ABSTRACT:

In Chile, one out of every ten men presents signs or symptoms of depression each year. However, few studies within Chile or other Latin American countries address the qualitative or narrative aspects of depression in men. Therefore, the objective of this study was to assess the narrative construction of depression and its symptoms in men. This qualitative study was based on interviews with nine Chilean men who had gone through an experience of this nature, which were conducted between June and October 2020. A life story methodology was used to explore depressive processes involved in each individual’s biography as well as the symptoms reported in each case. The results show that these men experienced a constellation of symptoms during de- pression, some of which are atypical as they do not match those described in diagnostic manuals. Three types of narratives were identified, and were termed frustration, breakdown, and insecurity.

KEYWORDS:
Masculinities; Depression; Men’s Health; Chile

INTRODUCTION

Depression is a public health concern that globally affects 322 million people every year.¹1. World Health Organization. Depression and other common mental disorders: global health estimates. Geneva: World Health Organization; 2017. However, it is estimated that there were 53.2 million additional cases due to the COVID-19 pandemic in 2020, mainly associated with increased infection rates, human mobility restrictions and income precariousness.²2. COVID-19 Mental Disorders Collaborators. Global prevalence and burden of depressive and anxiety disorders in 204 countries and territories in 2020 due to the COVID-19 pandemic. The Lancet. 2021;398(10312):1700-1712. doi: 10.1016/S0140-6736(21)02143-7. Overall, depression has greater impact on those individuals of low socioeconomic status, the unemployed³3. Paul KI, Moser K. Unemployment impairs mental health: Meta-analyses. Journal of Vocational Behavior. 2009;74(3):264-282. doi: 10.1016/j.jvb.2009.01.001., those suffering from a chronic health condition⁴4. Moussavi S, Chatterji S, Verdes E, Tandon A, Patel V, Ustun B. Depression, chronic diseases, and decrements in health: results from the World Health Surveys. The Lancet. 2007;370(9590):851-858. doi: 10.1016/S0140-6736(07)61415-9. and women. Low socioeconomic status, unemployment and precarious economy⁵5. Affleck W, Carmichael V, Whitley R. Men’s mental health: Social determinants and implications for services. Canadian Journal of Psychiatry. 2018;63(9):581-9. doi: 10.1177/0706743718762388. are among the social determinants of depression described in men. On a global scale, in terms of gender, 3.6% of men suffer from depression each year compared to 5.1% of women.⁶6. World Health Organization, Calouste Gulbenkian Foundation. Social determinants of mental health. Geneva: World Health Organization; 2014. However, the suicide cases, which are often associated with depression, are more prevalent in men, given the fact that 8 in every 10 suicides in Latin America are related to the male population⁷7. Vicente B, Saldivia S, Pihán R. Prevalencias y brechas hoy: salud mental mañana. Acta Bioethica. 2016;22(1):51-61. doi: 10.4067/s1726-569x2016000100006..

With regard to the access to health services in Latin America, half of those individuals who suffer from depression do not receive any type of care.⁸8. Kohn R, Ali AA, Puac-Polanco V, Figueroa C, López-Soto V, Morgan K, et al. Mental health in the Americas: an overview of the treatment gap. Revista Panamericana de Salud Pública. 2018;42:e165. doi: 10.26633/RPSP.2018.165. The study by Borges et al.⁹9. Borges G, Aguilar-Gaxiola S, Andrade L, Benjet C, Cia A, Kessler RC, et al. Twelve-month mental health service use in six countries of the Americas: A regional report from the World Mental Health Surveys. Epidemiology and Psychiatric Sciences. 2019;29(e53):e53. doi: 10.1017/S2045796019000477. conducted in six countries of the Americas, highlights the fact that men are less likely to seek mental health treatment. In the general population, both in men and women, some factors that explain a reduced access to mental health are linked to low schooling, low income and not having a partner.⁹9. Borges G, Aguilar-Gaxiola S, Andrade L, Benjet C, Cia A, Kessler RC, et al. Twelve-month mental health service use in six countries of the Americas: A regional report from the World Mental Health Surveys. Epidemiology and Psychiatric Sciences. 2019;29(e53):e53. doi: 10.1017/S2045796019000477. In Chile, specifically, the men who attend the services only represent 16.2% of those who seek treatment for depression in primary care.¹⁰10. Gobierno de Chile, Ministerio de Salud. Reportería programa salud mental año 2014-2019. Santiago: Departamento de Estadísticas e Información de Salud; 2019.

Although in Chile, as in the rest of the world, depression is more prevalent in women, male depression has a significant impact on the male population. According to the National Health Survey 2016-2017,¹¹11. Gobierno de Chile, Ministerio de Salud. Encuesta nacional de salud 2016-2017. Segunda entrega resultados. Santiago: Ministerio de Salud; 2018. in the last year, one in ten men exhibit signs and symptoms of depression. In turn, the Chilean Longitudinal Social Survey¹²12. Centro de Estudios de Conflicto y Cohesión Social. Radiografía del cambio social: Análisis de resultados longitudinales, estudio longitudinal social de Chile, ELSOC 2016-2018. Santiago: COES; 2018. showed that 9% of men present an annual prevalence of moderate/severe or severe symptoms of depression. Moreover, a higher prevalence of male depression has been found in the working-age population (25-64 years) and of low socioeconomic status (20.8% vs. 11.8% in the general population).¹³13. Gobierno de Chile, Ministerio de Salud, Universidad Católica de Chile, Universidad Alberto Hurtado. Encuesta nacional de salud 2009-2011. Tomo I. Santiago: Ministerio de Salud; 2011. Furthermore, data show that from the age of 45 there is an increase in both depression and suicidal ideation in males.¹¹11. Gobierno de Chile, Ministerio de Salud. Encuesta nacional de salud 2016-2017. Segunda entrega resultados. Santiago: Ministerio de Salud; 2018.^,1414. Gobierno de Chile, Ministerio de Salud, Dirección del Trabajo, Instituto de Seguridad Laboral. Primera encuesta nacional de empleo, trabajo, salud y calidad de vida de los trabajadores y trabajadoras en chile, 2009-2010. Santiago: Ministerio de Salud, Dirección del Trabajo, Instituto de Seguridad Laboral; 2011.

Masculinity and depression

Several studies on male depression have analyzed the intersection existing between depression and the construction of masculinity. Each historical time and specific context recognize a hegemonic masculinity that refers to a social practice, a set of attributes, norms and standards associated with the most admired form of masculinity, a masculinity that consists of that version of the masculine that occupies the hegemonic position in a given pattern of gender relations.¹⁵15. Connell RW. Masculinidades. México: UNAM; 2019. In other words, as Connell¹⁵15. Connell RW. Masculinidades. México: UNAM; 2019. points out, it is about that masculinity with greater legitimacy, authority or dominance at a given time and context. Therefore, hegemonic masculinity is built through cultural consensus¹⁶16. Messerschmidt JW. Hegemonic masculinity: formulation, reformulation, and amplification. United Kingdom: Rowman & Littlefield; 2018. and persuasion, with the influence of culture and institutions¹⁷17. Connell R, Messerschmidt JW. Masculinidade hegemônica: repensando o conceito. Revista Estudos Feministas. 2013;21(1):241-282.. Hegemonic masculinity also defines what an acceptable or unacceptable gender practice¹⁸18. Messerschmidt JW. The salience of “Hegemonic Masculinity”. Men and Masculinities. 2019;22(1):85-91. is. Olvera and Luna¹⁹19. Olvera C, Luna MG. El malestar en los hombres: una revisión de alcances. Caleidoscopio. 2019;(42):269-295. doi: 10.33064/42crscsh2148. highlight the feeling of malaise that men usually experience when they cannot conform to the standards of hegemonic masculinity . Furthermore, men usually consider depression to be a woman’s disease, or a sign of weakness or lack of manhood.²⁰20. Krumm S, Checchia C, Koesters M, Kilian R, Becker T. Men’s views on depression: A systematic review and metasynthesis of qualitative research. Psychopathology. 2017;50(2):107-124. doi: 10.1159/000455256.^,2121. Rochlen AB, Paterniti DA, Epstein RM, Duberstein P, Willeford L, Kravitz RL. Barriers in diagnosing and treating men with depression: a focus group report. American Journal of Men’s Health. 2009;4(2):167-175. doi: 10.1177/1557988309335823..

Almost two decades ago, Connell¹⁵15. Connell RW. Masculinidades. México: UNAM; 2019. noted that certain social values that are typically associated with masculinity, such as competition, success, self-demands or individualism are related to depressive processes in men. Along the same line, Krumm et al.²⁰20. Krumm S, Checchia C, Koesters M, Kilian R, Becker T. Men’s views on depression: A systematic review and metasynthesis of qualitative research. Psychopathology. 2017;50(2):107-124. doi: 10.1159/000455256., based on a recent review of qualitative studies, reported how during depression, men tend to compromise the standards associated with masculinity, such as being strong, successful, self-sufficient, self-controlled and competent. Oliffe et al.²²22. Oliffe JL, Kelly MT, Johnson JL, Bottorff JL, Gray RE, Ogrodniczuk JS, et al. Masculinities and college men’s depression: Recursive relationships. Health Sociology Review. 2010;19(4):465-477. doi: 10.5172/hesr.2010.19.4.465. emphasized the tension established between depression and the values of masculinity, such as rationality, competition, self-confidence, virility, attractiveness, emotional strength.

Male depression has been associated with the difficulty to attain the standards of hegemonic masculinity, that is, the ideal of manhood that is aspired in a given context.²³23. Valkonen J, Hännine V. Narratives of masculinity and depression. Men and Masculinities. 2013;16(2):160-180. doi: 10.1177/1097184X12464377. While not conforming to those ideals can lead to depression, experiencing depression can also place those men in a position of subordinate masculinity¹⁵15. Connell RW. Masculinidades. México: UNAM; 2019. due to the loss of health and attributes mentioned above. In turn, Oliffe et al.²²22. Oliffe JL, Kelly MT, Johnson JL, Bottorff JL, Gray RE, Ogrodniczuk JS, et al. Masculinities and college men’s depression: Recursive relationships. Health Sociology Review. 2010;19(4):465-477. doi: 10.5172/hesr.2010.19.4.465. also argued that depression may occur when individuals interpret that their masculinity is defective, incomplete or not conforming to the norm. In this sense, as stated by Krumm et al.,²⁰20. Krumm S, Checchia C, Koesters M, Kilian R, Becker T. Men’s views on depression: A systematic review and metasynthesis of qualitative research. Psychopathology. 2017;50(2):107-124. doi: 10.1159/000455256. discouragement can be experienced as a contradictory process because, although the mandate of masculinity norms is to be strong or successful, depression can make men feel weak, fragile, vulnerable, listless and/or perceive that they are failing in their performance, activities and projects.

It has been claimed that men often have difficulty expressing their emotions, which would negatively affect their mental health.²⁴24. Pease B. The politics of gendered emotions: Disrupting men’s emotional investment in privilege. Australian Journal of Social Issues. 2012;47(1):125-142. doi: 10.1002/j.1839-4655.2012.tb00238.x. According to Ramírez,²⁵25. Ramírez JC. Algunos elementos para el debate sobre la intersección entre masculinidad y emociones. En: Ramírez JC, ed. Hombres, masculinidades, emociones. México: Universidad de Guadalajara; 2020. p. 15-46. the notions of masculinity might be associated with suppressing, hiding as well as masking emotions. In turn, certain feelings, such as melancholy, sadness or sorrow, are considered to be difficult for men to face or recognize, while emotions, such as rage or anger would be part of their acceptable repertoires.²⁶26. Addis ME. Gender and depression in men. Clinical Psychology: Science and Practice. 2008;15(3):153-168. doi: 10.1111/j.1468-2850.2008.00125.x. In this sense, anger is considered an emotion that is closer to hegemonic masculinity and to the notion that men express themselves through action to demonstrate or affirm their manhood or power. Anger or rage as well as interpersonal conflicts and even violent behaviors can be masks²¹21. Rochlen AB, Paterniti DA, Epstein RM, Duberstein P, Willeford L, Kravitz RL. Barriers in diagnosing and treating men with depression: a focus group report. American Journal of Men’s Health. 2009;4(2):167-175. doi: 10.1177/1557988309335823. for depression. Several authors acknowledge¹⁶16. Messerschmidt JW. Hegemonic masculinity: formulation, reformulation, and amplification. United Kingdom: Rowman & Littlefield; 2018. that, in specific cases, anger can be considered a form of resistance to a depressed mood. When masculine power declines for some reason (loss of income, physical strength, health or sexual attractiveness), for example, anger would be a resource to recover or reinforce masculinity.

The social norms of masculinity hinder the capacity of men to express and recognize their depressive experience, thus hampering their search for help²⁷27. Chuick CD, Greenfeld JM, Greenberg ST, Shepard SJ, Cochran SV, Haley JT. A qualitative investigation of depression in men. Psychology of Men & Masculinity. 2009;10(4):302-313. doi: 10.1037/a0016672. and contributing to their resistance to seek care in the mental health services.²⁸28. Seidler ZE, Rice SM, Oliffe JL, Fogarty AS, Dhillon HM. Men in and out of treatment for depression: Strategies for improved engagement: Engaging men in treatment for depression. Australian Psychologist. 2018;53(5):405-415. doi: 10.1111/ap.12331. Moreover, the difficulty of men to recognize their malaise has also been described in general(19), as they fear being stigmatized, ridiculed, belittled for not being manly enough or losing their jobs if they admit that they are feeling depressed. Other strategies described in depressed men is that they can be selective about who they tell about their depression and that they develop strategies to seek help in the most discreet way possible.²⁰20. Krumm S, Checchia C, Koesters M, Kilian R, Becker T. Men’s views on depression: A systematic review and metasynthesis of qualitative research. Psychopathology. 2017;50(2):107-124. doi: 10.1159/000455256.

Symptoms of male depression

The diagnostic criteria for depression used in the health sector are set forth in the International Classification of Diseases, 11th revision (IDC-11) of the World Health Organization, and in the Diagnostic and Statistical Manual of Mental Disorders 5th Edition (DSM-V) of the American Psychiatric Association.²⁹29. American Psychiatric Association. Guía de consulta de los criterios diagnósticos del DSM-5. Arlington: American Psychiatric Association; 2014.^,3030. Gobierno de Chile, Ministerio de Salud. Guía clínica depresión en personas de 15 años y más. Santiago: Ministerio de Salud; 2013.^,3131. Organización Mundial de la Salud. Trastornos depresivos. En: CIE-11 para estadísticas de mortalidad y morbilidad [Internet]. 2019 [citado 11 jun 2021]. Disponible en: Disponible en: https://tinyurl.com/2p856upk .
https://tinyurl.com/2p856upk...

Both the IDC-11 and the DSM-V mention a depressed mood and loss of interest as the main symptoms of depression. The DSM-V includes anhedonia or loss of pleasure as a core manifestation of depression. Both manuals also highlight other possible symptoms: difficulty concentrating, feeling of worthlessness or excessive or inappropriate guilt, changes in appetite or sleep, agitation or psychomotor retardation, fatigue or loss of energy, and recurrent thoughts of death or suicide. The ICD-11 includes in this list feelings of hopelessness and the DSM-V the decreased ability to think or make-decisions. In addition to the symptoms described above, the regular and daily functional capacity, interpersonal relationships and/or the work of those individuals who suffer from these symptoms are seriously affected in depressive states.(29,31,32) Depression is diagnosed when a person experiences the core symptoms and four or five possible symptoms.²⁹29. American Psychiatric Association. Guía de consulta de los criterios diagnósticos del DSM-5. Arlington: American Psychiatric Association; 2014.^,3030. Gobierno de Chile, Ministerio de Salud. Guía clínica depresión en personas de 15 años y más. Santiago: Ministerio de Salud; 2013..

It has also been described that men experiencing a depressive process exhibit the typical symptoms mentioned in the diagnostic criteria above as well as other atypical ones also called: alternative, avoidant, outward or external symptoms. In this sense, other behaviors such as low frustration tolerance, irritability, anger, poor control of aggressive impulses, interpersonal conflicts, emotional stress, risky behaviors (health-related or accidents), alienation at work, suicidal attempts and alcohol or drug abuse.⁵5. Affleck W, Carmichael V, Whitley R. Men’s mental health: Social determinants and implications for services. Canadian Journal of Psychiatry. 2018;63(9):581-9. doi: 10.1177/0706743718762388.^,2020. Krumm S, Checchia C, Koesters M, Kilian R, Becker T. Men’s views on depression: A systematic review and metasynthesis of qualitative research. Psychopathology. 2017;50(2):107-124. doi: 10.1159/000455256.^,2828. Seidler ZE, Rice SM, Oliffe JL, Fogarty AS, Dhillon HM. Men in and out of treatment for depression: Strategies for improved engagement: Engaging men in treatment for depression. Australian Psychologist. 2018;53(5):405-415. doi: 10.1111/ap.12331.^,3333. Cavanagh A, Wilson CJ, Kavanagh DJ, Caputi P. Differences in the expression of symptoms in men versus women with depression: A systematic review and meta-analysis. Harvard Review of Psychiatry. 2017;25(1):29-38. doi: 10.1097/HRP.0000000000000128.^,3434. Londoño C, Peñate W. Síntomas de depresión en hombres. Universitas Psychologica. 2017;(4):1-19. doi: 10.11144/Javeriana.upsy16-4.sdeh.^,3535. Whittle EL, Fogarty AS, Tugendrajch S, Player MJ, Christensen H, Wilhelm K, et al. Men, depression, and coping: Are we on the right path? Psychology of Men & Masculinity. 2015;16(4):426-438. doi: 10.1037/a0039024.

Several authors suggest that the criteria of the diagnostic manuals are not sensitive to male malaise, that is, to how many men experience symptoms and emotions during the course of a depressive process.⁵5. Affleck W, Carmichael V, Whitley R. Men’s mental health: Social determinants and implications for services. Canadian Journal of Psychiatry. 2018;63(9):581-9. doi: 10.1177/0706743718762388.^,2626. Addis ME. Gender and depression in men. Clinical Psychology: Science and Practice. 2008;15(3):153-168. doi: 10.1111/j.1468-2850.2008.00125.x.^,3434. Londoño C, Peñate W. Síntomas de depresión en hombres. Universitas Psychologica. 2017;(4):1-19. doi: 10.11144/Javeriana.upsy16-4.sdeh.^,3636. Johnson JL, Oliffe JL, Kelly MT, Galdas P, Ogrodniczuk JS. Men’s discourses of help-seeking in the context of depression: Men’s help-seeking discourses in depression. Sociology of Health & Illness. 2012;34(3):345-361. doi: 10.1111/j.1467-9566.2011.01372.x.. It has also been suggested that male depression, in research and diagnosis, has not been adequately addressed, given that the atypical symptoms are not usually considered indicators. Thus, male depression would be underestimated in the epidemiological studies because the specific indicators through which it is expressed are not addressed in research.³⁴34. Londoño C, Peñate W. Síntomas de depresión en hombres. Universitas Psychologica. 2017;(4):1-19. doi: 10.11144/Javeriana.upsy16-4.sdeh.^,3737. Hildebrandt MG, Stage KB, Kragh-Soerensen P. Gender and depression: a study of severity and symptomatology of depressive disorders (ICD-10) in general practice. Acta Psychiatrica Scandinavica. 2003;107(3):197-202. doi: 10.1034/j.1600-0447.2003.02108.x.

METHODOLOGY

The research question was: which are the narratives about depression and its symptoms in Chilean men? The aim of this study is to analyze the narrative construction of male depression and its symptoms. For this purpose, interviews were conducted using a life story method with men from different areas of Chile who had gone through a depressive process in the last five years.

The study was conducted using a qualitative methodology and a multiple-case design based on narrative interviews with men who had experienced depression. The aim of these interviews was to explore in depth the subjective construction of their experiences during these depressive processes.(38,39,40) This study dealt with how these men narrated or recounted their depressive processes, and how they interpreted these experiences, emotions and symptoms. To this end, a life story or biographical narrative, understood as the narration that addresses the history, in this case, of the depressive processes experienced by the interviewees.³⁹39. Piña C. Tiempo y memoria: Sobre los artificios del relato autobiográfico. Proposiciones. 1999;29:1-5.^,4141. Bertaux D. Los relatos de vida: Perspectiva entnosociológica. Barcelona: Bellaterra; 2005.

Participants

For the preparation of the sample, a purposive sampling strategy was used to achieve a complete understanding of the phenomenon in its various manifestations.⁴¹41. Bertaux D. Los relatos de vida: Perspectiva entnosociológica. Barcelona: Bellaterra; 2005.^,4242. Patton M. Qualitative research and evaluation methods. 3rd ed. California: Sage; 2002. The estimation of the number of interviews was conducted according to variation and heterogeneity criteria.⁴¹41. Bertaux D. Los relatos de vida: Perspectiva entnosociológica. Barcelona: Bellaterra; 2005.

This study presents nine interviews conducted between June and October 2020 with Chilean men who had gone through a depressive process. Their ages ranged from 32 to 64 years. Six of them were cis-heterosexuals and three were cis gay. Four of them were fathers, but three of them were no longer in a relationship with the mother of their children. With respect to their place of residence, four of them lived in Santiago, the capital of Chile; two of them, in cities in the north of Chile and the remaining three in the south of Chile, although one in the latter group had recently moved to Santiago. One of them lived alone, three lived with their partners and five with their mother or both parents, either due to unemployment or lack of work, or because they were returning from a trip or due to the pandemic. With regard to their education, all the interviewees had university studies: five of them in social sciences, one in engineering, two in the field of education and one in the field of arts. With regard to their occupation, five of them were employed, two unemployed and two had sporadic jobs. At some point all of them had been diagnosed with depression by health care providers. Likewise, all of them had received psychotherapy and/or psychiatric medication. The interviewees reported processes of discouragement that had occurred before the pandemic, although the pandemic context was recognized as stressful, as a result of how situations such as social confinement or job search difficulties had affected their lives. (Table 1)

Interview production procedures

To contact the participants, a snowball or seed sampling strategy⁴²42. Patton M. Qualitative research and evaluation methods. 3rd ed. California: Sage; 2002. was used along with calls through social networks inviting to participate as interviewees in a study on male depression in Chile and take part in a biographical interview with the researcher. Specific eligibility criteria were included in the call, such as identifying themselves as men, residing in Chile, being between 30 and 60 years old, being affiliated with the public health care system and having gone through a depressive episode or major depression in the last five years, with or without a diagnosis. It was made clear that both the data and the process were confidential and that there was no financial compensation.

Exclusion criteria were: being currently suffering from depression and/or suicidal ideation. There were no cases that met the latter criteria. Specific eligibility criteria, such as age or health care system to which they were affiliated, were relaxed when the participants did not meet all of them.

An important limitation of the call strategy was that it was mainly answered by individuals with high levels of education and it was difficult- also considering the restrictions implemented due to the pandemic - to find more cases of lower socioeconomic level or schooling. The interviews on life story narratives⁴¹41. Bertaux D. Los relatos de vida: Perspectiva entnosociológica. Barcelona: Bellaterra; 2005. were conducted by the researcher following an interview script³⁸38. Piña C. La construcción del “sí mismo” en el relato autobiográfico. Documento de Trabajo 383. Chile: FLACSO; 1988.^,4343. Kvale S, Brinkmann S. InterViews: Learning the Craft of Qualitative Research Interviewing. Los Angeles: Sage; 2009., which began with the following instruction: tell me your story about depression. Then, aspects such as milestones, stages, trajectory, reasons, attributions and values during the depressive process³⁵35. Whittle EL, Fogarty AS, Tugendrajch S, Player MJ, Christensen H, Wilhelm K, et al. Men, depression, and coping: Are we on the right path? Psychology of Men & Masculinity. 2015;16(4):426-438. doi: 10.1037/a0039024.^,3838. Piña C. La construcción del “sí mismo” en el relato autobiográfico. Documento de Trabajo 383. Chile: FLACSO; 1988.⁾ were explored. Interviews were conducted via zoom, which was facilitated by the pandemic context, making it possible to include interviewees from different parts of Chile. All interviews were audio-recorded on the same platform and then literally transcribed (verbatim). Each interviewee was assigned a pseudonym to preserve anonymity.

Analysis procedure

The information obtained from the qualitative interviews was analyzed using a descriptive and interpretive method through a multiple-case approach.⁴¹41. Bertaux D. Los relatos de vida: Perspectiva entnosociológica. Barcelona: Bellaterra; 2005.^,4444. McLeod J. Case study research in counselling and psychotherapy. London: Sage; 2010. For this purpose, the methodology of narrative analysis of the biographical story³⁸38. Piña C. La construcción del “sí mismo” en el relato autobiográfico. Documento de Trabajo 383. Chile: FLACSO; 1988.^,4141. Bertaux D. Los relatos de vida: Perspectiva entnosociológica. Barcelona: Bellaterra; 2005. was used along with a critical approach to masculinities.¹⁵15. Connell RW. Masculinidades. México: UNAM; 2019.^,4545. Messerschmidt JW. Adolescent boys, embodied heteromasculinities and sexual violence. Center for Educational Policy Studies Journal Center for Educational Policy Studies Journal. 2017;7(2):113-126. doi: 10.26529/cepsj.172. The steps suggested by Connell in his study of the biographical method with men were followed.¹⁵15. Connell RW. Masculinidades. México: UNAM; 2019.⁾ In this study, he first addresses with a unique logic each interview as a case, and then conducts a cross-sectional analysis of all the cases. In the first step, a text was elaborated, including each life story ordered chronologically and thematically, and the greatest amount of detail and the interviewees’ most expressive quotes.³⁸38. Piña C. La construcción del “sí mismo” en el relato autobiográfico. Documento de Trabajo 383. Chile: FLACSO; 1988.^,3939. Piña C. Tiempo y memoria: Sobre los artificios del relato autobiográfico. Proposiciones. 1999;29:1-5. In the second step, an open coding of the interviews was performed to go deeper into the interpretation and analytical organizations of the categories⁴¹41. Bertaux D. Los relatos de vida: Perspectiva entnosociológica. Barcelona: Bellaterra; 2005.^,4646. Charmaz K. Constructing grounded theory: A practical guide through qualitative analysis. Los Angeles: Sage; 2006., coding each mentioned symptom and building thematic trees based on those symptoms. The same terms mentioned by the interviewees were used to recover from their stories the wide range of emotional experiences or symptomatic expressions during their depressive episodes. These analyses were conducted using Atlas.v8 software designed for the analysis of textual data.

Ethical Procedures

The ethical procedures of the study were approved by the Bioethics Committee of the Pontificia Universidad Católica of Valparaíso (BIOEPUC-H-346-2020). Each interviewee received an informed consent that detailed aspects such as voluntarism and confidentiality. The participants’ acceptance of consent was duly registered in each case.

RESULTS

Symptoms in male depression

The emotions and symptoms experienced by the interviewees during their depressive episodes are presented here. They reported a series of symptoms, which were organized according to the main themes detected, namely: a) emotional symptoms; b) atypical, avoidant or external symptoms; c) suicidal ideation symptoms; d) physical or bodily symptoms, and e) cognitive symptoms.⁴⁷47. Chevance A, Ravaud P, Tomlinson A, Le Berre C, Teufer B, Touboul S, et al. Identifying outcomes for depression that matter to patients, informal caregivers, and health-care professionals: qualitative content analysis of a large international online survey. Lancet Psychiatry. 2020;7(8):692-702. doi: 10.1016/S2215-0366(20)30191-7.. A broad notion of symptoms was followed, ranging from psychological malaise, emotions, physical signs as well as behaviors.

Emotional symptoms

Emotional symptoms were the most mentioned by the interviewees. Several of them were related to discouragement or sadness, others to anxiety, anguish, and feelings arising from frustration and rage. In turn, experiences of loneliness, emotional detachment and anhedonia were also reported.

In connection with the feeling of discouragement, the interviewees reported apathy, lack of energy and drive, tiredness, exhaustion, lack of interest, unproductiveness, loss of interest in work, listlessness, abatement, feeling overwhelmed, uneasiness, discomfort, restlessness, emotional distress or breakdown, burnout, mood swings and emotional lability. They also reported emotions such as sadness, sorrow, melancholy and low mood. Several interviewees also described experiencing anxiety during their depressive episodes, which was related to uncertainty and fear, such as fear of social situations or being evaluated, and obsessive thoughts. In specific cases, they also reported anguish, panic, despair or psychological pain and others, frustration, anger, irritability and bewilderment. Others experienced loneliness, social isolation, withdrawal and lack of interest in other people. The inability to experience joy and anhedonia were also mentioned as emotional symptoms. Finally, some of them mentioned being indifferent and unable to connect with others.

In most of the interviewees, demotivation, emotional exhaustion and lack of drive were recognized as emotional manifestations of depression, which led them to spend a long time isolated or lying in bed. This behavior could be observed in Juan’s story (59 years old). Juan is a gay man, whose depression was linked to several crises at various levels of his life: a relationship breakup after finding out that his partner had been cheating on him, a job dismissal, being unable to find a job for a long time, being financially disorganized and struggling with debts. He described this period not only as dark, marked by anxiety, loneliness and low libido, but also as a period of demotivation and sadness.

Marcelo (36 years old), in turn, mentions that he was going through a period of delayed grief for his father’s death and that he only allowed himself to experience sadness some time later. During that period he felt depressed, exhausted, anxious and experienced sleep disorders, low self-esteem, frustration and uncertainty. In Marcelo’s case, grief, the unstable work context, the lack of opportunities and the loss of independence produced a narrative of frustration and insecurity, two dimensions that were identified as key to his depression. He described some of his symptoms as follows:

In Germán’s case (64 years old) his depressive process was related to workplace harassment in the school where he had worked for decades. The new school management bullied several teachers for political reasons, urging them to resign. He felt abandoned by institutionality and, as a result, became demotivated, enraged and distressed; his libido had decreased, he increased the alcohol intake. His narrative of fracture was the result of the workplace harassment that he had suffered, which deeply affected him and interrupted his career trajectory.

The interviewees also reported various emotional symptoms that were related to low self-esteem, insecurity, lack of self-confidence, feelings of incompetence or incapacity, or feeling like a failure or vulnerable. Likewise, they mentioned symptoms that were linked to internal conflicts, such as loneliness and also hypersensitivity to criticism. In Marcelo’s story, for example, self-esteem was related to the narrative of insecurity in the workplace. In this context, there was a questioning of the value of his own work and the uncertainty regarding the possible professional areas where he could perform his work in case he needed to look for a new job. In all his narrative, there was a lack of clarity about his current job project in the context of the pandemic and future possibilities.

In the case of Tomás, (34 years old) his depressive processes were preceded by experiences of victimization due to sexual abuse in his childhood and the grief after his father’s death. Tomás presented a narrative of insecurity with very low self-esteem that was related to those traumatic experiences. In his story, he defined himself as insufficient, incomplete, worthless, and admitted not loving himself. Sadness and desolation were present in his depressive processes. He also mentioned how things started to lose value for him and ceased to fit in his work space. Tomás described how during his depression he gradually sank into darkness, also having suicidal thoughts.

Emotions of anger, irritability and frustration pervade this story, and were included in the next section for their relevance as atypical symptoms within male depression.

Atypical, avoidant and external symptoms

The interviewees reported several symptoms that are classified as atypical or alternative, which describe expressions of discouragement that are not usually considered socially or included in diagnostic manuals as constitutive of the symptomatology of depression.²⁰20. Krumm S, Checchia C, Koesters M, Kilian R, Becker T. Men’s views on depression: A systematic review and metasynthesis of qualitative research. Psychopathology. 2017;50(2):107-124. doi: 10.1159/000455256.^,2222. Oliffe JL, Kelly MT, Johnson JL, Bottorff JL, Gray RE, Ogrodniczuk JS, et al. Masculinities and college men’s depression: Recursive relationships. Health Sociology Review. 2010;19(4):465-477. doi: 10.5172/hesr.2010.19.4.465.^,2727. Chuick CD, Greenfeld JM, Greenberg ST, Shepard SJ, Cochran SV, Haley JT. A qualitative investigation of depression in men. Psychology of Men & Masculinity. 2009;10(4):302-313. doi: 10.1037/a0016672.^,3535. Whittle EL, Fogarty AS, Tugendrajch S, Player MJ, Christensen H, Wilhelm K, et al. Men, depression, and coping: Are we on the right path? Psychology of Men & Masculinity. 2015;16(4):426-438. doi: 10.1037/a0039024.^,3636. Johnson JL, Oliffe JL, Kelly MT, Galdas P, Ogrodniczuk JS. Men’s discourses of help-seeking in the context of depression: Men’s help-seeking discourses in depression. Sociology of Health & Illness. 2012;34(3):345-361. doi: 10.1111/j.1467-9566.2011.01372.x. The interviewees retrospectively associated these symptoms with their depressive process, that is, some time later they identified them as part of their depression. Feeling alienated, emotionally detached or disconnected from the present, being or placing themselves in airplane mode are among the symptoms they mention, as well as feeling stressed, irritable, confused, fucked-up, reactive, enraged with others or with themselves. Other atypical symptoms that were reported were becoming workaholics or being alienated at work. Finally, among this group of depressive manifestations, the excessive consumption of alcohol or drugs was also mentioned.

Frustration, anger and irritability are emotional expressions frequently described by the interviewees. Gabriel (38 years old) acknowledged them when recalling having abandoned his academic plans to devote himself to his responsibilities as a father. In this sense, abandoning his project of studying abroad resulted in frustration and anger (or bronca as used in several Latin American countries), which later gave rise to melancholy and sorrow. Later, Gabriel was diagnosed with chronic kidney failure that forced him to undergo dialysis. This diagnosis caused him a nervous breakdown, which resulted in depression; therefore this event was presented as a narrative of fracture, that is, as a relevant milestone⁴¹41. Bertaux D. Los relatos de vida: Perspectiva entnosociológica. Barcelona: Bellaterra; 2005. that marks a before and after in his biography.

Moreover, David’s depression (42 years old), on the other hand, was preceded by a job dismissal and the separation from his partner. As a result, he felt unmotivated, frustrated and fucked-up, which led him to isolate himself and drink too much alcohol. The dominant feelings of anger and indifference that seized him led him to shutting himself up in his home workplace, which deepened the tensions with his partner. At first he was not aware of being depressed. Furthermore, after his job dismissal, he could only get sporadic jobs in areas outside his profession. In this sense, on the one hand, David’s narrative exhibited, elements of frustration and anger that were linked to his job instability and, on the other hand, concern and dedication to his son.

Other atypical symptoms mentioned by David and Gabriel are related to excessive alcohol consumption. In David’s case, his job loss and unemployment led him to daily alcohol consumption and a feeling of finding refuge in drinking. On the other hand, Gabriel, added drugs such as cocaine, to his daily alcohol consumption, which he associated with the sorrow he was experiencing as well as with taking his life and body to the limit.

Symptoms of suicidal processpre

Several interviewees reported in their stories having gone through suicidal processes,⁴⁸48. Hjelmeland H, Knizek B. Methodology in suicidological research - Contribution to the debate. Suicidology Online. 2011;2:8-10.^,4949. Tomicic A, Martínez C, Rosenbaum C, Aguayo F, Leyton F, Rodríguez J, et al. Adolescence and suicide: Subjective construction of the suicidal process in young gay and lesbian Chileans. Journal of Homosexuality. 2021;68(13):2122-2143. doi: 10.1080/00918369.2020.1804253.⁾ which were manifested with symptoms such as the desire to disappear, to cease to exist, to die. Some of them expressed suicidal ideation, that is, thinking of a plan on how to commit suicide, and others even had suicidal attempts. These experiences are often associated with intense sadness, anguish and/or despair.

In the case of Raimundo (32 years old), a gay man from a small town in the north of Chile, his depression is linked to academic or work stress, a relationship breakup and insecurity. For a long time he had felt that he could not be himself, he tried to have a gender expression that would show him as heterosexual, excessively controlling what others might think of him. He presented a narrative of insecurity, showing lack of self-confidence permeated with sadness, exhaustion, isolation and suicidal thoughts. Raimundo had not only felt lonely and overwhelmed but he was also self-critical and sensitive to external criticism. His recent malaise was rooted in his adolescence within a homophobic context and an internalized stigma that did not allow him to fully accept and be himself.

In turn, in the case of Tomás (34 years old), his low self-esteem and precarious mental health had a long-standing history and were related to sexual abuse in childhood. Suicidal ideation was linked to a stage of mental health deterioration that even included farewell letters, which made him realize the severity and extent of his emotional malaise.

David had fantasized about the idea of jumping off a bridge in a car, especially when he was facing serious economic problems and that situation was prolonged in time. He was desperate and saw no way out. However, he knew that suicide was impossible given the bond he had with his son:

Physical or bodily symptoms

The interviewees reported various physical or bodily symptoms related to their depression, such as low energy, lack of physical energy, bodily listlessness, tiredness, drowsiness and the need to lie down during the day. These symptoms also included crying, discomfort with their own bodies, increased blood pressure, being agitated or accelerated, bodily stress, bruxism and muscle pain. They also reported physical symptoms such as weight and diet changes, as well as, sexual problems such as low libido, erectile dysfunction or anorgasmia, which were included in this group of symptoms.

In this regard, Marcelo (36 years old) experienced various symptoms associated with the body, such as difficulty falling asleep, muscle pains, involuntary movements, increased blood pressure and anguish. These feelings led him to seek medical help, and he was then referred to mental health care. At first, Marcelo was unaware of his depression, as it was being somatized, that is, expressed through bodily symptoms.

Gabriel (38 years old), in turn, exhibited various bodily symptoms such as jerking, tics, involuntary movements with restlessness and even panic attacks. His sexual life was affected for a long time, with anorgasmia, anxiety before having sex and panic attacks, a situation that he described as horrendous.

Cognitive symptoms

Finally, cognitive or mental symptoms were reported, such as lack of concentration, being in a pensive mood, not being fully attentive in the present, apathy, and memory problems. Other cognitive symptoms reported were: self-demand, guilt, self-criticism and self-deprecation. Symptoms such as being mentally blocked or closed to listening to others were also reported. Finally, a series of symptoms were also described that were linked to digressing, feeling lost, in shock or making bad decisions, being disorganized in what was done or mentally disorganized, procrastinating or being unproductive for not being able to write, study or work.

In this regard, Raimundo (32 years old) felt sad and bummed out; he had difficulty concentrating, was absent-minded, with his mind somewhere else, he questioned things and felt unable to act. In this case, there was a narrative of insecurity that expressed low self-esteem related to the difficulties he had encountered in accepting and revealing his sexual orientation in a homophobic and evangelical context.

In turn, Juan (59 years old) reported that during his depressive process, he procrastinated, felt mentally disorganized and had difficulty performing well in his master’s studies. These symptoms coincide with a relationship breakup, a job dismissal and financial disorganization.

Narratives about depression

The constellation of reported symptoms included them into different narratives, identifying three main ones. First, a narrative of frustration was observed either due to some specific event in their biography that affected them and/or due to not being able to comply with the norm or the standards of masculinity, such as having a stable job, being competent, successful or strong.

Moreover, the frustration expressed by the interviewees seems to be related to irritability and rage. Second, there is a narrative of insecurity, due to lack of self-confidence or low self-esteem. In some cases, insecurity is described prior to depression, either in childhood or adolescence or as a consequence of an experience of victimization or some other milestone. Conversely, in others, it is the depressive process that affects their self-esteem, reducing their sense of security or self-worth. Third, there is a narrative of fracture resulting from an important milestone in their biography that affects, shatters or leads the subject to emotional collapse and significantly impacts on his depressive process for reasons such as job dismissal, grief or the onset of disease. In the three narratives, difficulties are observed in complying with the norm or the values of masculinity, either as a cause or consequence of the depressive process.

DISCUSSION

The objective of this study has been to analyze the narrative construction of depression in adult men, particularly in terms of the symptoms associated with these processes of discouragement. For this purpose, nine Chilean men who had gone through a process of these characteristics were interviewed using a life story methodology. The focus placed on the symptoms of depression is relevant because they are the indicators often used, both to investigate and diagnose depression. Moreover, in the specific case of the male population, this focus becomes relevant because it is suggested that several of the usual symptoms in men are atypical,²⁰20. Krumm S, Checchia C, Koesters M, Kilian R, Becker T. Men’s views on depression: A systematic review and metasynthesis of qualitative research. Psychopathology. 2017;50(2):107-124. doi: 10.1159/000455256.^,2222. Oliffe JL, Kelly MT, Johnson JL, Bottorff JL, Gray RE, Ogrodniczuk JS, et al. Masculinities and college men’s depression: Recursive relationships. Health Sociology Review. 2010;19(4):465-477. doi: 10.5172/hesr.2010.19.4.465.^,2727. Chuick CD, Greenfeld JM, Greenberg ST, Shepard SJ, Cochran SV, Haley JT. A qualitative investigation of depression in men. Psychology of Men & Masculinity. 2009;10(4):302-313. doi: 10.1037/a0016672.^,3535. Whittle EL, Fogarty AS, Tugendrajch S, Player MJ, Christensen H, Wilhelm K, et al. Men, depression, and coping: Are we on the right path? Psychology of Men & Masculinity. 2015;16(4):426-438. doi: 10.1037/a0039024.^,3636. Johnson JL, Oliffe JL, Kelly MT, Galdas P, Ogrodniczuk JS. Men’s discourses of help-seeking in the context of depression: Men’s help-seeking discourses in depression. Sociology of Health & Illness. 2012;34(3):345-361. doi: 10.1111/j.1467-9566.2011.01372.x.⁾ that is, they are not included in the list of diagnostic manuals.

In the life stories analyzed here, various constellations of emotions and symptoms are described as an expression of depression. Several of them have affected the interviewees’ ability to function in specific areas of their lives, such as romantic relationships or work. Emotional, bodily and cognitive symptoms are identified in the different narratives. Moreover, cases of suicidal ideation are also described in these narratives. As has been observed in various other studies on male depression^{(20,22,27,35,36}), several atypical, avoidant or external symptoms, such as irritability, anger, frustration, emotional detachment, alienation at work, avoidance behaviors and alcohol and drug consumption are reported in this study. The atypical symptoms have so been called because they are not usually interpreted as depressive symptoms either by those who experience them, health care providers, as well as by diagnostic manuals. In this sense, it is relevant to have a better understanding of these atypical symptoms that, as Londoño et al.³⁴34. Londoño C, Peñate W. Síntomas de depresión en hombres. Universitas Psychologica. 2017;(4):1-19. doi: 10.11144/Javeriana.upsy16-4.sdeh. have pointed out, are frequent in males and, therefore, useful indicators for the research, diagnosis and intervention of male depression.

On the other hand, this study confirms that several men find it difficult to acknowledge their psychological distress, as in the case of depression¹⁹19. Olvera C, Luna MG. El malestar en los hombres: una revisión de alcances. Caleidoscopio. 2019;(42):269-295. doi: 10.33064/42crscsh2148. and to express their emotions during this type of processes.²⁴24. Pease B. The politics of gendered emotions: Disrupting men’s emotional investment in privilege. Australian Journal of Social Issues. 2012;47(1):125-142. doi: 10.1002/j.1839-4655.2012.tb00238.x.^,2525. Ramírez JC. Algunos elementos para el debate sobre la intersección entre masculinidad y emociones. En: Ramírez JC, ed. Hombres, masculinidades, emociones. México: Universidad de Guadalajara; 2020. p. 15-46. They tend not to see, to minimize or bottle up their emotions or malaise. Most participants did not recognize themselves as depressed in the first stage, despite the comments of those close to them. Over time, retrospectively, some of them recognized their experiences as a depressive process, which appears to confirm the difficulties of men to adequately identify this type of malaise. Overall, in the trajectories reviewed here, this is related to a delay in help-seeking, as well as low use of mental health services.

In the cases studied here, experiences such as the loss of a job or a relationship breakup, stress, victimization or health problems were causes of their depression. These reasons implied challenges and/or tensions to important aspects of their masculinity. Depression, in turn, made it difficult for them to comply with the norms and standards of hegemonic masculinity, reducing or losing attributes such as strength, power, success, security, competition or health. Thus, not being able to comply with the standards appears to be an important precedent or even, in specific cases, the explanations of their depression and its constellation of symptoms, as has been found in other studies. According to Oliffe et al.,²²22. Oliffe JL, Kelly MT, Johnson JL, Bottorff JL, Gray RE, Ogrodniczuk JS, et al. Masculinities and college men’s depression: Recursive relationships. Health Sociology Review. 2010;19(4):465-477. doi: 10.5172/hesr.2010.19.4.465. identifying one’s own masculinity as flawed in some aspects, incomplete or departing from the norm can end up in depression. Windmöller⁵⁰50. Windmöller N. Construção das masculinidades em depressão: revisão de literatura e análise de casos. Brasilia: Universidad de Brasilia; 2016., on the other hand, highlights the importance of the feeling of failure in male depression and Krumm et al.²⁰20. Krumm S, Checchia C, Koesters M, Kilian R, Becker T. Men’s views on depression: A systematic review and metasynthesis of qualitative research. Psychopathology. 2017;50(2):107-124. doi: 10.1159/000455256. in their review also add the experience of weakness, fragility and vulnerability as relevant elements of the depressive processes in men.

This qualitative research constitutes a contribution to a field that has been scarcely studied in Latin America, and brings to the fore the fact that, both for the study and treatment of male depression, it is important to retrieve the emotional language of the participants and identify the symptoms that express their malaise as they narrate or interpret them. A better understanding of how men experience and communicate their depressive processes and their intersections with the standards of masculinity may be relevant, in the first place, to advance in the research using instruments that collect information about the characteristics of this mental health problem in a more culturally sensitive way. Secondly, to improve the detection and diagnosis of male depression by expanding the criteria in the diagnostic manuals, and finally, to improve the design of mental health services in order to make them more relevant to the male culture.

The limitations of this study are related to the types of cases analyzed. First, it has been interpreted from the particular cases of adult men that were interested in voluntarily participating in an interview to share their experiences with depression. They are mostly men with a certain degree of reflection about their mental health processes and even masculinity. Furthermore, it should be taken into account that all the interviewees who responded to the call are men who are not only currently aware of having gone through depression and are interested in recounting their experiences, but also that all of them have a high level of education.

Based on these limitations, the challenges to be addressed in the future are to investigate male depression in men from various contexts, and to consider not only different socioeconomic levels, but also diverse geographical locations and labor sectors. Moreover, it is necessary to study men that have a more precarious access to mental health due to their living conditions and social exclusion, such as poor, migrants, indigenous as well as gender and sexually diverse. In this sense, studies on male mental health with an intersectionality approach are required. Additionally, it is particularly necessary to study male depression in contexts that threaten or cause the precarization of the lives of men, such as unemployment, or job or income loss during the pandemic. On the other hand, another challenge in this field is to investigate, with a perspective of gender and masculinities, other frequent mental health problems such as suicidal processes, anxiety, trauma and drug and alcohol abuse. Further research is also needed in the field of mental health services to understand the barriers that hinder depression care in men, as well as the biases of health providers in relation to this mental disorder. To conclude, an important challenge in this field is the advancement in policies and programs that enable greater emotional and mental health education for men that could facilitate them to recognize their suffering, seek support in their natural as well as specialized services, in case of symptoms or more severe problems affecting their ability to function.

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