"I said I didn't want to be alive anymore," Letourneau, 67, recalled telling his best friend.
He and his friend had gone for a walk when Letourneau confessed and pressed his friend about ways to die painlessly. His friend advised him to admit himself to a hospital.
"When I got back to the house, physically, I was shaking so much -- and emotionally. I couldn't stop," Letourneau said. "I knew I had to get help."
For many men, it takes a lot more than feeling down -- even for long stretches -- to recognize that they are depressed and then step through the doors of a hospital, therapist's office, or a friend's or relative's home to seek help. Men who are depressed may believe they have to defy certain stereotypes about what it means to be a man in order to get appropriate treatment, depression experts and patients say.
"When men get depressed, the depression can be quite severe," said Dr. Ian Cook, professor of psychiatry at the Geffen School of Medicine at UCLA and director of its Depression Program. "The challenge is getting men to acknowledge when they're depressed."
Depression affects about 15 million people in the United States, according to the National Institutes of Mental Health, and men report being depressed about half as often as women.
"It's unclear how much of this represents differences in biology and how much of this is a reporting bias," Cook said. "The stigma issues are somewhat different for men than they are for women."
Steven Lappen of Boston, Mass., has suffered depression since he was a teenager and cites the Frontier Myth, which champions a self-sufficient, hardy lifestyle and mentality for men -- and for women, but to a lesser degree -- as the masculine ideal.
"People lionize that because they want to have that ability," Lappen, 59, said. "Men are bound by that independent, go-it-alone attitude and that asking for help is a sign of weakness. And that is just nonsense because when that sense of self reliance is no longer adequate to the task of bringing them to the Promised Land, they become at risk."
Rather than admit to what they see as a failure to cope with life, men are more likely to abuse drugs and alcohol, isolate themselves, often by working more, and engaging in risky behavior such as gambling or having multiple sexual partners as a way to avoid confronting their illness, depression experts say.
"For the moment, it allows them to feel better and escape from the pain rather than entering the full impact of the depression," said Dr. Jonathan Alpert, psychiatrist and associate director of the Depression Clinical and Research Program at Massachusetts General Hospital. "Men are less likely to talk about lower self esteem or feeling bad about themselves. ... A man's attention is more likely to be gotten by a physical symptom than an emotional one."
The symptoms of depression most commonly seen in men may include loss of sleep or appetite, gaining or losing a significant amount of weight, headaches, irritability and a lack of concentration.
But, if no one recognizes that such symptoms mask an underlying depressed condition, the depression can go untreated for years. And, for men, depression can be lethal. While women attempt suicide more often than men, the rate of completed suicide is four times higher in men, Alpert said.
Lappen's first breakdown occurred during his first semester at college in 1969, when he became so depressed he could not get out of bed to go to class. He admitted himself to a hospital when he was faced with the choice to drop out of college or to fail all his classes. Even so, Lappen refused to take medications while in the hospital and after he was released four months later.
"I didn't want my temple contaminated by these medications," Lappen said. "All I was doing was denying the diagnosis. The pills were a reminder that something was broken in me that I couldn't fix."
Lappen's depression persisted, although he was able to complete college, and became severe again during his first semester of doctoral studies.
"I'd gotten a glass cutter, gotten a hose and found a remote site where no one would find me," Lappen said. "I felt my life as a creative individual was over and I would just die, at my own hands."
Lappen confessed his intent to kill himself to the counselor he was seeing, after which he admitted himself to a hospital.
"I had a realization that there was still a significant life force in me that did not want to cash out," Lappen said. "I thought I still had some talent and wanted to give myself a chance. But there are still times when I regret not following through."
While there are no studies to confirm whether the reported rates of depression in men are rising, clinicians say they have seen an increase, many of which are in the context of job losses.
"Losing a job is something anyone can understand, which makes it more acceptable to talk about it," Cook said. "It opens the door for people to learn about depression and to get help and that kind of direction can be a good thing."
Awareness and acceptance can go a long way to removing the stigma of male depression, but the illness is still viewed by many as a character flaw.
"How do you convert weakness to courage? You have to use the language of courage," Lappen said. "Asking for help means you are a social being and you're looking to fortify yourself. ... Convince [the depressed] person that asking for help is not weakness but is a sign of strength."
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