Over the last few years, there has been increased scientific effort to describe the gender-specific psychopathological picture of depressive disorders. The Department of General Psychiatry at the University of Vienna initiated a large investigation program to uncover the symptomatology and specific needs of depressed men. The starting point for research in this field has been the vast number of studies describing a higher lifetime prevalence of depression in females compared to males. Partly, these findings could be explained by differences in seeking professional help. Apart from this, the typical symptoms of male depression have not yet been included in the leading diagnostic manuals, so that depression in men is probably rather under-diagnosed.

The results of the suicide prevention program on the Swedish island of Gotland in the eighties gave proof of the hypothesis of a gender dimorphism in depressive disorder: a systematic training of local doctors lowered the high suicide rates by two-thirds. It was in fact somewhat surprising that the suicide rate in females decreased by about 90%, whereas the rate of men was quite unaffected. When specific strategies were developed to recognize and treat male depression, the suicide rate in males also decreased.

Clinical picture

The core symptoms of depression, such as depressed mood, reduced drive, depressive cognition, and sleep disturbances are comparable in both genders. Research programs such as the Gotland study suggest that symptoms such as dysphoria, irritability, aggressiveness, and a tendency to blame others are more common in males. There is also clear evidence from epidemiological studies, e.g. the "Epidemiological Catchment Area", that there is a link between depression and aggression. The symptomatology of male depression is summarized in the list below:

• Irritability and dysphoria
• Acting out, aggressiveness
• Low impulse control
• Anger attacks
• Tendency to blame others and to be unforgiving
• Low stress tolerance
• Higher willingness to take risks
• Behavior on the verge of social or legal standards
• Substance abuse (e.g. alcohol, nicotine)
• General dissatisfaction with oneself and one's behavior
• High suicide risk

Irritability is a state of mood that is characterized by lowered impulse control, increased anger, aggressiveness, and a strong feeling of discomfort. In this affective state, patients tend to overact for no reason at all, i.e. to react aggressively, which is regretted later on. It has been repeatedly observed that irritability is present before the onset of depressed mood and that it responds earlier to antidepressant treatment.

Anger attacks are an under-recognized but highly prevalent symptom in depression that is often reported by men: they are characterized by a sudden onset, not unlike a panic attack. Anger and rage are experienced by the patients as highly exaggerated and inadequate. During anger attacks, vegetative symptoms such as palpitations, dyspnea, flush, vertigo, sweating, paresthesia, tremor, increased anxiety, and feelings of loss of control are often encountered.

Men die about twice as often in accidents as women. The prevalence of accidents is of psychiatric relevance insofar as they are frequently related to an increased readiness to take risks, and in some cases accidents might be interpreted as suicidal or para-suicidal actions. While there is no sex difference in the rates of suicide attempts, men lead in the statistics of successful suicides in a ratio of 2:1.

Alcoholism is frequently encountered in patients suffering from depression, in general more often in men than in women.

Perhaps the depressive symptom pattern of males, with its reduced impulse control, a tendency for violent suicides and increased substance abuse, can be explained by a common neurochemical lesion in the sense of a dysfunction of both the serotonergic and the dopaminergic neurotransmitter systems.

Diagnosis

The diagnostic outlook of the doctor is of overwhelming importance for the recognition of psychiatric disorders. Making the correct diagnosis and optimizing the therapeutic outcome of the depressed man will only be possible with thorough knowledge of the specific features of male depression because many men present themselves primarily with physical complaints and do not actively mention emotional or social problems. In addition, depressive illness goes along with a social stigma that connotes psychiatric illness as weakness, thus leading to premature discontinuation of treatment and to a higher rate of relapse and recurrence.

Therapy

Nowadays, a broad array of antidepressants is available for the treatment of depressive disorder. In cases where symptoms such as irritable affect, dysphoria, and anger-attacks do not respond adequately to conventional antidepressant treatment, addition of a 5-HT1A-agonist, an anticonvulsant, or an atypical neuroleptic can be tried.

There is no typical "male antidepressant", but newer compounds that exert a serotonergic effect -- SSRI (selective serotonin reuptake inhibitors) or SNRI (serotonin and noradrenaline reuptake inhibitors, e.g. milnacipran, venlafaxine) -- are preferred because of the hypothetical pathophysiology.

When selecting an antidepressant its specific side effect profile should be kept in mind in order to maximize compliance and consequently the treatment outcome. Antidepressant-induced sexual dysfunctions are of especial importance in the treatment of male patients: TCAs (tricyclic antidepressants), SSRIs, and SNRIs can all induce erectile dysfunction. Disturbances of ejaculation and anorgasmia have been reported during treatment with these drug classes; loss of sexual interest is a typical depressive symptom and particularly difficult to distinguish from a drug-induced effect.

The prescription of antidepressants with a sedative effect -- TCAs, NaSSAs (noradrenergic and specific serotonergic antidepressants, e.g. mirtazapine), or SARIs (serotonin antagonist and reuptake inhibitors, e.g. nefazodone) -- may be problematic and can - at least initially - reduce the patient's fitness to drive a car.

Somatic comorbidity has also to be taken into consideration when choosing a patient's medication: TCAs can generate cardiovascular side effects, e.g. hypertension and tachycardia; immediately following a myocardial infarction only SSRIs should be prescribed, but in patients who are treated with anticoagulants, fluvoxamine can cause a drug interaction, so that frequent checks of the coagulation state are advisable. In elderly men with incipient dementia and a comorbid depressive syndrome, the use of TCAs can lead to a significant impairment of cognitive function due to the anticholinergic effects of the compounds. In renal insufficiency, TCAs, mianserine, and RIMAs (reversible monoaminoxidase inhibitors of type A, e.g. moclobemide) are associated with a relatively low risk; in hepatic illnesses paroxetine, citalopram and milnacipran can be recommended, while TCAs and MAO-Is (irreversible monoaminoxidase inhibitors, e.g. tranylcypromine) should not be used. Antidepressant-induced weight gain is a risk factor in patients suffering from diabetes mellitus; SSRIs have a rather low risk in these patients, although fluoxetine can initially induce hypoglycaemia.

The patient's suicide risk has to be assessed when selecting antidepressant medication; it is preferable to select a drug with a low toxicity (e.g. an SSRI); if the patient is acutely suicidal, admission to an inpatient clinic is absolutely necessary.

Psychotherapeutic intervention is effective as acute treatment as well as in the long-term therapy of depression; the combination of psychotherapy and psycho-pharmacotherapy is commonly regarded as superior to monotherapy. Women accept psychotherapy more willingly than men, and elderly men, who have the highest suicide rate, accept the use of psychotherapy least. It is necessary for doctors to motivate their patients and propose low-threshold psychotherapeutic care with the focus on addressing current problems, a defined duration and acceptable cost.

Depression in men is particularly remarkable with regard to the different symptomatology. The gender-specific role behavior of men with lower help-seeking behavior, combined with a rate of successful suicides that is twice as high as in women, shows the need for increased attention from doctors, especially general practitioners, who are the first line of consultation for most men.