It’s Time To Talk About Depression And Suicide In South African Men

Around twice as many women as men are reported to suffer from depression – but the suicide rate for men is five times higher. Is depression the new, silent killer of men?

Five years ago, Jack’s* son was born. It was a difficult birth, and he and his wife were told their child might not survive his first night. But he struggled through that night, and each day after that, until finally – after 10 days in the Neonatal Intensive Care Unit – he was strong enough to leave.

That day was life-altering; the new family was leaving the hospital, and the joy-filled phone calls didn’t stop. But one phone call they didn’t expect was one from Jack’s work; he’d been retrenched from the job he loved. The day that was supposed to be one of his happiest and most relieving had turned into one that left the family’s future uncertain.

After that, Jack’s son grew; but so did the dark cloud over them. His wife suffered from severe post-natal depression, and Jack was trying to keep everything together at home whist completing his PhD. “To say that I was anxious would be an understatement. I think if I had gone to a therapist then, it would really have helped. I thought I just needed to be stronger,” he recalls.

“I did absolutely nothing. I thought this was something I just needed to get through. That once the storm had passed, I would get better. I thought that medicating myself wouldn’t make the problems go away. I failed to think that it would make them bearable. I lived with crippling anxiety for years before I did something.”

Shortly before Jack’s 40th birthday, he and his wife separated, he had a work crisis, and he started losing patience with his young son for no reason. Jack was overwhelmed, unable to cope: he fell apart. Having narrowly escaped the noose, he reached out to his friends. His musician friends immediately came back with messages of love and support; but his football friends said nothing.

“I think if I had gone to a therapist then, it would really have helped. I thought I just needed to be stronger.”

– Jack

He began going to therapy, and was diagnosed with depression. “What helped me the most was admitting to myself that I wasn’t coping, that I was scared, that my behaviour was negatively impacting other people.”

But many men don’t reach out, they don’t get the help they need, and they suffer in silence, due to stigmas surrounding men and mental health. According to a 2012 study by South Africa’s Medical Research Council, over five times more men than women commit suicide in South Africa. In another study, in the Journal of Counselling and Development, men who had a higher conflict between learned gender roles and a healthy expression of emotion were more likely to be depressed and have a negative opinion of psychological counselling.

In 2018, ideas about what it means to be a man are changing, and we need to continue to challenge them – especially when it comes to depression. After all, the reasons you’re struggling to ask for help might be some of the reasons you need help in the first place.

Here is the low-down on being down.

What Is Depression?

In medical terms, depression is often referred to as ‘major depressive disorder’, says Dr. Eugene Viljoen, a respected clinical psychologist and sexologist who has been in private practice for over 25 years.

Depression is a “whole-body” illness, involving your body, mood and thoughts. It affects the way you eat and sleep, the way you feel about yourself, and the way you think about things, reports the South African Depression and Anxiety Group (SADAG), Africa’s largest mental health patient initiative.

At some point, most of us will have heard someone say that “depression is a chemical imbalance in the brain”. And until now, scientists believed an absence of the neurotransmitter serotonin (known as the “feel-good” chemical) was to blame for depression.

The reason the scientists believed this is because when people who suffered from depression were given drugs that increased serotonin levels, their symptoms began to be alleviated.

The problem with this belief? While chemicals are most definitely involved, assuming that depression is merely a mild chemical imbalance in the brain disregards just how complex the disease can be.

When scientists looked at the brain of a depressed person, they noticed that the hippocampus was much smaller than average. The hippocampus is responsible for memory and emotion; and the longer a person is depressed, the smaller their hippocampus becomes.

The cells and networks literally deteriorate. And as it turns out, research suggests stress may be a trigger for the decrease in the production of new neurons. Studies have shown that when the hippocampus is regenerated and new neurons are stimulated, mood improves. The reason scientists first linked serotonin to depression is because many modern drugs that increase levels of serotonin also indirectly promote and stimulate the production and growth of new brain cells.

And yet it’s still not that simple; genetic factors, trauma, the circadian rhythm, cytokines, the amygdala, monoamines… these and more are all variables that studies suggest play a role in depression.

But if all this science sounds like a foreign language, don’t worry – you just need to remember one thing. As AsapSCIENCE says: “Depression is a disease with a biological basis, along with psychological and social implications.”

Simply, that’s what depression is. So what is depression not? According to SADAG, depression is not the same as a short-lived blue mood. It is not a sign of personal weakness – and it’s not a condition that can be willed or wished away. People with depression cannot merely “pull themselves together” and get better.

What Are The Symptoms Of Depression?

The symptoms of depression differ from person to person. Not everyone experiences all the symptoms of depression, and the severity of the symptoms also differs widely, says Dr. Viljoen.

Some of the symptoms include: feeling sad; losing interest in activities you once enjoyed; changes in appetite, weight loss or weight gain unrelated to dieting; trouble sleeping, or sleeping too much; a loss of energy; an increase in purposeless activities (such as pacing); feeling worthless or guilty; a detororiation in social relationships; thoughts of death or suicide; and difficulty in thinking, concentrating or making decisions. (Of course, this is isn’t an exhaustive list, but it does show some of the most common symptoms.)

“Men and woman share the same core set of symptoms as described above. But there are some differences in terms of the way in which these symptom patterns present themselves,” says Dr. Viljoen.

In his experience, one of the most common ways men’s symptoms differ from those of women is in the way men project sadness. Women show more visible signs of emotion, such as crying. Men, on the other hand, tend to show less emotion and become more rigid.

“Men may not recognise their irritability, sleep problems, loss of interest in work or hobbies, and withdrawal as signs of depression. As a result, fewer men may recognise their depression and ask for the help they need,” reports SADAG.

One other notable way in which men’s and women’s symptoms differ is that women are more likely than men to exhibit the non-typical symptoms of depression, such as sleeping excessively and overeating; in contrast to the typical symptoms in males, such as not being able to sleep and loss of appetite, says Dr. Viljoen.

Depression is most often spoken about with reference to women because it’s reported that depression affects twice as many women as men. Other research suggests that men talk differently – and often, not at all – about the symptoms of depression.

“Because traditional masculinity runs counter to acknowledging vulnerability, this stands in the way of getting help early, which is vital for a good prognosis. Men, for example, are less likely than women to be diagnosed with depression; and while this is in part because of biological and environmental factors, it is also because men are often unwilling to seek treatment,” explains Dr. John Hunter, who has a PhD in psychology and runs workshops on mental health for corporates.

What Are The Different Types Of Depression?

According to the National Institute of Mental Health, the most common types of depression are psychotic depression, seasonal affective disorder, persistent depressive disorder and minor depression. Bipolar disorder is also common; and although it is different from depression, a person who has bipolar disorder will experience feelings of depression.

Major depression is characterised by depressive symptoms that interfere with your ability to work, sleep, study, eat and generally enjoy your life. Although a major depressive episode may only happen once in your life, it’s more common to have several episodes.

Psychotic depression includes severe depression that is accompanied by delusions and false beliefs as well as hallucinations, such as hearing or seeing things that aren’t there. These psychotic symptoms have themes of depression – for example, believing you’re poor or sick when you aren’t, or hearing voices that tell you that you’re worthless.

Seasonal affective disorder is when you experience depressive symptoms during the winter months every year, when there is less naturally occurring sunlight. Persistent depressive disorder, also known as dysthymia, is characterised by depressive symptoms that last for an extended period of time (two years or longer) but are less severe than the symptoms of major depression.

Minor depression is similar to persistent depressive disorder and major depression; but the symptoms are less severe, and may not last as long.

Bipolar disorder is different to depression, in that a sufferer doesn’t only experience extreme low moods, but also extreme high moods, known as mania (or a milder form of mania called hypomania).

Dr. Hunter first started experiencing depression in his third year of university, but it was only four years later that something changed: everything became better. For three months, Dr. Hunter felt ‘high’. “Without the use of drugs, I experienced an overwhelming sense of euphoria, confidence, energy, and sociability; the world seemed full of pleasure and promise, I felt enormously creative – my mind overflowed with ideas – and I slept just two or three hours a night over that entire period.”

But that feeling left with the same ferocity with which it had arrived. Suddenly, instead of being engulfed with joy, he was submerged in excruciating psychological pain, awful thoughts flooding his mind. “For at least an additional two months, the thought of ending my life and escaping from this pain was the only thing that brought me comfort,” he recalls. It was this pain that eventually led him to seek help – and be diagnosed with bipolar disorder.

Dr. Hunter has lived with bipolar disorder for over fifteen years. And he graduated his honours degree summa cum laude, his master’s cum laude, and was awarded the UKZN doctoral research scholarship.

With a PhD in psychology, he now offers talks and workshops to corporates, which even today tend to have masculine environments. He’s living proof that you are not your disorder, and that getting help can make your life not just bearable, but enjoyable.

What Are The Triggers Of Depression?

“Relationships, finances, the challenges of work, or caring for sick relatives or children can all be stressors,” says Dr. Hunter. In fact, a study published in the Journal of Epidemiology and Community Health found that losing a job increases the risk of suicide by two to three times.

Previous research has also found that men who are single, widowed or divorced are more likely to commit suicide, and breakdowns of relationships are more likely to cause men to kill themselves than women. This could be because women maintain close same-sex friendships throughout their lives, whereas men’s same-sex friendships tend to fade after they turn 30, concluded research by the Samaritans, an organisation that provides telephonic and face-to-face support.

“What men are vulnerable to is a sense of inadequacy,” says Dr. Hunter. “‘Am I good enough?’ ‘Am I successful enough?’ ‘Am I respected enough?’ The standards set by society are often unattainable, and magnified through social media; so while it’s healthy to set goals and challenge yourself, these goals may be beyond your reach, and cause significant distress when they can’t be achieved.

“Stress can be eased considerably through social support; but men are often reluctant to ask for help, which magnifies the impact of any stressors they experience.”

What Will People Think?

According to Dr. Viljoen, the most prevalent stigma still is the belief that you may be perceived as weak if you admit you’re struggling with your mental health. This is one of the major reasons men don’t seek professional help.

The most common response? “They usually say it’s something they should be able to rectify themselves,” says Dr. Viljoen. It’s the very same mentality that Jack* had; he thought he just needed to be stronger.

A 2015 study published in the Community Mental Health Journal found that men are far more likely to feel embarrassed about seeking professional help. The study also found that men are more likely to endorse stigmatised views of depression.

This research, funded by the Movember Foundation, demonstrated that while society views men who struggle with depression in a more compassionate light, those men who are suffering view their problems negatively, and are their own worst critics.

Many men self-medicate with drugs and alcohol; by the time they try to get help, health professionals see a drug and alcohol problem, rather than the illness that lies beneath. In fact, nearly 30% of people with substance abuse problems also have major or clinical experience of depression, reports WebMD. These substances have a direct affect on the neurotransmitters in the brain that help with mood regulation – which often leads to worse symptoms of depression, more guilt, and increasing worries about what people think.

The problem with stigma is that it restricts men’s willingness to seek help, reduces treatment compliance, and deters men from confiding in friends and family – all major factors in alleviating depressive symptoms. This means that men are more likely to seek professional help only after a suicide attempt, or when they are no longer able to function in their work or personal environment.

How Do I Tell My Family And Friends?

Confiding in your family and friends can be made less painful for you and for them if you follow a few basic steps.

Timing is everything; you don’t want to bring the subject up when they may be caught off guard – at an event, say, when you might be forced to put the conversation on hold.

Try making the conversation relevant in some way, advises Dr. Viljoen. A great way to do this is to use TV. If you’re watching something that has to do with the topic you want to discuss, you could start a conversation with the person you’re with.

Another way to get advice or reach out is to use the well-known “asking for a friend”. This alleviates the pressure on you, as well as allowing you to find out how much someone might know about a topic. And it also shows that you value the other person’s opinion.

Remember, the most common reason someone might have a negative reaction is that they don’t understand, or have little information about the topic. Dr. Viljoen says it’s also a good idea to have “bite-sized” conversations over a period of time, so that people have time to process what you’ve spoken about. Your family or friends will naturally have an emotional response because they care about you, so remember to explain the way you feel to them slowly and in a way they will understand. It’s also important for them to know they’re not responsible or to blame for how you’re feeling.

If you try to conceal depression, it can have a devastating effect on your relationships. Your partner may not understand what is going on, or may search for other explanations for your behaviour. And unhealthy coping mechanisms or male-specific symptoms can often have detrimental effects. For example, substance abuse or being irritable and aggressive could push your partner away. Recognising your behaviour and symptoms and being open in your communication can diminish conflict that could otherwise arise.

“However you try to start your conversation, try to have realistic expectations. It might not go as well as you’re hoping, but give it time,” explains Dr. Viljoen.

“The only thing that saved me from taking my own life was my ability to talk about my illness.”

– Geoff McDonald

How Do I Tell Work?

Geoff McDonald spent 25 years at Unilever, and was the Global Vice President of HR there. In 2008, he was diagnosed with anxiety-fuelled depression. “The only thing that saved me from taking my own life was my ability to talk about my illness. I can’t imagine what could have befallen me had I not been able to talk about it.”

After learning about how stigma about mental health was active in the workplace, and when he experienced it himself, McDonald decided to take his learnings from one large global corporate to workplaces around the world. He believes conversation is the most important factor in breaking stigma and catalysing change in a corporate environment that remains largely masculine.

His biggest piece of advice? Although ‘self-care’ is a buzzword at the moment, this buzz has benefits. Self-care and taking care of your general well-being are critical for performance, he says.

“We can talk about our physical health in the workplace – so why can’t we talk about our mental health?”

One in three South Africans will experience a mental disorder in their lifetime; and according to Sanlam’s Medical Advisor, Dr. Boshoff, this number is on the rise. That can affect your ability to work, your productivity, and how much time you need to take off. And yes, you might be able to take time off work. South African employees with mental health conditions are constitutionally protected thanks to the Code of Good Practice on Key Aspects of Disability in the Workplace.

But taking the time off that you need might cause anxiety over your salary and job security. Which is why you need to know your rights, as well as doing some proper financial planning. The good news is that the insurance industry treats psychiatric disorders the same way as any other chronic condition, so you’re able to claim for a range of benefits. In fact, 9% of lump-sum disability and 13% of income-protection claims admitted by Sanlam in 2017 were for mental health illnesses.

If your mental illness prevents you from performing your job, having cover is critical. Insurers work with the South African Society of Psychiatrists during the underwriting and claim stage. All you need to do is have your symptoms diagnosed by your doctor or specialist.

After insurance underwriters calculate risk, your insurer will provide sickness benefits that provide cover if you’re booked off sick, a disability benefit that provides cover if there is a total, permanent, or continuous disability to perform your job, and income protection, which provides certainty of income if you cannot work, permanently or temporarily.

“To help recovery, we need to remove as many stressors as possible – including fears about income and job security. Insurance assists with this. Work stressors – often masked as ‘burn out’ – are another big factor to address. Employers can introduce mental health days at the workplace to give employees a break from work stressors. It’s also a good idea to align these with therapy sessions, treatment, and cognitive or behavioural therapy,” says Dr. Boshoff.

What Are My Treatment Options?

According to the World Health Organisation (WHO), South Africa has the sixth-highest rate of suicide in Africa, with approximately 11.6 of every 100 000 people in this country committing suicide. And the majority of suicides and suicide attempts occur among individuals who suffer from undiagnosed and untreated depression.

Without treatment, symptoms of depression can last for weeks, months or years. However, by getting appropriate treatment, most people who suffer from depression experience improvements that help them, says SADAG. But what are your treatment options?

There is no single proven way of curing depression – different treatment methods work for different people. That’s why many professionals favour a holistic approach. Most recommend therapy, medication, and positive lifestyle choices such as exercising and getting enough sleep.

The first step would be to find a psychologist who can evaluate you.There are many different types of therapy, such as cognitive behaviour therapy, mindfulness-based cognitive therapy, and more. Your psychologist will decide if you need to be put on medication, which a psychiatrist will handle. Again, finding the right medication is often done by trial and error, which is why it needs to be handled by a professional.

Don’t get too hung up on (or overwhelmed by) the details, or the vast amount of information and options you can find with a simple search on Google. The main point is to prioritise your mental health; and that first step begins by speaking to someone, instead of suffering in silence.

How Do I Live With Depression?

Danilo Harkers, an occupational therapist at Akeso Arcadia Clinic, a private in-patient psychiatric clinic, stresses that mental illness does not discriminate, and can affect anyone. In order to improve your mental health you need to take a holistic approach, including the physical, spiritual, emotional and social health aspects of your life.

Lift Weights. In May, a JAMA Psychiatry meta-analysis of 33 clinical trials revealed that lifting weights can help to ease and even prevent depression. Your move? Incorporate resistance exercise training into your workouts.

Take Care Of Your Heart. A 2009 study published in the Annual Review of Clinical Psychology found that older adults who had physical health conditions, such as heart disease, had higher rates of depression than those who were healthy.

Get A Pet. Pets are increasingly being used to assist patients with mental conditions, according to SADAG. “There’s evidence that pets can reduce stress, anxiety and depression, and in some cases even cure depression,” says Dr. Guy Fyvie, Hill’s Pet Nutrition nutritional advisor.

Bottom line: “Men need to overcome this macho image that they can be like a machine,” says Geoff McDonald. “If we don’t care for machines, they break; and we should apply the same logic to ourselves.”

*Names have been changed.

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