So far we’ve discussed the history of depression, and explored its possible causes. Before we conclude this series next week with a guidebook on managing your melancholy, we of course need to stop to examine what depression actually looks like. How is it different from run-of-the-mill sadness, and how does it manifest itself, especially in men?
Today we’ll tackle those two questions.
What’s the difference between being sad and being depressed?
That’s the million-dollar question and the source of a lot of debate. It’s also a relatively modern query. As we discussed in our post on the history of the black dog, “depression” as a clinical diagnosis only arose in the early 20th century; before that you were just plain old melancholy — sometimes a little, and sometimes a lot. There wasn’t a clear dividing line, because depression wasn’t so much a disorder as a temperament.
The Diagnostic and Statistical Manual of Mental Disorders (DSM) has attempted to establish a set of standardized criteria that distinguishes “normal” sadness from clinical depression, but making the diagnosis remains an inexact science. This isn’t a physical tumor you can measure in centimeters, but a measuring of mood.
According to the DSM-V, for a spell of melancholy to be considered a Major Depressive Episode, it must persist for at least two weeks, and be accompanied by at least 5 of these symptoms:
• Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful).
• Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others).
• Significant weight loss when not dieting or weight gain (e.g., a change of more than 5 percent of body weight in a month), or decrease or increase in appetite nearly every day.
• Insomnia or hypersomnia nearly every day.
• Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
• Fatigue or loss of energy nearly every day.
• Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
• Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
• Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
Those symptoms can sound rather technical, so here’s a list of common signs put in layman’s terms by the Mayo Clinic:
• Feelings of sadness, emptiness, or unhappiness
• Angry outbursts, irritability or frustration, even over small matters
• Loss of interest or pleasure in normal activities, such as sex
• Sleep disturbances, including insomnia or sleeping too much
• Tiredness and lack of energy, so that even small tasks take extra effort
• Changes in appetite — often reduced appetite and weight loss, but increased cravings for food and weight gain in some people
• Anxiety, agitation, or restlessness — for example, excessive worrying, pacing, hand-wringing, or an inability to sit still
• Slowed thinking, speaking, or body movements
• Feelings of worthlessness or guilt, fixating on past failures, or blaming yourself for things that are not your responsibility
• Trouble thinking, concentrating, making decisions, and remembering things Frequent thoughts of death, suicidal thoughts, suicide attempts, or suicide
• Unexplained physical problems, such as back pain or headaches
Besides Major Depressive Disorder, the other form of depression that’s frequently diagnosed is “Persistent Depressive Disorder.” It’s less severe from day to day than a bout of MDD, but it lasts longer. PDP manifests in adults as a low mood that lingers for most of the day, for more days than not, for at least 2 years. During this 2-year period, depression-free intervals last no longer than 2 months. One’s low mood must also be accompanied by at least two of the DSM symptoms listed above.
Other than experiencing a cluster of symptoms, the main crux of either of these diagnoses is whether one’s mood creates “clinically significant distress or impairment.” In other words, does your disorder get in the way of your everyday life? Unfortunately, like the line between general sadness and depression itself, the standard here is somewhat hazy.
The DSM does not provide objective criteria for what constitutes “clinically significant distress or impairment,” so individuals, doctors, and therapists are left with making subjective calls as to when a low mood reaches this benchmark. For some people, it might mean their depression is preventing them from going to work or taking care of their families; for others, it could mean that their low mood is getting in the way of achieving unrealistically high expectations for happiness. Some research suggests that it’s largely the latter group that is going to their physician or psychiatrist for anti-depressants, while individuals with depression so severe they can’t even take care of basic life functions are often not getting treated at all — they lack the motivation to even make an appointment with their doctor.
All of this is to say that figuring out exactly when sadness becomes depression can be a fuzzy affair. While the DSM’s symptoms-based approach to diagnosis has given depression a more medical, and less stigmatized slant, critics argue that it’s also created such a broad net that it may cause some folks and doctors to view a bout of “normal” sadness or low spirits as a disorder.
Symptoms of Depression in Men
Making things more difficult in diagnosing depression is that men often show different symptoms than women. Because women generally report feeling depressed more often than men, the symptoms and signs the DSM and other diagnostic outlines have aggregated tend to be female-oriented. Consequently, many men who may be struggling with depression aren’t getting treated for it, and sadly, many of these men end up committing suicide; while women are more likely to get depressed, men are more likely to kill themselves, by a margin of more than 4:1.
While many men experience the symptoms of low mood, lack of interest in normal activities, problems sleeping, etc. that the DSM lays out, it’s also important for them to watch for the often uniquely male signs and symptoms of depression.
One thing to keep in mind as you think through the symptoms below is that just because you display one or more of them doesn’t necessarily mean you’re depressed. It’s important to put the signs in the context of the other criteria for depression such as the length you’ve been manifesting the symptom and whether it causes significant distress or impairment to your life. It’s also important to note that many of the symptoms below can actually be healthy responses to depression if used in moderation.
Prudence and wisdom should thus be used when checking yourself against this criteria; when in doubt, talk to a mental health professional.
Increased use of alcohol and other substances. There’s a common saying when it comes to gender and melancholy: women get depressed; men drink. And indeed, a typical response for men going through a prolonged low mood is to turn to alcohol and other mood-altering substances to blunt their despondent feelings. If you find yourself using these sorts of substances more than you usually do, it could be a sign that you’re depressed.
Distraction and escapist behavior. While there’s certainly nothing wrong with taking part in activities that distract you from your low mood (in fact, we’ll recommend it as a method for managing your depression), it can become a problem when those distractions are of a type that can make your depression worse or prevent you from living a thriving life. Common distractions men resort to when feeling depressed include TV watching, video game playing, and web surfing. There’s nothing wrong with these activities in moderation, but if done too much, they may actually make you feel more depressed — or at least no better than before. In a study in which participants were paged at random times during the day and asked to report on how they were feeling, people were found to experience their lowest mood when watching TV or surfing the web, especially late at night.
Another distraction men commonly turn to when depressed is pornography. While the good feelings that come with masturbating to porn can alleviate a low mood in the short-term, this habit can do more harm than good in the long-term. Repeatedly stimulating your dopamine production in an artificial way, whether through excessive porn use or substance abuse, leads to dopamine desensitization. And recent research has shown that dopamine desensitization can cause depression. Which makes sense. One symptom of depression is the lack of motivation to do things that once brought you joy. Dopamine is the neurotransmitter of motivation, so if your brain becomes deadened to it, your drive decreases, and you get into a funk.
Workaholism. Related to distractions and escapist behavior is workaholism. Instead of lying around the house in apathy, some men respond to their low mood by putting in extra time at the office. Again, this isn’t necessarily a bad response to depression. Focusing on your work can be a healthy way of harnessing your black dog. It can become a problem, however, when putting your nose to the grindstone causes “significant distress and impairment” to the other facets of your life like family and community responsibilities.
Irritability and uncontrolled anger. For men, anger and depression often go hand-in-hand. Melancholy for men might be best described not as an entirely gray existence, but rather a dark landscape occasionally punctuated with flashes of red. It may not be acute anger you experience either, but rather a constant low level of irritability and peevishness.
Sulking and aloofness. Many depressed men will become socially aloof, and when they are around people, they’ll sulk — just silently sitting there while the low mood and irritable emotions radiate from them.
Decreased sex drive. Depressed men will often have a depressed libido. This could be the direct result of blunted dopamine sensitivity, or be rooted in decreased testosterone levels, which in turn decrease dopamine production — the neurotransmitter that gives you your sex drive.
Increase in risky behavior. If you’re generally not a risk-seeking kind of guy, but suddenly find yourself doing things like gambling, drinking while driving, riding your motorcycle recklessly, etc., you may be depressed. Though you may not be, too. Again, it’s important to take a big picture approach when you’re reviewing these symptoms.
So are you depressed or just feeling low? As you can see, the line between the two just isn’t very clear.
The good news is that when it comes to light-to-moderate cases of depression, knowing if you’re technically, clinically depressed or not isn’t that important. And that’s because the methods you’ll use to remedy the situation are pretty much the same whether you’re actually depressed or just going through a gloomy spell. In fact, the best methods for tackling depression are things you should be doing even during the times when you’re not feeling melancholy.
And, if you have severe depression, well, you won’t have much doubt as to whether you’re struggling with the black dog or not. It will be quite evident. If you’re having trouble summoning up the motivation to even get out of bed, if your whole world’s gone gray and you don’t feel anything at all, and/or you’re experiencing suicidal thoughts, you’re almost assuredly clinically depressed. In this case, in addition to taking up the best practices we’ll lay out at the end of this series, you may need to talk to a mental health professional. If you won’t do that, at least talk to a friend, loved one, or clergyman; don’t keep how you’re feeling to yourself.
Ultimately, while it’s helpful to give something you’re experiencing a concrete name, depression is so complex, and manifests itself so individually, that I don’t recommend obsessing over clinical checklists in order to give yourself a label. Only you know for sure whether what you’re experiencing is normal and bearable, or is something that is getting in the way of the life you want to live. If it is, then you need to take action.