Amin A. Muhammad Gadit  ( Department of Psychiatry, Memorial University of Newfoundland, St. John s, NL A1B 2A3, Canada. )

The global scenario for depression as an illness is quite disappointing. Women were known to have higher prevalence rate for depression than men but this notion is falling apart as men are now outnumbering women in this regard. According to the National Institute of Mental Health (NIMH), about six million American men suffer from depression every year.¹ Researchers believe that typical depressive symptoms may not represent men\'s depression. Their expression would manifests as: increase in fatigue, irritability and anger and loss of interest in work and hobbies. In order to mask these symptoms, men tend to use drugs, alcohol or would self medicate. They also try to hide it with overwork or exposure to harm by risky behaviour. It is an established fact that men commit suicide more often than women. Men are said to be notorious in expressing their emotions and probably have the ingrained belief that it is a sign of weakness and does not conform well to their gender role.¹
It has also been revealed in studies that new fathers are also vulnerable to postpartum depression. The StatsCan² Canadian Community Health Survey on Mental Health and well-being found that 10% men experienced symptoms of surveyed mental health disorders. In the United Kingdom, studies have shown a major shift in the traditional gender imbalance with depression rising among men and decreasing among women. Among Canadians of all ages, four of every five suicides are in males. In UK, men are around three times more likely to kill themselves than women. In New South Wales, Australia, suicide has taken over car accidents as the leading cause of death in males since 1991.² Walinder and Rutz³ have proposed the concept of \'Male Depressive Syndrome\' that comprises of: low stress tolerance, an acting-out behaviour, a low impulse control, substance abuse, hereditary loading of depressive illness, alcoholism and suicide. They support this notion by data study showing stress-precipitated, cortisol-induced, serotonin-related and anxiety-driven depressive illness most often seen in males. Aggression and anger attacks among depressed males as a result of low impulse control are also observed in a study.⁴ Male depression has been related to stress reaction combined with serotonin deficiency and hypercortisolaemia.⁵ Regarding the Male Depressive Syndrome, researchers do emphasize on further work focusing on the gradual development of (masked) depression by men in mainly non-clinical samples.⁶
There is a struggle even about finding better methods for identifying men with postnatal depression with suggestions for development of better scales as this aspect of male depression has so far not been included in research.⁷ Scientists observed different EEG findings among male depressives. Quantitative EEG measurements in male depression appears to describe a pattern of aberrant inter-hemispheric synchrony/asymmetry and a profile of frontal activation.⁸ In terms of seeking help for depression, men do possess a negative attitude. While men are usually reluctant to talk about their depression, they may do so if the environment is conducive and the therapist is well-versed with men\'s psyche and the way to handle matters in discussion. Women present more with depressive symptoms as they have greater emotional literacy and more likely to volunteer how they feel.⁹ It has been advocated that health professionals should work towards a greater understanding of cultural masculinity in the service of conceptualizing, diagnosing and treating male clients/patients who may be suffering from a disguised form of this common mental illness. It is further suggested by Kilmartin¹⁰ that therapists should educate men about masculinity as an important context of their problem, and should attend closely to issues of emotional expression, premature termination of therapy and grief. In Pakistan, there are a number of studies conducted on the subject of depression but there is hardly any literature available on prevalence of male depression exclusively. A number of patients do present themselves for treatment of depression and anecdotal reports indicate the problem of depression among males may not be manifested as usual symptoms many a times. The concept of socially enforced masculinity norm similar to that described by Addis¹¹ is a bottleneck towards reaching a diagnosis. Men\'s general concerns are in the form of decreased libido, higher rates of hypochondriasis, and compulsive impulses, much similar to what Winkler¹² has stated. Problematic behaviours and aggression expressed by men are similar to those described by Kilmartin.¹⁰ Moreover, men\'s reactions to treatment and treatment providers, including their belief about incompetence among health care providers, frustration with antidepressants and psychotherapy treatment are issues that lead to a non-help seeking attitude.¹³ It has also been suggested that hypogonadism with low testosterone levels leading to depression in men may improve with testosterone augmentation.¹⁴
It is important that an appropriate depression scale be developed for detecting depression in men. Interview techniques for men in clinical settings should be modified and skills acquired for detecting depression with men\'s atypical presentation and expressions. Modules for psychotherapy may likewise be tailored while dealing with male patients keeping in view male psyche and cultural milieu. The matter may be more serious than what it appears. Should we now focus our attention to this serious but hidden problem?

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