We all know individuals who are of a more melancholy disposition than others. In A. A. Milne’s popular set of children’s stories, the friends of Winnie-the-Pooh include both Tigger – the bouncing, happy tiger; and Eeyore – the somber, plodding donkey. Even from a young age, we all understand that it is completely acceptable for individuals to have their own unique dispositions and levels of emotional valence.
However, when a friend or loved one’s general tendency towards being blue seems to worsen, and perhaps begins to impair day-to-day functioning, it is exceptionally difficult to assess the seriousness and potential danger of the situation. In particular, it can be hard to know when a period of melancholy crosses the line into untreated major depression.
Depression Can Be Misdiagnosed
A recent study published in the JAMA Internal Medicine journal by the American Medical Association indicated that in the United States, a large proportion of individuals seeking attention for depression-related symptoms are misdiagnosed. The study surveyed over 46,000 US adults aged 18 or older in 2012-2013.
Using an established scale to measure depressive symptoms, the study established that around 8.4% of the participants in the sample had depression. However, only 28.7% of those individuals had received treatment. Meanwhile, of those who were undergoing treatment for depression (either psychotherapy or antidepressant medication), only 29.9% screened positive for symptoms of major depression.
This means that there are some serious challenges associated with the correct identification of depression, and diagnosis and treatment is not necessarily always straightforward.
In an effort to widen the scope of research into the prevalence of depression misdiagnosis, another study conducted a meta-analysis of 118 different studies assessing the accuracy of depression diagnoses. The final analysis contained data from more than 50,000 patients across 41 different studies, in countries including the United States, Canada, and various European countries, among others.
In the end, the study suggested that for every 100 cases of potential depression seen by a primary care physician, 15 cases are false positives (treatment was prescribed when there was no real depression), 10 cases are missed (treatment is not prescribed when there is real depression), and 10 cases are correctly identified (treatment is provided for real, identified depression).
One reason for this pattern of diagnosis is the difficulty in ascertaining the difference between depression and psychological distress. The AMA study described in the previous section measured the difference between depression and serious psychological distress, and found that among adults who were undergoing treatment for major depression, 29.9% had depression and 21.8% had serious psychological distress.
In addition, factors such as age, culture, and available medical resources can impact diagnoses. In general, the studies concluded that developing a relationship with a mental health care professional and undergoing multiple diagnostic visits over a longer period of time can substantially increase diagnostic accuracy.
Signs to Look For
To address the complexity of depression diagnosis, there are several mnemonics that have been developed in an effort to make the symptoms of depression more memorable. The mnemonic below, published by Blenkiron, 2006, lists 10 symptoms of depression aligning with the 10 letters of the word. Here we present the list and supplement each item with a brief description.
As was apparent from the list above, each symptom presented must recur in an individual for a period of multiple days before it should be considered a possible indicator for major depression. Generally speaking, until multiple of the symptoms above are present much of the time for a sustained period lasting around two weeks, there should not be major cause for concern.
However, anyone with any concern over the mental health or safety of a friend or loved one should consult with a mental health professional. Individuals who fear for anyone’s immediate safety should contact emergency services.
By Dr. Syras Derksen,
Blenkiron, P. (2006). A mnemonic for depression. BMJ: British Medical Journal, 332(7540), 551.
Mitchell, A. J., Vaze, A., & Rao, S. (2009). Clinical diagnosis of depression in primary care: a meta-analysis. The Lancet, 374(9690), 609-619.
Olfson, M., Blanco, C., & Marcus, S. C. (2016). Treatment of Adult Depression in the United States. JAMA Internal Medicine, 176(10), 1482.
It is hard for young men to cry. Research has shown that crying is thought of as a female expression. Expectations for how men grieve are keenly felt. The influence of our culture can be so extreme that some men truly feel they are physically unable to produce tears in response to grief.
I’m going to a funeral tomorrow for an aunt who died suddenly of cancer. I have not cried and I wonder how much of this has to do with me and how much is because of our culture. If I won’t cry, how will I grieve?
I recently found an article that attempted to answer this question by interviewing 25 young men who had recently lost a male friend to a non-health related accident (e.g., car accident, drug overdose, etc.). From these interviews, a few themes came to the surface.
One young man's friend died at an after graduation party. They had been in the back of a van and at a stop on the road when they saw some friends on the sidewalk. His friend got out of the van and ran to the sidewalk, but as he crossed into the next lane he was hit by a bus. The accident happened in full view of his friends in the bus and on the sidewalk. In the interview, this young man described feeling shock after the incident and then passivity - there was nothing he could do. To describe his feelings he took a picture of an empty bucket on its side. With no action to be taken and no appropriate emotional response, all that was left was a feeling of emptiness.
For men, anger is one of the culturally acceptable responses to loss. Even violence is accepted in some circumstances. It is believed that men sometimes can't control their anger.
One of the young men being interviewed told the story of his friend who had been in a domestic disturbance. The police responded to the incident and shot his friend. During the interview he gripped the table in his anger. He had considered acting out in revenge, but hadn’t taken his anger that far.
“It’s a stupid male thing, but because it was a violent death, I felt a lot of retribution and revenge. I was consumed with anger and the [girls] went straight to sadness, not all the anger and stuff.”
Some of the young men did express sadness, but not many. Those who did usually had cultural influences that were non-western. For example, perhaps their parents had immigrated from another country. The sadness these men expressed seemed to come from unfinished business. They also sometimes felt that they could have done something to prevent the death. This left them dwelling in regret.
These three expressions of grief (emptiness, anger, and sadness) seemed to stem from three primary identities. The first of these identities is the "adventurer." The young men who seemed to follow this pattern defined their lives primarily by their pursuit of new experiences. They had little attachment to any one person, place, or thing. Their lives were founded on freedom. The idea of mourning with friends was considered a suffocating experience.
One young man’s friend died while he was traveling. He was struck with sadness and felt like his friend was “far away.” He decided that engaging in a new adventure through his continued travels was the best way to honour his friend. These individuals were primarily isolated, although they had short superficial relationships with co-adventurers, and their actions could seem insensitive to others.
The Father Figure
This identity was quite different from the adventurer. They focused on responsibility, loyalty, and protection instead of experience. These men felt they were successful if they maintained a strong family network, provided for their families, and achieved academically or in their work.
In grief these men thought of their role as supporting others who were left behind, particularly women. They felt they had to be strong, and part of that meant not showing emotion. Showing emotion was thought of as making it more difficult for others to contain or manage their emotions.
“You don’t want to trigger other people. When they’re trying to deal with [things differently]... you don’t want to, you know, step on boundaries.”
There was also a small group of men who seemed to have a re-birth after the death of their friend. The death was a wake up call from a dangerous or unmeaningful life. These young men resolved to change their lives and help others. In a way, this was like using their own life as a lamp to help direct others away from their own mistakes.
One young man who was addicted to alcohol had a friend die of a drug overdose. His friend’s death made him question his life. He decided he wanted to help others like his friend who had died.
“I just wanted to be happy and touch other people like [his friend] that are going through a hard time and let them know that it’s not as bad as it seems.”
After reading this study I could see myself in some of the descriptions. I could empathise with the emptiness and the feelings of responsibility some of these young men experienced. Our culture has certainly limited men’s ability to express themselves, and men have had to adapt the way they manage their emotions. Sometimes this happens in ways that are more constructive than others. Hopefully being aware of this grief process will help men to find peace and help those around them to understand their journey.
By Dr. Syras Derksen
Creighton, G., Oliffe, J. L., Butterwick, S., & Saewic, E. (2013). After the death of a friend: Young men’s grief and masculine identities. Social Science and Medicine, 84, 35-43.