Depression in Boys: Challenges in Diagnosis

Not long ago, schools kept boys and girls separate. Many private schools still do. Take a quick look online and you’ll find a sizeable list of schools with names ending in “…School for Boys” or “…School for Girls.” While the notion of separate boy’s and girl’s schools seems archaic, their fouding principles are logical. At the risk of oversimplifying things, the basic idea is that boys need men to teach them how to become men and girls need women to teach them how to become women. There’s more to it than that, of course, but that’s more or less the rationale.

It makes sense.

A recent trend in addiction treatment echoes the traditional notion of gender separation. More than a few gender-responsive substance use disorder recovery programs exist around the country. The centers offering these programs propose men and women develop addictions, stay addicted, and respond to treatment for alcohol and drug addiction in ways unique to their gender.

That also makes sense.

But when professionals diagnose mental health disorders in general, their go-to manual, the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), does little to differentiate between symptoms in boys and girls. This is not always a problem: we’re all human, after all. Introducing gender-specific diagnostic criteria for mood disorders could lead to bias and create institutional norms that skew treatment, affect insurance coverage, and negatively impact the health and well-being of one gender over another.

However, the fact remains that boys and girls are not identical. One area where differences appear is the way they behave when they develop a depressive disorder. This post addresses why we often mistake behaviors in boys – particularly anger – as a defiance or emotional regulation issue as opposed to what may actually be causing their anger: depression.

Depression in Boys: Why We Miss It

Dr. Myrna Weissman first identified gender differences in rates of depression in her 1977 paper “Sex Differences and the Epidemiology of Depression,” published in issue #34 of The Archives of General Psychiatry. Her research gave an empirical answer to the general question she kept hearing: “Why are women more depressed than men?” Her research showed rates of depression in women were almost double than those seen in men. Since then, scores of studies confirmed her findings: women present symptoms of depression at a consistent ratio of around 2:1. In the search to explain these differences, behavioral scientists have looked at a wide variety of factors, such as:

  • Socioeconomic status
  • Ethnicity
  • Genetics
  • Experience of gender discrimination
  • Experience of violence
  • Hormonal differences

While the majority of studies confirm that yes, women develop depression at higher rates than men, no scientific articles provide an answer to the question most people want an answer to, which, coincidentally, was Dr. Weissman’s impulse to perform her initial research:

Why are women more depressed than men?

Here’s the short answer: no one has an evidence-based explanation.

What Does the Data Mean, Then?

This ambitious meta-analysis that includes data from 1.7 million individuals from studies performed over four decades does not tell us why women get depressed more often than men. Nor do articles like this one in Psychology Today or this one in the Journal of Psychiatry and Neuroscience. The best they can do is offer descriptive statistics or correlative data. Or make statements like:

“Society-driven risk factors in women likely have a biological origin.”

That’s not very helpful. That’s almost harmful. It amounts to saying women get depressed because they’re hormonal. Without a real body of scientific evidence, there’s no way we’re going down that slippery slope.

While they offer no causal explanations, the articles we just cited do confirm the following:

  1. Gender differences in diagnosis begin to appear at around age twelve, widen during adolescence and early adulthood, then gradually decline during adulthood and even out after middle age.
  2. The differences appear more often in high-income countries than middle- and low-income countries.
  3. Gender differences in circulating hormones might play a role.

Yes – we know this article is supposed to be about boys. And it is. Bear with us: this is all relevant. We’re spending time talking about women because scientific data, as often happens, eventually trickles down and becomes, for lack of a better phrase, common knowledge. That’s what happened with depression: research says women develop depression more than men, so that’s what most of us think.

We’re left to guess at the reasons why.

And while we’re guessing, even the trained professionals among us tend to look for diagnoses other than depression when boys display angry, aggressive, and defiant behavior. This next assertion is not evidence-based, but we’ll offer it because it’s a reasonable conclusion, in light of all the correlative data presented above: we miss depression in boys simply because we think boys don’t get depressed as much as girls. It’s a classic case of confirmation bias: we go into a situation with a set of fixed ideas that are reflected in our final judgment about that situation. We don’t see depression in boys because part of us doesn’t expect to see it. That goes for therapists as well as lay people. If a therapist misses a diagnosis of depression in a young male, it doesn’t mean they’re a bad therapist. It means they’re human.

Masculinity and Mental Health

Studies connecting the dots between traditional male attitudes about masculinity – i.e. what it means to be a man – and depression are a relatively new phenomenon. While tentative steps toward examining the relationship between depression and masculinity appeared as early as the mid-1980s, it wasn’t until around ten years ago that researchers began asking questions about differences in the way men and women display depressive symptoms, as opposed to examining differences in rates of depression in men and women.

This recent trend in research reveals clear differences. Adolescent girls are likely to show symptoms more commonly associated with depression such as sadness, crying, guilt, and changes in appetite. Adolescent boys, though, tend to show depression in in the following ways:

  • Anger
  • Irritability
  • Difficulty concentrating
  • Sleeplessness
  • Suicide attempts

A study published just last year identified three traditional male gender norms that can have detrimental effects on overall well-being. The authors of the study concluded adherence to these norms can also contribute to depression. We’ve adapted the names of the norms slightly for the purposes of this article:

The Self-Reliant Male

This norm refers to the male who doesn’t need help for anything from anyone, ever. This man handles his problems. He doesn’t ask for help. He feels asking for assistance with anything from fixing his car to handling a tough boss to working through personal problems is a sign of weakness.

The Ladies Man

This norm refers to the male who’s driven to be attractive to more than one woman at a time. He’s in-demand. He’s attractive to all members of the opposite sex. He feels a sense of disappointment if every woman he meets is not attracted to him.

The Fighter

This norm refers to the male who’s willing to fight if provoked. If his masculinity is questioned in any way, he’s willing to get in a violent confrontation to prove to himself and anyone nearby that he is, indeed, a man.

Researchers found that men who conform to the Self-Reliant norm avoid seeking help for emotional problems, men who conform to The Ladies Man norm have difficulty establishing meaningful relationships, and men who conform to The Fighter norm have difficulty regulating their emotions and may act out violently when under stress. The consequences of conforming to all three norms leaves these males vulnerable: they tend not to ask for help, they don’t have people to speak openly and honestly with, and they tend to lash out when facing personal difficulties. These men are at risk of self-isolation, and ultimately, depression.

Men and Boys

Though perceptive therapists and counselors have long understood the connection between traditional masculinity and depression, and some research theorized that traditional masculinity may play a role in masking depression in men, we’re still left to connect the dots ourselves when considering the negative effects of these norms on younger men. Which we can do quite easily, when we consider things boys hear from almost the moment they’re born:

“Suck it up!”
“Boys don’t cry.”
“Man up and handle your business.”
“You gonna cry like a girl or do something?”

That last one is of particular interest to us, with regards to boys and depression.

We hear it most often when boys get bullied, take a hard hit on a football field (or any other sports field), or experience some sort of disappointment in life. We expect boys – we even teach them – to respond to both slights and disappointment with retaliatory or compensatory action. In the context of sports, the response grown men recommend to boys is often aggressive and violent. We don’t need data to back this up. Anyone who watches professional sports sees it plainly. A hockey or football player gets hit hard. Within minutes he tracks down the person who hit him and hits him back. And he tries to make his hit harder than the one he received, just to send a message.

This same pattern plays out in youth sports almost every day. Coaches will stand over a boy laying on a football field and shout something like, “That hurt, huh? Well get back up! Show number 42 what hurt is all about!” Dads teach it, too, when counseling their sons about dealing with playground bullies who push them around. “You can’t let them do that to you,” they say. “He’s going to keep on bullying you until you stand up to him and fight back.”

Disclaimer here: not all coaches do this, nor do all dads. But if we’re honest with ourselves, we’ll admit this is common practice.

It’s tricky, because bullies keep bullying if you let them. However, there’s a difference between standing up to a bully and returning violence with violence. Matching aggression with aggression is not synonymous with maintaining personal integrity. Safeguarding a position in the social hierarchy or successfully navigating playground politics can require courage, of course, but it does not necessarily require anger or aggression.

But that’s a tangent we don’t want to get distracted by. What concerns us is that boys learn to fight rather than talk, withdraw rather than talk, or put on a brave, manly face rather than talk. Boys learn to do just about everything rather than talk through or about their emotions.

New Attitudes for All

A cultural sea-change over the past five years offers evidence that the negative elements of these entrenched gender norms are transforming, slowly but surely.

The movement towards emotional literacy and the incorporation of social and emotional learning in school curricula helps. Boys now understand that some of the things they see and hear grown men do and say cause more harm than good. They also learn – with the help of adults – that examples of masculinity they see in movies and on television don’t do them much good, either. They begin to understand that asking for help is a sign of strength rather than weakness. Men who open up about their feelings show them that emotional vulnerability, while it can be painful and embarrassing at first, leads to growth and healing. Older male role models tend to be the most effective at teaching these lessons to boys, but as long as the learning happens, it doesn’t matter where it comes from: a female teacher, a male peer, a sister, a brother, or anyone.

About That Diagnosis…

This sea-change applies to therapists and mental health professionals charged with diagnosing boys as well. More and more often, they remember to examine their internal conditioning.  They understand the patterns of thought that affect us all affect them, too. Therapists remind themselves the violence they see in the boys they assess may be masking internal pain. The anger may exist to cover up depression. They know those boys – in their boy-like way – may really only trying to behave like the male role models that influence them every day. When these two trends coalesce – boys learning emotional literacy and adults reminding themselves that boys manifest depression differently than girls – then fewer and fewer boys will slip through the diagnostic cracks.

While there’s certainly a place for the traditional strong, male, silent type in this world, there’s also a place for sensitive and effusive male communicators. While there’s value in working things our for yourself, there’s also value in admitting you don’t have all the answers and asking for help with emotional problems when you’re in pain. In order to diagnose boys correctly and give them the help they need, we all need to see the entire person, and understand that these young men are learning as they go. They rely on us – the adults in their lives – to see them with a mixture of objectivity and compassion, and equip them with the tools necessary to navigate both their internal and external lives.