Older men are also less likely than older women to have received previous treatment for depression and to be referred to depression-management programs.
As a result, many older depressed men are falling through the cracks and have an increased risk of suicide, says Ladson Hinton, MD, an associate professor of psychiatry at the University of California-Davis. Hinton is a researcher on the study, which appears in the October issue of the American Journal of Geriatric Psychiatry.
"We have an epidemic of suicide among older men in this country and depression is an important contributing factor," Hinton tells WebMD. "So we have to develop ways to more effectively engage older men."
Men aged 65 and over are almost eight times as likely to commit suicide as their female counterparts. They have a suicide rate of 31.8 per 100,000, while older women have a suicide rate of 4.1 per 100,000.
Researchers Used 2 Approaches
To quantify older men's resistance to depression treatment, the researchers studied data on 1,600 depressed older adults from IMPACT (Improving Mood: Providing Access to Collaborative Treatment for Depression), a study addressing the management of late-life depression.
They also conducted interviews with 30 IMPACT-connected doctors, depression-care managers, and study recruiters.
"This study is valuable and novel for several reasons," says Colin Depp, MD, of the Sam and Rose Stein Institute for Research on Aging at the University of California in San Diego and the VA San Diego Healthcare System. Depp was not connected with the study.
"First, the patients in the study were broadly representative of older adults in primary care, as opposed to many other treatment studies of depression in older people," Depp tells WebMD. "Second, the study used a mix-method approach in which quantitative and qualitative data were gathered to determine the barriers to engaging services among men."
"Both kinds of data led to the same answer: older men are less likely than older women to engage in treatment for depression," Depp says. "The implications of this study are that treatments for depression, no matter how effective in clinical trials, will not make an impact on older men if they're not referred to appropriate care and followed up."
Significant Gender Gap Seen
Across many measures of treatment-seeking behaviors, Hinton's team observed a consistent gap between older men and older women.
They found that older men were significantly less likely to report "any antidepressant use in the past three months" (38% vs. 46%), "any depression care in the past three months" (41% vs. 50%) and "any lifetime depression care" (60% vs. 71%).
"But the most important of these measures was 'any potentially effective depression care in the past three months,'" Hinton says. "Because only 21% of older men and 31% of older women reported receiving such care, this shows that depression undertreatment affects both sexes, but especially affects older men."
The study also showed that older men were also significantly less likely than older women to report classical emotional symptoms of depression such as periods of crying or feeling sad or fatigued.
Older men were also less likely to say that they had other symptoms of depression, such as loss of interest or pleasure in daily activities or having appetite problems -- which made them more difficult to diagnose.
One manager quoted in the study said: "They will not say, 'I feel sad' or 'I feel depressed.' They'll say, 'I have a stomach ache.'"
'John Wayne' Attitudes Common
Hinton's team identified a subset of older men who were especially resistant to being labeled as depressed, getting treatment for depression, or enrolling in depression studies.
According to the ealth care providers interviewed for the study, such men tended to have an old-school, "John Wayne" image of masculinity, which teaches men to view depression as a "woman's problem," conceal emotional symptoms, and cope with emotional problems on their own.
"Older men saw depression as a moral weakness or something that should be overcome on one's own, limiting their tendency to seek help," Depp says. "Their desire to 'tough it out' was coupled with a fear that a psychiatric diagnosis would stigmatize them as being mentally ill or label them as 'crazy.'"
New Approaches Recommended
Although some health care providers said that older men need to "give up" these core masculine values in order to receive appropriate treatment, many others said that clinicians themselves need to change their approach.
"Many of the primary care providers we interviewed emphasized the need to be more flexible in dealing with older men who have a traditional sense of masculinity," Hinton says. "They cited the need to negotiate a way to talk about depression that is acceptable to older men and allows clinicians to treat their depression."
Such strategies may include using an open-ended interview style, helping neutralize stigma by using less-threatening direct or clinical language, and involving family members in all phases of treatment, according to the study.
"It may be useful to ask them if they're feeling more irritable or socially withdrawn," Hinton says. "We may also want to focus on complaints about physical symptoms and stress."
More Study Needed
"Although this study did not specifically investigate the effectiveness of strategies to surmount the barriers to engagement in depression, the authors rightly note that educational or screening initiatives need to be tailored to directly assess the barriers identified in this study," Depp says.
"The next study might be to use a similar qualitative approach, but, as the authors suggest, gather data from the older men themselves," Depp says. "We would want to know about what might persuade older men to believe depression can sometimes be as tough as they are."
"Clearly, engaging men in depression treatment is a problem across the age spectrum," Hinton says. "That's why the National Institute of Mental Health recently launched its 'Real Men, Real Depression' campaign to reach out to depressed men."
"But even though there's been a lot of talk about men, depression, and stigma, there's been less focus on older men," Hinton says. "Because of the high suicide rates among older men, we need to understand more about this difficult-to-reach group and reach them with effective treatments. We particularly need to understand more about older minority men who are making up an increasing share of the overall elderly population."
SOURCES: Ladson Hinton, MD, University of California-Davis. Colin Depp, MD, Sam and Rose Stein Institute for Research on Aging at the University of California-San Diego; VA San Diego Healthcare System. Hinton, L. American Journal of Geriatric Psychiatry, October 2006; vol 14: pp 884-892.
By Rick Ansorge
Reviewed by Louise Chang