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Subjective well-being and ‘male depression’ in male adolescents
Journal of Affective Disorders 98 (2007) 65 – 72 www.elsevier.com/locate/jad
Research report
Subjective well-being and ‘male depression’ in male adolescents A.M. Möller Leimkühler a,⁎, J. Heller, N.-C. Paulus a
Department of Psychiatry, Ludwig-Maximilians-University of Munich, Nuβbaumstr. 7, D-80336 Munich, Germany Received 28 February 2006; received in revised form 10 July 2006; accepted 11 July 2006 Available online 11 September 2006
Abstract Background: The concept of male depression is based on the hypothesis that typical symptoms of depression in men often seem to be masked by non-typical male distress symptoms not considered in common depression inventories. Although there is a large amount of clinical evidence, scientific evidence is still lacking. The study aims at further validating the concept of male depression, by obtaining information on symptoms reported by males, and analyzing the dimensional structure of the Gotland Scale of Male Depression [Rutz, W., 1999. Improvement of care for people suffering from depression: The need for comprehensive education. International Clinical Psychopharmacology 14, 27–33.]. Methods: A community sample of male adolescents aged 18 (n = 1004) was asked to complete the WHO-5 Well-being Index [Bech, P., 1998. Quality of life in the psychiatric patient. London: Mosby-Wolfe.] and the Gotland Scale of Male Depression [Rutz, W., 1999. Improvement of care for people suffering from depression: The need for comprehensive education. International Clinical Psychopharmacology 14, 27–33.]. Principal component analysis with promax rotation was calculated to analyze the dimensional structure of the Gotland Scale. Cluster center analyses were used to classify the sample according to the symptoms' characteristics. Results: General well-being was rather reduced, and 22% of the respondents were seen to be at risk of male depression. There was no evidence for the hypothesis that young males tend to mask their depressive symptoms with distress symptoms. Depressive and male distress symptoms appeared to be mixed in a dominant factor, while male distress symptoms constitute an additional minor factor. A cluster of 38% of those at risk for depression could be identified who reported significantly elevated male distress symptoms. Irritability turned out to be the single item of the Gotland Scale with the highest item-total correlation. Limitations: Risk of depression was not assessed by an additional depression scale or evaluated by a clinical rating. Conclusions: Male distress symptoms should be considered when diagnosing depression in men. Further research is needed with respect to comorbidity and differential diagnoses, which should also include bipolar depression. © 2006 Elsevier B.V. All rights reserved. Keywords: Male depression; Adolescents; Irritability; Distress symptoms
1. Introduction ⁎ Corresponding author. Tel.: +49 89 5160 5785; fax: +49 89 5160 5522. E-mail address: [email protected] (A.M. Möller Leimkühler). 0165-0327/$ - see front matter © 2006 Elsevier B.V. All rights reserved. doi:10.1016/j.jad.2006.07.007
The concept of male depression is based on studies of an educational program on depression and suicide prevention on the Swedish Island of Gotland in the 1990s (Rutz et al., 1995, 1999). Rutz has postulated a ‘male depressive syndrome’, which is supposed to differ from
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common depressive symptoms among females. It includes sudden and periodically lowered stress tolerance in otherwise stress-resistant men, impulsive–aggressive or psychopathic behavior in otherwise nonpsychopathic men, and suddenly occurring endorphin- or serotoninrelated behavior such as alcohol and/or drug abuse or abusive equivalents (workaholism, excessive jogging, etc.) in otherwise non-abusive men. According to this, depression in men often seems to be masked by atypical symptoms like irritability, anger attacks, hostile–aggressive–abusive behavior and alexithymia, which may be misleading when trying to detect depression in men. As symptoms such as irritability and anger are not included in the international leading classification systems, it is not surprising that no gender differences in the quality of depressive symptoms in male patients diagnosed as depressive according to these classification systems have been found. The Gotland studies have resulted in a screening instrument for detecting depression in men, “The Gotland Scale of Male Depression”, which has recently been validated (Bech, 2001; Zierau et al., 2002). It consists of typical depressive symptoms as well as emotional distress symptoms which are supposed to predominate in males. The concept of a specific male depressive syndrome is strengthened by findings from the Amish (Egeland et al., 1983) and Jews (Levav et al., 1993) which show an equal sex distribution of unipolar depression when alcohol abuse is not a confounding diagnostic factor. Although the term ‘male depression’ has received increasing attention in the media, scientific evidence is still limited (Rochlen et al., 2005). Previous studies with respect to gender differences in depressive symptoms consistently found that men report fewer depressive symptoms than women, and few gender differences could be observed in the quality of symptoms in community studies. However, the diagnostic schedules mostly used in epidemiological research have focused on typical depressive symptoms, so that ‘male’ symptoms may have been overlooked. There are a few findings indicating that potentially ‘male’ symptoms, such as non-verbal hostility (Katz et al., 1993) and trait hostility (Fava et al., 1995) are more prevalent in depressed men. Findings from Angst et al. (2002) indicate that untreated males of a community sample report depressed mood significantly less frequently than females, and that treated depressed males report fewer symptoms than females. All symptoms assessed were more prevalent in females, except the need for alcohol in periods of reduced well-being. Focussing particularly on gender-related pathways to depression, results of a Danish population study (Bech, 2001) indicate that, in females, early symptoms of
reduced well-being pass directly into major depression, whereas males gradually pass into depression via stress, aggression and alcohol abuse. Another Danish study on male out-patients treated for alcohol dependency (Zierau et al., 2002) found that when non-typical symptoms as well as typical depressive symptoms were assessed (Gotland Scale of Male Depression), 39% of the patients were found to have a probable or definite depression, while depression was detected only in 17% of the patients when a traditional depression inventory was used. With regard to depressive inpatients, the results of two Austrian studies (Winkler et al., 2004, 2005) suggested that men had higher scores in affective rigidity and blunted effect and suffered from anger attacks more often. In a German study with depressive inpatients (Möller-Leimkühler et al., 2004), neither the frequency nor the mean scores of the ‘male’ symptoms differed significantly between males and females. However, ‘male’ symptoms like irritability, aggressiveness and antisocial behavior were more strongly intercorrelated in depressed males than in depressed females. With respect to different male age-groups, young men seem to be a special risk group, not only with regard to increasing rates of offending behavior (Archer, 1994), conduct disorders (Smith, 1995), and increasing psychological distress (Jorm and Butterworth, 2006), but also with regard to depression. Since the 1980s rates of depression in young men have also been increasing (Klerman and Weissman, 1989; Fombonne, 1994; Culbertson, 1997), but at the same time there is a poor treatment rate of depressed young men, which is especially true for those aged 14 to 24 years (Wittchen et al., 1999). It is supposed, that this is mainly due to selfperceptions and norms of appropriate masculinity (Lin and Parikh, 1999; Möller-Leimkühler, 2002). However, undertreatment of depression is not only due to a lack of help-seeking, but is also due to the problem of detecting depression. 2. Aim of the study With respect to male depression, there is a special need to investigate community samples because “male” depressive symptoms seem to be more pronounced in non-clinical groups, and because the effects of male help-seeking behavior result in a strong selection bias in treated samples. Thus, the aim of the present study is to obtain further information about male distress symptoms in the context of possible depression, and to further validate the Gotland Scale of Male Depression by
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conducting a community survey among male adolescents. The following issues will be addressed: – general well-being – risk of male depression – characteristics of male distress symptoms and traditional depressive symptoms – dimensional structure of the Gotland Scale of Male Depression – clusters of subgroups depending on different symptom patterns, and – best indicators of the risk of male depression. 3. Methods and subjects 3.1. WHO-5 Well-being Index The WHO-Five Well-being Index (WHO-5) was developed from the WHO-10 Well Being Index (Bech, 1998; Heun et al., 1999). It is a brief self-rating screening instrument for depression covering the three core items of depression according to ICD-10: mood, interests, and energy. Each of the five items is rated on a 6-point Likert scale from 0 (= not present) to 5 (= constantly present). Within the range from 0 to 25, a raw score ≤ 13 suggests poor well-being, and that respondents should be tested for depression (WHO, 1998). Additionally, the raw score is transformed to a percentage score from range 0 (worst thinkable well-being) to 100 (best thinkable well-being). The WHO-5 is a highly sensitive instrument, but its specificity is rather low, so that a relatively high rate of false-positive screenings can be expected (Henkel et al., 2004). 3.2. The Gotland Scale of Male Depression The Gotland Scale of Male Depression (Rutz et al., 1995; Rutz, 1999; Walinder and Rutz, 2001) is a screening instrument for male depression consisting of 13 items which are rated on a 4-point Likert scale from 0 (=not present) to 3 (=present to a high degree). Originally the scale was developed as a unidimensional construct. Later, Zierau et al. (2002) proposed a splitting into two subscales: the distress subscale (7 items: being stressed, aggressiveness, irritability, feeling of displeasure, overconsumption of alcohol or related substances, behavior changes, greater tendency to self-pity) and the depression subscale (6 items: being burned out, tiredness, difficulty making decisions, sleep problems, hopelessness, family history of depression or suicide). The total score of the 13 items has a theoretical range from 0 to 39. The standardisation of the total score is: 0–12 = no depression,
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13–26 = probable depression and 27–39 = definite depression. Psychometric properties were acceptable when used in a population with alcohol abuse disorder (Zierau et al., 2002). In the present study the internal consistency (Cronbach's alpha) for the total scale was 0.81, for the distress subscale 0.71, and for the depression subscale 0.65. Both subscales were significantly intercorrelated (Spearman's Rho = 0.61; p = 0.000). Convergent validity of the Gotland Scale was satisfying due to its correlation with the WHO-5 (Spearman's Rho = −0.56; p = 0.000). 3.3. Subjects In Germany at the age of 18 all young men are called up to register for military or alternative service at an authority called “Kreiswehrersatzamt” in their region. These young men represent an age-homogenous crosssectional population sample. For this reason, and in order to reach a maximum number of young males who could be asked to participate in the study, the “Kreiswehrersatzamt” of Munich was contacted. In cooperation with the medical staff all young men who had been called up for registration from July to September 2003 were asked to complete the self-rating scales during the waiting time between their physical examinations. The study was presented as an investigation of the University of Munich focussing on stress experience and subjective well-being in young men. It was emphasized that participation was voluntary, data collection and processing anonymous, that the study was completely independent of the physical examination and that the only reason for addressing these young men was research practicability. The completed questionnaires were returned in closed envelopes. 1004 young men could be included into the study with a response rate of 95%. 4. Results The mean age of the young men was 18.5 years (1.18). Most of them (78.2%) were school pupils with (or attaining) the secondary school level I certificate or the certificate from vocational schools (48.7%); 41.1% of them were attaining the general qualification for university entrance. 52.3% lived in Munich, 47.7% in small towns and villages surrounding Munich. 4.1. Well-being and risk of (male) depression According to WHO-5, the mean percentage score is 55.28 (17.27). Compared to norm values of the Danish population (no German data available), this result demonstrates a rather reduced well-being of the
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Table 1 General well-being in male adolescents of the present study compared to a population sample and different clinical samples (WHO-5 Wellbeing Index) Sample
n
WHO-5 percentage score
Male adolescents Danish populationa Non-mental disordersb Mental disordersb Depressedb
1004 9542 1162 358 116
55.28 (17.27) 86.70 (18.99) 66.27 (19.57) 43.66 (21.96) 31.91 (21.38)
a b
(Bech et al., 2003). (Christensen et al., submitted for publication).
respondents scoring between persons with non-mental and mental disorders (Table 1). When applying the WHO scoring for mental vulnerability (raw score of the WHO-5 ≤13), 44.2% of the respondents appeared to be at risk of depression, and in these cases the WHO suggests a more specific screening in a second step. As mentioned above, this rate of possible depression might be extremely elevated because of the diagnostic characteristics of the WHO-5 (high sensitivity, low specificity). When this subgroup was again screened for male depression with the more specific Gotland Scale of Male Depression, 35.2% of the adolescents showed possible signs of male depression. With respect to the total sample, the Gotland Scale generates a depression risk for 22.0% of the respondents (included are 0.9% with definite depression) with a mean sum score of 17.60 (4.29). 4.2. Characteristics of male distress symptoms and depressive symptoms In order to test the hypothesis that young men tend to report more male distress than traditional depressive symptoms, the mean sum scores of the distress and the depression subscales of the Gotland Scale were compared. Results document no difference in the mean sum scores of distress and depression subscales, independent of the risk of depression (non-risk group: distress subscore = 2.59 (1.92) and depression subscore = 3.39 (2.12); risk-group: distress subscore = 8.79 (2.99) and depression subscore = 8.81 (2.56)). When differentiating the sample depending on different patterns of the distress and depression subscale scores, non-depressive males reported more depressive symptoms than distress symptoms, and males at risk for male depression reported significantly more distress-symptoms than depressive symptoms (Table 2). Those at risk for male depression and reporting predominating distress symptoms had a significantly higher total score on the Gotland Scale compared to the sub-
Table 2 Percentage of different patterns of distress and depression symptoms (Gotland Scale of Male Depression, n = 999) Symptom patterns Distress subscore N depression subscore Distress subscore = depression subscore Distress subscore b depression subscore
No depression
Depression possible
n = 779
n = 220
27.2
45.5
17.2
10.0
55.6
44.5
χ2 = 24.36; p = 0.000.
group with predominating depressive symptoms (18.25 (4.65) vs. 16.89 (3.87); p = 0.000). 4.3. Dimensional structure of the Gotland Scale of Male Depression In order to prove whether the theoretical subscales ‘depression’ and ‘distress’ are complying with underlying empirical factors, a principal component analysis was conducted. Promax rotation was chosen because of the intercorrelatedness of the subscales (Spearman's Rho = 0.61; p = 0.000). The Kaiser–Olkin measure was = 0.877 and thus indicates that the inter-item correlations were highly appropriate for conducting a factor analysis. In order to select the number of factors, a screeplot was generated, which yielded two factors accounting for most of the variance (Table 3).
Table 3 Factor loadings of the 13 items of the Gotland Scale of Male Depression (male distress symptoms and loadings N0.4 are printed in bold) Items Difficulty making decisions Displeasure Family history of depression or suicide hopelessness Sleep problems Tiredness Irritability Overconsumption of alcohol or related substances Self-pity Behavior changes Being stressed Aggressiveness Being burned-out Proportion of explained variance Eigenvalue
Component 1
Component
0.738 0.569 0.559
−0.252 0.092 −0.215
0.540 0.538 0.527 0.496 0.492
0.191 0.019 0.118 0.302 −0.038
0.430 0.421 −0.271 −0.075 0.225 31.667 4.117
0.219 0.283 0.939 0.804 0.553 9.261 1.204
A.M. Möller Leimkühler et al. / Journal of Affective Disorders 98 (2007) 65–72 Table 4 Corrected item-total correlations of the Gotland Scale of Male Depression (highest correlations are printed in bold; all correlations are significant at p b 0.01) Symptoms
Total sample (n = 999)
No depression (n = 779)
At risk of depression (n = 220)
Being stressed Aggressiveness Being burned out Tiredness Irritability Difficulty making decisions Sleep problems Displeasure Overconsumption of alcohol/substances Behaviour changes Hopelessness Self-pity Family history of depression/suicide
0.478 0.513 0.624 0.610 0.628 0.389
0.351 0.358 0.483 0.518 0.474 0.263
0.249 0.352 0.276 0.262 0.455 0.267
0.576 0.541 0.440
0.477 0.348 0.307
0.215 0.330 0.309
0.516 0.544 0.477 0.337
0.316 0.353 0.315 0.246
0.349 0.447 0.239 0.333
The dominant first factor has an Eigenvalue of 4 and consists of a mixture of depressive symptoms and male distress symptoms explaining 32% of the variance. The minor second factor contains mainly male distress symptoms, but explains only 9% of the total variance. As the principal component analysis lends evidence to a unidimensional structure of the Gotland Scale with one major mixed depression–distress component, the theoretical subscales are not verified. 4.4. Clusters of subgroups depending on different symptom patterns In order to distinguish a ‘depressive’ and a ‘distress’ cluster in our sample, cluster center analyses were computed separately for the risk and the non-risk group. Cluster analysis is a technique for classifying data into clusters with the aim that the cases in the same cluster are as similar as possible and the cases in different clusters are as dissimilar as possible. For large samples, cluster center analysis is recommended because it is based on a more economic algorithm. For the subgroup of males at risk of male depression (n = 220), two cluster centers could be identified which differ significantly (distance = 2.10; p = 0.000) with the exception of the following: tiredness, difficulty making decisions, displeasure and overconsumption of alcohol or related substances. The second cluster, the ‘distress cluster’, includes those males who reported higher distress symptoms than
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those of the first ‘depressive cluster’. Elevated distress symptoms are also associated with a higher sum score of the Gotland Scale compared to lower distress symptoms (cluster 1) (20.92 (4.50) vs. 15.59 (2.47); p = 0.000). The findings concerning the non-risk subgroup (n = 779) are similar. Again, the two clusters differ significantly (distance = 1.84), while in the second ‘distress cluster’ all symptoms are significantly elevated ( p = 0.000) with the exception of self-pity, which is increased, although not significantly. Again, for the males belonging to the distress cluster, the total score of the Gotland Scale significantly exceeds that of the ‘depressive cluster’ (8.78 (2.18) vs. 4.10 (2.40); p = 0.000). 4.5. Best indicator of the risk of male depression Corrected item-total correlations were calculated to determine which individual item of the Gotland Scale contributed most to the scale total. Independent of the risk of depression, the male distress symptom ‘irritability’ appears to be the best indicator of male depression (Table 4). 5. Discussion 5.1. Reduced well-being Well-being, risk of male depression, and symptom profile were investigated in a sample of 1004 male adolescents who had been called up for registration for military service. The 18-year-old respondents reported a reduced well-being which ranged between the values for persons with non-mental and mental disorders. At first sight, these findings may be biased by the specific situation in which the respondents completed the questionnaires, because this is usually a very uncomfortable situation for young males. However, in another study (Möller-Leimkühler and Yücel, in preparation) male university students reported a well-being score of 43%, which is even worser than that of the present sample. Therefore, it is more plausible that these findings do reflect the consequences of increasing health risks in adolescents compared to all other age groups. In particular, the incidence rate of depression is highest in young adults, of whom 25% experience a depressive episode by the age of 24 (Kessler, Walters 1998). Research in adolescents has come to interpret the augmenting health strains in this age group as the costs of individualism (Hurrelmann, 1990; Eckersley and Dear, 2002). However, Galambos et al. (2006) had shown that depressive symptoms and expressed anger
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declined, whereas self-esteem increases in the critical years of emerging adulthood, thus referring to the agerelatedness of well-being. 5.2. Detection of male depression The Gotland Scale of Male Depression detected a substantial rate of young males (22%) probably suffering from male depression. The question whether this scale is superior compared to traditional depression questionnaires in that it identifies a higher rate of untreated males at risk of depression can not be answered because a traditional depression questionnaire was not included in the study, due to the need not to put the participation of the subjects in the study at risk. This is a principal limitation of the present study. 5.3. Male distress symptoms and depression Although there are several methodological limitations, data give support to the significance of male distress symptoms, which are reported simultaneously with common depressive symptoms in the present sample. Factor analysis revealed one dominant mixed depression–stress component which supports the originally supposed unidimensional structure of the Gotland Scale. In sum, there is no evidence for the hypothesis that depressive symptoms are masked by distress symptoms. At least, this is true for the present sample of male adolescents, who may more easily report depressive symptoms than males in older age groups. According to the results of the cluster center analysis of males at risk, elevated depressive symptoms are reported in most of the cases, but there is a different subgroup of males (38%, the ‘distress cluster’) reporting elevated distress symptoms, which result in the highest total scores of the sample. It can not be excluded that this finding may be due to a report bias if again two different subsyndromes are presumed: males at an elevated risk of depression might have underreported depressive symptoms compared to distress symptoms in order to keep a masculine image. When comparing symptom characteristics between the non-risk and risk group, depressive symptoms appear to be a general phenomenon among 18-year-old males. It can be supposed that depression does not develop directly by an aggravation of depressive symptoms, but indirectly by an aggravation of male distress symptoms. This conclusion is in line with the results of Bech, who could identify stress and aggression as male pathways to major depression in a Danish community study (2001). Consequently, the level of male distress symptoms may indicate an increased vulnerability for depression in males.
5.4. Male depression or unspecific male coping patterns? The data from this study lend only preliminary support to the concept of male depression, not only due to the restricted design of the study, but also due to the construction of the Gotland Scale of Male Depression. Though it is the only screening instrument available to date, it is limited because of its item development. Items such as aggressiveness, irritability or stress and burn-out each refer to complex constructs, which need a complex measurement but are assessed each by only one item. Moreover, they are not selective, but appear to overlap to a certain extent. Another question is whether the Gotland Scale of Male Depression covers all relevant aspects of how males may experience depression. There are several descriptions based on clinical experience in the literature (Pollack, 1998; Cochran and Rabinowithz, 2000; Real, 1998; Diamond, 2005), but these descriptions have not been used to construct male depression questionnaires for epidemiological research. One of the major problems is related to the specificity of the male distress symptoms. Do they justify classification of a new subtype of depression, or do they refer to comorbid conditions like personality disorders, alcohol dependence or ADHS? Rihmer (2004) has argued that, since male distress symptoms, in particular irritability, which appears as the most significant symptom of male depression in the present study, are also the leading features of depressive mixed states, and depressive mixed states are about twice as common in bipolar than in unipolar depression (Benazzi and Akiskal, 2005), it is possible that the male depressive syndrome is linked rather to bipolar depression than unipolar depression. Additionally, bipolar depression is often associated with deviant social behavior in adolescents (Dilsaver and Akiskal, 2005), and the suicide risk of bipolar patients is much higher than in unipolar patients (Rihmer and Kiss, 2002). Apart from aspects of comorbidity and potential misdiagnosis, male distress symptoms represent general externalizing coping strategies which are assumed to be linked to norms of masculinity. Dysfunctional patterns of male stress response may be especially pronounced in subgroups of males, if their male identity is threatened and fear of stigmatization of being ‘unmale’ arises. 6. Conclusions Further research is needed to clarify the specificity of male depression and the differential diagnoses of male depression, in particular bipolar depression. With regard
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to epidemiological research and clinical practice, it is recommended to consider male distress symptoms/male coping as additional diagnostic criteria in depression assessments in order to improve the detection of depression in men and facilitate early treatment. This is also important in order to avoid misdiagnoses like alcohol dependence or personality disorders, which may conceal depression in males. References Angst, J., Gastpar, M., Lépine, J.-P., Mendlewicz, J., Tylee, A., 2002. Gender differences in depression. Epidemiological findings from the European Depres I and II studies. European Archives of Psychiatry and Clinical Neuroscience 252, 201–209. Archer, J., 1994. Male Violence. Routledge, London. Bech, P., 1998. Quality of Life in the Psychiatric Patient. MosbyWolfe, London. Bech, P., 2001. Male depression: stress and aggression as pathways to major depression. In: Dawson, A., Tylee, A. (Eds.), Depression — Social and Economic Timebomb. British Medical Journal Books, London, pp. 63–66. Bech, P., Olsen, R.L., Kjoller, M., Rasmussen, N.K., 2003. Measuring well-being rather than the absence of distress-symptoms: a comparison of the SF-36 Mental Health subscale and the WHOFive Well-Being Scale. International Journal of Methods in Psychiatric Research 12, 85–91. Benazzi, F., Akiskal, H.S., 2005. Irritable–hostile depression: further validation as a bipolar depressive mixed state. Journal of Affective Disorders 84, 197–207. Christensen, K.S., Bech, P., Fink, P., submitted for publication. Measuring mental health outcomes in primary care. Cochran, S.V., Rabinowitz, F.E., 2000. Men and depression. Clinical and Empirical Perspectives. Academic Press, San Diego. Culbertson, F.M., 1997. Depression and gender. American Psychologist 52, 25–31. Diamond, J., 2005. The Irritable Male Syndrome. Rodale Inc., Emmaus. Dilsaver, S.C., Akiskal, H.S., 2005. High rate of unrecognized bipolar mixed states among destitute Hispanic adolescents referred for “major depressive disorder”. Journal of Affective Disorders 84, 179–186. Eckersley, R., Dear, K., 2002. Cultural correlates of youth suicide. Social Science and Medicine 55, 1892–1904. Egeland, J.A., Hostetter, A.M., Eshleman, S.K., 1983. Amish Study III: the impact of cultural factors on diagnosis of bipolar illness. American Journal of Psychiatry 140, 67–71. Fava, M., Nolan, S., Kradin, R., Rosenbaum, J., 1995. Gender differences in hostility among depressed and medical outpatients. The Journal of Nervous and Mental Disease 18, 10–14. Fombonne, E., 1994. Increased rates of depression: update of epidemiological findings and analytical problems. Acta Psychiatrica Scandinavica 90, 145–156. Galambos, N.L., Barker, E.T., Krahn, H.J., 2006. Depression, selfesteem, and anger in emerging adulthood: seven-year trajectories. Developmental Psychology 42, 350–365. Henkel, V., Mergl, R., Kohnen, R., Allgaier, A.-K., Möller, H.-J., Hegerl, U., 2004. Use of brief depression screening tools in primary care: consideration of heterogeneity in performance in different patient groups. General Hospital Psychiatry 26, 190–198.
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Research report
Subjective well-being and ‘male depression’ in male adolescents A.M. Möller Leimkühler a,⁎, J. Heller, N.-C. Paulus a
Department of Psychiatry, Ludwig-Maximilians-University of Munich, Nuβbaumstr. 7, D-80336 Munich, Germany Received 28 February 2006; received in revised form 10 July 2006; accepted 11 July 2006 Available online 11 September 2006
Abstract Background: The concept of male depression is based on the hypothesis that typical symptoms of depression in men often seem to be masked by non-typical male distress symptoms not considered in common depression inventories. Although there is a large amount of clinical evidence, scientific evidence is still lacking. The study aims at further validating the concept of male depression, by obtaining information on symptoms reported by males, and analyzing the dimensional structure of the Gotland Scale of Male Depression [Rutz, W., 1999. Improvement of care for people suffering from depression: The need for comprehensive education. International Clinical Psychopharmacology 14, 27–33.]. Methods: A community sample of male adolescents aged 18 (n = 1004) was asked to complete the WHO-5 Well-being Index [Bech, P., 1998. Quality of life in the psychiatric patient. London: Mosby-Wolfe.] and the Gotland Scale of Male Depression [Rutz, W., 1999. Improvement of care for people suffering from depression: The need for comprehensive education. International Clinical Psychopharmacology 14, 27–33.]. Principal component analysis with promax rotation was calculated to analyze the dimensional structure of the Gotland Scale. Cluster center analyses were used to classify the sample according to the symptoms' characteristics. Results: General well-being was rather reduced, and 22% of the respondents were seen to be at risk of male depression. There was no evidence for the hypothesis that young males tend to mask their depressive symptoms with distress symptoms. Depressive and male distress symptoms appeared to be mixed in a dominant factor, while male distress symptoms constitute an additional minor factor. A cluster of 38% of those at risk for depression could be identified who reported significantly elevated male distress symptoms. Irritability turned out to be the single item of the Gotland Scale with the highest item-total correlation. Limitations: Risk of depression was not assessed by an additional depression scale or evaluated by a clinical rating. Conclusions: Male distress symptoms should be considered when diagnosing depression in men. Further research is needed with respect to comorbidity and differential diagnoses, which should also include bipolar depression. © 2006 Elsevier B.V. All rights reserved. Keywords: Male depression; Adolescents; Irritability; Distress symptoms
1. Introduction ⁎ Corresponding author. Tel.: +49 89 5160 5785; fax: +49 89 5160 5522. E-mail address: [email protected] (A.M. Möller Leimkühler). 0165-0327/$ - see front matter © 2006 Elsevier B.V. All rights reserved. doi:10.1016/j.jad.2006.07.007
The concept of male depression is based on studies of an educational program on depression and suicide prevention on the Swedish Island of Gotland in the 1990s (Rutz et al., 1995, 1999). Rutz has postulated a ‘male depressive syndrome’, which is supposed to differ from
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common depressive symptoms among females. It includes sudden and periodically lowered stress tolerance in otherwise stress-resistant men, impulsive–aggressive or psychopathic behavior in otherwise nonpsychopathic men, and suddenly occurring endorphin- or serotoninrelated behavior such as alcohol and/or drug abuse or abusive equivalents (workaholism, excessive jogging, etc.) in otherwise non-abusive men. According to this, depression in men often seems to be masked by atypical symptoms like irritability, anger attacks, hostile–aggressive–abusive behavior and alexithymia, which may be misleading when trying to detect depression in men. As symptoms such as irritability and anger are not included in the international leading classification systems, it is not surprising that no gender differences in the quality of depressive symptoms in male patients diagnosed as depressive according to these classification systems have been found. The Gotland studies have resulted in a screening instrument for detecting depression in men, “The Gotland Scale of Male Depression”, which has recently been validated (Bech, 2001; Zierau et al., 2002). It consists of typical depressive symptoms as well as emotional distress symptoms which are supposed to predominate in males. The concept of a specific male depressive syndrome is strengthened by findings from the Amish (Egeland et al., 1983) and Jews (Levav et al., 1993) which show an equal sex distribution of unipolar depression when alcohol abuse is not a confounding diagnostic factor. Although the term ‘male depression’ has received increasing attention in the media, scientific evidence is still limited (Rochlen et al., 2005). Previous studies with respect to gender differences in depressive symptoms consistently found that men report fewer depressive symptoms than women, and few gender differences could be observed in the quality of symptoms in community studies. However, the diagnostic schedules mostly used in epidemiological research have focused on typical depressive symptoms, so that ‘male’ symptoms may have been overlooked. There are a few findings indicating that potentially ‘male’ symptoms, such as non-verbal hostility (Katz et al., 1993) and trait hostility (Fava et al., 1995) are more prevalent in depressed men. Findings from Angst et al. (2002) indicate that untreated males of a community sample report depressed mood significantly less frequently than females, and that treated depressed males report fewer symptoms than females. All symptoms assessed were more prevalent in females, except the need for alcohol in periods of reduced well-being. Focussing particularly on gender-related pathways to depression, results of a Danish population study (Bech, 2001) indicate that, in females, early symptoms of
reduced well-being pass directly into major depression, whereas males gradually pass into depression via stress, aggression and alcohol abuse. Another Danish study on male out-patients treated for alcohol dependency (Zierau et al., 2002) found that when non-typical symptoms as well as typical depressive symptoms were assessed (Gotland Scale of Male Depression), 39% of the patients were found to have a probable or definite depression, while depression was detected only in 17% of the patients when a traditional depression inventory was used. With regard to depressive inpatients, the results of two Austrian studies (Winkler et al., 2004, 2005) suggested that men had higher scores in affective rigidity and blunted effect and suffered from anger attacks more often. In a German study with depressive inpatients (Möller-Leimkühler et al., 2004), neither the frequency nor the mean scores of the ‘male’ symptoms differed significantly between males and females. However, ‘male’ symptoms like irritability, aggressiveness and antisocial behavior were more strongly intercorrelated in depressed males than in depressed females. With respect to different male age-groups, young men seem to be a special risk group, not only with regard to increasing rates of offending behavior (Archer, 1994), conduct disorders (Smith, 1995), and increasing psychological distress (Jorm and Butterworth, 2006), but also with regard to depression. Since the 1980s rates of depression in young men have also been increasing (Klerman and Weissman, 1989; Fombonne, 1994; Culbertson, 1997), but at the same time there is a poor treatment rate of depressed young men, which is especially true for those aged 14 to 24 years (Wittchen et al., 1999). It is supposed, that this is mainly due to selfperceptions and norms of appropriate masculinity (Lin and Parikh, 1999; Möller-Leimkühler, 2002). However, undertreatment of depression is not only due to a lack of help-seeking, but is also due to the problem of detecting depression. 2. Aim of the study With respect to male depression, there is a special need to investigate community samples because “male” depressive symptoms seem to be more pronounced in non-clinical groups, and because the effects of male help-seeking behavior result in a strong selection bias in treated samples. Thus, the aim of the present study is to obtain further information about male distress symptoms in the context of possible depression, and to further validate the Gotland Scale of Male Depression by
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conducting a community survey among male adolescents. The following issues will be addressed: – general well-being – risk of male depression – characteristics of male distress symptoms and traditional depressive symptoms – dimensional structure of the Gotland Scale of Male Depression – clusters of subgroups depending on different symptom patterns, and – best indicators of the risk of male depression. 3. Methods and subjects 3.1. WHO-5 Well-being Index The WHO-Five Well-being Index (WHO-5) was developed from the WHO-10 Well Being Index (Bech, 1998; Heun et al., 1999). It is a brief self-rating screening instrument for depression covering the three core items of depression according to ICD-10: mood, interests, and energy. Each of the five items is rated on a 6-point Likert scale from 0 (= not present) to 5 (= constantly present). Within the range from 0 to 25, a raw score ≤ 13 suggests poor well-being, and that respondents should be tested for depression (WHO, 1998). Additionally, the raw score is transformed to a percentage score from range 0 (worst thinkable well-being) to 100 (best thinkable well-being). The WHO-5 is a highly sensitive instrument, but its specificity is rather low, so that a relatively high rate of false-positive screenings can be expected (Henkel et al., 2004). 3.2. The Gotland Scale of Male Depression The Gotland Scale of Male Depression (Rutz et al., 1995; Rutz, 1999; Walinder and Rutz, 2001) is a screening instrument for male depression consisting of 13 items which are rated on a 4-point Likert scale from 0 (=not present) to 3 (=present to a high degree). Originally the scale was developed as a unidimensional construct. Later, Zierau et al. (2002) proposed a splitting into two subscales: the distress subscale (7 items: being stressed, aggressiveness, irritability, feeling of displeasure, overconsumption of alcohol or related substances, behavior changes, greater tendency to self-pity) and the depression subscale (6 items: being burned out, tiredness, difficulty making decisions, sleep problems, hopelessness, family history of depression or suicide). The total score of the 13 items has a theoretical range from 0 to 39. The standardisation of the total score is: 0–12 = no depression,
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13–26 = probable depression and 27–39 = definite depression. Psychometric properties were acceptable when used in a population with alcohol abuse disorder (Zierau et al., 2002). In the present study the internal consistency (Cronbach's alpha) for the total scale was 0.81, for the distress subscale 0.71, and for the depression subscale 0.65. Both subscales were significantly intercorrelated (Spearman's Rho = 0.61; p = 0.000). Convergent validity of the Gotland Scale was satisfying due to its correlation with the WHO-5 (Spearman's Rho = −0.56; p = 0.000). 3.3. Subjects In Germany at the age of 18 all young men are called up to register for military or alternative service at an authority called “Kreiswehrersatzamt” in their region. These young men represent an age-homogenous crosssectional population sample. For this reason, and in order to reach a maximum number of young males who could be asked to participate in the study, the “Kreiswehrersatzamt” of Munich was contacted. In cooperation with the medical staff all young men who had been called up for registration from July to September 2003 were asked to complete the self-rating scales during the waiting time between their physical examinations. The study was presented as an investigation of the University of Munich focussing on stress experience and subjective well-being in young men. It was emphasized that participation was voluntary, data collection and processing anonymous, that the study was completely independent of the physical examination and that the only reason for addressing these young men was research practicability. The completed questionnaires were returned in closed envelopes. 1004 young men could be included into the study with a response rate of 95%. 4. Results The mean age of the young men was 18.5 years (1.18). Most of them (78.2%) were school pupils with (or attaining) the secondary school level I certificate or the certificate from vocational schools (48.7%); 41.1% of them were attaining the general qualification for university entrance. 52.3% lived in Munich, 47.7% in small towns and villages surrounding Munich. 4.1. Well-being and risk of (male) depression According to WHO-5, the mean percentage score is 55.28 (17.27). Compared to norm values of the Danish population (no German data available), this result demonstrates a rather reduced well-being of the
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Table 1 General well-being in male adolescents of the present study compared to a population sample and different clinical samples (WHO-5 Wellbeing Index) Sample
n
WHO-5 percentage score
Male adolescents Danish populationa Non-mental disordersb Mental disordersb Depressedb
1004 9542 1162 358 116
55.28 (17.27) 86.70 (18.99) 66.27 (19.57) 43.66 (21.96) 31.91 (21.38)
a b
(Bech et al., 2003). (Christensen et al., submitted for publication).
respondents scoring between persons with non-mental and mental disorders (Table 1). When applying the WHO scoring for mental vulnerability (raw score of the WHO-5 ≤13), 44.2% of the respondents appeared to be at risk of depression, and in these cases the WHO suggests a more specific screening in a second step. As mentioned above, this rate of possible depression might be extremely elevated because of the diagnostic characteristics of the WHO-5 (high sensitivity, low specificity). When this subgroup was again screened for male depression with the more specific Gotland Scale of Male Depression, 35.2% of the adolescents showed possible signs of male depression. With respect to the total sample, the Gotland Scale generates a depression risk for 22.0% of the respondents (included are 0.9% with definite depression) with a mean sum score of 17.60 (4.29). 4.2. Characteristics of male distress symptoms and depressive symptoms In order to test the hypothesis that young men tend to report more male distress than traditional depressive symptoms, the mean sum scores of the distress and the depression subscales of the Gotland Scale were compared. Results document no difference in the mean sum scores of distress and depression subscales, independent of the risk of depression (non-risk group: distress subscore = 2.59 (1.92) and depression subscore = 3.39 (2.12); risk-group: distress subscore = 8.79 (2.99) and depression subscore = 8.81 (2.56)). When differentiating the sample depending on different patterns of the distress and depression subscale scores, non-depressive males reported more depressive symptoms than distress symptoms, and males at risk for male depression reported significantly more distress-symptoms than depressive symptoms (Table 2). Those at risk for male depression and reporting predominating distress symptoms had a significantly higher total score on the Gotland Scale compared to the sub-
Table 2 Percentage of different patterns of distress and depression symptoms (Gotland Scale of Male Depression, n = 999) Symptom patterns Distress subscore N depression subscore Distress subscore = depression subscore Distress subscore b depression subscore
No depression
Depression possible
n = 779
n = 220
27.2
45.5
17.2
10.0
55.6
44.5
χ2 = 24.36; p = 0.000.
group with predominating depressive symptoms (18.25 (4.65) vs. 16.89 (3.87); p = 0.000). 4.3. Dimensional structure of the Gotland Scale of Male Depression In order to prove whether the theoretical subscales ‘depression’ and ‘distress’ are complying with underlying empirical factors, a principal component analysis was conducted. Promax rotation was chosen because of the intercorrelatedness of the subscales (Spearman's Rho = 0.61; p = 0.000). The Kaiser–Olkin measure was = 0.877 and thus indicates that the inter-item correlations were highly appropriate for conducting a factor analysis. In order to select the number of factors, a screeplot was generated, which yielded two factors accounting for most of the variance (Table 3).
Table 3 Factor loadings of the 13 items of the Gotland Scale of Male Depression (male distress symptoms and loadings N0.4 are printed in bold) Items Difficulty making decisions Displeasure Family history of depression or suicide hopelessness Sleep problems Tiredness Irritability Overconsumption of alcohol or related substances Self-pity Behavior changes Being stressed Aggressiveness Being burned-out Proportion of explained variance Eigenvalue
Component 1
Component
0.738 0.569 0.559
−0.252 0.092 −0.215
0.540 0.538 0.527 0.496 0.492
0.191 0.019 0.118 0.302 −0.038
0.430 0.421 −0.271 −0.075 0.225 31.667 4.117
0.219 0.283 0.939 0.804 0.553 9.261 1.204
A.M. Möller Leimkühler et al. / Journal of Affective Disorders 98 (2007) 65–72 Table 4 Corrected item-total correlations of the Gotland Scale of Male Depression (highest correlations are printed in bold; all correlations are significant at p b 0.01) Symptoms
Total sample (n = 999)
No depression (n = 779)
At risk of depression (n = 220)
Being stressed Aggressiveness Being burned out Tiredness Irritability Difficulty making decisions Sleep problems Displeasure Overconsumption of alcohol/substances Behaviour changes Hopelessness Self-pity Family history of depression/suicide
0.478 0.513 0.624 0.610 0.628 0.389
0.351 0.358 0.483 0.518 0.474 0.263
0.249 0.352 0.276 0.262 0.455 0.267
0.576 0.541 0.440
0.477 0.348 0.307
0.215 0.330 0.309
0.516 0.544 0.477 0.337
0.316 0.353 0.315 0.246
0.349 0.447 0.239 0.333
The dominant first factor has an Eigenvalue of 4 and consists of a mixture of depressive symptoms and male distress symptoms explaining 32% of the variance. The minor second factor contains mainly male distress symptoms, but explains only 9% of the total variance. As the principal component analysis lends evidence to a unidimensional structure of the Gotland Scale with one major mixed depression–distress component, the theoretical subscales are not verified. 4.4. Clusters of subgroups depending on different symptom patterns In order to distinguish a ‘depressive’ and a ‘distress’ cluster in our sample, cluster center analyses were computed separately for the risk and the non-risk group. Cluster analysis is a technique for classifying data into clusters with the aim that the cases in the same cluster are as similar as possible and the cases in different clusters are as dissimilar as possible. For large samples, cluster center analysis is recommended because it is based on a more economic algorithm. For the subgroup of males at risk of male depression (n = 220), two cluster centers could be identified which differ significantly (distance = 2.10; p = 0.000) with the exception of the following: tiredness, difficulty making decisions, displeasure and overconsumption of alcohol or related substances. The second cluster, the ‘distress cluster’, includes those males who reported higher distress symptoms than
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those of the first ‘depressive cluster’. Elevated distress symptoms are also associated with a higher sum score of the Gotland Scale compared to lower distress symptoms (cluster 1) (20.92 (4.50) vs. 15.59 (2.47); p = 0.000). The findings concerning the non-risk subgroup (n = 779) are similar. Again, the two clusters differ significantly (distance = 1.84), while in the second ‘distress cluster’ all symptoms are significantly elevated ( p = 0.000) with the exception of self-pity, which is increased, although not significantly. Again, for the males belonging to the distress cluster, the total score of the Gotland Scale significantly exceeds that of the ‘depressive cluster’ (8.78 (2.18) vs. 4.10 (2.40); p = 0.000). 4.5. Best indicator of the risk of male depression Corrected item-total correlations were calculated to determine which individual item of the Gotland Scale contributed most to the scale total. Independent of the risk of depression, the male distress symptom ‘irritability’ appears to be the best indicator of male depression (Table 4). 5. Discussion 5.1. Reduced well-being Well-being, risk of male depression, and symptom profile were investigated in a sample of 1004 male adolescents who had been called up for registration for military service. The 18-year-old respondents reported a reduced well-being which ranged between the values for persons with non-mental and mental disorders. At first sight, these findings may be biased by the specific situation in which the respondents completed the questionnaires, because this is usually a very uncomfortable situation for young males. However, in another study (Möller-Leimkühler and Yücel, in preparation) male university students reported a well-being score of 43%, which is even worser than that of the present sample. Therefore, it is more plausible that these findings do reflect the consequences of increasing health risks in adolescents compared to all other age groups. In particular, the incidence rate of depression is highest in young adults, of whom 25% experience a depressive episode by the age of 24 (Kessler, Walters 1998). Research in adolescents has come to interpret the augmenting health strains in this age group as the costs of individualism (Hurrelmann, 1990; Eckersley and Dear, 2002). However, Galambos et al. (2006) had shown that depressive symptoms and expressed anger
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declined, whereas self-esteem increases in the critical years of emerging adulthood, thus referring to the agerelatedness of well-being. 5.2. Detection of male depression The Gotland Scale of Male Depression detected a substantial rate of young males (22%) probably suffering from male depression. The question whether this scale is superior compared to traditional depression questionnaires in that it identifies a higher rate of untreated males at risk of depression can not be answered because a traditional depression questionnaire was not included in the study, due to the need not to put the participation of the subjects in the study at risk. This is a principal limitation of the present study. 5.3. Male distress symptoms and depression Although there are several methodological limitations, data give support to the significance of male distress symptoms, which are reported simultaneously with common depressive symptoms in the present sample. Factor analysis revealed one dominant mixed depression–stress component which supports the originally supposed unidimensional structure of the Gotland Scale. In sum, there is no evidence for the hypothesis that depressive symptoms are masked by distress symptoms. At least, this is true for the present sample of male adolescents, who may more easily report depressive symptoms than males in older age groups. According to the results of the cluster center analysis of males at risk, elevated depressive symptoms are reported in most of the cases, but there is a different subgroup of males (38%, the ‘distress cluster’) reporting elevated distress symptoms, which result in the highest total scores of the sample. It can not be excluded that this finding may be due to a report bias if again two different subsyndromes are presumed: males at an elevated risk of depression might have underreported depressive symptoms compared to distress symptoms in order to keep a masculine image. When comparing symptom characteristics between the non-risk and risk group, depressive symptoms appear to be a general phenomenon among 18-year-old males. It can be supposed that depression does not develop directly by an aggravation of depressive symptoms, but indirectly by an aggravation of male distress symptoms. This conclusion is in line with the results of Bech, who could identify stress and aggression as male pathways to major depression in a Danish community study (2001). Consequently, the level of male distress symptoms may indicate an increased vulnerability for depression in males.
5.4. Male depression or unspecific male coping patterns? The data from this study lend only preliminary support to the concept of male depression, not only due to the restricted design of the study, but also due to the construction of the Gotland Scale of Male Depression. Though it is the only screening instrument available to date, it is limited because of its item development. Items such as aggressiveness, irritability or stress and burn-out each refer to complex constructs, which need a complex measurement but are assessed each by only one item. Moreover, they are not selective, but appear to overlap to a certain extent. Another question is whether the Gotland Scale of Male Depression covers all relevant aspects of how males may experience depression. There are several descriptions based on clinical experience in the literature (Pollack, 1998; Cochran and Rabinowithz, 2000; Real, 1998; Diamond, 2005), but these descriptions have not been used to construct male depression questionnaires for epidemiological research. One of the major problems is related to the specificity of the male distress symptoms. Do they justify classification of a new subtype of depression, or do they refer to comorbid conditions like personality disorders, alcohol dependence or ADHS? Rihmer (2004) has argued that, since male distress symptoms, in particular irritability, which appears as the most significant symptom of male depression in the present study, are also the leading features of depressive mixed states, and depressive mixed states are about twice as common in bipolar than in unipolar depression (Benazzi and Akiskal, 2005), it is possible that the male depressive syndrome is linked rather to bipolar depression than unipolar depression. Additionally, bipolar depression is often associated with deviant social behavior in adolescents (Dilsaver and Akiskal, 2005), and the suicide risk of bipolar patients is much higher than in unipolar patients (Rihmer and Kiss, 2002). Apart from aspects of comorbidity and potential misdiagnosis, male distress symptoms represent general externalizing coping strategies which are assumed to be linked to norms of masculinity. Dysfunctional patterns of male stress response may be especially pronounced in subgroups of males, if their male identity is threatened and fear of stigmatization of being ‘unmale’ arises. 6. Conclusions Further research is needed to clarify the specificity of male depression and the differential diagnoses of male depression, in particular bipolar depression. With regard
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