-up. It seems that gender role socialization’s effect on men may keep many undiagnosed with mental health issues. Due to the fact that most men are raised to avoid feelings of weakness and to keep concerns to themselves, a large number of men will live life without necessary mental health treatment. The implications speak to depression’s effect on relationships, fatherhood, sexual life, and general mental wellness.

Symptoms

Studies have proven that from a very young age, boys in our society are pushed to suppress vulnerable and sad feelings. On the other hand, anger is an emotion boys are encouraged to express. It seems as though it would be difficult to closely examine the symptoms of depression in men, especially at the risk of mistaking anger as depression, instead of what perhaps really exists – anger as a mask for sadness or fear. A study performed in 2008 inquired about the sex differences and symptom patterns of recurrent major depression in siblings. Participants in this study were recruited voluntarily from different sites across Europe (Denmark, Germany, Ireland, Switzerland, London, and the United Kingdom) and the United States (St. Louis). A total of 878 people participated in the study, 270 of which were men. Ages of the participants ranged from 18 – 80 years old, and the average age was 45. All of the subjects were interviewed using the Schedules for Clinical Assessment in Neuropsychiatry (SCAN). The SCAN items were coded to evaluate the severity of symptoms in association with depression (Moskvina 2008).

Previous studies, mentioned in the article, found that men suffer more from insomnia and agitation as a depressive symptom. It was also stated that men’s pathway towards depression is sometimes caused by alcohol and or substance abuse. Some of the items used to evaluate symptoms of depression in this study include worrying, restlessness, irritability, loss of hope, loss of energy, loss of libido, and the loss of appetite. This is not a complete list of items that were used in the interviews, but rather a sample of the many items listed. The results indicated that women had an earlier onset for depression, and that women also experienced more severe symptoms of depression on particular items on the scale, such as tearfulness, loss of self-esteem, appetite gain, weight gain, and hypersomnia. Overall, the researches concluded that women more frequently experience atypical depressive symptoms. While the results of the study were said to be significant, it is hard to take the results as they are without first examining a few key aspects of how men experience depression, and why that in itself may have caused the study to fail in certain aspects, and thusly cause the results to be distorted (Moskvina 2008).

If a young boy grows up in a culture parallel in values to that of the United States or Western views in general, he may have faced oppression from the imaginary “Boy Code.” The boy code, comprised of four rules, is intentionally (or unintentionally, depending on the structure of the family and care-giving situation) set for young men to follow in many cultures. It begins with the “Sturdy Oak” proposal. This is the belief that men should act as self-reliant, stoic, and emotionally stable beings. More precisely, boys shouldn’t grieve publicly or openly communicate natural responses such as pain. However, it is socially acceptable for men to express anger (this attraction to rage follows the second rule of the boy code; “Give ‘em Hell”), so conceivably men could channel their sadness through their expression of anger. This camouflage is an important aspect when searching for depression and depressive symptoms in men (Pollack, 1999).

The expression of sorrow and depression in men is found through the way they have been taught to articulate their feelings – through anger, or not at all by way of silence. The third law of the boy code, being the “Big Wheel”, means achieving power and dominating a situation or another person or group of persons, which is a result from the shamefulness associated with unhappiness. Being driven to succeed represses feelings of failure or melancholy. A majority of the items used in the interview were highly emotion-based (worrying, tearfulness, loss of hope, appetite loss) which could be hard for a male to identify with. These traits don’t represent depression symptoms for men, but rather they represent what society has deemed to be “feminine” qualities. The final rule to follow according to the boy code, “No Sissy Stuff” is the most devastating. It teaches boys and men that having traits such as empathy, being emotionally expressive, or co-dependent is strictly assigned to women. Boys are taught to shut down and to rely solely upon themselves, and, because of this, must stumble later in life with the struggle to express depressive emotions and thoughts (Pollack, 1999).

Diagnosis

There are several difficulties that are encountered when diagnosing men with depression.  American society has placed social strains on men, encouraging the constraints of the previously mentioned “boy code.” There is a widespread social stigma afflicting males that experience depression or any other mental distress, which may be seen as a sign of weakness. The National Institute of Mental Health (NIMH) has set out to disprove this way of thought. The Real Men Real Depression (RMRD) campaign was a large-scale effort to raise awareness of depression in men. This campaign primarily focused on the fact that “Men are less likely than women to recognize, acknowledge, and seek treatment for their depression” (NIMH, 2003). Rochlen, McKelley, and Pituch (2006) examined 209 male college students and their reactions to brochures containing information on depression. The men were found to react in a more positive and open manner to the brochure provided by the RMRD campaign. This RMRD brochure contained material specifically referring to, and directed towards, males. The men in the study were asked to evaluate the brochures on their appeal and how they affected their personal attitudes towards seeking professional help.

Strike, Rhodes, Bergmans and Links (2006) looked more thoroughly at exactly why men seem to be under diagnosed with depression. Strike et al. (2006) found that men seem to be experiencing “fragmented pathways” to mental health care. Men attribute their persistent mental health problems to irregular, infrequent, and unpleasant experiences with mental health service providers. Strike et al. (2006) compiled their information and perceived several practices inflicted upon men that prevent diagnosis. Personal practices include: (a) the failure to identify or acknowledge mental health problems, (b) an inability to articulate feelings and emotions, and (c) difficulties navigating the referral system. Five health care provider practices were identified including: (a) having a patient’s problem’s mislabeled, (b) the failure to identify or acknowledge underlying factors, (c) disrespectful treatment of patients, (d) insufficient assessment, and (e) over reliance on medications. Finally there were two episodes that men claim to have experienced that caused them to cease treatment. These include: (a) the use of drastic measures in order to be taken seriously for treatment, and (b) experience of indignities during hospitalization.

Ultimately, Strike et al. (2006) has provided the research that shows that health care providers, and men alike, need to reconstruct their paradigm of what a depressed male looks like. With the help of the RMRD campaign, men will be free of the stigma of depression. It is also appearant that health care providers must re-examine their business practices to better provide for their male patients. As our understanding of men and depression grows, our practices and perspectives must adapt and be constantly scrutinized for their effectiveness.

Treatment

NIHM suggests four types of depression treatment including medications, psychotherapy, electroconvulsive therapy, and herbal therapy. An examination performed by a physician is the first step when seeking medical health. The physician will check for medical conditions such as viral infection, thyroid disorders and also low testosterone levels. Any or all of these conditions can cause men to experience depressive symptoms. Once the patient has been fully evaluated the physician will choose a treatment option. The most common form of treatment is medication known as SSRIs (Selective Serotonin Reuptake Inhibitors and MAOIs (Monoamine oxidase inhibitors). Medications must be taken for several weeks and at different dosage levels before the patient may experience increased moods.

Along with taking psychotropic medication, patients are often encouraged to attend therapy sessions. Cognitive Behavioral Therapy (CBT) and Interpersonal Therapy (IPT) are both found to be affective for depressive disorders. Alternative methods of treatment include electroconvulsive therapy and herbal therapy. Electroconvulsive therapy is used in extreme cases of depression in which the patient cannot take medication or the patient’s condition is life-threatening. The process consists of 12 treatments in which electrical impulses are delivered to the brain, causing a seizure. Herbal therapy is still under intense investigation as to its legitimacy. Aside from the previously mentioned methods of treatment for men, there are other accessible treatment options as well. It is imperative that we use the research provided by Strike et al. (2006) and the RMRD campaign. Using aesthetic approaches to therapy may be an affective way to make counseling more appealing to men. Many psychologists are taking this approach seriously by redecorating their offices with more masculine features including leather chairs and sports-themed art. Men also break the stereotypical mold of counseling sessions by referring to them as “meetings” or “consultations”, which highlights the socially acceptable image of a man bonding through an activity as well as the professional and sophisticated manner in which therapy might occur amongst educated and intelligent persons.

Concluding Remarks

Not only are men confronted with the task of growing up to be strong, independent, masculine, dominant, and care-free individuals, but they must also do this without yielding to societal pressures – men are not allowed by our society to fear, feel pain, and, specifically, to be depressed. It is a strange fate that men are urged to defend their country, their loved ones, and their homes alike, but are barred from feelings other than aggression, frustration, or impatience in regards to their struggles and imperfections. This paper has attempted to provide a glimpse into the research done regarding the existence of masculine norms and gender differences, as well as a glance into the identification and treatment of depression amongst men.

Masculinity is a multivalent term that owes much to the Western ideals borrowed from centuries past and enhanced as the future stretches onward. Though men are hardly fighting with spears, hunting daily for dinner, or charging into battle in horse-drawn chariots, societal expectations run so deeply in our culture that the strength of men is seen as something of the quality of adamant and is not subject to change. The proposed “boy code” has illuminated the way in which men are raised to obey concepts that continue to challenge their innate sensitivity and their willingness and ability to experience a wide breadth of emotions. Locked away are the feelings of weakness and fragility, only to be replaced by equally as damaging, if not more menacing, feelings of anger, frustration, unrest, and an unrealistic sense of invulnerability. By challenging the norms of masculinity, men wade into dangerous territory where they may be free to experience the full range of emotions, but also cast their stoic image to the wind for the world to pull apart at a whim. Depression may set in largely due to the shackles placed upon boys at a young age – ideas of what men are suppose to be often limit and bankrupt the male population.

Gender differences do exist in the expression as well as the experience of depression amongst men and women alike. If gender plays a role in depression, shouldn’t scientists, therapists, and laypersons alike be interested in such findings? The feminine qualities supported by the culture provide room for women to relate to one another through their emotions. This, in turn, leads many to seek out counseling or other professional help. The verbalization of their depression, or symptoms thereof, is not only encouraged, but is applauded as a signal to the world that a woman has mastery over her body and her mind such that she is able to recognize the need for help and is happy to receive it. Males, on the other hand, are continually told to keep their feelings to themselves, to be independent, and told to work the hardest they can to keep the imagery of perfection alive. Depression, if expressed at all, comes out as aggression or by the misuse of drugs or alcohol, among other things. Gone, also, is the tendency for males to seek out help, especially from other men (male psychologists, psychiatrists, etc). The bearing of one’s soul to another man is a great risk, which probably, more often than not, brings forth disappointing results for most, if not all men. The further study of gender differences and expression/experience of depression among males is needed if men are to be liberated of the invisible binds that keep them from treatment, from relational activity, and from personal growth.

Along with the gender differences is the notion that men are hard to diagnose and study simply because there aren’t enough of them that seek treatment. This is one of the major stumbling blocks for medical researchers and therapists alike. If men feel uncomfortable seeking out the help they need, due to the masculine norms, gender differences in experience and expression, then the hope to gather accurate and groundbreaking information is somewhat stifled.  When men do seek treatment it is important to notice that medications are often misused, contributing to further depression and the degeneration of the mental and emotional state. Another danger can be found in the way researchers gather their information. If treatment includes the seeking out of a therapist and a re-evaluation or check up at a time in the future, most men drag their feet in their efforts or abandon them altogether.

The importance of altering masculinity and gender rules cannot be overstated. There is a direct link between the manner in which a man is raised to think about acceptable emotions and life’s harsh demands. To ignore the part society plays in the poisoning of the male mind, from a young age throughout his lifespan, is to do every man a great disservice. Professionals in the field of Psychology must pursue efforts to welcome and inform men concerning their mental wellness and their battles with depression.

References

Brownhill, S., Wilhelm, K., Barclay, L., & Schmied, V. (2005). ‘Big build’: Hidden depression in men. Australian and New Zealand Journal of Psychiatry, 39, 921-931.

Hyde, J. H., Mezulis, A. H., & Abramson, L. Y. (2008). The ABCs of depression: Integrating affective, biological, and cognitive models to explain the emergence of the gender difference in depression. Psychological Review, 115, 291-313.

Jackson, S. (2007). The effects of masculinity and gender role conflict on adolescent boys’ psychological well being. Unpublished doctoral dissertation, Tennessee State University, Nashville.

Mahalik, J. R., & Rochlen, A. B. (2006).  Men’s likely responses to clinical depression: What are they and do masculinity norms predict them? Sex Roles, 55, 659-667.

Moskvina, V. Et al. (2008). Sex differences in symptom patterns of recurrent major depression in siblings. Depression and Anxiety, 25, 527-534.

National Institute of Mental Health. (2003). Real men. Real depression. Retrieved December 18, 2003, from http://menanddepression.nimh.nih.gov

Pollack, W. (1999). Real boys. New York: Henry Holt and Company.

Rochlen, A., McKelley, R., & Pituch, K. (2006). A preliminary examination of the “Real Men. Real Depression” campaign. Psychology of Men and Masculinity, 7, 1524-9220.

Ryan, J., Carriere, I., Ritchie, K., Stewart, R., Toulemonde, G., Dartigues, J., Tzourio, C., & Ancelin, M. (2008). Late-life depression and mortality: Influence of gender and antidepressant use. The British Journal of Psychiatry, 192, 12-18.

Sigmon, S. T., Pells, J. J., Boulard, N. E., Whitcomb-Smith, S., Edenfield, T. M., Hermann, B. A., et al. (2005). Gender differences in self-reports of depression: The response bias hypothesis revisited. Sex Roles, 53, 401-411.

Strike, C., Rhodes, A., Bergmans, Y., & Links, P. (2006). Fragmented pathways to care: The experiences of suicidal men. The Journal of Crisis Intervention and Suicide Prevention, 27, 31-38.

Unknown Author. (2008, June). Diagnostic Evaluation and Treatment. NIMH, Men and Depression. Retrieved December 8, 2008, from http://www.nimh.nih.gov/health/publications/men-and-depression/diagnostic-evaluation and-treatment.shtml

Unknown Author. (2005, July). Psychology Matters; Men: A Different Depression. American Psychological Association. Retrieved December, 8, 2008, from http://www.psychologymatters.org/mendepress.html

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