THE BIOLOGY OF DEPRESSION
We now know that in addition to psychological elements, depression can often be caused by biological factors, most notably by an imbalance in certain neurotransmitters, such as serotonin, that seem to directly affect emotional well-being. Medications that correct these imbalances—so-called SSRIs (selective serotonin reuptake inhibitors) such as Prozac (fluoxetine), Zoloft (sertraline), and Paxil (paroxetine)—have been shown to be helpful to many people, including children, suffering depression. But neurotransmitter levels are also affected by psychological phenomena, such as daily stress, loss of a loved one, or an early trauma, all of which may change the biological and chemical workings of the brain, leaving it vulnerable to depression. Exercise levels can change neurotransmitter levels in a different way, improving your mood and your biology.
We are just beginning to understand the complex interrelationships between the biological and psychological aspects of our emotional systems. As with the heart, some people are born with a genetic predisposition to heart disease; they inherit a weak heart, high blood pressure, or a tendency to atherosclerosis. Such individuals will have to work hard to prevent heart disease. But heart disease doesn’t have to come about through genetics. If a previously strong heart receives enough abuse—a poor diet, chronic smoking, or a habitual lack of exercise—it will become vulnerable to a heart attack. Likewise, depression seems to run in some families, but a vulnerability to it can be created at any point, through early deprivation, a lack of healthy loving relationships, or repeated blows to one’s self-esteem.
While I believe the biological, or “organic,” components of clinical depression (and the medical treatments for them) are of paramount importance and need to be carefully studied, my primary focus here is on what other psychologists and I have discovered about external psychological factors that can lead boys toward serious sadness or depression—factors such as a boy’s family life, how he’s treated at school, the quality of his friendships, and what kind of emotional support he gets on a regular basis.
THE COST, AGAIN, OF SOCIETY’S DISCONNECTION
In my view, so many of the symptoms of depression that boys experience are caused by gaps in how we, as a society, address the inner emotional worlds of our boys. As discussed in earlier chapters, boys are often pushed too early to be independent of those people—their parents—who have so far been their main source of comfort and nurturance. I believe that the pain of being separated from and losing these people, in and of itself, is enough to depress just about any boy. While neither the trauma of premature separation nor “abandonment” leads all boys to become depressed, either may create a deep sadness in many boys, making them vulnerable to depression later, either as boys or as men.
Further, I believe that many boys become susceptible to depression because of the emotional scarring they receive through society’s shame-based hardening process. No matter how healthy a boy’s emotional system was when he started life, it quickly becomes compromised by the hardening he feels is necessary to avoid feelings of shame, and by his denial (because of shame) of vulnerable emotional states such as sadness, disappointment, and despair. Every boy needs to cry sometimes, to seek the comfort of loving arms, to tell someone how much he hurts and to have them respond with empathy. Yet because of the gender straitjacket that inhibits boys from ever completely experiencing these feelings (let alone expressing them) and insists that they don’t need help, boys actively repress feelings of sadness in an unhealthy way that can lead them to feel lonely and frightened, or push them toward more severe forms of depression.
But the straitjacket also brings about sadness and depression in boys in yet another important way. As we’ve discussed, our gender-stereotyped myths about boys mislead us to believe that boys do not care much about their relationships with friends and families and that boys are generally tough, “cocky,” and independent. Yet we’ve also learned that, in reality, most boys experience all sorts of insecurities, feel tremendously dependent on their friends and families, and in many areas (for example, at school or when dating) are prone to large fluctuations in self-esteem. Boys yearn for connection—they care a lot about their relationships and about how they are liked by others. But because we are so often confused by the old myths, we may tend not to pay attention to the emotional ups and downs in our sons’ friendships and relationships and thus be unaware of the devastating feelings of shame our sons may experience when these friendships or relationships are not going well or have come to an end. Such shame in a boy, if no one detects it and explores it with him, can lead him to feel profoundly sad, afraid, and disconnected from the rest of the world, and even to become clinically depressed.
DEPRESSION OVER RELATIONSHIPS
Yet researchers have perennially doubted the intensity or basic emotional importance of boys’ relationships and so have assumed that problems in them would be unlikely to cause boys to become sad or depressed. Thus a study on depression in adolescent boys and girls conducted by Joan Girgus and her colleagues at Princeton University hypothesized that “levels of depression in early adolescent girls are more closely related to their popularity with peers than in early adolescent boys”—an assumption based on “the frequent argument that women are more likely than men to base their self-esteem on their relationships with others and on the approval of others.” But the results of the study were not as expected. “Surprisingly, the boys’ depression scores were significantly correlated with both popularity and rejection, whereas the girls’ depression scores were only significantly correlated with rejection. Thus, girls and boys are apparently equally vulnerable to depression as a function of poor peer relationships.”
Another study, by Paul Rohde, John Seeley, and David Mace, in Eugene, Oregon, also found that boys suffer when they don’t have healthy relationships. This study focused on the extent to which delinquent adolescents develop ideas about suicide, and it found that boys were more likely to think about suicide if they were suffering stressful life events and if they lacked social supports in situations such as when they were lonely and had few close relatives. The authors concluded that suicidal behavior for boys is closely linked to their social connections.
We now know that the opposite is also true—that strong relationships can prevent boys from sliding into depression or engaging in risky, self-destructive behaviors in the first place. The National Longitudinal Study on Adolescent Health, also mentioned in Chapter 7, found that teenagers who felt connected to their families were less likely to experience emotional distress. They were also less likely to engage in violence, attempt suicide, or use harmful substances. The key factors were parents who “shared activities” with teens, who were physically present at key times during the day, and, most important, who expressed warmth, love, and caring. Also, as we learned in our discussion about adolescence, Blake Bowden, at Cincinnati Children’s Hospital Medical Center, found that teens who ate dinner with their parents at least five nights a week were significantly better adjusted than classmates who dined alone.
In my opinion, we simply must resist being fooled by a boy’s mask. Boys are not Lone Rangers, and at all ages they need to be told that they’re good, that they make good friends, that they’re needed and loved. And, like all human beings, they particularly need caring support when their relationships are disrupted or come to an untimely end.
CHANGING RATES OF DEPRESSION: IT’S A GUY THING TOO
Perhaps one of the main reasons we often fail to detect (and thus to treat) depression in boys is that depression has been seen as something that girls and women suffer far more often than boys and men do.
The reality, however, does not seem to follow our gender-stereotyped assumptions.
Some 3.5 million children under the age of nineteen are clinically depressed in this country—about 5 percent of children in that age group. According to IMS America, a research company, some 580,000 prescriptions for Prozac, the most popular antidepressant drug, were written for children
ages five and older in 1996. In studies conducted in 1990 and 1991, Professor Susan Nolen-Hoeksema and her colleagues at Stanford University found that from ages eight through twelve, more boys reported depression than girls, and that these boys’ scores for depression were consistently higher than those of girls. Interestingly, these Stanford studies reflected that the most important symptoms of depression in prepubescent boys were behavior disturbances (such as being irritable or misbehaving) and anhedonia (a lack of pleasure, especially in relation to friends and friendships). Of course these kinds of symptoms, taken alone, would not generally qualify for a diagnosis of depression. This helps to explain why many boys, especially older boys who may display only these kinds of symptoms, could easily have their depressive states overlooked or misdiagnosed.
In one of the largest studies of depression in children, a survey in 1982 of 2,790 children in rural Pennsylvania, Smucker at Penn State found that there were no differences in the numbers of boys and girls who were depressed, nor in the severity of their depressions—suggesting that girls and boys may be equally susceptible to depression. In another poll of 1,000 teenagers conducted for Ms. magazine in 1997, 28 percent of young women aged fifteen to twenty-one stated they feel depressed daily or several times a week, and 20 percent of young men in the same age group reported to the magazine that they feel depressed just as frequently.
These studies on the incidence and severity of depression in boys are staggering. It’s quite probable that many of the studies may actually under-report the incidence of depression in boys, especially among older boys, because of boys’ reluctance to confess to sadness or vulnerability. Because boys feel pressured to mask their genuine pain, many boys, in the context of psychological studies or surveys, may fail to admit—or even know—that they’re experiencing depression.
This has already been shown to be true of men. Angst and Dobler-Mikola in Switzerland found that men and women who are depressed report their problems very differently. The men tended to minimize their pain. The researchers started with depressed men and women whose emotional problems had caused them similar levels of impairment at work. One could assume that these men and women were suffering similar levels of emotional pain. Yet the men in this group reported far fewer symptoms of depression than women.
Angst and Dobler-Mikola also found that, over time, men tended to forget how depressed they had been in the past. Men and women who had the same number of symptoms of depression were interviewed one year later. Men recalled many fewer symptoms of depression. Men seem to actively suppress their memories of a vulnerable, sad time.
In a similar way many boys may tend to deny or “forget” their pain when questioned by research scientists. While some studies are designed to evoke more candid responses from boys, many (in fact, probably most) are not. This can lead to research results that, among other things, end up underestimating the actual incidence of depression among boys.
But what’s most important, of course, is not to debate which gender is more prone to depression but to understand that all human beings, despite gender, are all too eminently vulnerable to depression and that the only way to help reduce the incidence of depression is first to recognize this, and then to learn how to detect symptoms early on and master what to do when these symptoms begin.
RECOGNIZING SADNESS AND DEPRESSION IN BOYS
Learning how to detect sadness in boys is actually a separate process from learning how to recognize an actual depression. While there’s a lot of overlap, it’s important to distinguish the normal strategies a healthy boy uses to cope with feelings of sadness from the symptoms of an actual depression. So much of the difference has to do with the degree of a boy’s behavior—how much he acts a certain way, how intense his behavior is, and how long the behavior lasts. For instance, a boy who occasionally shuts himself into his room when he’s feeling down is probably just momentarily feeling sad. By contrast, the boy who frequently comes home from school, goes into his room, shuts the door, and refuses to talk to anyone is obviously exhibiting behaviors that fall squarely within the continuum of depression. Likewise, a boy who has a bad day and doesn’t feel like coming to the dinner table is clearly quite different from one who consistently refuses to eat or dine with his family. Where diagnosing depression in boys becomes more difficult, of course, is when boys’ behaviors fall between the temporary “bad mood” and the comportment of somebody who is obviously unwell. Also, as we’ve seen, adults may not recognize depression in boys when it is expressed as anger or agitation rather than as sadness, hopelessness, withdrawal, and despair.
SADNESS BUT NOT DEPRESSION
Admittedly, recognizing sadness and depression in boys tends to be more difficult than recognizing them in girls. When girls feel sad, they generally rely on a very different coping style than boys. Girls, according to psychologist Susan Nolen-Hoeksema of Stanford University, tend to “ruminate” on their sadness, its symptoms, and its possible causes. Also, research shows that most girls are more likely to cry, admit their feelings of unhappiness, hopelessness, or helplessness, and seek out support from friends and family. In a recent poll, researchers found that when girls feel sad, almost half (45 percent) say they talk to friends. Only 26 percent of the boys polled said they would turn to friends for support.
In contrast, when boys feel sad, they do not tend to dwell, or “rumisnate,” on their unhappiness. And while certainly some will go directly to friends or family for comfort and support, the majority attempt either to simply “let go” of their painful feelings or instead to take an “action-oriented” strategy to resolve them. Fourteen-year-old Ross told me how he deals with being sad. “About once a week, I get upset about something, but I forget about it pretty soon. I find a friend and go play ball or just hang out. I put it aside and just move on.”
Other times, Ross says, he just gets mad. He told me about a time he got in a fight with a friend. “I came home really sad and went up to my room. I just sat on my bed and listened to music. I was sad, then I got mad—really tense and really mad—and then I yelled and punched my pillow a bunch of times. That’s how my sadness is, mixed in with a lot of aggression. Being sad is the same as being mad for me.”
Ross’s response is typical of many boys who cope with mild sadness by distracting themselves. They play ball, hang out with friends, listen to music, or watch TV. When emotions are running so high that simple distraction doesn’t work, a boy will tend to withdraw for a while, needing to be alone to ride out the storm and reemerging from his sadness only after the worst of the pain is passed. Many boys in the “Listening to Boys’ Voices” study spoke of the need to “let things blow over.”
Listen, for instance, to Mark, a bright and energetic fifteen-year-old:
“There’s a mold you should fit into if you’re a guy. You’re supposed to be on the strong, aggressive side, have social strength, and strength of will, and strength of body. You can’t break like a twig in the wind.”
“So how do you deal with things when you’re feeling weak, when things aren’t going so great?” I asked.
“When I get angry,” Mark answered, “I try to just let it go. I usually try to rationalize it in my head, to explain to myself that I shouldn’t be that angry about it. I try to either think about it calmly, or not think about it at all so it won’t bother me anymore. When I feel sad, I look for something to throw it into perspective. . . . It kind of goes away or I concentrate on something else.”
Because he has internalized the sense that showing too many unresolved feelings can be counterproductive, Mark feels critical of other boys who are unable to keep a lid on their emotions. “Some guys get obsessed with one annoying point in their life, but if they only let go of it, their life would be much better. It wouldn’t take them a lot of effort to let go of it. I wish they would just act rationally or calmly, just kind of take it a little quieter and less vocally, like everyone else told them to.”
Mark seems to equate expressing his vulnerability with a
n acute sense of shame, fearing severe penalties for failing to adapt to the mold. “If you don’t fit in, then you’re a loser, you’re worthless, you look stupid, and no one likes you. People tend not to associate with you. They push you off in the corner. After a while, if you respond badly, if you just respond by getting more and more depressed, people don’t react well to that.” Mark’s comments reflect how any gap in a boy’s self-confidence—any admission that he’s feeling sad or depressed—becomes a cause for others to reject him. And then again if a boy continues to internalize his feelings of sadness and pain and doesn’t learn how to suppress them, he may fear they’re only going to get worse. Mark explains:
“If you try to shut yourself inside your head and not ever come out, then it’s just going to be worse. There’s no way to get away from it.”
But if some boys like Mark deal with sadness by simply attempting to “let it go,” others rely on the “timed-silence syndrome” we discussed earlier. When a boy feels hurt or unhappy, he may prefer to lick his wounds in private, where he will not be shamed by others. He comes up for air—and may seek out help from parents or friends—only after experiencing a period of silence and private grieving. The advantage of this strategy for a boy is that no one ever sees his sadness. He averts shame. The disadvantage, of course, is that unless parents know this syndrome when they see it, they may have a difficult time detecting his sadness.
My sense is that boys who successfully use distracting and withdrawing strategies including “timed silence” still need other people to help them recover from their emotional pain. After withdrawing to let the worst of the storm pass, most boys go out of their way to reconnect with family and friends. When he’s ready to reemerge, a boy needs to interact with others: to play a mindless game of ball with friends, to have mom say, “Glad things seem better,” to have dad offer a special trip for ice cream, or even to have the same old argument with his sister about the TV schedule. When this happens, a boy knows that life goes on. His shame melts away. The people who care about him are still around and can be counted on.
Real Boys Page 42