Introduction

Claiming the lives of boys’ and men across all age groups, male suicide, and by extension male depression, is a significant global health issue [1]. Depression and suicide sex differences research has highlighted important patterns and diversity, including higher rates of diagnosed depression in women, and male suicide rates that are three times that of females [2]. To more fully understand and effectively respond to this public health problem, a range of approaches, including gender analyses, have been used to elaborate on men’s (and women’s) depression and suicide [3]. The key intent of the work focused on men’s depression and suicide risk has been to advance the development and implementation of tailored clinical services to promote mental health and ultimately reduce male suicide [4]. In line with this, the current review focuses on men’s depression and suicide, exploring the extant research to suggest some ways forward for the field to continue promoting the mental health of men. In linking male depression and suicide here, it is key to note that we are not espousing depression as the only route to suicide; instead, we offer a review of two deeply entwined issues to better understand and address the discordant relationship between men’s low rates of formally diagnosed depression and high rates of suicide [5•]. Specifically, the current review discusses recent literature addressing the following: (1) the case for male depression as a distinct clinical phenotype and (2) men’s help-seeking and engagement with professional mental health care.

The Case for Male Depression as a Distinct Clinical Phenotype

Findings across Western and non-Western countries that women are diagnosed with depression twice as often as men have given rise to sex differences research and gender analyses aiming to more fully interrogate and address this widely reported finding [6]. One long-standing hypothesis, originating in the work of Rutz and colleagues [7], is that some men’s expression of depression is characterized by symptoms that are not captured by diagnostic criteria and commonly used clinical depression screening tools. The net result of this is that depression in men is missed or mis-diagnosed—and by extension undertreated by practitioners [8, 9••]. The diagnostic criteria for major depressive disorder focus on symptoms including sadness, anhedonia, and worthlessness among somatic domains of sleep and appetite disturbance. While these symptom clusters accurately reflect the experience of depression for many men, a broader conceptualization may also be required [10, 11]. In an attempt to clarify this distinction in symptomatology, researchers have identified a range of externalizing symptoms that differentiate a phenotypic variant of male depression. While conceding these externalizing symptoms may exist within and across an array of mood and other disorders, over the last two decades, studies have consistently indicated, albeit in varying configurations and constructs, that men experiencing depression are more likely than women to exhibit symptoms of irritability, anger, substance misuse, risk-taking, impulsivity, and over involvement in work [8, 11, 12, 13, 14•]. Moreover, these externalizing symptoms of male depression are also risk factors for suicide [15]. Within this literature, the much cited Martin et al.’s [9••] sex differences study, drawn from a nationally representative US sample, narrowed externalizing male depressive symptoms to anger attacks/aggression, substance misuse, and risk-taking while acknowledging that men were also likely to endorse many traditional depression symptoms. A systematic review and meta-analysis of 32 studies comprising a total of 108,260 participants synthesized work addressing sex differences in men and women with depression [14•], confirming that men with depression reported substance misuse, risk-taking, and poor impulse control more often, and with more intensity, than women with depression.

A number of tools have been developed to more thoroughly evaluate externalizing symptoms of male depression. The Gotland Male Depression Scale (GMDS; [13]) was the first of its kind, including a range of externalizing and prototypic symptoms. The GMDS has been criticized for its unreliable factor structure and inconsistent results [16]. Subsequently, the Masculine Depression Scale (MDS; [17]) was developed, but was also critiqued for a two-dimensional structure, leading to the more recent development of the Male Depression Risk Scale (MDRS) in an effort to address previous psychometric limitations [12]. Initial construct validity studies of the MDRS support its use [15], with the MDRS demonstrating structural stability, stable correlation with prototypic measures of depression (i.e., PHQ-9; [18]), and reliable differences between the sexes and test-retest validity within individuals [12, 19•]. The MDRS comprises six externalizing depression symptom domains: (1) emotion suppression, (2) drug use, (3) alcohol use, (4) anger and aggression, (5) somatic symptoms, and (6) risk-taking via self-report (relative to the preceding month). Originally developed in Australia, the MDRS was re-validated in a nationally representative Canadian male sample and found to have sensitivity relative to the PHQ-9 in identifying men with a recent suicide attempt [20•]. This finding built on previous research reporting that men with an externalizing depression symptom profile were significantly more likely to have had a recent suicide plan or attempt [21]. Comparing by age, younger Canadian men (18–25 years) reported markedly higher suicidal ideation in the context of externalizing symptoms of depression compared with older men [20•].

Taken together, empirical findings that suggest externalizing symptoms may be a particular phenotypic feature of depression in men have grown significantly, as have assertions lobbying clinical attention to screening for externalizing symptoms among men in conjunction with current “gold standard” self-report scales for assessing prototypic depression (i.e., the PHQ-9). As the field of study into male depression continues to evolve, future studies will address unresolved issues related to the phenomenology and assessment of depression in men. Cavanagh et al. [14•] and others [8, 12] have not argued for adjustments to established prototypic clinical tools used to diagnose depression in males. Instead, the case for male depression has focused on establishing the clinical relevance of externalizing depressive symptoms and associations with suicidality, proffering the potential of this work to advance clinical efficiencies for better identifying men at risk.

Researchers have theorized that driving these externalizing symptoms of depression are men’s alignments to masculine norms, the socially prescribed rules for how a man should behave [17, 22]. Supporting this, Rice and colleagues [12] reported an interaction between sex (male/female) and conformity to masculine norm categories for externalizing depression symptoms, but not for prototypic symptoms assessed by the PHQ-9, indicating a gender effect for externalizing symptoms but not for prototypic symptoms. Genuchi and Mitsunaga [23] used the MDS to highlight college men as more often exhibiting externalized depressive symptoms when compared with college women. Asserted here was that men’s experiences and expressions of a distinct externalizing set of symptoms were influenced by their alignment to masculine norms [23]. Genuchi and Valdez [24] also examined how adherence to masculine gender role norms and anger predicted depressive symptoms in college men, reporting that trait anger moderately predicted depressive symptoms; however, no masculine norms were associated with male students’ endorsement of depressive symptoms. Some qualitative work has explored the differences between men’s diverse expressions of masculinity (known as masculinities) and offered inductively derived insights for why anger, substance misuse, and self-isolating practices might pass as typical masculine behaviors—rather than be indicative of, and formally evaluated as depressive symptoms. Specifically, men’s alignment to idealized masculinities that condone the expression of anger, substance misuse, and solitary pursuits as every day manly practices is purported to mask internalizing depressive symptoms [25] and suicidality [26]. In summary, the case for male depression continues to be finessed but is increasingly supported by population studies and meta-analytic work [9••, 14•].

Men’s Help-Seeking and Engagement with Professional Mental Health Care

Widely reported in the literature is men’s reticence for seeking professional mental health care [27] and sex differences wherein males comprise only a third of those seeking help for mental health concerns [28]. However, in the context of depression and suicidality, there is much diversity in men’s help-seeking and their engagement with professional mental health care. While many men lack insight or disavow depressive symptoms or suicide risk, in turn denying the need for professional help [27], up to 60% of men who die by suicide have accessed health care services in the year prior to their death [29]. This contrast, often positioned as a binary (i.e., men refusing care versus men in care), operates across a continuum of refusing care, being in care, and being lost to follow-up (between care). Two distinct bodies of work preside to explain men’s mental health help-seeking. The first has focused on describing factors influencing men’s resistance to seeking professional mental health care. A second, somewhat emergent literature has begun to investigate men’s engagement with professional mental health care to better understand what works clinically, as well as what adjustments might reduce the number of men “lost to follow-up” and those who suicide despite seemingly being “in care.”

The work describing men’s reticence for seeking help for depression and suicidality has highlighted a range of important issues. These include low literacy [30], social stigma and self-stigma [3], and fear of being seen as weak for having a mental illness, a perceived deficit amplified by some men’s inability to self-manage and/or conceal their ailment amid giving in to “needing” as well as “taking” professional help [31•]. Men’s resistance to help-seeking has most often been explained by their alignments to masculine norms (e.g., strength, stoicism, and self-reliance) [31•]. Seidler and colleagues’ [32••] review of 37 men’s depression help-seeking studies acknowledged the potential for some masculine ideals to affirm and norm men’s mental health help-seeking. This review suggested that strength- and courage-based masculine norms could be used to promote men’s depression help-seeking [32••]. This position was supported in a recent Australian randomized controlled trial reporting that a male-focused documentary on men’s mental health had the capacity to shift adherence to maladaptive masculine norms and improve men’s help-seeking intentions [33]. The influence of these de-stigmatizing efforts has likely added positively to the recent increase in men’s help-seeking for mental health concerns [34].

In addition to these broader society-wide efforts, related literature has investigated a range of individual factors potentially influencing men’s help-seeking intentions. Call and Shafer [35] found that male depression symptoms alone (i.e., aggression, substance misuse) did not increase the odds of men seeking help for depression. Rice et al. [16] reported that men with unremitting prototypic depression symptoms over 15 weeks experienced greater help-seeking barriers than those with resolved symptoms or no symptoms. Adding to this, Ogrodniczuk et al. [36] highlighted the juxtaposition embedded in Canadian men’s acknowledgement that depression was a serious health concern amid self-reporting that they were poorly informed, and without the tools necessary to access help themselves. Collectively, these findings regarding men’s help-seeking intentions confirmed significant knowledge deficits and barriers related to treatment for depression and suicidality among men, pointing to the potential benefits of tailored public health campaigns and targeted information (e.g., [33]). While men’s reticence for depression and suicidality help-seeking may be reduced by strength-based masculinities, public awareness raising and de-stigmatizing efforts [31•], the focus on men’s engagement with professional mental health also bares many complexities and challenges for men who do access services.

Driven by consistent findings that up to 60% of men who suicide have accessed professional health care services in the year leading up to their death [29], research investigating men’s engagement with professional mental health care has grown in recent times. The need for, as well as the intricacies of this work was highlighted in a study by Wide et al. [37•], wherein four of the 97 male respondents indicated current suicidal thoughts (via a confidential demographic questionnaire) in the clinic waiting room ahead of seeing their family physician. However, in the post-consult check of the four men’s medical notes, there was no suggestion that the men had disclosed suicidal thoughts to their physician. That four respondents were potentially at risk for suicide amid engaging professional help [37•] underscored the need to better understand the interplay between men’s help-seeking and professional health services [38]. Some work has investigated men’s perspectives about, and preferences for professional care. Whittle et al.’s [39] review of 17 studies investigating men’s accounts of depression and suicidality indicated penchants for practical solutions and problem solving. Berger et al. [40] reported that having a genuine connection and mutual understanding with clinicians was critical to men’s willingness to talk openly about their depression. Among men who had received psychotherapy for depressive symptoms, the benefits of active strength-based approaches to empower and bridge men toward effective self-management of depressive symptoms were highlighted [41]. Based on findings from Seidler et al. [41], exploration of men’s depression treatment experiences, three recommendations were offered to improve men’s engagement with professional mental health care: (1) orient to system, (2) establish trust and share control, and (3) action emphasis toward empowerment.

Building on the literature describing men’s experiences of professional mental health care services has been an effort to develop guidelines for working with boys and men. Seidler et al.’s [42•] scoping review of 46 articles reporting recommendations for treating men underscored the need for clinician’s to reflect on the influence of their own, as well as the client’s gender socialization, the importance of providing clearly structured, transparent and goal-oriented interventions, and the incorporation of strength-based approaches to build rapport and therapeutic alliances. Seidler et al.’s [42•] review argued for, and mapped gender-sensitized clinical services as the means to more fully engaging men in psychological treatments, with practitioners and researchers in the field echoing these calls, most recently in a Delphi expert consensus study [43]. Moreover, Grace et al.’s [44] study of service providers’ perspectives reported that creating safety, trust, rapport, and meaningful relationships was the gateway to sustained connection with professional services. The recently released American Psychological Association guidelines for psychological practice lobbied psychologists with 10 gender-based “strategies” for working with boys and men [45] and have drawn diverse ontological, epistemological, and political debates [46]. This has been somewhat divisive with oppositional sides viewing the guidelines as positioning men and masculinity as the problem versus a lack of system reform for the services offered to men [47]. A further issue for the field is that marginalized subgroups of men, including gay and Indigenous men, might have their experiences and needs subsumed or assumed to fit within an overarching, all-encompassing masculinity framework (wherein gender vis-à-vis masculinity is de-linked from other social determinants of health) [48, 49].

In summary, it is important to recognize that some men’s reticence for seeking help prevails. Therefore, reformulating restrictive masculine norms by affirming men’s mental health challenges and uptake of professional care is critical. Likewise, literature addressing men’s engagement with professional mental health care has shed important light on strategies intended to optimize male care for depression and suicidality.

Conclusion

By recognizing male depression symptoms—both prototypic and externalizing—and being cued to the barriers and the nuances of men’s help-seeking for depression and suicidality, clinical services can be adjusted to afford important benefits to men. These adjustments are, however, reliant on translating long-standing depression and suicide sex differences work, as well as emergent gender-sensitized guidelines to tailor clinical services. To clarify, the findings from, and discussion of this recent literature are not solely a call to action for practitioners; rather, a need for reciprocity is acknowledged wherein clinical services also shape research and policy to advance men’s mental health. Related to this point, “help” for men’s depression and suicidality has increasingly diversified to peer- and community-based approaches as well as interventions offered through social media and e-health platforms [50, 51]. Much of this promising work can augment—and shape and be shaped by—clinical services, in collectively better understanding and addressing the discordant relationship between men’s low rates of formally diagnosed depression and high suicide rates [5•].

Though much of the work in men’s depression and suicidality originates from sex differences research, the potential benefits of tailored men’s mental health services are increasingly evident and critically important. In sum, advances in screening, diagnosing, and effectively treating male depression and suicidality have essential benefits for all—women, children, other men, and those who identify on the continuums between male and female binaries. The multiple “causes” driving men’s depression and suicide work are therefore worthy of continued investment from a social justice viewpoint, and the capacity for diminishing the emotional and economic burden and suffering that accompany male depression and suicide.