Major depressive disorder (MDD) is a highly heterogeneous diagnosis wherein the nine MDD criterion signs and symptoms reflect 256 unique symptom combinations. Accordingly, MDD comprises a broad set of phenotypes observed across clinical practice, including primary care. With intensifying global efforts to prevent male suicide, attention has rapidly focused on better understanding men's experiences of MDD. Pertinent to these efforts is the operationalization of MDD, which is characterized by the two cardinal symptoms of depressed mood and anhedonia (the loss of interest or pleasure in all, or nearly all, activities for most of the day nearly every day). However, debate remains regarding the adequacy of this conceptualization of depression as applied to men socialized within dominant discourses of masculinity that prohibit men acknowledging or seeking help for depression. The text revision of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) offers a noteworthy change to the sex and gender considerations for MDD. While the nine diagnostic criteria for an MDD diagnosis have remained unchanged relative to the preceding DSM-5 text (because the purpose of DSM's text revision version is to update the text, not change diagnostic criteria), an important new phenomenological statement has been added. Whereas DSM-5 offered no guidance related to associated gendered symptom expression apart from commenting on the epidemiology and gender paradox of suicide attempts (higher among females) and suicide deaths (higher among males), DSM-5-TR offers the following: There is some evidence for sex and gender differences in phenomenology and course of illness. Women tend to experience more disturbances in appetite and sleep, including atypical features such as hyper-phagia and hypersomnia, and are more likely to experience interpersonal sensitivity and gastrointesti-nal symptoms. Men with depression, however, may be more likely than depressed women to report greater frequencies and intensities of maladaptive self-coping and problem-solving strategies, including alcohol or other drug misuse, risk taking, and poor impulse control. In general, women are more likely to internalize (e.g., withdraw , cry), and men are more likely to externalize (e.g., display anger, utilize alcohol to cope). Naturally, this has prompted the consideration of a biological basis for differences. Yet, compelling evidence of biological differences underpinning men's depression symptoms and their maladap-tive self-coping and problem-solving strategies remains scarce. We therefore call for a unified global research effort to
address this problem. Consideration should be given to implementing brief screening for male depression symptoms (e.g., the MDRS-7) as part of electronic medical record systems, both in primary care settings and longitudinal studies. At a minimum, incorporation of externalizing symptoms within diagnostic criteria for adult MDD (either via removal of the developmental age caveat for irritability, or through additional
symptom criteria) is likely required.