Gender: A Question of Diagnosis?

It is pretty much considered common knowledge that women show higher rates of depression than men. 

But what if that's wrong?

Some food for thought/discussion, taken from Terrence Real's book I Don't Want To Talk About It:

"In national figures on mental disorders, women outnumber men by two to one among those diagnosed exclusively as depressed. The lifetime incidence of a major depressive episode in women is 21.3% of the total population, while in men, the disorder strikes only 12.7%. But if we factor into the equation "personality disorders" and chemical dependency, the totals even right back out again. Antisocial personality in women runs at 1.2% of the total population, while in men it is 5.8%. Drug dependency in women runs at 5.9% of the total population, while in men it is 9.2%. And alcoholism in women runs at 8.2% of the total population, while in men it is 20.1%. When the incidence of these disorders is added to the incidence of depression, it balances the level of pathology in each sex" (p. 84).

Here is my best representation of the chart included on the same page of the text:

Lifetime Incidents of Mental Disorders

(as percentage of the population)

                              

                                                        Men        Women        Both

Affective Disorders

Major Depressive Episode                                   12.7          21.3            17.1       

Manic Episode                                                         1.6             1.7              6.4

Dysthymia ("mild depression")                            4.8            8.0            6.4

Anxiety Disorders 

Panic Disorder                                                         2.0           5.0             3.5

Agoraphobia                                                             3.5           7.0             5.3

Social Phobia                                                           11.1          15.5             13.3

Simple Phobia                                                          6.7          15.7             11.3

Generalized Anxiety                                                3.6            6.6              5.1

Substance Abuse Disorders

Alcohol Abuse                                                         12.5           6.4              9.4

Alcohol Dependence                                              20.1           8.2            14.1

Drug Abuse                                                                5.4          3.5              4.4

Drug Dependence                                                     9.2          5.9              7.5

Other Disorders

Antisocial Personality                                              5.8           1.2             3.5

Nonaffective Psychosis                                             0.6          0.6            0.7

Totals                                                                       48.7       47.3         48.0

It seems too simple, doesn't it, to just total it all up and say men and women must be equal. Keep in mind here, that I am not stating any of this as scientific fact based on experimental data - by rules of ethics, any data dealing with mental disorders must be qualitative in nature. But to get you thinking out of the box on this stuff, I present you with Real's argument regarding men and depression.

The first concept to understand is that of "overt" versus "covert" depression. They mean exactly what they sound like. Overt depression refers to the kind of depression that is fairly easy to spot - fitting the "mold" if you will, of a major depressive episode. Click here for the DSM IV criteria for major depression.  Covert depression, by contrast, does not fit the model put forth by the DSM IV. It is largely hidden from those around the person and often from the person him/herself. I, personally, would add to this the idea that the characteristics of covert depression are often believed to be part of the personality of the sufferer. It is also called "masked depression," "underlying characterological depression," and "depression equivalents" (p. 41). 

Keeping in mind the chart above, consider the following:

"A number of studies looking at who gets labeled as being depressed have been carried out nationwide. Some, like the Potts study involving no less than 23,000 volunteer subjects, have been conducted on a massive scale. The results of most of them show a tendency for mental health professionals to overdiagnose women's depression and underdiagnose the disorder in men.

In a study of a different nature, psychologists were given hypothetical psychiatric "case histories" of patients with a variety of complaints. Only one variable was changed, the sex of the client. Consistently, psychologists diagnosed the depressed "male" clients as more severely disturbed than depressed "female" clients. On the other hand, women alcoholics were viewed as being more severely disturbed than their male counterparts. These conflicting results show that an overlay of gender expectations complicates the judgment of clinicians. It seems that they are punishing clients of both sexes with more severe diagnosis for crossing gender lines. If it is unmanly to be depressed and unwomanly to drink, then a depressed man must really be disturbed, just like an alcoholic woman"(p. 40). 

I do not doubt that gender roles and expectations play a large part in diagnosing mental disorders. It is easy to chalk the numbers up to biological sex differences, but we can't get an accurate picture of what is really going on until we remove the bias in diagnosing patients. But there is also the socialization factor to account for:

"The problem with this well-established psychiatric tradition is that it ignores the effects of gender. In our society, woman are raised to pull pain into themselves - they tend to blame themselves, feel bad. Men are socialized to externalize distress; they tend not to consider themselves defective so much as unfairly treated; they tend not to be sensitive to their part in relational difficulties and not to be as in touch with their own feelings and needs....When researchers compared the high rates of externalization in men with their low rates of depression they speculated that men's capacity to externalize might somehow protect them from the disease. But while the capacity to externalize pain protects some men from feeling depressed, it does not stop them from being depressed; it just helps them to disconnect further from their own experience" (p. 82).

We know that there are many more women in this country in therapy than there are men. Why might that be?

"The withdrawn depressed girl in the back of the classroom is seen as somehow less troubled than the acting-out, disruptive boy in the front row. Because psychotherapy since Freud has been 'talking cure,' it relies on the patient's insight into his or her problems and feelings as its chief therapeutic agent. One difficulty with such a methodology is that it is much more in keeping with the traditional skills of woman than with those of men. Men do not have readily at hand the same level of insight into their emotional lives as women, because our culture works hard to dislocate them from those aspects of themselves. Men are less used to voicing emotional issues, because we teach them that it is unmanly to do so. Even a cursory look at gender socialization in our culture indicates that a man would be far more likely to act out distress than to talk about it, while a woman would have the skills, the community, and the ease to discuss her problems. Having forcefully pushed our boys and men away from the exercise and development of these psychological skills, we add insult to injury when we turn around and label them more disturbed and less evolved than women who have been encouraged to keep them" (p. 82).

This reminds me of PhizzleDizzle's comment about boys being diagnosed with ADHD for acting out. I am not implying that many of these boys do not truly have ADHD that requires medication. But one has to wonder if at least some of these boys are suffering from depression that goes unnoticed because of their inability to verbalize what they are experiencing. 

Real and many other men's studies experts believe that the substantially higher rates of substance abuse and addiction in men result from undiagnosed depression which, quite frankly, makes sense. It is a form of "acting-out" negative feelings through self-medication. If we attempt to treat the substance problem without treating the depression, very low success rates will be par for the course. 

Those of you who have some training in psychology courses might recall that Freud's psychoanalysis was done almost exclusively on women. Every single form of psychotherapy has its roots in Freud's work, no matter how differently it may appear from the outside. One could argue that psychology was based in the idea that women needed help in coping with life. Freud set off the chain belief system that male coping skills were the norm, and that women were the exception. 

There are a couple of problems with this, obvious sexism aside. 

First, it means that the very foundation of psychotherapy requires that a client/patient be able to effectively verbalize the difficulties that they are having. If you can't say "I'm really sad" or "this really upset me" - you are at a severe disadvantage in talk therapy. This suggests to me that a large portion of the population out there is unable to get the help that they need. In order to remove the "women as overly-emotional and unstable" stigma, we need to find ways to connect with men who have mental health issues. 

Secondly, it is extremely difficult to change the foundation of psychotherapy as talk-based. We know that psychotherapy is helpful and valuable to those who have access to it. But like anything else, you can't fix something unless and until you know it's broken. Try to imagine for a second what mental health treatments would look like if they were not based on self-reporting. Can you? Because I can't. Only YOU know when you're not feeling right. It would be easier for our society as a whole to start raising boys who are not only self-aware, but who are also able to express themselves to others than it would be to try and find ways around verbalization. 

I wish I could c&p Real's entire book into the pages of my blog, but not only is it entirely impractical, it's illegal. So I implore all of you - if you are a man or you have a father, a brother, a husband, a son, any man in your life period - pick up a copy of this book and read it cover to cover. Even if you find yourself disagreeing with Real, it will make you think.

And isn't that why we're all here, anyway?