Additionally, the presence of externalising symptoms such as anger, substance misuse and risk-taking in some men is coupled with a lower frequency and intensity of typical depressive symptoms such as depressed mood, appetite or sleep disturbance.39 This increases the risk of a missed diagnosis or misdiagnosis. Consequently, researchers have questioned the sensitivity of screening measures for depression in male populations.
A large representative US study found that gender discrepancies in depression symptoms are much less pronounced when externalising markers are considered, in turn suggesting we may be underestimating men’s difficulties with depression.38 Externalising symptoms such as irritability, excessive drinking, drug taking or aggression have been found to have direct links with both current suicidal risk and past suicide attempt.4 This makes them worthy of attention and assessment when working with men, above and beyond typical expressions of distress.40
The Australian-developed Male Depression Risk Scale (MDRS) is a 22-item screening tool designed to assess externalising mood problems in men (Table).41 The MDRS has good sensitivity and specificity for identifying men reporting past two-week suicide ideation and has been validated in both younger and older men.41-44 A seven-item short form of the MDRS is forthcoming. Additionally, a prompt list has been developed for use with men in mental health discussions specifically in a general practice.45,46 Alongside a formal measure such as the MDRS, this prompt list could provide useful insight into the male patient’s experience.
As the gatekeepers for treatment of depression in men, GPs have a role that can, and should, extend beyond prescribing antidepressants as an automatic or premature response, albeit necessary in some situations. Indeed, if a male patient is at the beginning of their mental health journey, and is yet to comprehend fully their internal experience, where their symptoms stem from and how to best manage them, then less intensive psychological or lifestyle-based intervention may be more acceptable and useful.
Alongside validation, active listening and basic psychoeducation, GPs should seek out and lean on the male patient’s strengths and interests to collaboratively build a plan of action. GPs who refer a patient to a mental health clinician should ensure that the patient can openly voice to them any uncertainty or anxiety about the process, and clarify that there are always multiple treatment avenues to try. Promising to follow up with external providers will communicate to the patient that his GP is an ally with an open ear.
Depression may be more common in men than prevalence rates currently suggest. GPs are highly influential in driving improvement in the detection, diagnosis and treatment of men’s mental health concerns. GPs continue to confront the stresses and strains of this complex and time-consuming work to provide their male patients with the best care possible. Seeking ongoing opportunities to improve clinical engagement is essential for men with depression. Although men have historically been reluctant to reach out and engage in help-seeking for their mental health, the next generation of young men appear more open to help-seeking, making them more able and willing to grapple with mental health concerns. MT