A man's stereotypical self-image as the "strong, silent type" and the stigma of depression are major reasons why older men are less likely than women to be referred to studies of depression, to seek treatment for depression, and to recognize and express symptoms of depression, according to clinicians and recruiters interviewed for a new study from the UC Davis Department of Psychiatry and Behavioral Sciences.

The study provides some of the strongest evidence to date that depressed older men are less likely than women to receive treatment for their depression, underscoring the importance of these barriers.

Among some older men, the study found, traditional views of masculinity and the stigma associated with mental illness lead to a tendency to reject a diagnosis of depression, and to conceal or mask symptoms of the condition. Authored by associate professor of psychiatry Ladson Hinton, the study appears in the October 2006 edition of the American Journal of Geriatric Psychiatry. The study contributes further evidence to gender disparities in depression care documented in previous studies, and identifies reasons for these disparities.

Higher suicide rates

The findings are important in the arena of public health because of depression's association with suicide in older adults. Older men have higher rates of completed suicide: 31.8 per 100,000 in men age 65 and older, compared with 4.1 per 100,000 in older women. The reasons for gender disparities in depression care among older adults are poorly understood, the study states.

Among the reasons found in prior research are more negative attitudes among men toward seeking help for mental health problems, lower disclosure rates of depressive symptoms, lower rates of health service use, and more "atypical" presentations of depression. However, the problem of under-treatment in older men has received little focused attention.

For their study, Hinton and his research team examined the data from a large, multisite study of a disease management program for late-life depression in primary care, called IMPACT (Improving Mood: Providing Access to Collaborative Treatment for Depression). The IMPACT participants were 1,800 adults 60 and older with major depression or dysthymic disorder from 18 primary care clinics, affiliated with eight health-care organizations in the United States.

The UC Davis researchers analyzed gender differences in history of depression treatment, as well as referral rates and symptoms. To better understand lower rates of depression treatment and referral to IMPACT of older men, the researchers also conducted qualitative interviews with 30 key individuals connected to IMPACT, including referring physicians, depression care managers and study recruiters, to learn about the challenges in recruiting and treating depressed older men.

Hinton and his team found that, compared with older women, older men were much less likely to be referred to IMPACT, to recognize and describe symptoms of depression, and to have received prior treatment for depression. The interviews identified factors that were important contributors to the gender disparities: the manner in which men experience and express their depression, traditional masculine values, and the stigma of depression.

'Mask their depression'

The IMPACT interviewees reported that older men experience and express their depression in ways that do not fit well with diagnostic criteria, making a diagnosis more difficult. Some of the IMPACT principals speculated that older men "might have more difficulty accessing and recognizing their feelings," while others believed men were "actively trying to conceal or mask their depression." For example, one primary care provider, when asked if men present their depression differently than women, said, "They try to hide it, basically, whereas women are more open and they come and talk … because it is their nature for some reason."

"Because older men tend not to endorse depressed mood or sadness, they were often felt to be more reluctant to accept the diagnosis of depression and the treatment recommendations," states the

UC Davis study.

'John Wayne'

Older men often described as "old school" or the "John Wayne type" were considered difficult to diagnose and treat "because they perceived the cultural meaning of depression to be in conflict with their own view of themselves as men," the study says. It noted that "clinicians made a direct connection between more traditional views of masculinity and difficulties with diagnosis and referral to specialty mental health."

One of the IMPACT clinicians said that in her view, "'giving up' these core masculine views … was an important step in the treatment process." Another physician reported that some older men "just do not think that tough guys go talk to psychologists or psychiatrists, and fool around with that type of monkey business."

The association of depression with severe mental illness, or "craziness," was another barrier to care, although it was cited less frequently than the other obstacles. One depression care manager cited stigma to explain the greater tendency of men to express their depression in physical rather than emotional terms. The manager said, "They will not say, 'I feel sad' or 'I feel depressed.' They'll say, 'I have a stomacache.'" A primary care physician described a depressed and psychotic older man who was expressing suicidal thoughts, but nevertheless was unwilling to see a psychiatrist because he feared it would "mark him as crazy."

Hinton and his team state that their findings suggest future avenues for education and intervention for older men with depression. When dealing with more traditional older depressed men, clinicians may need to tailor standard educational approaches to directly address the attitudinal barriers identified in the UC Davis study. One such initial approach might be to de-emphasize professional labels and place more emphasis on symptoms and sources of stress. Health care providers interviewed by the UC Davis researchers suggested other strategies, such as using an open-ended interview style, using less direct or clinical (i.e., threatening) language to discuss depression, and involving family in all phases of treatment.

More study needed

The researchers acknowledge that their study "should be considered as exploratory and hypothesis-generating because of the modest number of interviews conducted." An expanded study "with a more representative sample of clinicians and patients would be likely to deepen our understanding" of the themes identified in the study, and to identify other important factors.

"The public health importance of improving care for depression among older men is clear," the study states. "Older men experience higher rates of completed suicide than any other age and gender group. Because depression is one of the most important suicide risk factors, elucidating gender-specific aspects of depression care has the potential to reduce this disparity, close the gender gap in depression treatment, and lessen the enormous burden of suffering for older adults and their families."

The second author on the study was Mark Zweifach, a psychiatrist from Kaiser Permanente, Southern California. Other collaborators on the study were Sabine Oishi and Lingqui Tang, both from UCLA; and Jurgen Unutzer, from the University of Washington. The study was funded by the John A. Hartford Foundation and the National Institute on Aging.

The American Journal of Geriatric Psychiatry can be found online at www.AJGPonline.org.

David Ong is a senior public information officer for the UC Davis Health System.