So Tough It Hurts

Henry T.'s life was never easy—he'd always had trouble getting close to people, and he depended on alcohol to take the edge off his loneliness. Throughout middle age, Henry endured bouts of the blues, though he always bounced back after a few months. Following retirement from his job as a graphic designer, however, Henry, now 68, experienced his worst depression ever. In the dead of one New York State winter, he stopped going out, stopped shaving, stopped washing. Many nights he couldn't sleep. His appetite vanished, and he shed 25 pounds.

By the summer of 2004, Henry's depression had become so deep that relatives in his hometown of Pittsburgh, fearing he might take his own life, convinced him to move back home. At the urging of a worried cousin, Henry reluctantly agreed to see Charles F. Reynolds III, M.D., director of the late-life mood-disorders center at the University of Pittsburgh Medical Center (UPMC).

With this decision Henry took the first—and most difficult—step toward reclaiming his life.

Though depression is a disease that afflicts both genders, a growing number of researchers believe men bear unique burdens that make it much harder for them to get treatment. For one thing, women suffering the disease tend to acknowledge their pain and seek help. Men—particularly older ones—don't.

The Road to Wellville

20: Percentage of men over 50 estimated to have depression or chronic low mood

30: Percentage of men with depression who seek treatment for their condition

90: Percentage of men treated for depression whose condition is significantly relieved

"It's not considered unwomanly to be emotional and vulnerable, but a real man would never be so 'weak' as to let his emotions get the best of him," laments therapist Terrence Real, best-selling author of I Don't Want to Talk About It: Overcoming the Secret Legacy of Male Depression (Scribner, 1997). "There's a lot of shame involved, and this sets up what I call compound depression—a man gets depressed about being depressed."

Epidemiologists estimate that up to 10 percent of the patients over 50 seen in primary care settings suffer major depression like Henry's. If you add in dysthymia—a less severe form of chronic low mood—this figure jumps to 20 percent. Though no one has an exact count, even the most conservative estimates hint at an epidemic. It's probable that 10 million or more older Americans are enduring this torment.

Even worse: their suffering is largely unnecessary. New treatments for late-life depression can restore hope and even joy to most patients. "Depression is one of psychiatry's great success stories, and study after study shows that 90 percent of men who receive help get significant relief," says Real. "Unfortunately, somewhere between 60 to 80 percent of depressed men never get the treatment they need. And that is a heartbreaker."

At 8:00 a.m. on a gray winter morning, Henry arrived at a psychiatric research lab on the campus of the UPMC. A technician led him to a gurney and inserted an IV line into a vein in his elbow crook. Within minutes a solution of radioactive sugar molecules was wending its way through Henry's circulatory system en route to his brain.

The tech slid the gurney forward, centering Henry's head inside a PET scanner. Over the next hour the machine collected data on the metabolic activity of Henry's brain.

Later that afternoon a computer finished reconstructing Henry's data into a multicolored picture of a mind in agony. To a lay observer, the image looked like a metaphor for hell itself: flickering orange flames on his brain's convoluted fringes giving way to a singeing white heat in its dead center.

"This shows direct evidence of a sick brain," said Reynolds. "Henry's scan clearly indicates that the specific areas of his brain involved with mood have shifted into overdrive."

Such images support a radical change in the way doctors understand depression. As recently as the 1970s, many psychiatrists still considered the condition purely psychological, the consequence of faulty toilet training or similarly nonsensical causes.

Today, aided by state-of-the art scanning techniques and an explosion of insights into genetics, neurotransmitter systems, and synaptic wiring, the true picture of the disease has changed utterly. Depression is now understood as a physical illness of the brain.

Still, diagnosing the disease—especially in older men—can be tricky. Even if men are willing to discuss their feelings with a doctor, they may lack the vocabulary. "They'll just say they feel lousy—they're not sleeping well, food doesn't taste right, they're not having any fun, they can't concentrate," says Barry Lebowitz, Ph.D., deputy director of the Stein Institute for Research on Aging at the University of California, San Diego. "They end up endorsing every single symptom of depression except for one, which is sadness. In older guys, we now know depression often exists strictly in bodily perceptions."

This pattern is so common that it's even got an unofficial nickname among those who treat it: "depression without sadness." Experts in the phenomenon are not yet sure if victims truly don't feel sad—or if they simply lack the insight to articulate their feelings.

Therapist Real suspects that many afflicted men try to numb their pain with drinking, compulsive gambling, uncontrolled sexuality, or temper tantrums. "For such men, the experience of depression is not about feeling bad so much as about losing the capacity to feel at all," he says.

Real calls such behaviors "an addictive defense." Patrick McCathern knows the pattern all too well. A spokesperson for the National Institute of Mental Health (NIMH) Real Men/Real Depression Campaign, McCathern spent years attempting to distract himself from his own dark moods by relying on male stoicism, workaholism, and social withdrawal. When his wife finally divorced him, his mood spiraled so far out of control that he found himself turning to alcohol.

"Prior to that severe depression," McCathern says, "I barely ever drank. But when my depression set in, I found myself having a couple beers a day, and pretty soon it was six or eight followed by a bottle of Jägermeister."

McCathern says he understood that such self-medication was hurting him, yet he couldn't avoid being seduced by the short-lived relief he found in a bottle. "You don't want to drink, but it's a hard thing not to," he notes.

For men whose depression is complicated by substance abuse, the odds skyrocket for what is arguably the biggest difference between male and female versions of the disease: suicide completion rates. NIMH data suggest that women attempt suicide three times more often than men do, often as a cry for help, but men are four times more likely to finish the job. The single highest suicide completion rate for any demographic group in the United States is older white males. By age 85 men are more than ten times as likely as women to kill themselves.

McCathern, a retired Air Force sergeant, came within seconds of becoming just such a statistic. In a moment he now describes as the darkest of his life, he draped a noose over his bathroom door, placed his neck inside it, and slumped forward. "I was maybe 20 seconds away from passing out when one of my dogs walked in," says McCathern. "I was beyond caring what my friends or family might think. I felt so worthless and guilty, I didn't think I deserved to be consuming oxygen on the planet anymore.

"But when my dog looked up at me with his bright beagle eyes, it was like he was saying, 'What about us? We love you.' It occurred to me that if I died, who'd get my dogs water and feed them? I'd be ending my pain—but just starting the suffering for them."

McCathern removed the noose and dialed his only remaining friend. She drove him to the local ER—the first step in a long but ultimately successful journey back from the brink.

Though depression can strike at any time of life, it hits older men with a particular vengeance. "A lot of big stuff comes at men when they grow older," Reynolds explains.

Retirement Those who have derived their main sense of identity and self-esteem from careers can suddenly find themselves feeling purposeless.

Bereavement Losing a spouse is an important risk factor for depression, with roughly one in five of those widowed developing the disease in the first year. Men are especially vulnerable, because they tend to have fewer close friends to lean on than women do.

Disability Cardiovascular diseases, including heart attacks and strokes; chronic pain from osteoarthritis or lower-back injuries; insomnia; and other medical conditions common with age can all precipitate depression.

The exact mechanism has not yet been nailed down, Lebowitz says, but it looks likely that depression following sudden disability has both a psychological component (that is, it's depressing to lose the ability, say, to move or speak normally) and a neuroanatomical component (injury to specific brain regions can directly dampen mood).

Once disability triggers depression, the two conditions can feed off each other, though it doesn't have to be this way. A March 2005 study published in the Journal of the American Geriatrics Society showed that treating an older man's depression often translates into significant improvements in his physical health and functioning, as well.

The first step to getting a misfiring brain back in shape is a search for physical conditions that might be contributing to the problem. Certain medications—such as beta-blockers, used to treat high blood pressure—may send susceptible men into a serious slide. A simple change in medication can frequently eliminate the problem—as can monthly shots of vitamin B12 for patients whose blood tests low for this vital compound.

Usually, however, restoring long-term emotional well-being depends upon a more intensive, multipronged attack, particularly when the depression is complicated by addictions. "Part of my bread and butter these days," says Real, "is educating mental health professionals that traditional therapy by itself is often ineffective for male depression. You can't help a guy unless you first get him to attend to the fact that he's drinking a six-pack a day."

With a treatment plan in place for addictions and other conditions contributing to the depression, physicians can also work directly on lifting the mood itself. There are two main strategies for this, frequently applied in tandem: medicine and psychotherapy.

Medications Though many older men are dead set against antidepressant drugs such as Prozac or Wellbutrin—convinced that taking medicine means they're "crazy" or they'll get "hooked"—the truth is, modern medications have proven highly effective. Neither mind-altering nor addictive, they work over time to restore a normal chemical balance in the brain.

But drug treatment has its downsides. For one thing, the first drug tried usually works in only about 50 to 60 percent of cases. It also takes a minimum of four to six weeks before the drug's full effects kick in.

If the first drug doesn't work, there's no reason to despair. Often the second or third drug will do the trick. In the case of Tom Johnson, former CEO of CNN, it was not until his doctor tried a fifth medication that he finally found relief. "I know that what works for me does not necessarily work for another person," he says, "but I feel I owe my life to my doctor and the drug Effexor."

Another drawback, especially with older patients, is the potential for side effects, from sleep disturbance and nervousness to nausea and erectile difficulties. Not everyone gets these, and often they abate over time, but a change in drugs can resolve troublesome side effects.

Psychotherapy As effective as medication can be, there's another remarkably potent treatment: psychotherapy, a.k.a. the talking cure. And today's short-term, science-backed therapies have little in common with the lengthy, sometimes counterproductive Freudian probings of yore.

Three specific forms of therapy, in particular, are proven approaches that quickly give patients the tools to lift their moods. The treatments are cognitive-behavioral therapy, or CBT, which teaches how to recognize and successfully counter the negative thinking that fuels depression; interpersonal therapy, or IPT, which fosters better communication and conflict-resolution skills; and problem-solving therapy, which teaches ways of breaking down problems into manageable units that can be tackled one at a time.

All three approaches usually require 10 to 16 weekly sessions. Men receive practical advice and homework assignments to cement the skills. For many, this directive aspect has great appeal. "There are a lot of pluses to the traditional male role," says Real. "Men are not averse to hard work. Once you get the guy on board with these therapies, usually you've got a draft horse who is ready to pull and go the distance."

Future help For those few whose depression resists treatment, other therapies are on the way. One of the most promising is deep brain stimulation, or DBS, which is akin to placing a pacemaker in a key area of the brain. In a pilot study in the journal Neuron, researchers from Emory University in Atlanta and the University of Toronto reported that several patients spontaneously described, at the exact moment electrical stimulation was applied, a "sudden calmness" and a "disappearance of the void."

Following Henry's initial PET scan, Reynolds prescribed an antidepressant medication and a 16-week course of interpersonal therapy. Within several months Henry's symptoms lifted entirely, at which point he returned to the lab for a follow-up brain scan. This showed the improvement wasn't merely subjective.

"For two years," says Henry today, "I was so depressed and afraid that I could barely leave my house. Now, my true personality is back. I go out all the time, and I'm even considering starting a new career. My advice to other depressed men is to go to a doctor, explain your problem, and get on the right track to treatment. No matter how bad you think you have it, there is always reason for hope."

And, although seeking treatment may be difficult, Real says, fathers with depression have a special responsibility to do so. "Depression is like a fire in the woods passing from generation to generation to generation," he says. "This will keep going until one man in one generation turns around and faces that fire and does something about it. A man with the courage to bring spiritual peace to himself is also sparing the generations that come after him."

Jim Thornton wrote about Alzheimer's disease in the September-October 2005 issue of AARP The Magazine.

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