The role of masculinity in men's help-seeking for depression: A systematic review

Highlights

• Men may find it difficult to recognise and communicate symptoms of depression.

• Men prefer collaborative interventions involving action-oriented problem solving.

• Masculine norms like stoicism conflict with depression, heightening self-stigma.

• Masculine norms may inhibit help-seeking and reinforce maladaptive coping styles.

• Reframing a more fluid masculinity to integrate depression may boost help-seeking.

Abstract

Aim

Conformity to traditional masculine gender norms may deter men's help-seeking and/or impact the services men engage. Despite proliferating research, current evidence has not been evaluated systematically. This review summarises findings related to the role of masculinity on men's help-seeking for depression.

Method

Six electronic databases were searched using terms related to masculinity, depression and help-seeking. Titles and abstracts were reviewed and data systematically extracted and examined for methodological quality.

Results

Of 1927 citations identified, 37 met inclusion criteria. Seventeen (46%) studies reported qualitative research; eighteen (49%) employed quantitative methods, and two (5%) mixed methods. Findings suggest conformity to traditional masculine norms has a threefold effect on men experiencing depression, impacting: i) their symptoms and expression of symptoms; ii) their attitudes to, intention, and, actual help-seeking behaviour; and, iii) their symptom management.

Conclusion

Results demonstrate the problematic impact of conformity to traditional masculine norms on the way men experience and seek help for depression. Tailoring and targeting clinical interventions may increase men's service uptake and the efficacy of treatments. Future research examining factors associated with men's access to, and engagement with depression care will be critical to increasing help-seeking, treatment uptake, and effectual self-management among men experiencing depression.

Introduction

Whilst the prevalence of major depressive disorder continues to rise, making it the leading cause of disability worldwide, depression rates in men are consistently found to be nearly half those of women (Ivancic et al., 2014, Kessler et al., 2005, World Health Organization, 2008). Importantly, the lower rates of male depression don't reflect better mental health compared to females given that men exhibit significantly higher rates of substance use and physical violence (Harrison et al., 2004, Martin et al., 2013) and account for three-quarters of suicides in western countries (Australian Bureau of Statistics, 2015, Centers for Disease Control and Prevention, 2013).

It has been proposed that men's conformity to traditional masculine norms such as stoicism, self-reliance and restrictive emotionality, which stem from dominant models of male socialisation in the Western World (Pleck, 1995), is tied to the lower rates of depression diagnoses often seen in men (Addis and Mahalik, 2003, Mahalik and Rochlen, 2006). However, this discrepancy in rates of diagnosis might be better interpreted by considering reticence for help seeking, since effective diagnosis is wholly dependent upon initial presentation by men to available health services. Among men, high conformity to traditional masculine norms has been correlated with less help-seeking behaviour and more negative attitudes toward seeking psychological treatments (Levant, Wimer, & Williams, 2011), with men repeatedly found to be half as likely to seek help for mental health concerns from a GP or mental health professional compared with women (Addis and Mahalik, 2003, Judd et al., 2008). This finding is consistent across countries, racial and ethnic groups and throughout the lifespan (Addis & Mahalik, 2003). Galdas, Cheater & Marshall (2005) call for further investigation into this help-seeking gap, rightly suggesting that a richer understanding of this male behavioural pattern will guide practitioners to improve their understanding, diagnosis and treatment of men.

Addis (2008) suggests that the relative ‘invisibility’ of the gendered nature of men's mental health in the existing literature has left the field devoid of theoretically-based insight, resulting in consistent negative outcomes for the wider community. His critical examination of four contrasting frameworks underpinning gender and depression in men highlights the lack of a unifying conceptual framework, but is an initial step toward greater precision in the empirical research. These frameworks encompass comparative sex differences, the perspective that men ‘mask’ their symptoms and experiences of depression, the effects of gendered socialisation on symptom expression, and how men respond to negative affect in general. When combined, these frameworks serve to elucidate reasons men often deny illness, suppress negative affect and exhaust internal psychological and physical resources to avoid admitting depressive symptoms, waiting until late in the illness trajectory before seeking help (Oliffe & Phillips, 2008). Good and Wood (1995) termed this impact of masculinity double jeopardy, suggesting some men were at risk for psychological distress amid being unlikely to seek help for their problems.

The process of help-seeking does not solely encompass the initial act of seeking help, but additionally involves the features and patient experience of the consultation and treatment[s] that takes place thereafter. The effects of conformity to traditional masculine norms often extend to therapy, and are labelled ‘therapy interfering processes’; these chiefly include significant fear of coercion and stigma, leading to difficulties with attendance, engagement and an unstable therapeutic alliance (Englar-Carlson, 2006, Richards and Bedi, 2015, Spendelow, 2015). Whilst recognition of mental illness and treatment options have increased recently following large-scale awareness campaigns including ‘Real Men, Real Depression’ in the United States, (Rochlen, Whilde & Hoyer, 2005) it appears that a help-seeking gap remains for men experiencing depressive symptoms, with clinicians, researchers and policy makers alike attempting to shift, counteract, and challenge the essentialist perspective that psychotherapy and masculinity are diametrically opposed (Meth, 1990, Eckert et al., 2010, Jorm et al., 2006).

A common theme throughout the existing literature is a reductionist emphasis on traditional masculinity as a pathology or deficit when considered in the context of mental health. It is important to note that this empirical trend is at odds with the social constructionist theories of multiple masculinities, which are fluid, relational and may co-exist (e.g., Connell, 1995). However, as Kiselica and Englar-Carlson (2010) postulate, it has become customary for researchers and clinicians to target pathology and what is “wrong” with men in order to address these issues, rather than to emphasise the positive aspects of being a man in order to advance male-centred healthcare. It is important to note that the wealth of existing data on this issue is not inaccurate, but rather incomplete (Englar-Carlson & Kiselica, 2013). Traditional masculinity is therefore interpreted as a valid but singular representation within a ‘constellation’ of masculinities; in proposing their Positive Psychology/Positive Masculinity model (PPPM), Kiselica and Englar-Carlson (2010) highlighted the need to bridge these deficit models and take a strength-based approach in understanding and effectively treating men's mental illness.

Poor mental health outcomes in men are problematic for individuals and society, with functional impairment and/or premature death often-occurring at the most economically productive time of men's lives (Möller-Leimkühler, 2002). Reticence for help-seeking is also linked to lower socio-economic status and resistance to help-seeking can be further heightened as depressive symptom severity increases. In turn, social and cognitive disability following depression is increased in the aftermath of such inaction (Scott & Collings, 2010). Despite the importance of increasing help-seeking for depression among men, to date there has been no systematic review of existing research in the area. As such, it appears that help-seeking, considered as a process which includes pathways into the healthcare system as well as the assessment and treatment of symptoms, is a broad but suitable starting point to explore the effect of masculinities on men's depression in a systematic evaluation of the literature. Within a field as rapidly evolving as that of men's depression, there is the threat for particular theories and studies to dominate and lead to a stagnant, empirical homogeneity. Therefore, the aim of this review was to rigorously collate and present findings from the existing literature related to the role of masculinity on men's help-seeking for depression and provide recommendations for future work in the area.