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Men and Depression: Screening and Treatment in Primary Care Settings

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Depression in Men

Approximately twelve percent of the patients seen by a primary care physician have major depression.  Recognizing that these patients-particularly male patients-have depression may be difficult as they usually describe symptoms such as fatigue, sleep problems, headaches, unspecified pain, or other vague symptoms. Other medical conditions may also be present and have similar symptoms, thus contributing to the failure to treat depression.  In addition, the rate of depression secondary to some other disorder is high.  Not only can depression co-occur with substance abuse, anxiety disorders or personality disorders, but is also seen with heart disease, diabetes, and many other illnesses.  Depression can be a risk factor for other illnesses, can impair the ability to participate in treatment, or can be stimulated by the stress of such illnesses. Treatment (Live link to diagnostic evaluation and treatment section of booklet.) of depression in all of these situations can benefit the patient.

Although depression is diagnosed more often in women, there is increasing awareness that men are commonly affected but may deny or minimize symptoms.

However, the degree of suffering of these undiagnosed depressed men is real and comparable to that of any other medical condition.  Recognizing the symptoms of depression and making certain that the patient receives adequate, effective treatment and appropriate referral can be rewarding both to the patient and the primary care physician.

Signs, Symptoms, and Screening for Depression

To assure that the patient who has depression is diagnosed and receives appropriate treatment, the U.S. Preventive Services Task Force (USPSTF) has issued new depression screening recommendations  encouraging primary care physicians to routinely screen their adult patients for depression.  If younger patients show signs of depression, screening is also recommended for them.
 
Simple screening questions can detect about half of depressed patients in clinical care settings.  A "yes" response to the following two questions will detect major depression: 

  • "Over the past two weeks, have you felt down, depressed, or hopeless?"
  • "Have you felt little interest or pleasure in doing things?1

If the patient says, "yes" to these two questions, to be diagnosed as having major depression, he or she should have at least four of the following additional symptoms:

  • Significant weight loss or gain, or decrease or increase in appetite
  • Disturbances in sleep patter
  • Noticeable agitation or slowness
  • Fatigue or loss of energy
  • Inappropriate feelings of worthlessness or guilt
  • Diminished ability to concentrate or make decisions
  • Recurrent thoughts of death or suicide.

These symptoms must persist for at least two weeks and must be accompanied by noticeable impairment in social relationships and work functioning.  A patient with minor depression would have two to four of these symptoms and would find it difficult to appear to function normally.1  Other indications of depression you might look for in your patient are:

  • Family predisposition to depression
  • Previous history of psychiatric disorder
  • Two or more chronic diseases
  • Stressful home or work environment
  • Multiple vague symptoms, aches and pains
  • Loss of interest in sexual activity
  • Older adult

If depression is indicated by the patient's answers, a thorough physical examination to rule out other causes of the depressive symptoms should be the next step.  Certain medications as well as some medical conditions such as a viral infection,  hypothyroidism, or low testosterone level can cause the same symptoms as depression, and the physician should rule out these possibilities through examination, interview, and lab tests.  If no such cause of the depressive symptoms is found, a psychological evaluation should be done.  This can include any one of several depression measurement scales.  Choice of a scale should be based on personal preference and ease of use.  Some depression scales suitable for use in evaluating men are the PRIME-MD (American Academy of Family Physicians), the Beck Depression Inventory, the Center for Epidemiological Studies-Depression (CES-D), and the Zung Depression Rating Scale. PRIME-MD offers evaluations of all these screening instruments.2  If more information is needed, go to one of the Internet search engines and type in the name of the scale. 

These questionnaires can be completed by the patient or through an interview with the physician or other health professional such as a nurse practitioner or physician's assistant.  Most scales can be completed in 5 to 10 minutes.

Additional Considerations When Screening for Depression

 Some people with symptoms of depression have in the past had episodes of increased energy and activity with inability to relax or sleep.  Sometimes they describe these periods as "highs."  Sometimes they describe a depression that "comes and goes."  There is a possibility that they have bipolar disorder instead of unipolar depression.  In such a case, a referral to a mental health professional should be considered.  A patient who has bipolar disorder should first be prescribed a mood stabilizing medication.  Then, if an antidepressant is needed, it can be given in addition.  An antidepressant taken without a mood stabilizer can cause a swing into mania.
 
 The patient may have been "self-medicating" with alcohol or other substances of abuse. Alcohol or other substance use could also be contributing to the individual's depression.  The physician should consider whether specific interventions directed to substance abuse might be indicated in addition to the treatment of depression.

 The patient may have other medical conditions  requiring medications (e.g., diabetes, glaucoma, hypertension, coronary heart disease, cancer, etc.) to be considered in both diagnosis and treatment.

Treatment Options

The patient who has just been diagnosed with depression should be reassured that depression is common and can be successfully treated with careful collaboration between doctor and patient.  A discussion of treatment programs will help the patient to understand his own role in the treatment process.  Depression can be treated with medication, psychotherapy ("talk therapy"), or a combination of the two.  Unless the depression is minor, therapy is usually begun with an antidepressant medication.  A description of medications used in the treatment of depression can be found at the National Institute of Mental Health (NIMH) Web site.

If psychotherapy is indicated, you will probably want to refer him to a mental health professional who works with one of the common types of psychotherapy.  New "talk therapies" are often relatively brief, 6 weeks to a few months.  Group therapy may be helpful as well. 

A therapy often used today is cognitive/behavioral therapy in which a primary focus is in changing negative styles of thinking. This often involves "homework" assignments between sessions.  Another type of therapy is interpersonal psychotherapy , which focuses on the patient's disturbed personal relationships that may cause or increase depressive symptoms.

If the patient is interested in participating in a clinical trial for depression, there is information available on the NIMH web page and at www.clinicaltrials.gov .

In discussing medication with the patient, impress upon him that:

  • As a doctor, you need to know all medications, both prescribed and over-the-counter, vitamins, minerals, and herbal supplements being taken at present.
  • You also need to be told of the use of alcohol and other substances.
  • It usually takes several weeks to receive the full therapeutic benefit of the medication.  Even if the patient feels better, he should stay on the medication until you mutually agree it is no longer needed, usually at least 4 to 9 months.
  • The patient should never quit taking medication "cold turkey." 
  • It is best for you as the doctor, together with the patient, to work out a schedule of gradually discontinuing the medication.
  • The "patient information inserts" that come with the medications are important and should be read.  They will list possible side effects to look for.
  • Side effects, even if they are very short-term, should be reported to you. Persistent sexual side effects should be reported.  Such side effects are common during treatment with many but not all antidepressants, and will be a concern for many men.  These can be reduced with changes in type or dosage of antidepressant medication, or, in some cases, the addition of other medications. 
  • A regular schedule of contacts or appointments should be made and adhered to.
      
    References

1. United States Preventive Services Task Force.  Screening for depression:  recommendations and rationale. Annals of Internal Medicine, 2002; 136: 760-4. 
2. Sharp LK, Lipsky MS.  Screening for depression across the lifespan:  A review of measures for use in primary care settings.  American Family Physician, 2002; 66(6): 1001-8.