Positive Strategies Men Regularly Use to Prevent and Manage Depression

A National Survey of Australian Men

Judy Proudfoot; Andrea S. Fogarty; Isabel McTigue; Sally Nathan; Erin L. Whittle; Helen Christensen; Michael J. Player; Dusan Hadzi-Pavlovic; Kay Wilhelm


BMC Public Health. 2015;15(1136) 

In This Article



An online survey was developed using the information gained from the earlier qualitative investigation.[19] Particular strategies suggested during that investigation formed the basis for the survey questions, using the language that the men had used. Both prevention and management strategies were included. Prevention strategies were defined as strategies men use 'to keep myself feeling OK, or on an even keel from day to day'. Management strategies were defined as strategies used 'to pick myself up in the times I'm feeling flat or down'. The survey was in two sections: Men were asked whether they used the strategies for either prevention or management of their mental health, how frequently they used them, or their openness to using them (0 = 'I do this regularly'; 1 = 'I do this occasionally'; 2 = 'I don't do this, but I think it is a good idea'; 3 = 'I don't do this and I wouldn't ever'). In the second part of the survey, participants were asked to record any additional prevention or management strategies not mentioned in the list that they found useful (see Appendix).

The survey was piloted by ten men affiliated with the lead institution, using the Think Aloud Method[21] which invites participants to verbally express their thought processes to a researcher while completing the survey. This enabled identification of questions requiring clarification or simplification, as well as respondent tolerance for the length and subject matter of the survey. Adaptations were made on the basis of their feedback. The final survey consisted of 26 positive prevention and management strategies, with a free text box at the end for other strategies respondents wished to add. The survey was anonymous and was delivered using QuestionPro,[22] an online survey software package. Screening and completion of the survey took approximately 20–25 min.

The online survey was publicised throughout Australia, via the lead institute's professional and digital networks, including social media, a press release and promotion via several radio stations. Entry criteria were kept to a minimum to allow maximum participation and broad-ranging responding. Individuals were eligible to participate if they were: male, aged 18 years or more, resident in Australia, comfortable reading and writing in English, willing to consent online and able to access the internet.


Demographics. Standard demographic data were collected, including age (years), location (postcode), Indigenous status, relationship status (never married, married, de facto, separated, divorced, widowed), employment status (full-time, part-time, retired, self-employed, full-time home duties, temporarily or permanently unable to work due to illness or injury, able to work but unemployed, full-time student, other), and highest level of education received (primary, secondary, trade/technical certificate/apprenticeship, other certificate/diploma, bachelor degree, postgraduate degree). Participants also reported the number of stressful events they had experienced in the previous year (0 = none; 1 = one to two; 2 = three or more).

Depression.Depression risk was assessed using the Male Depression Risk Scale (MDRS),[23] comprised of 22 items on an eight-point scale (0–7), where participants rate how often an item applied to them in the previous month. Total scores range from 0 to 154, with Cronbach's α = .90 in this sample. Additionally, subscale scores are calculated for six symptom domains: distress (0–28; α = .82), drug use (0–21; α = .95), alcohol use (0–28; α = .92), anger and aggression (0–28; α = .91), somatic symptoms (0–28; α = .78), and risk-taking (0–21; α = .71). Depression symptoms were assessed by the Patient Health Questionnaire-9 (PHQ-9).[24] The PHQ-9 is comprised of nine items on a four-point scale (0–3), rating how often in the past 2 weeks a person has been bothered by a range of symptoms. Total scores range from 0 to 30 (α = .91 in this sample), with clinically significant cut-points that indicate no/minimal (0–4), mild (5–9), moderate (10–14), moderately severe (15–19) or severe (20+) depression.

Risk Management

A robust risk management procedure was in place throughout the project. Participants reporting severe depression (total PHQ-9 score of 20 or more) or current suicidal ideation (score > 0 on PHQ-9 item ix "thoughts that you would be better off dead or of hurting yourself in some way") automatically triggered the risk protocol. 'At-risk' participants were encouraged to use a special call back service which had been set up for the project. Participants provided their contact details to Lifeline via a confidential messaging service. Lifeline then contacted the participant and carried out a risk assessment with appropriate follow-up. The project's risk protocol was also triggered at a second point in the survey, based on participants' responses to a question about whether they had ever attempted to take their own life. Any participant who responded with 'yes, in the past month' automatically received a message offering them the confidential Lifeline call-back service. Participants who responded 'yes, in the past 12 months' or 'yes, but it was more than 12 months ago' received crisis line details with the recommendation that they do not hesitate to contact them if the thoughts recur.

Data Analysis

All data analyses were conducted using IBM SPSS Statistics 22.[25] For both prevention and management analyses, the 26 positive self-help strategies were categorised into five groupings: (i) self-care – strategies aimed at physical fitness and health maintenance; (ii) pleasurable activities – strategies aimed at increasing pleasure; (iii) achievement – strategies aimed at completing tasks, daily routines and setting goals; (iv) cognitive – strategies aimed at reframing thoughts and/or perspectives on a problem; (v) connectedness – strategies aimed at engaging with others. Analyses were based on 0 = does not use regularly; 1 = regularly uses. Relationships between use of these strategy groupings and demographic variables were assessed using chi-squared analyses.

For multivariate analyses, relationship status was dichotomised (0 = no current relationship; 1 = current relationship), as was employment (0 = not currently employed; 1 = currently employed) and educational attainment (0 = no university degree; 1 = university degree). Dependent variables were (i) depression risk (MDRS) and (ii) symptoms of depression (PHQ-9). Listwise Pearson product moment correlations were used to assess bivariate relationships between the dependent variables and continuous variables. Point biserial correlations were used to assess relationships between dependent variables and categorical variables. Multivariate hierarchical linear regression analyses were used to assess the relationships between (1) depression risk and regular use of prevention strategies; and (2) depression symptoms and regular use of management strategies. Non-modifiable predictors (e.g., age) were entered first, and regularly used strategies were entered in the second sequence to explore their specific association with depression risk and symptoms. Four models were specified, as follows:

Model 1 Prevention: total MDRS score was entered as the dependent variable and demographic factors were added into the model to control for age, employment, education, relationship status and number of stressful events in the previous year. Model 2 Prevention: as above, with regularly used prevention strategies entered separately in a second block. Model 1 Management: total PHQ-9 score was entered as the dependent variable, and demographic factors were added to control for age, employment, education, relationship status and number of stressful events in the previous year. Model 2 Management: as above, with regularly used management strategies entered separately in a second block.

Collinearity was assessed using tolerance values of less than .1 and variance inflation factor values of more than 10.[26]

Ethics, Consent and Permissions

The study was approved by the UNSW Human Research Ethics Committee (HREC13077) and all participants indicated consent by checking an online box before commencing the survey.