Depression: Gender MattersPage 8 of 11

6. A Better Instrument for Assessing Male Depression

Most patients with symptoms of depression are treated in primary care settings—not by mental health professionals (Sharp and Lipsky, 2002). Depressed patients present with feelings of sadness, loneliness, irritability, worthlessness, hopelessness, agitation, and guilt that may be accompanied by an array of physical symptoms. Recognizing depression in a primary care setting may be particularly challenging because of time constraints and because patients, especially men, rarely report emotional difficulties. To the contrary, patients with depression who present to primary care professionals are more likely to describe somatic symptoms such as fatigue, insomnia, pain, loss of interest in sexual activity, or various vague symptoms (Suh and Gallo, 1997).

There is no laboratory test to establish the diagnosis of clinical depression. Instead, a trained interviewer conducts a clinical interview to determine if the patient meets established criteria. The most commonly used criteria, which are updated periodically, are the DSM-IV-TR or the International Classification of Diseases, Tenth Revision (ICD-10).

A number of questionnaires are available to help clinicians identify and diagnose adult patients with major depression. Based on a review of studies between 1970 and 2000, Williams and colleagues (2002) evaluated eleven questionnaires ranging in length from 1 to 30 questions that were assessed in 28 studies. Six are depression-specific:

  • Beck Depression Inventory (BDI)
  • Center for Epidemiologic Studies Depression Screen (CES-D)
  • Zung Self-Assessment Depression Scale (SDS)
  • Depression Scale (DEPS)
  • Geriatric Depression Scale (GDS)
  • Single Question (SQ)

The BDI, the CES-D, and the SDS were developed specifically to identify depression. They include similar numbers of questions. They use response formats that rely on classifying frequency of symptoms or ranking symptom severity. These three instruments are among the most thoroughly evaluated in primary care and can be used to rate the severity of depression and monitor response to therapy.

Although these instruments are widely used and accepted, a number of researchers believe that the most widely used assessment scales are gender biased (Cole et. al., 2000; Stommel et al., 1993). They tend to include that are generally more true of women than of men. They also leave off questions that depressed men, but not depressed women, might answer positively.

Is There a Male Depressive Syndrome?

Due to increasing suicide rates in the 1980s, the Swedish Committee for the Prevention and Treatment of Depression (PTD) organized a training program on the diagnosis and treatment of depression for all the general practitioners on the island of Gotland (Rutz et al., 1995). The researcher’s were surprised to find the rate of depressive suicides in females decreased dramatically after the PTD program, while the proportion of male depressive suicides was almost unchanged after the PTD education (Rutz, 2001a).

Based on the Gotland studies, Rutz (1999) postulated a “male depressive syndrome,” with symptoms that differ from common depressive symptoms among females. According to this view, depression in men often seems to be masked by atypical symptoms like irritability, anger attacks, aggression, stress, anxiety, and fatigue. A number of studies (Diamond, 2010; Oquendo et al., 1999; Möller-Leimkühler, 2003) have shown that the high suicide rate in men may result from under-diagnosis of depression. Since symptoms such as irritability and anger are not included in leading international classification systems, depression may be overestimated in females and underestimated in males (Salokangas et al., 2002).

The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), originally published by the American Psychiatric Association in 1994 and revised most recently in 2000, has become the world’s standard. Among its criteria for evaluating a person for major depression is that at least one of three abnormal moods significantly interfered with the person’s life:

  1. Abnormal depressed mood most of the day, nearly every day, for at least 2 weeks.
  2. Abnormal loss of all interest and pleasure most of the day, nearly every day, for at least 2 weeks.
  3. If 18 or younger, abnormal irritable mood most of the day, nearly every day, for at least 2 weeks.

Based on these criteria, many clinicians focus on depressed mood and loss of interest and pleasure when evaluating adults, and they don’t think of irritability as a symptom of depression, at least in those over the age of 18.

In a review of the literature, Whitfield (2003) found 209 studies published in peer-reviewed journals that linked depression with a history of childhood trauma. Although there have been a number of theories put forth to explain male depression, a theory based on gender-specific vulnerability to trauma has important clinical implications. Pollock (1998) postulates:

Historical, cultural, and economic forces have affected parenting styles so that, as boys, men will suffer a traumatic disruption of their early holding environment, a premature psychic separation from both maternal and paternal caregivers. This is a normative male, gender-linked loss, a trauma of abandonment for boys which may show itself later as an adult through symptomatic behavior, characterological defense and vulnerability to depression.

Based on his theory of gender-specific vulnerability to trauma, Pollock (1998) suggests a classification he calls “Major Depressive Disorder—Male Type.” Pollock posits a number of symptoms, including the following :

  • Increased withdrawal from relationships: May be denied by patient.
  • Overinvolvement with work activities: May reach a level of obsessional concern, masked by comments about “stress” (burnout).
  • Increasingly rigid demands for autonomy.
  • Shift in the interest level of sexual encounters: May be either a decrease or an increase (differentiate from mania).
  • Increase in intensity or frequency of angry outbursts.
  • New or renewed interest in psychoactive substance self-administration.
  • Denial of any sadness and an inability to cry.
  • Harsh self-criticism: Often focusing on failures in the arenas of provider and/or protector.
  • Depleted or impulsive mood.
  • Avoiding the help of others: The “I can do it myself” syndrome. (Pollock, 1998)

Other theories seeking to understand the different ways males and females express depression focus on role conditioning (Kilmartin, 2005; Lynch and Kilmartin, 1999; Real, 1997). These theories are based on research showing that masculinity is culturally defined as anti-femininity (Brannon, 1985; Pollack, 1998; Kilmartin, 2005). Men are conditioned to express themselves in opposite ways to those of women. If women “act in” their feelings, men “act out.” Thus Kilmartin (2005) suggests that, diagnostically, male symptoms of depression should include the following:

  • Bad temper
  • Aggression
  • Substance abuse
  • Physical and sexual risk-taking
  • Emotional numbness
  • Over-involvement in work or sports or both
  • Impoverished friendships

It was because symptoms like those noted above were not included in standard depression scales that I developed the Diamond Male Depression Scale (DMDS) to supplement other scales in common use.

The Diamond Male Depression Scale

The Diamond research study was designed to clarify the theoretical constructs related to depression and to see which symptoms are most predictive of depression and suicide risk as well as which symptoms most distinguish depressed men from depressed women. A summary of the research findings can be seen here.

Study Population

A total of 1072 individuals (323 females and 749 males) filled out the Diamond Male Depression Scale (DMDS) questionnaire. Ages ranged from 18 to 80 with a mean age of 51. Most respondents were from the United States, but people responded from a total of 45 countries. Previous research indicated that men, particularly depressed men, would be less likely to respond than women, so a specific effort was made to reach out to that group.

In addition to the author’s website,, announcements were sent out through (a site for people interested in depression and bipolar disorder) and (a site focused on depression and men). The sample was predominantly older, male, married, employed, white, educated, and living in the United States. There was considerable reporting of psychiatric illness in the participants and their families.

Data Collection Tools

The Diamond Male Depression Scale questionnaire was administered online to a population of men and women. The questionnaire had seven sections. The first included demographic information on age, sex, marital status, relationship happiness, children, race, employment, income, education, and veteran status. Additional information was sought in this section on whether the subjects had been diagnosed with a depressive illness or other common mental illnesses and whether family members had been so diagnosed.

The second section presented 51 questions that included atypical symptoms thought to be associated with male-type depression. The selection of questions was based on clinical experience of the author over the past forty years as well as previous research focused on atypical symptoms thought to be more common in males than females (Cochran and Rabinowitz, 2000; Kilmartin, 2005; Lynch and Kilmartin, 1999; Real, 1997; Rutz, 1999).

The third section contained the 20-question Center for Epidemiologic Studies Depression Screen (CES-D) mentioned earlier. The fourth section focused on suicidal ideation and intent and included four questions taken from the Beck Hopelessness Scale as well as two questions that asked directly about suicidal ideation and intent.

The fifth section addressed issues surrounding the drinking of alcoholic beverages. It contained the four questions from the CAGE scale assessing alcohol abuse and one question that asked about the quantity of alcohol consumed. The sixth section asked about possible co-morbidities, including a number of physical illnesses and medications thought to be associated with depression. The seventh section included the questions from the Gotland Male Depression Scale.

To read more about the Diamond Male Depression Scale, click here.

DMDS and Its Subscales

Three subscales were identified and then correlated with the CES-D depression scale.

Sub-Scale 1: Emotional Acting-In Depression

This scale focused on feeling negative, stressed, empty, and other internal expressions of depression and included the following items from the full 51-item questionnaire:

  • d28 I feel I’d like to get away from it all.
  • d34 I feel that things are stacked against me.
  • d35 People I count on disappoint me.
  • d36 I feel stressed out.
  • d40 I feel emotionally numb and closed down.
  • d41 I feel hopeless about the future.
  • d42 I feel powerless to improve things in my life.
  • d43 I feel my life has little worth or value.
  • d44 I have little interest or pleasure in doing things.
  • d45 I find I am complaining about things in my life.
  • d46 I feel sorry for myself.
  • d48 I feel burned out.
  • d49 I feel empty inside.
  • d50 I feel tired even when there is no reason to be so.
  • d51 I have difficulty making everyday decisions.

Sub-Scale 2: Emotional Acting-Out Depression

This scale focused on such things as being difficult, irritable, angry, and other external emotional expressions of depression and included the following items from the full 51-item questionnaire:

  • d1 I flare up quickly.
  • d2 I have trouble controlling my temper.
  • d22 I am easily annoyed, become grumpy, or impatient.
  • d27 Other people “drive me up the wall.”
  • d29 When others disagree with me I get very upset.
  • d37 It doesn’t take much to set me off.
  • d38 I have difficulty maintaining self-control.

Sub-Scale 3: Physical Acting-Out Depression

This scale focused on such things as violence, gambling, alcohol abuse, and other external, physical expressions of depression and included the following items from the full 51-item questionnaire.

  • d4 I have hit someone when I was provoked.
  • d8 I work longer hours because going home is stressful.
  • d10 I gamble with money I have set aside for other things.
  • d11 I drive fast or recklessly as a way of letting off steam.
  • d12 If I’m feeling low, I’ll use sex as a pick me up.
  • d23 I have felt I should cut down on my drinking or drug use.
  • d30 I feel like picking a fight with someone.
  • d31 I get so jealous or possessive I feel like I could explode.

Gender, Depression, and Suicide Risk

All three sub-scales were significantly correlated with the traditional CES-D depression scale, indicating that they are, in fact, measuring aspects of depression:

  • Scale 3, Physical Acting-Out, showed significant gender differences between depressed males and depressed females.
  • Scale 1, Emotional Acting-In and Scale 2, Emotional Acting-Out, also showed differences between depressed men and women, but not as significantly as with Scale 3.
  • Even non-depressed men and women showed significant differences in how they responded to items on Scale 3. This is important since it allows clinicians to assess possible danger for men even before symptoms get serious enough to be labeled as “depression.”
  • Scale 1, Emotional Acting-In showed a significant positive relationship with suicide risk, showing that it is a useful scale to examine suicide risk potential.
  • Increasingly, there was a negative relationship between Scale 2, Emotional Acting-Out, Scale 3, Physical Acting-Out, and suicide risk.

We could argue that “acting out” might be an alternate way of killing oneself so that those who use those methods may be “killing themselves slowly.” A number of clinical researchers (Kilmartin, 2005; Lynch and Kilmartin, 1999; Real, 1997; Rutz, 1999) have suggested that “acting out” in behaviors such as drinking too much, anger, and aggression may be ways in which some people express their hopelessness.

The present study suggests that the theoretical construct of a “male depressive syndrome” is valid. Further, it offers an expanded conceptual framework as to what symptoms should be included and includes the development of three subscales to more accurately describe such a syndrome. Future research should be directed at developing studies to validate the scales and to develop scores for levels of risk for depression.

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