He held his face in his hands and sobbed. “I wish I had sought help sooner.”
I looked across at his frail frame, as he sat in his wheelchair.
Akash (name changed) had been clinically depressed for months, and the pressure of work and the demands of family overwhelmed him to such an extent that he decided to end his life. Except that the jump from the 5th floor of his office building only landed him with a spinal cord injury, which meant complete and irreversible paralysis below his neck.
“This life is worse than the one I had previously. I am dying a million deaths every day.”
He sobbed uncontrollably for a few minutes and then we went on further, into our session.
In separate incidents that made it to the news this past week, two ostensibly (and highly) successful men committed suicide. There are several more such cases that happen every day that go unreported, and it made me reflect on the issue of depression in men that we just don’t talk about. I am not even going to use a euphemism such as “stress” instead of depression, because that would mean downplaying a serious issue. Using euphemisms tend to become a nice way to shove things under the carpet, hoping they would magically disappear. But the reality is much starker.
“Boys don’t cry.”
How many times have we said this to our boys or heard it ourselves? From when we are young we are told to behave in certain ways, which in turn become ingrained behaviors. We condition boys from a very young age to not express emotion, equating emotions with weakness.
Men are told to be strong, to be in control of themselves, and consequently perceive expressing their innermost feelings as a threat to their masculinity. Where it gets far more troubling is when you couple it with fear of failure, a constant striving to be successful, to never take your eyes off of ambition, on top of the expectation to ascribe to beliefs such as “Mard ko dard nahin hota” (“Men don’t feel pain”).
Here’s the inevitable reality though. Men will experience moments of despair, feelings of being overwhelmed, the stresses and strains of daily living, and they will – unless addressed appropriately and in time – spiral into hopelessness and helplessness.
But men most commonly react to this inevitable reality by denying it, trying to cover it up, or camouflage their symptoms and address only the ones that take a physical manifestation, such as diffuse pains, headaches, sleeping disturbances, or sexual problems. And as a result depression in men often gets overlooked and untreated, leading to significant consequences such as impacting close relationships, productivity at work, proclivity to substance use, emotional regulation, decline in overall enjoyment of life, eventually spiraling so deep that it pushes men to commit suicide.
If that sounds extreme, here’s some data.
In 2016, the last year that global data is available from the World Health Organization (WHO), there were an estimated 793,000 suicide deaths worldwide. Most were men. Suicide is still the single biggest killer of men under the age of 45. Forty percent of countries have more than 15 suicide deaths per 100,000 men; only 1.5% of the countries in the study show a rate that high for women.
But wait, don’t women tend to have higher rates of depression diagnoses? So how does that add up?
There’s a simple but unsurprising reason for it.
Men seek help for mental health less often.
Think about that for a minute.
It’s not that they aren’t struggling with the same issues as women, but the denial of mental health problems, or simply not knowing that they have significant mental health issues may be putting them at greater risk for suicide. And that becomes a reason for the reduced frequency with which they seek assistance from professionals.
A UK British Medical Journal study found general primary care consultation rates were 32% lower in men than women; and consultation rates for depression were 8% lower in men than women. And in a country like India, a further double whammy comes in the form of the stigma associated with seeking mental health services because of the labels, unsolicited advice, unwanted judgments, and differential treatment we as recipients of mental health services beget.
I particularly wanted to talk about depression in men for just these above mentioned reasons. Men may be less tuned to recognizing the signs and symptoms of depression. They may not want to talk about it, may deny the presence of tell-tale signs of depression, or may mask it with other behaviors.
How do we recognize those signs and symptoms?
Men may typically show the classic signs of clinical depression such as: persistent sadness, anxiety, or feelings of “emptiness,” trouble concentrating, remembering details, and making decisions; feelings of guilt, worthlessness, and helplessness; pessimism and hopelessness; fatigue; insomnia or hypersomnia (sleeping too much); irritability; restlessness; loss of interest in things once pleasurable; reduced interest in sex; appetite loss or overeating; and suicidal thoughts or attempts.
However, men are also more likely than women to experience symptoms of depression that may just sneak up and masquerade as behavioral disruptions, such as the following.
· Physical pain: Frequent headaches, backaches, cramps, sleep disturbances, digestive disorders that don’t respond to conventional treatment.
· Anger: From being mildly irritable, to being sensitive to criticism, to road rage, short spurts of temper, and in severe cases violence and hostility particularly towards others. Some men may become abusive and controlling to hide their insecurities or their fear of rejection and abandonment.
· Impulsive, reckless behavior: Engaging in dangerous sports, excessive gambling, substance abuse (in an attempt to self-medicate), and engaging in unsafe sex.
The triggers for the downward spiral could be many, and of course personalized to each individual, but the common ones for men tend to be financial difficulties, unemployment, failure to prove self-worth through success at work, and lately what I think is a rising concern: existential crises.
Social isolation and feeling disconnected from friends and family when one is at the topmost rung of the career ladder often serves as a push at the precipice too. We just don’t invest enough in nurturing our relationships outside of work, so when the pressures mount, how do we destress when we find ourselves alone?
In my clinical practice, I see women who seek help for the couple when the relationship is threatened. That’s right, she’s not seeking help just for herself, it’s for both of them.
Because “I don’t have a problem, it’s her,” is the most common reason their spouses give for not being the ones to seek help in the first place.
As sessions progress and men decide to give relationship therapy a shot, mental health issues in men, be it anxiety, mood, personality disorders or any other, seem to be one of the common wedges causing dents in the relationship. Women often tend to internalize and will ruminate over their feelings and find answers or solace by talking to friends or a counselor. Men, on the other hand, will externalize and often become irritable, hostile, or in extreme cases show rage, and that starts causing rifts between the two people.
It all comes down to what is still perceived as alien to and by men. That it’s okay for men to cry, to talk about how they feel when they are down in the dumps. That tears are not a sign of weakness, and neither is vulnerability. To accept that our strength lies in the fact that we learn from failures, that we bounce back from adversity, with our knees bloodied and hearts broken. That our self-worth should not be defined by our net worth, or what we are seen as in the eyes of our peers, competitors, or others we work with.
Ultimately, it’s the quality of our minds, our hearts, our sense of meaning and purpose in life, our inner world, and how we choose to script our stories that matter. It’s having that friend or family member you could talk to when you are struggling, just so that you know you are not alone.
The bottom line is, we all need a safe, accepting, non-judgmental space to share our feelings. And yes, the “we” here especially applies to men. Together, we can decide to bring that shift in our scripts we create of masculinity and femininity. We can decide to change our attitudes about mental health issues and seeking counseling.
Let’s open up our eyes, ears and hearts to the fact that the best of us (men included) may need a shoulder at one point or another. And let’s embrace those who need us.
Because boys can cry too.