Is there a "hidden epidemic'' of male depression?

Alan Schlingenbaum, a 43-year-old computer consultant in Wellesley, was a regular guy. Which is to say, he got his work done and acted “the way a male acts on the world,” he says.

What he “wasn’t so good at” was intimacy — with his wife, his friends and himself.

His wife — now his ex-wife — dragged him into therapy with Terrence Real, a Watertown social worker and author of “I Don’t Want to Talk About It,” the best-selling book about men and depression.

Sure enough, after a few sessions, Real told him he was depressed.

“What are you talking about? You’re crazy!” Schlingenbaum retorted. Then he read Real’s book and became a convert.

Through therapy and a men’s group, he says he’s turned his covert depression into overt depression and is the better for it: “Just what I’ve learned so far is paying off for me in the kinds of relationships I have.”

Real, who is co-director, with psychologist Carol Gilligan, of the Harvard University Gender Research Project and a senior faculty member of the Family Institute of Cambridge, contends that depression is a “hidden epidemic” among men. If covert depression is taken into account, he argues, men are just as depressed as women, despite reams of statistics to the contrary.

“There’s a cultural collusion in covering this up,” he says, because men are brought up to disavow their feelings.

The result of all this unacknowledged depression, Real says, is an “unholy triad” of behavior — self-medication (by drinking, gambling, drugging, compulsive spending, sex, TV or work), isolation and lashing out (irritability, abuse and murder).

Not a pretty picture, but could all those “bad” guys be depressed?

“That’s ridiculous. . . It’s like saying you really have something but it looks like something else. If it looks like something else, it is something else,” says Dr. Myrna Weissman, a Columbia University psychiatrist who studies the incidence of psychological disorders.

Slapping a diagnosis on men who act out may even do harm because it “gives someone the sick role when maybe they’re just not very nice,” says Weissman, whose widely respected data, published in July in the Journal of the American Medical Association, show that over a lifetime, 7.4 percent of women and 2.8 percent of men suffer major depression, the most serious form.

“Gambling is not depression. Some people who drink are depressed, but that doesn’t mean alcoholics are depressed,” she says. And if men are beating their wives, “they should stop, but I don’t think saying they are depressed is necessarily helpful.”

Even when questions are designed to avoid gender bias, she says, women suffer far more than men — in country after country.

But even psychiatric epidemiologists disagree about what counts as serious depression.

Dr. Alan Romanoski, a Johns Hopkins University psychiatric epidemiologist, agrees with Weissman that “it’s wrong to infer depression,” that is, a particular emotional state, just from observed behavior. “Life is tough enough trying to figure out the conscious world without trying to take on the subconscious, too.”

Take drinking — and the feelings presumed to underlie it. Psychiatrists used to think if someone could only understand why he drank, he’d stop, Romanoski says. But they had “no success whatsoever treating alcoholism and as a result, psychiatry fell into disrepute in the recovery movement and rightly so.”

But unlike Weissman, who studies lifetime rates, Romanski studies the prevalence of major depression at any given moment, and finds that, tallied this way, men and women suffer equally. But with clinically significant, though milder depression, things do get lopsided — with 8 percent of women and 3 percent of men affected, he says.

But other data seem to support Real’s belief that depression is widespread among males, including national suicide rates — 18.6 annually per 100,000 men, versus 4.4 per 100,000 women.

And figures from the National Center for Health Statistics, based on 1992 research by Harvard sociologist Ronald Kessler, suggest that over a lifetime, equal numbers of men and women — roughly half of each group — have some kind of psychiatric disorder, though this counts not just depression but anxiety and substance abuse as well.

Over a lifetime, Kessler says, 24 percent of women have a depressive disorder, versus 15 percent of men; for anxiety, it’s 31 percent for women, 19 percent for men. Substance abuse, however, affects 35 percent of men and 18 percent of women.

Gender differences in psychiatric illness are changing, he says, “but unfortunately for women, women are catching up more quickly in alcohol and drug problems than men are in depression and anxiety. If sex roles are involved, and they have to be in certain ways, it looks like changes in sex roles have led to worse problems for women relative to men.”

Still, Harvard psychologist Carol Gilligan finds Real’s thesis “very convincing.” Masculinity “is terribly restricting to men,” she says, in part because it implies “real men don’t get sad.” Part of depression is “about not being able to feel sad.”

Psychologist William Pollack, co-director of the Center for Men at McLean Hospital, also believes depression is vastly underdiagnosed in men. A 1991 Rand study showed doctors miss 67 percent of depression in men because they’re looking for what Pollack calls “feminized” symptoms like crying, not the irritability, anger and work “burnout” men often express.

And while Dr. Peter (“Listening to Prozac”) Kramer doesn’t agree totally with Real, he does agree that “undiagnosed depression in men wreaks havoc. They do all sorts of things rather than get treatment.” Depression, he adds, also “causes divorce as often as divorce causes depression, and I’d say more,” whichever spouse is depressed.

And there are those, like psychiatric epidemiologist Dr. Kostas Lyketsos of Johns Hopkins, who say the real “philosophic question is, is there bad in this world, and are there people who can’t be helped?”

Real answers this way: “The women’s movement and morally driven thinkers hold men responsible for bad behavior, but don’t hold men empathically. The men’s movement and psychology are tuned in to men’s wounding, but not the damage men inflict on others. My work is about holding men accountable for irresponsible behavior but holding them with empathy and love.”

The implication of Real’s message is that if men who act out would just get help, they — and the people around them — would be better off. But Lyketsos isn’t buying.

Imputing depression to men reminds him of the false memory debate in women, in which it was often taken as a given that a woman with psychological problems had been sexually abused and needed extensive therapy to dig out old “memories.”

“Nobody should be under the illusion that therapy is always good,” he says. With some people, it can “mess them up by creating a dependence and having them constantly question themselves.”

For men who really are depressed, though, the answer probably is to seek help. And for women involved with them, the first step is also to get the guy into therapy, if he’ll go. If he won’t, the next step, says Real, is to say, “If you don’t think you have a problem, then we have a problem as a couple and we need help.”

Often, it’s not the men who are “in conscious distress so much as the people who live with them,” he adds.

Still, Real argues, “the cure for covert depression is overt depression” and “intimacy is the ultimate cure for depression in men.”

This can be a tall order. “It’s a big pain in the butt to learn all this,” concedes Real. “Men would rather be left alone in some ways.

“But if you swallow the pill that you have to learn it, you’ll be happier and healthier, your family will be happier and healthier and you’ll live longer. Most men are not stupid. They understand this.”

Amen!

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