ReviewThe role of masculinity in men's help-seeking for depression: A systematic review
Introduction
Whilst the prevalence of major depressive disorder continues to rise, making it the leading cause of disability worldwide, depression rates in men are consistently found to be nearly half those of women (Ivancic et al., 2014, Kessler et al., 2005, World Health Organization, 2008). Importantly, the lower rates of male depression don't reflect better mental health compared to females given that men exhibit significantly higher rates of substance use and physical violence (Harrison et al., 2004, Martin et al., 2013) and account for three-quarters of suicides in western countries (Australian Bureau of Statistics, 2015, Centers for Disease Control and Prevention, 2013).
It has been proposed that men's conformity to traditional masculine norms such as stoicism, self-reliance and restrictive emotionality, which stem from dominant models of male socialisation in the Western World (Pleck, 1995), is tied to the lower rates of depression diagnoses often seen in men (Addis and Mahalik, 2003, Mahalik and Rochlen, 2006). However, this discrepancy in rates of diagnosis might be better interpreted by considering reticence for help seeking, since effective diagnosis is wholly dependent upon initial presentation by men to available health services. Among men, high conformity to traditional masculine norms has been correlated with less help-seeking behaviour and more negative attitudes toward seeking psychological treatments (Levant, Wimer, & Williams, 2011), with men repeatedly found to be half as likely to seek help for mental health concerns from a GP or mental health professional compared with women (Addis and Mahalik, 2003, Judd et al., 2008). This finding is consistent across countries, racial and ethnic groups and throughout the lifespan (Addis & Mahalik, 2003). Galdas, Cheater & Marshall (2005) call for further investigation into this help-seeking gap, rightly suggesting that a richer understanding of this male behavioural pattern will guide practitioners to improve their understanding, diagnosis and treatment of men.
Addis (2008) suggests that the relative ‘invisibility’ of the gendered nature of men's mental health in the existing literature has left the field devoid of theoretically-based insight, resulting in consistent negative outcomes for the wider community. His critical examination of four contrasting frameworks underpinning gender and depression in men highlights the lack of a unifying conceptual framework, but is an initial step toward greater precision in the empirical research. These frameworks encompass comparative sex differences, the perspective that men ‘mask’ their symptoms and experiences of depression, the effects of gendered socialisation on symptom expression, and how men respond to negative affect in general. When combined, these frameworks serve to elucidate reasons men often deny illness, suppress negative affect and exhaust internal psychological and physical resources to avoid admitting depressive symptoms, waiting until late in the illness trajectory before seeking help (Oliffe & Phillips, 2008). Good and Wood (1995) termed this impact of masculinity double jeopardy, suggesting some men were at risk for psychological distress amid being unlikely to seek help for their problems.
The process of help-seeking does not solely encompass the initial act of seeking help, but additionally involves the features and patient experience of the consultation and treatment[s] that takes place thereafter. The effects of conformity to traditional masculine norms often extend to therapy, and are labelled ‘therapy interfering processes’; these chiefly include significant fear of coercion and stigma, leading to difficulties with attendance, engagement and an unstable therapeutic alliance (Englar-Carlson, 2006, Richards and Bedi, 2015, Spendelow, 2015). Whilst recognition of mental illness and treatment options have increased recently following large-scale awareness campaigns including ‘Real Men, Real Depression’ in the United States, (Rochlen, Whilde & Hoyer, 2005) it appears that a help-seeking gap remains for men experiencing depressive symptoms, with clinicians, researchers and policy makers alike attempting to shift, counteract, and challenge the essentialist perspective that psychotherapy and masculinity are diametrically opposed (Meth, 1990, Eckert et al., 2010, Jorm et al., 2006).
A common theme throughout the existing literature is a reductionist emphasis on traditional masculinity as a pathology or deficit when considered in the context of mental health. It is important to note that this empirical trend is at odds with the social constructionist theories of multiple masculinities, which are fluid, relational and may co-exist (e.g., Connell, 1995). However, as Kiselica and Englar-Carlson (2010) postulate, it has become customary for researchers and clinicians to target pathology and what is “wrong” with men in order to address these issues, rather than to emphasise the positive aspects of being a man in order to advance male-centred healthcare. It is important to note that the wealth of existing data on this issue is not inaccurate, but rather incomplete (Englar-Carlson & Kiselica, 2013). Traditional masculinity is therefore interpreted as a valid but singular representation within a ‘constellation’ of masculinities; in proposing their Positive Psychology/Positive Masculinity model (PPPM), Kiselica and Englar-Carlson (2010) highlighted the need to bridge these deficit models and take a strength-based approach in understanding and effectively treating men's mental illness.
Poor mental health outcomes in men are problematic for individuals and society, with functional impairment and/or premature death often-occurring at the most economically productive time of men's lives (Möller-Leimkühler, 2002). Reticence for help-seeking is also linked to lower socio-economic status and resistance to help-seeking can be further heightened as depressive symptom severity increases. In turn, social and cognitive disability following depression is increased in the aftermath of such inaction (Scott & Collings, 2010). Despite the importance of increasing help-seeking for depression among men, to date there has been no systematic review of existing research in the area. As such, it appears that help-seeking, considered as a process which includes pathways into the healthcare system as well as the assessment and treatment of symptoms, is a broad but suitable starting point to explore the effect of masculinities on men's depression in a systematic evaluation of the literature. Within a field as rapidly evolving as that of men's depression, there is the threat for particular theories and studies to dominate and lead to a stagnant, empirical homogeneity. Therefore, the aim of this review was to rigorously collate and present findings from the existing literature related to the role of masculinity on men's help-seeking for depression and provide recommendations for future work in the area.
Section snippets
Data sources and search strategy
The current article adheres to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Moher, Liberati, Tetzlaff & Altman, 2009; See supplementary file 1). Both qualitative and quantitative studies were identified through six electronic databases searched in August 2015 (MEDLINE, PsycINFO, SCOPUS, CINAHL, Web of Science and Proquest Central). A search strategy was iteratively devised for use with MEDLINE and adapted for other databases with no date or language
Results
The aforementioned search strategy generated 1696 references. Among these, 49 potentially relevant abstracts were identified. Following review of the full-text of these articles, 37 eligible articles remained. Fig. 1 presents the PRISMA flow diagram for the selection process of included studies.
Discussion
Provided in the current review is a much-needed synthesis of the existing research investigating the relationship between masculinity and help-seeking in men with depression. Whilst it is broad, the existing research reflects an emerging field of empirical enquiry with an extensive qualitative basis but a limited number of longitudinal or interventional studies. Our review provides a comprehensive summary of available evidence, both qualitative and quantitative, to interpret current
Conclusions
Overall, our results demonstrate the negative impact of adherence to traditional masculine norms on the way men experience and seek help for depression. Findings suggest that tailoring standard clinical interventions for men may increase the uptake, adherence and efficacy of treatment. Specifically, behavioural interventions such as CBT may be targeted toward men's strengths, offering problem-solving tools to promote and sustain behavioural changes long-term. Future research, which should
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
ZES and AJD developed and performed searches, screened results, retrieved papers and abstracted data. ZES performed data synthesis and wrote the manuscript. HD and SR assisted in data extraction, synthesis and review of the manuscript. JO reviewed and edited the manuscript analysis and discussion. All authors contributed to the review design, participated in the interpretation of the data and gave approval of the final version to be published.
References (70)
Suicidal action, emotional expression, and the performance of masculinities
Social Science & Medicine (1982)
(2012)- et al.
Looking for Mr. PG: Masculinities and men’s depression in a northern resource-based Canadian community
Health & Place
(2013) - et al.
Men’s accounts of depression: Reconstructing or resisting hegemonic masculinity?
Social Science & Medicine (1982)
(2006) - et al.
Men’s use of positive strategies for preventing and managing depression: A qualitative investigation
Journal of Affective Disorders
(2015) - et al.
Gender disparities in the treatment of late-life depression: Qualitative and quantitative findings from the IMPACT trial
The American Journal of Geriatric Psychiatry
(2006) - et al.
An empirical test of a mediation model of the impact of the traditional male gender role on suicidal behavior in men
Journal of Affective Disorders
(2008) Barriers to help-seeking by men: A review of sociocultural and clinical literature with particular reference to depression
Journal of Affective Disorders
(2002)- et al.
Men, depression and masculinities: A review and recommendations
Journal of Men’s Health
(2008) - et al.
The men’s stress workshop: A gender-sensitive treatment for depressed men
Cognitive and Behavioral Practice
(2010) - et al.
Development and preliminary validation of the male depression risk scale: Furthering the assessment of depression in men
Journal of Affective Disorders
(2013)
Gender and the association between mental disorders and disability
Journal of Affective Disorders
Gender and depression in men
Clinical Psychology: Science and Practice
Men, masculinity, and the contexts of help seeking
The American Psychologist
Geschlectsuntershiede in der Psychiatrie
Causes of Death, Australia, 2013. Catalogue No. 3303.0
Men’s reactions to mental health labels, forms of help-seeking, and sources of help-seeking advice
Psychology of Men & Masculinity
Psychological distress, masculinity ideology, and self-threat: A model of men’s attitudes toward help seeking
Male-friendly psychotherapy for boys and men
Detecting depression in men: A matter of guesswork
International Journal of Men’s Health
For men only’: a prompt list pre-test in primary care
Australian Family Physician
Web-based Injury Statistics Query and Reporting System (WISQARS)
A qualitative investigation of depression in men
Psychology of Men & Masculinity
Masculinities
Analysing Data and Undertaking Meta-Analyses
Changes in depression-related mental health literacy in young men from rural and urban South Australia
The Australian Journal of Rural Health
Exploring men’s and women's experiences of depression and engagement with health professionals: More similarities than differences? A qualitative interview study
BMC Family Practice
Masculine norms and the therapy process
Affirming the strengths in men: A positive masculinity approach to assisting male clients
Journal of Counseling & Development
Men and health help-seeking behaviour: Literature review
Journal of Advanced Nursing
Male gender role conflict, depression, and help seeking: Do college men face double jeopardy?
Journal of Counseling and Development
Men’s help seeking for depression: The efficacy of a male-sensitive brochure about counseling
The Counseling Psychologist
The rates and management of psychological problems in Australian general practice
Australian and New Zealand journal of psychiatry
The male experience of depression
Perspectives in Psychiatric Care
Rodeo cowboys: Conforming to masculine norms and help-seeking behaviors for depression
Journal of Rural Mental Health
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