Edited by: Wulf Rössler, Charité – Universitätsmedizin Berlin, Germany
Reviewed by: Gabriele Klärs, Federal Centre for Health Education (BZgA), Germany; Kathleen Pöge, Robert Koch Institute (RKI), Germany; Petra Kolip, Bielefeld University, Germany
This article was submitted to Public Mental Health, a section of the journal Frontiers in Psychiatry
This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
There is broad evidence of men's reluctance to seek help for mental health problems. Studies support the generally-held assumption that men are less likely than women to get assistance from mental health professionals for problems (
Further studies of a systematic review refer to the adverse effects of male role expectations and social pressures to perform well as family providers and fathers with consequences for help-seeking behavior. Depression was frequently perceived as a threat to men's roles as family provider and many participants reported feelings of inadequacy and incapability compared to their situation before depression (
In addition to the impact of expectations regarding male roles on help-seeking behavior, studies revealed positive as well as negative experiences of (mental) health service use among men with depression. A recent qualitative study referred to conflicts that men experienced in relation to antidepressant use (
Even though traditional masculine norms play an important role in reinforcing men's reluctance to seek help, qualitative studies showed that some men seemed to benefit from just the same norms by perceiving these ideals as a healthy resource (
Despite emerging evidence for the diversity of men's experiences of help-seeking and service use, many studies provide a one-dimensional understanding of mental health behavior among men with depression, including reduced service use. Beyond this, there is a lack of knowledge on how men's specific needs in cases of depression are addressed by mental health services. Moreover, the impact of norms concerning traditional masculine roles for men with depression who have already utilized mental health services is unclear. Previous studies on mental health professionals' view about the impact of male gender for the treatment of men with depression stress the need to develop gender-sensitive services (
This qualitative investigation is part of the mixed-methods study “Constructions of Masculinity and Mental Health Behavior of Men with Depression” (MenDe) funded by the German Research Foundation. The study aims for a comprehensive analysis of men's constructions of masculinity and the consequences for their mental health behavior. Through an analysis of the diversity of concepts of masculinity, the study contributes to a more detailed picture of depression among men.
In the first step, based on a sample of 250 men with depression, a latent class analysis was performed and three types of a combination of masculinity orientation and job-related attitudes were identified (
Participants were recruited both inside and outside healthcare settings in Southern Germany. Eligible patients were asked by doctors or other clinical staff about their willingness to participate in the study. After expressing their willingness to participate, research workers contacted the patients, informed them about the aims of the study and verified the patients according to the following inclusion criteria: patients must be male, aged between 18 and 64, diagnosed or self-identified as having depression and sufficient German language skills. The study's exclusion criteria were organic mental disorder, dementia, anorexia with body mass index (BMI) <17, addiction and bipolar disorder or schizophrenia.
We conducted narrative-biographical interviews (
Interview guide.
Living with depression | As you know, we are especially interested in men's experiences with depression. We would like to know how it impacts your life, what are your coping strategies and what kind of services are helpful for you. |
We are not only interested in the acute phase of your depression, we would also like to ask about your whole life, i.e., how the depression developed. Could you describe step by step from past to present what your experiences were? | |
Experiencing first symptoms of depression until… | …You told me, that you went to a GP/into a clinic (or similar). Could you tell me what led to that visit and what happened next? |
Receiving the diagnosis depression until… | …You told me, that you went into a clinic (or similar). Did you receive a diagnosis? Could you elaborate on how the visit/stay went? |
Mental service use until… | …you told me, that you received treatment for depression. Could you tell me about your treatment in depth? What kind of experiences did you have in the clinic (or similar)? |
Evaluation of mental health services | How do you review and rate the mental health services, retrospectively? |
Illness theory | What caused your depression in your opinion? |
Life change | How has illness changed your life (your person, others, professionally, and privately)? |
Coping with depression | What helps you to cope with your illness? |
What makes it difficult? | |
Masculinity and depression | Could you explain whether and if yes how masculine norms influenced your help-seeking decisions and service use experiences? |
Undiscussed themes | Is there anything, that was not discussed during this interview but is important to you? |
Twelve interviews were conducted by a researcher (TS) between March and June 2018. The place for the interviews was chosen by the respondents. Interviews took place either at home or in the facilities of Ulm University, from which audio was recorded, transcribed verbatim, and anonymized. The duration of the interviews was between 27 and 133 min, with a mean of 75 min. Respondents were asked to answer socio-demographic questions at the end of the interview.
Interview transcripts were analyzed using qualitative content analysis (
Interviewees' characteristics (
Characteristics of the clinical sample of participants (
Steve | 50–54 | Social profession | Divorced | 3 | No | Psychologist Psychiatrist GP |
James | 55–59 | On sick leave (construction) | Married | – | – | Psychologist |
Daniel | 50–54 | Unemployed | Married | 2 | No | Psychologist Psychiatrist GP |
George | 45–49 | Rehabilitation (construction) | Married | 1 | Yes | Psychologist Psychiatrist |
Jack | 50–54 | On sick leave (marketing) | Married | – | – | Psychologist Psychiatrist GP |
Oliver | 55–59 | Public administration | Married | 3 | Yes | Psychologist |
Luke | 55–59 | Technical profession | Married | 2 | No | Psychologist |
Mark | 50–54 | Marketing | Divorced | – | – | Psychiatrist |
Alex | 55–59 | Transportation | Married | 2 | No | None |
Edward | 60–64 | On sick leave (human services) | Married | 2 | No | Psychologist |
Henry | 30–34 | Technical profession | Single | – | – | Psychologist |
Harry | 45–49 | Technical profession | Married | – | – | Psychiatrist |
Based on the qualitative analysis, we summarized themes which refer to men's (i) attitudes toward depression; (ii) perception of societal views on depression; (iii) Family environment: between role expectations and social support; and (iv) experiences with mental health services (
Core themes, categories, and subcategories,
Men's attitudes toward coping with depression: critical stance toward masculine norms | Trivialized symptoms of depression | Temporary condition, normal state of health, downplaying symptoms | 10 |
Individualized problem solving | Own problems, refused help-seeking | 7 | |
Hid depression due to masculine norms | Avoiding feelings, appearing strong, never crying, breadwinner | 7 | |
Avoided help-seeking to save career options | Secrecy, maintaining employability, safeguard career option | 6 | |
Change in attitudes toward mental health problems | wake-up call, changed harmful attitudes, self-competence, noticing warning signs earlier | 11 | |
Salutogenic perspective on depression and help-seeking | depression as an important life experience, Chance to reflect attitudes, positive coping strategies, being sensitive | 10 | |
Men's perception of societal views on depression: the stigma of being depressed and “unmanly” | Assessed as being incapable of coping with distress | Not taken seriously by others, incompetent | 12 |
Stigma toward help-seeking and having depression | Clinic-related stigma, can't hide it, rejecting inpatient services | 12 | |
Stigma toward the inability to work | Failure to fulfill norms, shunned by workmates, discrimination, lazy | 10 | |
Stigma of being unmanly | Weak, vulnerable, looser | 8 | |
Growing acceptance | Societal acceptance, become more open | 8 | |
Family environment: between role expectations and social support | Loss of empathy in the family environment related to mental health problems | Cannot mention depressive symptoms, annoying | 14 |
Depression not taken seriously | Pseudo-problem, trivialize | 9 | |
Lack of understanding related to failure to recover | “inability” to recover, must be healthy | 6 | |
Suffering from paternal role expectations | never recognized, fatherhood and role expectations | 8 | |
(Mental) health service use: between obstacles and enablers | Open-minded and appreciative environment as a coping resource | Lack of interest, downplaying depression, relativize depression | 11 |
Partners' emotional support | Supportive, encouraging, friendly contact | 21 | |
Service users' social support during and after inpatient services | Face-to-face exchange, similar illness-related background | 14 | |
Group counseling for men to facilitate disclosure of weaknesses | Feeling accepted, no questions why, listening, sympathy, and empathy | 15 | |
Familiarity of peer-led men-only groups | Same gender, same problems, address anxieties, open up to someone | 11 |
The majority of interviewees reported that masculine norms influenced their attitudes toward depression as well as their decision to seek help. Some of them reported having “trivialized” their symptoms in terms of a “temporary” condition, which was expected to return quickly to a normal state of health: “It's a bit difficult at the moment, but it'll be fine again soon” (Luke, 55–59 y). Most participants reported having tried to solve mental health problems on their own instead of seeking mental health services. Along these lines, some interviewees described their own as well as men's socialization in general as having an emphasis on avoiding feelings, appearing strong and never crying. One participant reflected masculine norms meant that he never disclosed mental health problems, saying that “[…] it doesn't exist among men. Men are the breadwinners, the problem solvers, the doers” (Luke, 55–59 y). In order to meet traditional masculine norms concerning societal roles, respondents decided not to disclose their mental health problems and to post-pone their own needs:
You have to play your part in the world of business. This means you can rarely be honest anywhere. That's the main thing, not to actually show how you're really doing (Steve, 50–54 y).
Interviewees explained low levels of help-seeking behavior as being a means of maintaining their employability as well as to safeguard career options. Therefore, one respondent reported that shortly after being admitted to a psychiatric ward due to a mental breakdown, he asked to be discharged “in order to go to work” (Jack, 50–54 y). In line with a critical stance toward masculine norms, the analysis indicates a change in attitudes toward mental health problems during recovery processes. Interviewees emphasized a salutogenic perspective on depression and help-seeking. Respondents perceived having depression as an important “life experience” (Alex, 55–59 y) or a “necessary wake-up call” (Harry, 45–49 y). This perspective awakened them to the need to change harmful attitudes toward work and life: “Before my illness, work came first. And now I have to say I'm the top priority and I only do what is good for me” (Luke, 55–59 y). Some participants viewed their depression primarily as a chance to reflect on their attitudes, which led to positive coping strategies in everyday life (Alex, 55–59 y). Due to their critical stances toward masculine norms, interviewees recommended being “more sensitive to looking after oneself and noticing these warning signs earlier” (Luke, 55–59 y). Others suggested detaching oneself from traditional masculine norms that inhibit help-seeking and service use for depression: “This kind of thing, of ‘I cannot show weakness, I cannot be sick’ should be avoided” (Jack, 50–54 y).
Participants referred to a variety of gender-related stigma experiences which could be classified into two categories: firstly, participants reported being assessed as incapable to adequately cope with mental distress. Depressive symptoms were not taken seriously by others who alleged that mental disorders are a result of an inability to deal with distress: “I've often heard people say ‘Get a grip! Don't make such a fuss’” (Luke, 55–59 y). Secondly, stigma experiences were related to the failure to fulfill norms relating to work. One respondent reported that he had been shunned by workmates and management due to his failure to cope with mental health problems: “They said I didn't appear to be sick and that they had never been sick in their lives” (Luke, 55–59 y). The analysis revealed that “not being sick” was associated with attributes of being strong, successful and self-reliant conveyed by the employment environment. In contrast, mental health problems in the workplace left interviewees feeling weak and vulnerable. Thus, they reported that their depression-related incapacity to work made them feel stigmatized by other colleagues. Participants were labeled “loser,” “lazy,” or “incapable” (James, 55–59 y). Along with these experiences, respondents on sick leave reported being afraid that “outside my house somebody could ask me ‘What are you doing for work these days?’” (Jack, 50–54 y) Some participants developed strategies in order to meet work-related norms, e.g., by telling people “I'm a freelancer. I'm working from home at the moment” (Jack, 50–54 y). Against this background, respondents stated that seeking help continues to be viewed negatively as it is connected with the inability to cope with mental distress: “It's certainly still the case that people say, ‘Oh, he needed help, he can't do it himself’” (Oliver, 55–59 y). Interviewees perceived little understanding of what it means to have a depressive disorder and seek help within different social and job-related contexts. Some respondents reported fears of being stigmatized, which led to them rejecting inpatient services:
The goal is under no circumstances to check into a clinic, because then the stigma is even bigger. That means you can't hide it any more, either at work or in your private life (Oliver, 55–59 y).
However, some participants perceived a slowly growing societal acceptance for professional help-seeking. One respondent noted that “People used to be locked up. All psychiatric institutions used to be completely closed off, and in the last 15 years they've become much more open” (Daniel, 50–54 y).
Participants reported both negative and positive experiences within their familial context during the help-seeking process. Some men perceived a loss of empathy that might be related to the duration of mental health problems: “I feel like I can't really mention my depressive symptoms at home anymore, because obviously it's annoying [for my family]” (Oliver, 55–59 y). Participants described a lack of understanding regarding their depression and their “inability” to recover:
The worst thing is my environment: “You've been to the hospital twice now, you are taking the medication and you have been on holiday, you must be healthy now” (Jack, 50–54 y).
Others reported that the diagnosis of “depression” was not taken seriously by family members but seen as a pseudo-problem (Daniel, 50–54 y). Within the familial context, paternal role expectations were an important issue for some participants: “My family couldn't understand that I, a father, didn't go to the hardware store today, because I didn't feel good. It was never really recognized” (James, 55–59 y). In contrast, an open-minded and appreciative family environment was seen as assisting in the seeking of professional help (Harry, 45–49 y). Further findings underlined the supportive role of the partner as the “rock” (Jack, 50–54 y) in the help-seeking process: “Without my wife, I wouldn't still be sitting here. I wouldn't have accepted any help, and I would be sitting somewhere in a clinic where I wouldn't be able to open the door by myself” (Jack, 50–54 y).
Participants described both negative and positive experiences with (mental) health service use. Some respondents reported a lack of interest as well as a downplaying of depressive symptoms by GPs which led to them no longer seeking help:
The GP said, “Yeah, my God, I'm seeing you again? So, what have you got? Problems at work? So, a lot of people have problems. Don't get so upset!” (Oliver, 55–59 y).
In some men's views, GPs tended to relativize depressive symptoms and recommended calming oneself down. In contrast, other interviewees reported the role of GPs as being a gateway to mental health services and being generally supportive and encouraging as well: “I told him everything. And then he pressed a note into my hand and said I had to go to the clinic immediately” (Alex, 55–59 y). Alongside structures of formal service use, interviewees pointed out the positive role of other informal service users' social support during and after inpatient services. They reported the key role of a face-to-face exchange with fellow service users, especially those with a similar illness-related background, which was described as a supportive feature during the help-seeking process. Respondents felt accepted without being questioned by others: “There was no question of why… just this listening and sympathy and being there for you” (Luke, 55–59 y). In particular, group counseling for men with depression was perceived as facilitating the disclosure of weaknesses. For this reason, interviewees preferred approaches that enabled them to address anxieties in a group of fellow service users who identify with the same gender. Relatedly, participants highlighted the familiarity of men-only groups in the context of inpatient services: “You can really show your true self. You can show weakness and it won't be interpreted negatively. Nobody laughs at you” (Steve, 50–54 y). Because of societal expectations due to masculine norms as well as perceived stigma of being “unmanly,” some participants defined inpatient services as a sheltered space: “You're in a kind of cocoon, where you're protected, where you feel really comfortable. Where you're doing well” (Luke, 55–59 y). Others described inpatient services as being their first opportunity to open up to someone else: “That was the first time I was able to be open about my problems like that” (James, 55–59 y). These interviewees perceived inpatient services as being a protection against external expectations which they were unable to meet due to mental health problems. Instead of having to meet the expectation of being active and responsible, service users are allowed to be “passive” recipients:
I really appreciate the clinic. To be free of my responsibilities for a while. In a clinic, you're completely relieved of it. You're given a plan to work through (George, 45–49 y).
Consistent with the change in attitudes toward mental health-related help-seeking, interviewees described their experiences of inpatient services as an “educational resource”, where they could benefit from fellow patients' life experiences and learn how to cope with depressive symptoms: “I learned a lot through meeting people with the same problems. That makes you smarter, when you know how to deal with it” (Alex, 55–59 y).
The objective of our study was to explore experiences and attitudes toward depression, help-seeking and service use in a sample of men undergoing treatment for depression. Our findings suggest that men with depression retrospectively give both negative and positive experiences of help-seeking and service use. On the one hand, they report the adverse impact of masculine norms as well as stigma experiences. On the other hand, results indicate a transformation of their attitudes toward traditional masculine norms by critically reflecting on non-help-seeking behavior as well as maladaptive work patterns. In this regard, peer-led men-only groups were seen as assisting the disclosure of anxieties.
Retrospectively, the interviewees perceived that they trivialized and downplayed their symptoms, which they justified using the societal role of caring for their family or to meet career-related expectations. This is in line with previous studies showing that men who suffer from depression have difficulties disclosing their mental health problems, reasoning that traditional masculine norms such as being strong, successful, and self-reliant inhibit help-seeking behavior (
Additionally, our findings also report on stigma experiences, which relate to the inability to cope with mental distress as well as to perform expected job- and family-related roles. The concept of mental illness stigma describes a process that involves labeling, stereotypes, separation, loss of status, and discrimination (
Some interviewees indicated negative experiences in seeking GPs' help for depression, whereas other participants pointed out the importance of GPs as gateways to mental health services. This discrepancy is in line with results from a qualitative study that identified positive factors that may assist men's help-seeking decisions (
Contrary to the power of traditional masculine norms as an obstacle to seeking help, our findings indicate a change of attitudes toward service use during the participants' recovery processes. Our qualitative analysis pinpointed a critical stance toward masculine norms as well as a salutogenic perspective on depressive illness and service use experiences among interviewees after seeking help. In contrast to the assumption that psychiatric service use contradicts masculinity (
Because study participants had used mental health care services prior to the study, results only refer to participants who had successfully sought help. Therefore, our findings are not able to explain reasoning processes in men who have never sought help for mental health problems. Another limitation is the small sample size as well as participants' high age (mean = 52), which means it is not possible to reveal age-related differences in help-seeking attitudes and behavior. However, there may be variances of dealing with depression in the light of society's expectations, e.g., relating to the male “breadwinner” role. Alongside the need for age-differentiated analyses, future studies could focus on fathers with depression to explore the meaning of fatherhood for coping with depression. While most of the reviewed literature demonstrated how masculine norms create barriers in seeking help for depression, more evidence on preferred types of service use is needed, e.g., in terms of the role of GPs as a potential point of contact for further information about mental health services. Furthermore, other findings suggest that the educational level is associated with the rigidity of gender roles, i.e., that a low level of education corresponds to rigid gender roles. Future research could focus on differences between milieus and along socio-demographic factors (i.e., education) to examine these hypotheses. Finally, our results show that it would be of great interest to conduct quantitative studies examining mental health needs among men with depression in a broader population. Although our study did not reveal any impact of socioeconomic status (SES) to masculinity orientations and service use behavior quantitative studies should include measurement of SES.
Despite its limitations, our study calls for interventions to improve help-seeking among men with depression. Findings highlight the need to consider perceived discrimination against men with depression. Interventions to reduce the stigma of being “unmanly” and to improve men's capacity to cope with being unable to work should be developed. Peer-led men-only groups may increase participants' self-esteem and assist in disclosing weaknesses. In the context of GPs' mediating role, training for health professionals concerning the impact of masculine norms on mental health is recommended. GPs competent in recognizing depressive symptoms may be able to play a key role in helping men by acting as a mediator for further psychiatric services. Finally, public campaigns are needed to change society's negative view of mental illnesses, help-seeking and service use among men as well as women with depression. One example approach that could be used to target the male population is the “
The original contributions presented in the study are included in the article/supplementary materials, further inquiries can be directed to the corresponding author/s.
The studies involving human participants were reviewed and approved by the ethics committee of Ulm University, Germany (Ref. Nr. 202/15). The patients/participants provided their written informed consent to participate in this study.
SK, RK, HG, TB, and PB proposed the project idea. SK supervised the project. KF, MP, MSc, HG, and PB helped with participant recruitment. TS, AM-S, MSt, and SK undertook literature research and conducted and analyzed the interviews. TS drafted the manuscript. All authors contributed to and approved the final manuscript.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
We are grateful to clinical providers for their support with participant recruitment as well as to all participants.