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In Review Series
Critical Issues in Men’s Mental Health
Dan Bilsker, PhD
1
, Andrea S. Fogarty, PhD
2
,
and Matthew A. Wakefield, MA
3
Abstract
This narrative review highlights key issues in men’s mental health and identifies approaches to research, policy and practice
that respond to men’s styles of coping. Issues discussed are: 1) the high incidence of male suicide (80% of suicide deaths in
Canada, with a peak in the mid-50 s age group) accompanied by low public awareness; 2) the perplexing nature of male
depression, manifesting in forms that are poorly recognised by current diagnostic approaches and thus poorly treated; 3) the
risky use of alcohol among men, again common and taking a huge toll on mental and physical health; 4) the characteristic ways
in which men manage psychological suffering, the coping strengths to be recognised, and the gaps to be addressed; 5) the
underutilization of mental health services by men, and the implication for clinical outcomes; and 6) male-specific approaches to
service provision designed to improve men’s accessing of care, with an emphasis on Canadian programs. The main conclusion
is that a high proportion of men in Western society have acquired psychological coping strategies that are often dysfunctional.
There is a need for men to learn more adaptive coping approaches long before they reach a crisis point. Recommendations are
made to address men’s mental health through: healthcare policy that facilitates access; research on tailoring interventions to
men; population-level initiatives to improve the capacity of men to cope with psychological distress; and clinical practice that is
sensitive to the expression of mental health problems in men and that responds in a relevant manner.
Abstract
Enjeux importants de la sante
´mentale des hommes Cet examen narratif pre
´sente les principaux enjeux de la sante
´mentale des
hommes et e
´nume
`re les approches de la recherche, des politiques et de la pratique qui re
´pondent aux styles d’adaptation des
hommes. Les enjeux discute
´s sont : 1. l’incidence e
´leve
´edefac¸on inquie
´tante du suicide masculin (80 % des de
´ce
`s par suicide au
Canada, avec une pointe dans le groupe d’a
ˆge de mi-cinquantaine) accompagne
´e d’une faible sensibilisation du public; 2. la nature
de
´routante de la de
´pression masculine,qui se manifeste sous des formes mal reconnues par les approches diagnostiques actuelles
et qui est donc mal traite
´e; 3. l’usage risque
´de l’alcool par les hommes, encore une fois re
´pandu de fac¸on inquie
´tante, qui a detre
`s
lourdes re
´percussions sur la sante
´mentale et physique; 4. les fac¸ons caracte
´ristiques des hommes de composer avec la souffrance
psychologique, les aptitudes d’adaptation a
`reconnaı
ˆtre et les lacunes a
`aborder; 5. la sous-utilisation par les hommes des services
de sante
´mentale et l’implication pour les re
´sultats cliniques; et 6. les approches typiquement masculines de la prestation de
services conc¸ue pour ame
´liorer l’acce
`s aux soins pour les hommes, en mettant l’accent sur les programmes canadiens. La
principale conclusion est qu’une forte proportion d’hommes dans la socie
´te
´occidentale ont acquis des strate
´gies d’adaptation qui
sont souvent dysfonctionnelles. Il y a un besoin pour les hommes d’apprendre plus d’approches d’adaptation, bien avant
d’atteindre le point d’une crise. Des recommandations qui abordent la sante
´mentale des hommes se trouvent dans : les poli-
tiques de sante
´qui facilitent l’acce
`s; la recherche sur la personnalisation des interventions pour les hommes; les initiatives dans la
population pour renforcer la capacite
´des hommes de s’adapter a
`la de
´tresse psychologique; et la pratique clinique qui est sensible
a
`l’expression des proble
`mes de sante
´mentale chez les hommes et qui y re
´pond de fac¸on pertinente.
Keywords
Barriers to treatment, Common mental disorders, Depressive disorders, emental health, Gender, Healthcare utilization
1
Department of Psychiatry, Faculty of Medicine, University of British Columbia, British Columbia, Canada
2
Black Dog Institute, University of New South Wales, Sydney, Australia
3
Department of Psychology, Simon Fraser University, Burnaby, British Columbia, Canada
Corresponding Author:
Dan Bilsker, PhD, Department of Psychiatry, Faculty of Medicine, University of British Columbia, British Columbia, Canada.
Email: dan@psychsafety.org
The Canadian Journal of Psychiatry /
La Revue Canadienne de Psychiatrie
1-7
ªThe Author(s) 2018
Reprints and permission:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/0706743718766052
TheCJP.ca | LaRCP.ca
Canadian
Psychiatric Association
A
ssociation des psychiatres
du Canada
Introduction
There is increasing public awareness of the importance of a
gendered perspective on the mental health of Canadian men.
This perspective considers effective intervention
approaches, barriers to accessing appropriate care and psy-
chological coping issues. It has been observed that men’s
mental health issues have been ‘hidden in plain sight’. For
example, even though it is well known that most suicide
deaths are males, there has historically been a lack of atten-
tion to this dramatic gender disparity, whether in health
research, policy, or care delivery. The research literature
on men’s mental health, policy addressing this area, and
psychological care specifically targeting men are all in early
stages of development.
The aim of this review is to highlight some of the key
issues in men’s mental health. The time is right to implement
new approaches to research, policy and practice that respond
to men’s styles of coping, vulnerability and psychological
suffering. We are past the point where mere calls to action
will suffice.
Critical Issues
Male Suicide
Suicide in men has been described by a leading researcher as
a ‘silent epidemic’.
1
It is ‘silent’ because there is low public
awareness regarding the magnitude of this problem, with
surprisingly little research and few preventive efforts specif-
ically targeting male suicide. Furthermore, men are reluctant
to seek help for suicidality. It is ‘epidemic’ because of the
high incidence and because it is a major contributor to men’s
mortality: between the ages of 15 and 44 y, suicide is among
the top 3 sources of men’s mortality.
2
Across all countries
reporting these data (except China and India), the male sui-
cide rate that is 3- to 7.5-times that of women.
3
In Canada,
the male suicide rate is about 3 times that of women.
4
Figure 1 charts the age- and gender-specific incidence of
suicide in Canada, based on data from 2000 to 2011. The
chart shows 2 patterns:
The male suicide rate increases fairly steadily with
age, peaking in the late 40s, then falling significantly
and rising again in the 80s.
Male rates of suicide are greater than female rates at
all ages and substantially greater across most of the
lifespan.
The peak in suicide rate among Canadian men in their 40s
and 50s is surprising in light of past data showing a peak of
suicide in younger age groups.
5,6
However, a change in this
suicide pattern seems to be underway. It is apparent that our
knowledge of men’s suicide is lagging behind changes in the
age-specific incidence of this cause of death.
7
Until we
understand the underlying reasons for this relative increase
in men’s suicide rates in middle age, including potential
cohort effects, we will not be able to implement effective
preventive action.
To address male suicide, it will be important to understand
how suicidality manifests in men and how it can be detected
at an early stage. A recent review found that signs indicative
of increased suicidal risk in men include ‘desperation and
frustration in the face of unsolvable problems, helplessness,
worthlessness, statements of suicidal intent’.
8
However, the
reviewers highlight the uncertainty regarding the sensitivity
and specificity of these signs in identifying men’s suicidal
risk and call for prospective research to identify signs of
imminent risk of suicidal ideation, attempt, or death in men.
A recent longitudinal study of 13,884 men found that one
aspect of Western role norms of masculinity may contribute
to men’s suicide ideation, in that men who strongly identified
as ‘self-reliant’ had 34%greater odds of reporting thoughts of
suicide.
9
However, suicidal thinking alone is not a sufficient
predictor of an imminent attempt.
10
An intriguing qualitative
study examined factors that interrupt suicide attempts in men,
finding that ‘suicidal ideation may be reduced through pro-
vision of practical help to manage crises, and helping men to
focus on obligations and their role within families’.
11
Further,
in a survey of men who had previously made a suicide
attempt, 67%reported ‘thinking about the consequences for
family’ helped prevent future attempts.
12
Follow-up analyses highlight some tensions between sui-
cidal men and their support systems that interfere with effec-
tive suicide prevention.
13
For example, it is difficult to
identify which changes in behaviour signify imminent risk
of an attempt v. normal fluctuations in mood; or difficulty in
monitoring signs of risk while still affording at-risk men
privacy and autonomy. Though recent work suggests that
men are more likely than women to develop an ‘acquired
Figure 1. Average Age-Specific Suicide Rates Ages 10þfrom 2000
to 2011. (Reproduced with permission from Jones W, Goldner EM,
Butler A, McEwan K. Informing the future: mental health indicators
for Canada technical report. Mental Health Commission of Canada
RFP No. MHCC-DATA-2013-2014-02; 2015. Page 314.)
2The Canadian Journal of Psychiatry
capability’ for suicide through greater insensitivity to pain
and reduced fear of death,
14
there is still considerable debate
over the role of biology
15
v. social factors (e.g., men tend to
have a higher occupational exposure to pain-habituating
experiences
16
).
Male Depression
Epidemiological research shows that the incidence of uni-
polar depression in men is half that for women.
17
Three main
explanations have been proffered. First, men are simply less
likely to experience depression, for unclear reasons. Second,
men are reluctant to acknowledge depressive symptoms due
to aspects of male socialization.
18
Third, men experience
depression in a specific way, with different symptoms, such
that the standard operational criteria for depression (which
typically emphasise internalizing symptoms such as sadness
and worry) are not valid in a male population.
19,20
This latter
explanation is built upon the concept of ‘male depressive
syndrome’, where externalizing symptoms (e.g., anger, alco-
hol misuse, risk-taking) are considered indicative of men’s
depression yet not diagnostically recognised as such.
21,22
A
recent systematic review compared the patterns of symptoms
in men and women diagnosed with unipolar depression, find-
ing relatively minor differences. They found that effect sizes
for these symptoms were small except for risk taking and
poor impulse control, indicating that differences between
genders on most symptoms may have only minor clinical
relevance for the assessment and treatment of depression.
23
However, if men’s depression is qualitatively different,
many men will not be ‘diagnosed’ as depressed and thus will
be absent from the literature. There is some evidence that
men describe depression using language (e.g. ‘stressed’,
‘angry, ‘tired’) that does not concord with existing clinical
criteria, or endorse different warning signs of depression
(e.g., being ‘irritable’, ‘on auto-pilot’, and ‘more aggressive
towards others’).
12
It is notable that the concept of a male-
version depression raises the question of depression’s onto-
logical status—we lose the epistemic shelter of operational
definition (as in the DSM, where depression is that which
meets the criteria) and must seek a theoretical definition of
depression encompassing different presentations.
Men and Substance Use
Alcohol has the greatest impact upon men’s mental health
across all substance use. The overuse of alcohol to cope with
psychological distress, resulting in significant mental health
impact and dependence, is common in men. Men are 2- to
3-times more likely than women to have a serious alcohol
use problem.
24,25,26
In a 2012 study of mental health and
substance use disorders in Canada, it was found that ‘males
had higher rates of substance use disorders in the past 12
months ...6.4%of males and 2.5%of females reported
symptoms consistent with substance use disorder’.
27
Alcohol use is a risk factor for a number of serious dis-
orders and sources of mortality.
28
As one might expect from
their relatively high rate of use, men suffer disproportionately
from the health impacts of alcohol: data from 2004 show the
rate of global deaths attributable to alcohol use as almost 6-
times higher for men (6.3%) than for women (1.1%).
29
It is
worth noting that alcohol dependence is a strong contributor
to suicidality, suggesting a partial explanation for the associ-
ation between male gender and suicide mortality.
30
Regarding the mitigation of alcohol-related risk in men, a
systematic review of long-term outcome in alcohol depen-
dence found that men show strikingly worse outcomes than
do women.
31
Yet, another review found that effort in the
primary care setting to reduce levels of problem drinking
is equally efficacious for men and women.
32
An intriguing development is the potential role of canna-
bis as a substitute for alcohol in individuals who have been
using alcohol in a risky manner.
33
Notably, in US states that
have legalised medical cannabis, decreases in deaths due to
motor vehicle accidents and suicide have been observed; it
has been suggested that these decreases may be related to
substitution of alcohol by cannabis in young men.
34,35
There
is a need for research in this area.
Opioid misuse (especially fentanyl) has come into sharp
focus due to the staggering number of associated overdose
deaths. Despite intense public concern, only recently has
attention been drawn to the preponderance of men in these
deaths: for example, a review of fentanyl overdose deaths in
British Columbia between 2012 and 2017 found that 82%
involved men.
36
Although there has been some research on
gender differences in opioid use,
37,38
little is known about
the reasons for this substantial disparity in overdose deaths.
We speculate that the same social influences and coping
strategies leading men to overuse alcohol foster other forms
of substance misuse as well.
How Men Cope with Psychological Distress
Recent research has studied the ways in which men cope
with psychological suffering. Recent reviews have attributed
the use of negative coping styles to the tendency of some
men to adhere rigidly to certain stereotyped features of mas-
culinity: misuse of alcohol and drugs to numb distress; con-
cealing and ignoring negative emotions; engaging in risky
behaviours; or valuing self-reliance and autonomy over pro-
fessional care.
39,40
Such approaches can increase the risk of
suicide, if used in conjunction with social isolation and with-
drawal from relationships.
11
Some men report attempts to redefine notions of mascu-
line coping; for example, where help-seeking allows for the
maintenance of traditional roles such as providing for the
family.
41
A research group in Australia has been examining
positive coping strategies used by men: far from relying only
on negative coping strategies, many men reported enacting
various prevention and management strategies for mood
maintenance.
39,42
Interestingly, these positive strategies fell
La Revue Canadienne de Psychiatrie 3
along a continuum – some men were more comfortable with
‘typically masculine’ approaches (e.g. problem solving,
achievements, structured plans, goal-setting) while others
were open to using less ‘masculine’ strategies (e.g. accep-
tance of vulnerability, talking openly about problems, seek-
ing help). Crucially, some men described only becoming
open to such strategies after significant periods of distress.
Men’s Use of Mental Health Care
A considerable body of research has identified a notably
lower utilization of mental health care by men.
43
One might
assume that this usage pattern reflects a lower rate of com-
mon mental health conditions such as depression, but the
available research data tends to point rather to men’s reluc-
tance to access mental health care; i.e., a pervasive disincli-
nation to seek help in dealing with psychological distress,
whether help from the health system, family members, or
friends.
44,45
Indeed, men are often unwilling to express or
acknowledge psychological suffering.
46
A recent review
found that the degree of individual adherence to masculine
role norms negatively impacts help-seeking, such that treat-
ment is delayed until internal resources are depleted or a
crisis-point reached.
47
Barriers to help-seeking, such as a
need for control, self-reliance or tendency to minimize symp-
toms, are more likely in the context of long-standing depres-
sion in men.
48
A recent meta-analysis reported a stronger link
between conforming to masculine norms and reduced help-
seeking than with mental health outcomes per se.
49
Interest-
ingly, Canadian research found that men were unlikely to
disclose distress to their doctors, regardless of measures of
masculinity or symptom severity.
50
Taken together, the research implies a knock-on effect
where men do not perceive the need for care, immediate
support systems do not identify male-specific warning signs,
diagnostic criteria do not detect men with mental health prob-
lems, and men delay treatment until problems are too severe
to ignore. Efforts have been made to address this poor ‘acces-
sing of care’ (v. ‘access to care’) and there are indicators of
change.
51
For example, in Australia, the proportion of men
with mental health problems who used appropriate services
has increased from 32%in 2006–2007, to 40%in 2011–
2012.
52
However, there is substantial room for improvement.
Male-Specific Mental Health Services
A recently released policy review, ‘Keeping It Real’, empha-
sizes the importance of implementing novel programs that
reach out to men, and designing care approaches that
enhance coping.
53
Promising examples of online interven-
tions to enhance psychological coping include the Mood-
Gym program; however, such online interventions show
lower uptake and adherence in men.
54,55,56
A review noted
a ‘high drop-out rate amongst males in particular and certain
programmes such as MoodGym appear insufficiently enga-
ging to adult men’.
55
Nonetheless, we would argue that
given existing challenges to men’s timely accessing of
appropriate care, development of e-health interventions is
still a promising avenue, particularly where such programs
are designed with men’s input.
Male-specific programs include:
The Australian ‘Well@Work’ program, which aims
to improve workplace mental health in male-
dominated workforces (e.g., police, fire, and emer-
gency services);
57
An ambitious mental health prevention and promo-
tion program targeting adolescent boys via
community-based sports clubs, funded by the Move-
mber Foundation;
58
A Canadian adaptation of the Australian Men’s Shed
program, which focuses on the mental health of older
men;
59,60
HeadsUpGuys, a website where men can access psy-
choeducation regarding depressive symptoms among
men, practical tips for preventing and dealing with
depression, how to access professional services, and
videos of men who have overcome depression;
61
BroMatters, which provides psychoeducation about
stress, depression, and alcohol use, along with self-
help in the form of CBT, mindfulness relaxation pro-
grams and strategies for workplace stress.
62
DUDES Club, a ground-breaking program primarily
targeting the health and well-being of indigenous men
in Vancouver, BC’s Downtown Eastside—a group of
men facing high risk of addiction, poverty, and home-
lessness.
63
The goal of DUDES Club is to promote
health literacy and build a sense of ‘brotherhood’. It
integrates traditional indigenous medicine and teach-
ings and provides access to healthcare professionals
who facilitate interactive ‘health discussions’.
Although several of these programs have received forma-
tive evaluation, it must be emphasised that none has been
proven effective by controlled research trials. They are pro-
mising but unproven.
Conclusions
The central conclusion we derive from the literature on
men’s mental health is this: a high proportion of men in
Western society have acquired psychological coping strate-
gies that are often dysfunctional and leave them vulnerable
to a number of negative physical or psychological outcomes.
This acquisition is not necessarily inherent to being male, but
rather a product of various degrees of socialization to West-
ern role norms. The problematic coping strategies include:
Failing to obtain appropriate support from friends,
family, or healthcare providers;
Overusing alcohol to lessen emotional suffering
4The Canadian Journal of Psychiatry
Denying suffering, ‘sucking it up’
Isolation, or reducing social connectedness in times of
distress
Each of these coping strategies will, in situations, be
appropriate and adaptive; for example, indifference to suf-
fering in emergency situations where certain tasks must be
accomplished. Likewise, brief periods of isolation can
relieve stress. However, using these strategies excessively
or rigidly leaves men vulnerable to a wide range of negative
consequences and less able to access the health buffering
effects of diverse social support networks.
64
There is a need
for men to learn adaptive coping approaches long before
they reach a crisis point.
Recommendations
Policy
Healthcare policy should mandate that Health Services to
men be delivered in a way that is appropriate and accep-
table to those men in need. Male-focused programs appear
to hold considerable potential for improving our manage-
ment of men’s mental health. However, such programs
have thus far reached only a small proportion of the male
population, and it is unclear how scalable they are to the
male population vulnerable to mental health conditions and
psychological suffering.
Further, though many countries have mental health stra-
tegies that acknowledge gender differences, very few articu-
late strategies aimed at men. Future policy development
should identify men as a vulnerable population and articulate
specific strategies to address the known factors that increase
mental health risk among men. A useful resource for policy
development is the Keeping It Real report, which focuses on
policy development aimed at young men’s mental health.
53
Research
The Canadian research agenda should make men’s mental
health a priority, including outcome research to determine
how existing treatment methods could be tailored to a male
population and how men can be encouraged to increase
appropriate use of mental health services.
65
Furthermore,
suicide-prevention research, which has focused on teens and
young adults, should prioritize middle-aged men, as they are
the most vulnerable group.
Population Health Intervention
Population-level initiatives should be implemented to
enhance the capacity of Canadian men to cope with psycho-
logical distress and thus help prevent the negative conse-
quences of poorly managed suffering. Such an initiative
would be based on evidence about positive coping strategies,
tailored knowledge translation, and social marketing. One
approach would involve community education and
prevention campaigns that engage with traditional notions
of masculinity and seek to reframe men’s vulnerability to
mental health problems, men’s typical responses to such vul-
nerability, and the act of help-seeking as brave and a ‘mascu-
line’ thing to do.
66
Another would involve novel delivery of
treatment and skills development to larger population groups,
whether through new technology or diverse settings. Contin-
ued development and evaluation of online interventions
designed to engage men is a promising approach.
Clinical Practice
This review points to several important aspects of clinical
work with male patients. First, men are more prone to anger
and interpersonal aggression, a coping pattern with substan-
tial negative impact on quality of life and relationships.
There is a need for enhanced clinical focus on identifying
and modifying anger coping skills in men. Second, identify-
ing high-risk use of alcohol is a key issue in the clinical care
of men. High-risk use is, of course, far more common than
diagnosable alcohol dependence (which requires intensive
treatment). Controlled drinking or supported self-care inter-
ventions are appropriate for most men overusing alco-
hol.
67,68
Third, the clinician must be sensitive to suicidality
in men, even where the patient dismisses his own emotional
suffering and presents relationship or occupational crises in a
calm and ‘rational’ manner.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
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