MIND 

Mind is the leading mental health charity in England and Wales.

14/01/03

FACTSHEET

MEN’S  MENTAL  HEALTH

• Suicides by men comprise 75% of all suicides in the UK
• Older men have the highest suicide rates in the UK
• Young men have the fastest rising suicide rates in the UK
• Doctors are less likely to diagnose men with depression than women
• Studies suggest that depression occurs as often in men as in women
• Men are less likely to seek medical attention than women
• Physical illness is a major contributory factor in men developing mental distress
• 1 in 7 men who become unemployed will develop depression within 6 months
• Men are more likely than women to experience long term unemployment
• Unemployment is a major cause of depression and suicide in men
• 50% of victims of domestic violence are men
• Men make up 96% of the UK prison population
• Men are more likely to be given custodial sentences than women for the same offence
• 58% of remand prisoners have been assessed as having mental health problems
• 39% of sentenced prisoners have been assessed as having mental health problems
• Alcohol and substance abuse is 5 times more common in men than in women
• Men tend to have an earlier onset of schizophrenia and a poorer prognosis than women

Introduction

This factsheet aims to address general mental health issues which are relevant to all men in Britain, and to look at specific issues which are relevant to particular groups of men.  The subject of men and their mental health has been for long an under-recognised, under-researched and under-resourced area. Mainly due to large increases in male suicide, men’s mental health is currently coming to be recognised as a major public health issue.

In the last few decades the society we live in has undergone a sea change. As we enter the new millennium men appear to be more vulnerable to mental health problems and to suicide than ever before. Why is this? There is no easy answer, it is probably a combination of factors. There is a tradition of men being reluctant to talk about their problems or express their feelings. Men are less likely than women to go to their GP with psychological problems; if they do go to their GP they are more likely to present with physical problems which may not be recognised as a manifestation of mental distress. Men have suffered more severely than women in the shrinkage of heavy industry and traditional manufacturing jobs. Young men and boys are doing less well than girls at school and in further education. The breakdown of traditional gender roles and the concept of the “new man” have left many men feeling uncertain of what is expected of them, particularly in terms of significant relationships.

Men and Mental Distress

Mental distress can take many forms.  Most forms of mental distress are not specific to one gender, however, different issues can arise for the different genders. The following section addresses issues of particular relevance to men’s mental health.

Civil Admission to Hospital

The number of men formally admitted to NHS hospitals under Part II of the Mental Health Act (Sections 2, 3 and 4) has almost doubled in recent years. Between 1988-89 and 1998-99 formal admissions of men rose from 6,200 per year to 12,300. In the same period formal admissions of women rose by 48%, from 8,100 to 11,900.[1] Black men, in particular, have high admission rates to hospital under section, and are over represented in secure units.

Depression

A number of recent studies conclude that depression occurs as often in men as in women,[2] even though women get diagnosed and treated twice as often as men [3]. A number of reasons have been suggested for why depression in men remains hidden or unrecognised. Men often do not acknowledge their depression to others or even themselves because it is considered “unmanly”. Depression is a disorder of mood and feelings, and in mainstream culture, men are not supposed to succumb to emotional pain or admit they are having emotional problems. It has been suggested that men may manifest depression differently than women. “Hidden” or “covert” depression may be the driving force behind several of the problems we think of as being typically male – alcohol and drug abuse, domestic violence and failures in intimacy.[4]

(for further information, see Mind’s booklet “Understanding Depression”)

Schizophrenia

There are gender differences in both the presentation and the course of schizophrenia. Men are more likely to have an early onset of schizophrenia, typically in the late teens to mid-twenties. DSM IV suggests that men diagnosed with schizophrenia have a poorer prognosis for recovery than women.[5] It has long been held that males and females are affected in roughly equal numbers, however, hospital-based studies suggest a higher rate of schizophrenia in males, whereas community-based surveys have mostly suggested an equal sex ratio.

(for further information, see Mind’s booklet “Understanding Schizophrenia”)

Substance Abuse

Alcohol abuse and dependence is far more common in men than women, with a male-to-female ratio of 5:1. Alcohol and drug use is the major contributory factor in violent crime. 62% of violent offenders were drinking at the time of the crime. The prevalence of violence in people who meet the criteria for a diagnosis of alcoholism is twelve times higher than that of the general population, and is sixteen times higher for those with a diagnosis of drug abuse.[6] Solvent abuse is predominantly a young male problem, with males accounting for 70%-80% of solvent abuse.

(for further information, see Mind’s booklet “Understanding The Psychological Effects of Street Drugs”)

Personality Disorders

More men than women are diagnosed with antisocial, paranoid and schizoid or schizotypal personality disorders. [7] Antisocial personality disorder is predominantly found in men and usually begins early in life. Men with antisocial personality disorder comprise 63% of male remand prisoners in the UK, and 49% of sentenced male prisoners.

(for further information, see Mind’s booklet “Understanding Personality Disorders”)

Attention Deficit Hyperactivity Disorder

Research suggests that men experience a disproportionate number of childhood disorders, for example attention deficit hyperactivity disorder and conduct disorder. [8]

(for further information, see Mind’s booklet “Understanding Attention Deficit Hyperactivity Disorder”)

Post-Traumatic Stress Disorde>

Individuals at high risk of developing post-traumatic stress disorder include combat veterans, fire-fighters and victims of violence. Studies of groups of at-risk individuals show prevalence rates of PTSD to be at least three times as high as within the general population.

(for further information, see Mind’s booklet “Understanding Post Traumatic Stress Disorder”)

Men and the Healthcare System

Men appear to be more reluctant to seek help than women. Men’s low utilisation of services is sometimes used to reject calls for providing more services. Some men don’t seek help because they believe that a man should solve his problems by himself, some simply don’t know where to turn for assistance, and others fear that “the system” is designed to help women, not men.[9]

The common assertion that women have higher levels of ill health than men is now being questioned. Studies suggest that gender differences have become over-simplified and should be re-examined periodically to monitor the impact of changes in gender roles on people’s experiences of health and illness.[10] It is not just the impact of lifestyles and biology, but society’s expectations of men that need to be addressed. Such expectations have created an environment in which men are less able than women to recognise physical and emotional distress and to seek help. Available data shows that for most illnesses men are less likely than women to consult their general practitioners.[11]

Women visit their doctors around twice as often as men, and women form the majority of patients treated in hospital. Men will often delay visiting the doctor for serious conditions.

An American Medical Association study in 1990 found that men don’t go to the doctor because of fear, denial, embarrassment, and threatened masculinity. To admit to having pain or some other problem is seen as a confession of weakness. It can threaten male pride and the stereotype of man in a “provider” role. The male denial factor appears to be unrelated to occupation, age, race or socio-economic status.

Screening programmes are provided for women-related cancers such as breast and cervical cancer. However, there is no screening of equivalent cancers affecting men, such as prostate and testicular cancer. This despite the fact that deaths from prostate cancer, 10,000 per year, are almost as high as deaths from breast cancer, and 6.7 times higher than deaths from cervical cancer. Between 1981 and 1998 male death rates for cancer of the prostate rose by 28%, while during the same period, female rates for breast cancer dropped by 15%[12].

Health promotion posters and leaflets published by the NHS, for doctors surgeries and elsewhere, target women only issues such as breast and cervical cancer. It is unusual to find a single health leaflet targeting men-only conditions.

Social Causes of Men’s Mental Distress

Society conditions men and boys to conform to certain masculine stereotypes. From an early age boys get hurt, abused, ignored, humiliated and called names for showing any vulnerability. Boys are denied access to natural healing processes; they are told not to cry, not to show their feelings, to be fearless, to behave like a man, not a girl.

One effect of this conditioning is that males are reluctant to ask for help from doctors, counsellors, family and friends. Men tend to seek help only in a crisis, by which time the problem has often escalated.

This conditioning is often internalised and then acted out in many forms of abuse and self-abuse which are detrimental to health and well-being. Typical behaviour patterns include: minimising or ignoring injuries and illnesses, suppressing and denying feelings of pain and distress, presenting an image of being tough, controlled, invulnerable.

Men often use addictions and over-activity (such as over-working) to numb the pain or distract themselves from it. Excessive risk-taking is another typical behaviour, as is becoming violent and abusive.

The Royal College of Psychiatrists says men are probably just as likely to get depressed as women, but frequently feel that it is “unmanly” and “weak” to ask for professional help.

Launching the new leaflet on depression, “Men Behaving Sadly”, Dr Philip Timms, a consultant psychiatrist at Guys Hospital, said: “It’s a male cultural thing. Men are more likely to want to be independent and less dependent on family and friends.” 

Men’s fear of talking about their problems can mean they avoid conflict and difficult discussions, resulting in communication breakdowns and relationship problems. Many men turn to drink and drugs to blot out negative emotions, but this can lead to violence and relationship problems.

Research also shows that one in ten new fathers becomes depressed, particularly if their partner is experiencing post-natal depression.

Family Life

Men appear to suffer more than women when their relationships break down. Most divorces and separations are initiated by women, and in the vast majority of cases, the man did not want their family to spilt up. Men are, in over 70% of cases[13] divorced by their wives against their wishes. Also, when a relationship breaks down, men may lose touch with their children as well as their partner, and may have to find a new home.

A UK study of divorced men[14] found that if a man takes the step of marrying and has children: he has a 50:50 chance of divorcing and losing custody of his children. He has a 1 in 3 chance of losing his home, and a 1 in 10 chance of losing contact with his children forever. UK courts have a powerful default of awarding custody of children to the mothers in 91% of cases.

Delegates at a seminar organised by the Home Office (1999), called “Boys, Young Men and Fathers”, heard how boys who had no contact with their fathers were more likely to be violent, get hurt, get into trouble and do less well at school. A recent study, “Leading Lads” [15], confirmed that a significant association exists between the level of involvement by fathers and a boy being in trouble with the police. The study found that 35% of boys with little or no involvement from their father had offended, while only 18% of boys with a highly involved father had offended. Highly involved fathers emerged as a major factor in boys’ general well-being. A caring, emotionally supportive father seems to protect boys against depression or suicidal thoughts.

Employment

Between 1979 and 1994, dramatic changes in patterns of employment considerably affected both the numbers of men and women in work and the type of work they do. During these years there was a 16.8% drop in the number of men in employment and a 12.2% increase in the number of women.[16] During the same period, 90% of the jobs created have been perceived as “women’s work”, while a similar percentage of jobs were lost in what was traditionally perceived as “men’s work”.[17] Traditional industries that have employed men such as mining, steel works, ship building and other heavy industries have closed in large numbers.

In losing many jobs in manufacturing and heavy industry, Britain has become the first European country whose work force is, in the majority, female.[18] Within this new working environment, men are more likely to experience long-term unemployment, and the less well skilled a man is, the more likely he is to be unemployed.

In the age group 18-24, there are over three males to one female who have been unemployed for a year or more. The longer the period of unemployment, the wider the gap becomes between men and women.

Men in full-time employment work an average of 41.9 hours per week compared to women’s 37.6 hours per week. The unemployment rate for men is three times that of women. It stands at 76% of total unemployment figures, as opposed to women’s 24%.

Professor Glyn Lewis, from the University of Wales, and Dr Andy Sloggett, from the London School of Tropical Medicine, studied data on suicides occurring between 1983 and 1992.[19]  They found that unemployment was associated with a doubling of the suicide rate. They also found that lack of job security was a risk factor. Their research suggests that “Employment may have a particularly important role in defining an individual’s place in the community, and unemployment could lead to alienation from the rest of society. This study provides strong support for the possibility that reduction in unemployment would also reduce rates of suicide.”

It has also been noted that men in unskilled employment are twice as likely to kill themselves compared with other men in the general population.[20]

Research suggests that social exclusion is a major component of the psychological isolation that unemployed men experience.[21] Recent research has shown that approximately 1 in 7 men who become unemployed will develop a depressive illness in the next 6 months.[22]

When men become unemployed, this can put a great deal of pressure on families, and disrupt relationships. Changing patterns of employment are thought to contribute to increasing divorce rates and the break up of families.[23]

Race is also a very important factor in relation to male unemployment. The unemployment rate for black and minority ethnic men is higher than for white men. The gender imbalance in patterns of employment is also reflected across all ethnic groups.[24]

Education

Female teachers comprise 80% of primary school teachers and 52% of secondary school teachers.

Males’ expected years of schooling is 16 years, compared with females’ 17 years.[25]

A recent study found that children who attended nurseries with male as well as female staff had a more balanced view of the world. However, only 1% of childcare workers are male, and the researchers found that a significant proportion of these male workers were made to feel like outsiders both by parents and colleagues.[26]

Physical Causes of Mental Distress in Men

Physical illness can be a major contributory factor in men developing emotional problems. Physical illnesses, especially long-term conditions, and hospital stays can lead to depression in men.

Recent research in Finland [27] studied 30,000 men over an eight year period. Their findings established a link between cholesterol and mood.  The risk of depression and suicide amongst men with the lowest cholesterol was nearly double that of men with the highest levels of cholesterol. Among the 280 men who were treated for depression in hospital, a link between low cholesterol and poor mental health was established. A further 111 men committed suicide, and in these cases, researchers found a ?significant association? between low cholesterol and severe depression. Professor Timo Partonen, who led the study, suggested that low levels of cholesterol may lead to a decrease in serotonin levels in the brain, in turn leading to poor control of aggressive (suicidal) impulses. This idea is supported by the finding that cholesterol is abnormally low in men after suicide attempts. Partonen suggests that GP's and psychiatrists should monitor blood cholesterol in patients being treated for depression.

Researchers from the Queen’s Medical Centre in Nottingham have found that men who are depressed are three times more likely to develop heart disease.  These findings have been confirmed by research in America.[28] This link does not appear to be influenced by other factors such as deprivation or high blood pressure and was not relevant for women. The researchers suggest a number of possible explanations for the link. Depression may lead to unhealthy lifestyles, such as failure to take exercise or an increase in smoking, which could increase strain on the cardio-vascular system. It is thought that some anti-depressant drugs can pose problems. Being depressed also impacts on the nervous system, with a knock-on effect on the heart, and can alter the balance of chemicals in the body.

The reason that the link between depression and heart disease appears to only exist in men is unclear, although men appear to be more sensitive to chemical changes in the body. Conversely, the study also found that men with heart disease had an increased chance of depression after developing heart disease. The researchers also question whether GP's are less likely to recognise or diagnose depression in men unless it appears to be particularly severe.

Circumcision is practised on some male infants as a routine, and on others as a result of religious or cultural tradition. It is also practised on adult males as a result of certain medical conditions.

There is strong evidence that circumcision can be overwhelmingly painful and traumatic. The physical and sexual loss resulting from circumcision is gaining recognition, and some men have strong feelings of dissatisfaction about being circumcised.

Studies into the practice of circumcision often refer to the practice as “traumatic”.[29] [30] Research suggests that some boys, and adult males, may experience post-traumatic stress disorder as a result of circumcision. [31] Examples of PTSD symptoms include recurrent thoughts and dreams about, and avoidance of the topic of circumcision. Other symptoms include emotional numbing and inappropriate anger which may increase with time after the traumatic event. Both infant and adult circumcision can result in a loss of sexual sensitivity and, in some cases, can result in impotence.[32]

Negative feelings about the penis are related to the idea of body image. This includes value judgements about how the body is thought to appear to others, and can have a great impact on how men live their lives.

Erectile dysfunction, or impotence, is one of the most common chronic medical disorders in men over the age of 40 years. One study found that 35% of men aged 40-70 reported moderate or complete impotence, with 52% of the group reporting some degree of erectile dysfunction.[33] The prevalence and severity of this disorder increases with age, and is a major quality-of-life issue for older men. Erectile dysfunction can lead to depression and relationship problems.

Young Men and Boys

The Samaritans’ recent report Young Men Speak Out[34] surveys young male attitudes in the UK. The report highlights the fact that twelve young men kill themselves every week.  The report suggests that macho stereotypes are preventing young men from asking for help. The survey of young male attitudes reveals that young men in distress are more likely to use violence and anti-social behaviour to express themselves than they are to tell someone how they feel.

The Samaritans’ report found that only 39% of suicidal young men would consider phoning the Samaritans. The report states that young men considering suicide are often reluctant to use the Samaritans’ service because of the social stigma surrounding talking about feelings. Young male culture denies emotional support to young men and encourages them to appear tough and to bottle up their emotions.

The Samaritans’ survey into young male attitudes found that:

• 67% of suicidal young men say they have nowhere to turn for emotional help
• Suicidal young men are four times more likely to smoke and ten times more likely to take an illegal drug to relieve stress
• More than one in three young men would “smash something up” instead of talking about their feelings
• Less than one in five young men would ask their father for emotional support
• 78% of depressed and suicidal young men have experienced bullying
• 69% of suicidal young men have experienced violence from an adult
• 50% of suicidal young men have been in trouble with the police compared with to 17% of the non-suicidal

Adrienne Katz, co-author of the Young Men Speak Out research, said: “Many of the lads I spoke to said ‘Nobody ever asks me how I really feel’. We have to let lads know that it is safe to talk and that they won’t be judged by society for being open about their feelings.”

Around 11% of 5 – 15 year old boys in the UK are diagnosed as having some form of mental health problem, this compares with 8% of girls in the same age group.[35]  Whereas the rates of emotional disorders were similar for boys and girls, the prevalence of conduct disorders was found to be twice as common among boys as girls. For hyperkinetic disorders, such as Attention Deficit Hyperactivity Disorder, the ratio was found to be even greater, with the prevalence in boys being four times that in girls (2%, compared with 0.5%).

Boys and Education

In recent years there has been an alarming decline in boys’ attainment and participation at school, which has been noted in almost all industrial countries. Parents and teachers note that boys both have trouble, and cause trouble, at school to a far higher degree than girls. Boys examination results, literacy rates and retention rates are falling.

Teachers point out that boys are often unmotivated, lack confidence, see learning as un-masculine, and are depressed and demoralised about their future. According to national statistics, only 9% of 14 year old boys nationwide get grades in the range A – C in English.[36]

Research has shown that when boys and girls are mis-behaving equally, boys receive more frequent and severe penalties. Boys, particularly low-achievers, receive 8 to 10 times the reprimands of female classmates. These reprimands are more likely to occur in front of classmates, whereas girls are more likely to be taken aside to be reprimanded.[37]

The Cotswold experiment was developed to meet the challenge of boys’ poor attainment in English. The Cotswold School, a secondary school in Leicestershire, assigned boys and girls to separate English classes. The choice of texts, poetry and discussion materials was tailored to boys’ interests in the boys’ classes. In addition, class sizes were reduced to about 21, and some intensive writing and reading support was instituted for the boys.

As a result of the experiment, after two years in the gender-segregated classes, the number of boys in the high-scoring range had increased by almost 400%. The girls did significantly better too.

The Cotswold experiment acknowledges that boys generally have a slower development of language skills. It also takes into account the key life skills of self-expression, self-awareness and communication – the very things which men traditionally lack. The boys in the experiment became more expressive, creative and linguistically skilled, thus more equipped for life.

Older Men

As men age, a number of hormonal, physiological and chemical changes occur in their bodies. This is sometimes referred to as the male menopause, and is also known as viropause or andropause. These changes begin generally between the ages of 40 and 55, though they can occur as early as 35 or as late as 65. These changes can affect all aspects of a man’s life.

Generally between the ages of forty and fifty a number of hormones in the male body begin to decline. Lowered levels of dopamine, oxytocin, vasopressin, growth hormone, melatonin,  thyroid hormone, and testosterone may decrease sex drive, increase depression and weight gain, and contribute to a general decrease in health and well-being. The male body begins to lose its firmness and change shape. Characteristic  medical conditions like enlarged prostate develop. Sexual functioning is often compromised by hormonal imbalance, illness, medications, mind or mood. Stamina and temperament can be affected too.  Emotionally, like their female counterparts, men can have severe repercussions from viropause, including severe depression and suicide.[38]

It is known that the prostate gland is the most frequently diseased organ in the human body.[39] All men are susceptible to contracting the three major disease of the prostate: prostatitis; benign prostatic hyperplasia (BPH), also known as enlarged prostate; and prostate cancer. It has been stated that: “A man’s odds of getting one of these three diseases approaches 100%.”[40] In other words, a man living into old age will almost certainly develop one of these three diseases of the prostate.

While Well Women clinics are a common feature in primary care, there is no male equivalent. While gynaecologists specialise in treating female problems, there is really no physician speciality trained to deal with the wide variety of problems facing men.

Older men have the highest suicide rates in the UK. Suicide in older men is strongly associated with depression, physical pain or illness, living alone, and feelings of hopelessness and guilt.

Community surveys suggest that as many as 16% of older people may be experiencing depression, but that only a fraction of these may be known to GP or psychiatric services. Research also found that community-based psychiatric services were seeing less than 25% of older people with depression who later went on to commit suicide.[41]

Violence Against Men

There is a common myth about domestic violence, that the vast majority of the time women are the victims and men are the perpetrators. However, all serious studies of domestic violence show a roughly equal balance between the genders. A UK MORI poll[42] found that 18% of men have been the victim of domestic violence by a female partner, as opposed to 13% of women by a male partner. Only 4% of women explained that their violent behaviour was as a result of drink or drugs, compared to 10% of men.

Home Office figures[43] show that general reporting of violence against the person is equal between genders. The British Crime Survey reports that 4.2% of women and 4.2% of men said they had been the victims of violence in the past year.

Violence against men exceeds violence against women in every category, apart from sexual assault, including frequency and severity of assault. 68% of all homicide victims are male. Both male and female murderers are more likely to kill males than females. Mothers are more likely to kill their sons than their daughters.[44]