Depression is ubiquitous among aging men. It affects approximately 13% of all men during their lifetime, with rates increasing with age to 40% of men between 40–60 years of age. This age-worsening factor is reflected in suicide rates that triple in midlife and reaches 4–10 times the rate of females in geriatric men. These extremely high suicide rates are independent of culture as the World Health Organization has reported very high suicide rates in men over 75 years of age in all reporting countries but one.
Depression appears to present differently in men than in women. Men tend to have more irritability, anger and insomnia. Men are more likely to deny their depression and consequently act it out with aggressive behavior or alcohol abuse. Shame and stigma are overrepresented in male depression. Men tend to withdraw socially and emotionally. It would be fair to suspect depression in men with the three A’s—anger, alcohol abuse, and anhedonia. As one of my patients so eloquently summed it up, “I don’t get depressed— I get drunk and then I get even!”
The risk factors for male depression include a positive family or personal past history of depression, drug and alcohol abuse, presence of chronic illness, decreased sexual potency, work stress and marital problems. Men are more difficult to recruit to active treatment because of the denial of symptoms or minimization of impact of the illness. However, men are often motivated to comply with treatment when they realize the positive effects that treating depression can have on chronic illnesses like diabetes and hypertension. Improved earning ability and improved sexual functioning can be motivating factors for treatment.
Emerging research has focused on the role of male hormones in depression. We know that women can have depressive challenges that are associated with perimenopause/menopause. However, men can go through similar testosterone declines that have been referred to as andropause, male climacteric states, viropause or low testosterone syndrome. This usually begins in middle-aged men and continues with aging into elderly years. It can be associated psychologically with depressed mood, low self-confidence, fearfulness, irritability, low libido, and impaired sexual functioning. The irritability is especially expressed as poor tolerance to stressful life events that were previously handled more effectively. Some have speculated that this is a major cause of depressions that do not respond appropriately to medications.
Andropause can cause physical symptoms, such as loss of body hair, thinning/drying of skin, anemia, obesity, headaches, decreased muscle strength and increased fatigue. Balding and hair loss does not predict andropause. It is overrepresented in men with diabetes and asthma and can start in the 40s, but definitely should be suspected in the mid-50s and beyond. It should always be ruled out in men with depression who do not respond appropriately to antidepressants.
Laboratory evaluation of testosterone can simplify the diagnostic process. Total serum testosterone levels follow a diurnal variation that is higher in the early morning (7–8 a.m.) and lower in the evening (7–8 p.m.). Total testosterone levels include a component that is freely circulating in the bloodstream and another predominant component that is bound to plasma proteins called Sex Hormone Binding Globulin (SHBG).
The free component is the biologically active component, but this declines if the amount of SHBG increases and captures it from circulating freely in the bloodstream. SHBG increases with age and the free testosterone does not. Thus, the percentage of biologically active free testosterone decreases with age and the bound version increases. The early morning total testosterone level is used as a screening test for andropause, with the normal range on most assays being 325-1,000 ng/dl.
Andropause can also be caused by zinc deficiency, elevated prolactin hormone levels from antipsychotics or pituitary disorders, lipid lowering medications and alternative treatments, such as saw palmetto and flaxseed oil.
Testosterone can be replaced in the form of patches, gels, pills, injections and oral adhesives. DHEA is used as a precursor to testosterone. It usually takes four weeks to see an antidepressant effect from hormone replacement. However, hormone replacement should not be used in mania/hypomania, prostatic cancer, pedophilia, or any antisocial or aggressive states.
Michael R. Lyles, M.D., is an AACC Executive Board Member and is in private practice with Lyles & Crawford Clinical Consulting in Roswell, Georgia.
