Externalising and Prototypic Depressive Symptomology in Older Men: Implications for Depression Screening in Men Across the Lifespan

Abstract

A growing body of evidence suggests that some men with depression present with externalising or male-type symptoms such as substance misuse, anger, risk-taking, emotion suppression, and somatic complaints. It has been argued that this presentation may potentially constitute a male phenotypic variant of the disorder. This has been theorised to result from masculine gender role socialisation emphasising stoicism and avoidance of emotional vulnerability. These symptoms fall outside the predominantly internalising prototypic symptoms (e.g., low mood, anhedonia) listed in current depression criteria (e.g., DSM-5-TR) and screening tools. Thus, although many men do present with prototypic symptoms of depression, exclusive use of prototypic screening tools may fail to identify some males at risk of depression—and by extension—suicide. However, despite increased research attention in this area, there is a paucity of studies exploring the relationship between adherence to masculine norms and prototypic and externalising depressive symptomology in older men. Furthermore, current tools assessing externalising symptoms have not been purposefully validated in older men, who are at increased risk of suicide. The overarching aim of this thesis was therefore to extend research on men’s symptoms of depression with a focus on older males, exploring age differences in adherence to masculine norms and prototypic and externalising depressive symptomology. Four studies were completed to address these aims. The first study (Chapter 2) involved secondary analysis of a large population sample of men aged 15-55 years (N = 14,516) to examine age group differences in conformity to masculine norms and its impact on self-reported prototypic depression symptoms and depression history. The findings indicated that although overall conformity to masculine norms declined with age, extreme conformity to masculine norms in the oldest age group (i.e., those 51-55 years) was associated with increased risk of clinically significant prototypic depression symptoms. Extreme conformity to masculine norms also decreased the likelihood of men reporting that they had received treatment for, or experienced symptoms of, depression in the preceding twelve months. However, this relationship was not evident in those aged 51-55 years. Importantly, this study demonstrated that only some masculine norms, particularly self-reliance, appear to be problematic in the context of men’s mental health when strictly adhered to. The second study (Chapter 3) examined whether the Male Depression Risk Scale (MDRS-22; Rice et al., 2013) is a valid measure of externalising and male-type symptoms of depression in older males. This was achieved through analysis of data collected from a large community survey of younger (n = 510; 18-64 years) and older (n = 439; 65-93 years) men. The findings indicated that the MDRS-22 is a psychometrically valid measure of externalising and male-type symptoms of depression in older men and is significantly linked to prototypic depression symptoms and previous depression diagnoses in younger and older men. However, with a length of 22 items, the MDRS-22 is impractical for wide-scale use in time-limited primary care settings, particularly if used alongside prototypic depression screening tools. Thus, the third study (Chapter 4) focused on developing a short form of the MDRS to make it more useful and accessible in primary care settings. This was done via data collected as part of the same community survey as Study 2. The MDRS-22 was refined to a brief seven item measure (MDRS-7) which included all six domains from the original tool. Findings also indicated that the MDRS-7 detected unique cases of men who score below threshold on widely used prototypic measures of depression, and that MDRS-7 scores are significantly linked to psychological distress and current suicidality for men. Moreover, the MDRS-7 was also shown to be effective at predicting elevated prototypic depression symptoms at follow-up. The final study (Chapter 5) involved follow-up data obtained from the community sample involved in Studies 2 and 3. This study (N = 326 men) focused on better understanding possible mechanisms through which adherence to masculine norms impacts men’s mental health. Specifically, this study examined the mediating role of psychological inflexibility in the relationship between conformity to masculine norms and prototypic and externalising symptoms of depression in men. Findings indicated that psychological inflexibility significantly mediated the relationship between conformity to masculine norms and depression (both prototypic and externalising symptomology) and suggest that psychological inflexibility is more strongly linked with poor mental health than conformity to masculine norms. Overall, the studies reported in this thesis advance current understanding of older men’s symptoms of depression, highlighting the importance of examining externalising symptoms of depression in men across the lifespan, and the potential utility of increasing psychological flexibility in men with strict adherence to masculine norms as a means of improving mental health outcomes. Clinical implications, strengths, limitations, and recommendations for future research are discussed.