Men and Depression Seeing and Believing

Abstract: Men appear less able to ask health practitioners for help with their feelings for fear of appearing ‘needy’, in contrast to women. Chinese Medicine practitioners have a role in both facilitating a man to feel and express his unhappiness, and to provide interventions in the form of herbs and acupuncture.

Is it possible that many male patients, whose signs and symptoms range from fatigue to hypertension have underlying feelings of frustration, depression and disappointment in work and relationships? How much do these issues need to be acknowledged by the patient for the signs and symptoms to be resolved? What is our role, as practitioners, in recognising and treating the depression and facilitating the expression of this unhappiness? These men, whose esteem is often performance-based (i.e. based on what they achieve rather than who they are), may experience loneliness and difficulty in finding meaning in life and intimacy in relationships, but may have no way of knowing how they feel. These are some of the issues I attempt to address in this paper.

As Kramer asserts in his article on The Fragile Male, from conception to death males are biologically more fragile than females, yet cultural expectations of masculinity which shape the experience of boys as they grow up suppose that they are less so. Does the emotional life of boys need more care than we think? Infant boys are both more sensitive than girls and more demanding and difficult, yet society assumes that boys should be tougher. If baby boys are harder to care for, and their emotional needs are not met (for example by not receiving enough appropriate attention from their parents), their emotional habits can become ‘wired in’ and they may be more liable to feel lonely as adults. Feeling isolated from his partner, friends and family, contact with us as practitioners may be the one attempt a man makes to heal himself.

Women are twice as likely as men to seek help for depression, but men are four times as likely to kill themselves, whilst male psychiatric patients outnumber women. The violent crime rate is soaring (for most of this violence men are both the perpetrators and the victims), and men are much more likely to experience addiction disorders, especially substance abuse. There is a hidden cost to society in terms of lost productivity, divorce, one parent families and violence. This makes male depression a public health issue. Recent research has revealed that men are more likely to recognise feelings of stress rather than depression, are likely to avoid people when stressed and are less likely to seek help from doctors. The problem may be compounded by the clinician’s failure to respond to a man’s cries for help, because of cultural expectations of men and their toughness.

If men because of culture (east and west) are unable to give due weight and voice to emotions as causes of disease, and any historical female voice in the development of Chinese medicine is missing, we might ask what gaps and silences exist in the development of Chinese medicine due to this gender imbalance?

What is our role as practitioners? Chinese Medicine from it’s birth has recognised emotions as a cause of disease. With its central tenet of addressing the person as a whole, and its brilliance at untangling complex patterns of imbalance, it offers the prospect of a remedy for the cause.
However, to what degree is it necessary to recognise and acknowledge feelings in order for imbalance to resolve? I argue that we need the skills to recognise imbalanced emotions and to hear what men might be asking for. Much of what we measure in Chinese medicine diagnosis is quantitative, how hot, how thirsty, how tired, but feelings are a qualitative value that may need specialist training.

As authentic witnesses, to must connect convincingly with our male patient and recognise his unhappiness even if he himself does not, in other words “To read all the detailed signs and symptoms which appear externally and also to have a perception of the unity of the patient through the jingshen”.

Firstly I may have a sense of this by how the man appears: the strength of eye contact on the first greeting, his posture and the sound of his voice, for example sighing or excessively quiet speech. Secondly, the content of responses about neutral subjects such as the weather can also reveal a great deal. Lastly, if I think there may be an issue around constraint or unhappiness, I always ask men how they feel about different aspects of their lives; this may take several attempts before I get answers but I persist.

Depressed men may lack the power to restore the order of life at the level of the jingshen, especially after an emotional blow. Grief and fear injure the Heart, and such an attack by pathogenic emotional conditions makes lack of joy a cause of disease. Anger injures the Liver and Spleen and sadness is the root of much anger; that is to say that sadness, fear and insecurity may lie behind aggressive behaviour. The character for anger, ‘Nu’, is explained as the feelings of a female slave under the hand of a master, which suggests suppressed anger. Father Larre14 suggests that emotions “rise directly from the heart of the zang, they are the reaction of the zang to an exaggerated stimulation or something which has a lack of mastery of its own power”.

Having recognised the emotions underneath the pathology, how do we help remedy matters? My experience of treating depressed men is that it nearly always involves regulating qi stagnation, clearing heat and damp, softening the Liver and protecting the Heart, Spleen and Stomach from the Liver’s overbearing tendencies. It goes without saying that the zang most associated with depression is the Liver, and treatment almost always involves regulating Liver qi. It is then a question of deciding the extent of the damage from constrained qi, whether there are signs of damp and more usually damp heat, and whether this heat is disturbing the shen. There may be concurrent signs of qi deficiency, and a typical presenting pattern is Liver-Spleen disharmony.

Acupuncture
I have found acupuncture to be very conducive to treating people with anxiety and depression. Many patients might deny how extensive their feelings of tension and depression are until immediately after acupuncture, when feeling much more relaxed they can acknowledge the contrast in how they feel. I nearly always use a point combination of either Neiguan P-6 or Shenmen HE-7 or both, with Sanyinjiao SP-6, Taichong LIV-3 and Fenglong ST-40 or Zusanli ST-36 and find this combination of points especially calming. The needle technique depends on the patient, but very often an even needling style is used and the needles are left in for 20 minutes, unless the patient appears very tense when they may be retained for a further 5-10 minutes.

Case examples

Male, 44 years.
N. came to my clinic with no very obvious complaint except a vague sense of his energy being poor (in fact, when we discussed it together, it was actually quite good) and poor concentration. He also mentioned restless sleep with slight heat sensations but with no anxiety. Further questioning revealed that during the day he exerienced a listless irritable feeling, thirst and excess heat with some heartburn. His appetite was currently poor and he often felt bloated. At the second session, I asked him about his job which he described as meaningless, and we explored his feelings about his relationship. His wife was suffering from anxiety and this upset him. It was difficult to get N. to describe how that ‘upset’ made him feel, and eventually he settled on a tightness in his tummy and heaviness in the chest. Tongue: thin yellow coating, slightly red edges. Pulse: wiry. Diagnosis: constrained qi with heat. Depression has caused the disruption of the flow of qi (and blood) leading to heat and damp

He had three treatments of acupuncture once a fortnight: Neiguan P-6, Fenglong ST-40, Taichong LIV-3, Yanglingquan GB-34, Sanyinjiao SP-6. I additionally prescribed Modified Jue Yu Wan (Release Constraint Decoction), 18 bags of herbs taken over 36 days concurrently with the acupuncture: Chai Hu (Radix Bupleuri) 9, Huang Lian (Rhizoma Coptidis) 6, Zhi Zi (Fructus Gardeniae Jasminoidis) 9, Dan Shen (Radix Salviae Miltiorrhizae) 9, Bai Shao (Radix Paeoniae Lactiflorae) 9, Mu Dan Pi (Cortex Moutan Radicis) 9, He Huan Pi (Cortex Albizziae Julibrissin) 9, Ye Jiao Teng (Caulis Polygoni Multiflori) 9, Gan Cao (Radix Glycyrrhizae Uralensis) 6.
Within three weeks of beginning the treatment he felt much better, and at a three month review he felt very positive. He still returns for the occasional acupuncture session. It seemed to me that a number of factors helped everything to fall into place: the Chinese medicine, his ability to acknowledge that he found his job boring, a new focus on his career, and a recognition that he could support his wife to get some help.

Male, 47 years. P. came into my clinic suffering from post viral syndrome. A year before he had suffered influenza and since then had an approximate six weekly cyclical pattern of heat sensations (sometimes cold), headaches, fatigue, poor mental focus, irritable bowels (bloating, wind, distension and constipation), restless sleep a feeling of tightness in the chest, heartburn and reduced appetite. Tongue: thick frothy yellow coating, red body. Pulse: wiry. Over the subsequent three visits more information was forthcoming and it became apparent that he had been ill for five years before the onset of the ‘flu. On further questioning, the patient revealed that prior to this illness he had had a serious complaint made against him at work which meant that his colleagues ‘lost faith’ in him. The complaint was due to lead to a tribunal but the accuser had died before this could take place. After talking about his feelings, he identified that he had had no ‘closure’ for the entire traumatic time, and at this point much anger was expressed. Diagnosis: pathogenic damp heat at the shaoyang level on a background of Liver qi stagnation. Acupuncture: Shenmen HE-7, Yanglingquan GB-34, Taichong LIV-3, Sanyinjiao SP-6, Jiexi ST-41, Baihui DU-20. A variation of Da Chai Hu Tang (Major Bupleurum Decoction) was prescribed: Chai Hu (Radix Bupleuri) 12, Huang Qin (Radix Scutellariae Baicalensis) 9, Zhi Shi (Fructus Citri seu Ponciri Immaturus) 9, Da Huang (Rhizoma Rhei) (first week only) 9, Bai Shao (Radix Paeoniae Lactiflorae) 9, Zhi Zi (Fructus Gardeniae Jasminoidis) 9, Fu Ling (Sclerotium Poriae Cocos) 9, Gan Cao (Radix Glycyrrhizae Uralensis) 3. 42 bags of herbs were given in combination with acupuncture over 3 months (treatments were given fortnightly or less) . The herbs and acupuncture quickly cleared away the heat and stagnation, allowing P. to see more clearly how much unhappiness lay underneath his physical symptoms. By taking exercise, eating a healthy diet and addressing the long held anger and grief, his confidence rose increasingly and he was able to return to work.

Male 42, S. looked older than his years and was overweight. He complained of sluggishness. Further investigation revealed a feeling of depression and difficulty in finding meaning in life, with heat sensations, irritability and frequent sighing. He loved his wife but was on the verge of trying to extract himself from the marriage because he felt stifled and bored. His job was an endless round of pressure and targets which led to no sense of achievement or satisfaction. Tongue: red body, with thick yellow coating. Pulse: wiry. Diagnosis: damp heat in the Liver and Gallbladder. Acupuncture was given once a month: Neiguan P-6, Shenmen HE-7, Yanglingquan GB-34, Taichong LIV-3, Sanyinjiao SP-6, Fenglong ST-40. A variation of Long Dan Xie Gan Tang (Gentiana Longdancao Decoction to Drain the Liver) was also
prescribed: Long Dan Cao (Radix Gentianae Scabrae) 6, Huang Qin (Radix Scutellariae Baicalensis) 9, Zhi Zi (Fructus Gardeniae Jasminoidis) 9, Ze Xie (Rhizoma Alismatis Plantago-aquaticae) 6, Che Qian Zi (Semen Plantaginis) 9, Chai Hu (Radix Bupleuri) 9, Sheng Di Huang (Radix Rehmanniae Glutinosae) 9, Fu Ling (Sclerotium Poriae Cocos) 9, Mu Xiang (Radix Saussureae seu Vladimirae) 9, Gan Cao (Radix Glycyrrhizae Uralensis) 3 (16 bags over 30 days). S. had really lost any sense of joy or fun in his life, so we spent quite a lot of time chatting about ‘waste of time’ pursuits like football and the cinema, and how these might help bring fun back into his life. We struck a bargain about exercise (he agreed to walk everywhere) and about reducing his beer consumption. Eventually he and his wife decided they needed to take up salsa dancing and he joined an over forties football team. The acupuncture and herbs helped restore meaning to what had seemed futile and pointless phase of his life.

Male 40, professional. M. presented with tiredness and irritable bowel syndrome (distension, discomfort and irregular bowel movements). A shy and reticent man, he eventually identified feelings of hopelessness and black despair, and unhappiness in his marriage with no sense of warmth, love and affection with his spouse. Tongue: normal. Pulse: wiry. Diagnosis: disharmony between the Liver and Spleen. Acupuncture: Shenmen HE-7, Zusanli ST-36, Sanyinjiao SP-6, Taichong LIV-3, Qiuxu GB-40 (treatment given once monthly for 1 year) and periodic prescribing of a variation of Xiao Yao Wan (Rambling Decoction): Chai Hu (Radix Bupleuri) 9, Bai Shao (Radix Paeoniae Lactiflorae) 9, Fu Ling (Sclerotium Poriae Cocos) 9, Huang Qi (Radix Astragali) 15, Mu Xiang (Radix Saussureae seu Vladimirae) 9, Sha Ren (Fructus seu Semen Amomi) 9, Gan Cao (Radix Glycyrrhizae Uralensis) 3. Much of our time in the sessions would pass in silence, and many of the same issues would be revisited and the same conclusions drawn. His parents had only offered very conditional love, and slowly it evolved that M. held a lot of hidden anger towards them which acted like a barrier to all feelings of love and intimacy. From the very first session that I saw M., I talked in terms of him seeing a pyschotherapist, but he was very reluctant to do this. Eventually he saw the need to have some form of counselling, most especially when we talked about the possibility of his children copying his patterns of behaviour.

Conclusion
My experience of treating depressed men is that initially the patient rarely recognises the feelings of hopeless despair or hidden resentment and anger that underlie their symptoms, and that at some point in the treatment it is necessary to acknowledge and express these feelings. Biological and social constraints work against the emotional interests of males, and men may withhold their feelings from health practitioners for fear of appearing needy. Herbs and acupuncture allow the patient the tranquillity needed to properly process and transform these pathogenic influences. When the Shen is residing in the Heart, and qi and blood flow, a sense of balance ensures a clear mental outlook. The connection felt with the practitioner enables the patient to feel supported during the process, and if necessary seek additional help from other health professionals.

[1] Kraemer S. The fragile male.  Lessons from everywhere BMJ 321;1609:1612

[2] Hanson D, Moller H, Olsen J.  Severe peri-conceptional life events and the sex ratio in offspring: follow up study based on 5 national registers.  BMJ 1999; 319:548-9

[3] Differences in life expectancy at birth, England and Wales 1997/9

[4] Kindlon D, Thompson M.  Raising Cain: protecting the emotional life of boys.  London: Michael Joseph 1999

[5] Fivush R. Exploring sex differences in the emotional content of mother-child conversations about the past.  Sex Roles 1989

[6] Cicchetti D TuckerD.  Development and self-regulatory structures of the mind.  Dev Psychpathol.1994;65:1678-93

[7] Kraemer S. The fragile male.  Lessons from everywhere BMJ 321;1609:1612

[8] McClure GMC, Changes in suicide in England and Wales 1960-1997.  Br J Psychiatry 2000

[9] Rutter M, Giller H, Hagell A. Anti social behaviour in young people. Cambridge University Press 1998

[10] Rout U.  Gender differences in stress, satisfaction and mental well being among general practitioners in England.  Psyco. Health med 1999

[11] Tudiver F, Talbot Y.  Why don’t men seek help?  Family physicians’ perspectives on help-seeking behaviour in men.  J Family Practice 1999

[12] Larre C, Rochat de la Valle, The seven emotions, Monkey Press

[13] Su Wen chapter 5

[14] Larre C, Rochat de la Valle, The seven emotions, Monkey Press

[15] Rout U.  Gender differences in stress, satisfaction and mental well being among general practitioners in England.  Psyco. Health med 1999



Sarah Price is Senior Lecturer in Chinese herbs at the Northern College of Acupuncture, and is currently undertaking an MSc in Epidemiology at University of Edinburgh. She lives and practises in Edinburgh. Contact Sarah : [email protected]