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

Disclosures

BMC Public Health. 2015;15(1136) 

In This Article

Discussion

The specific focus on the positive strategies that participants use to maintain their mental health and wellbeing differentiated these findings from previous research which has predominantly highlighted men's use of negative coping strategies.[10,14,27] Moreover, our study highlights that men are not only prepared to use positive strategies for their mental health, but they reported that they are using these strategies – and regularly. Our results also demonstrate that the men in this study report regular use of a broad variety of strategies in the service of prevention and management of depression.

While recent findings indicate that a greater proportion of men are seeking help for mental health problems,[12] there is still a large gap, with at least 60 % of men not seeking help when it is needed and with men over-represented in death by suicide. Our results indicate that a large majority of the men surveyed do use positive strategies in tough times. This aligns with a 2010 survey of men and women, which found that 52 % reported using any of four specified self-management strategies for their mental health.[28] The difference between our research and other studies is that the positive strategies we report here were identified by men, and are thus likely have utility and applicability to a range of men in similar situations. In addition, the sheer variety of strategies presented shows that men view their mental-health as connected to their physical health, their social connections, helping others, talking to others, and recognising the need for rewards, a sense of humour and, not being too hard on oneself. This concords with a previous Australian survey, which found that respondents rated lifestyle interventions (e.g., physical activity, relaxation) as likely to be helpful to promoting recovery in mental health.[29]

Our results show an inverse relationship between participants' depression risk and the regular use of self-care (e.g., 'eat healthily' or 'exercise'), achievement (e.g., 'plan out my time' or 'set goals for the future') and cognitive (e.g., 'use humour to reframe my thoughts and feelings') prevention strategies. With regard to management strategies, the men in our sample reported that decreased symptoms of depression were significantly and independently related to regular use of cognitive strategies (e.g., 'notice my thought patterns and try to change my perspective'). This aligns with previous research showing that regular use of achievement strategies is associated with lower risk of depression[9,10] and the overwhelming evidence demonstrating the effectiveness of cognitive therapies in reducing depression risk and depression symptoms.[30–32] Also consistent with previous research, our data showed that younger age and more stressful events were predictors of higher depression risk, while employment and higher levels of education predicted lower depression symptomology.[33–38]

However, in contrast with previous research,[37] we found that relationship status was not a significant predictor of either depression risk or depression symptoms in multi-variate analyses. Similarly, while regularly using self-care strategies (e.g., diet or exercise) were significantly associated with lower depression risk, the same relationship was not observed with depression symptoms. This is unexpected, given previous research which has emphasised the influence of poor quality diets[39,40] and lack of exercise on mood,[41] the clinical benefits gained with exercise,[42] and recommendations to incorporate dietary improvements and increased physical activity into depression treatment plans.[43–45] It may be that our results simply reflect ongoing questions about the required nature of dietary improvements, or how much exercise is necessary to relieve depression symptoms. For example, a 2013 Cochrane review concluded that exercise has a small effect size and is no more effective than psychological or pharmacological therapies in reducing symptoms of depression.[46] A 2009 review emphasised that exercise routines typically only have a measurable effect on depression symptoms when routines are maintained over the long term.[47] Given the cross-sectional nature of our data, it is not possible to be certain how long the participants had been exercising for, which may account for the lack of an independent relationship with depression symptoms found.

In addition to the results of multivariate analyses, the survey found that, on the whole, the men reported a broad openness to using strategies they do not currently employ. For both prevention and management, more than 40 % of the sample were open to seeing a health professional, joining a group, club or team, practising meditation, or mindfulness or gratitude, and in the case of management of low mood, setting goals for the future. Some conflicting views were also noted, for example, a majority reported being open to having a mentor or joining a group, while a minority held strongly opposing views (i.e., they would never use these strategies). However, with the exception of 'following faith, religion or spiritually', where the majority said they would never use this strategy, most participants either used, or were open to using, nearly all of the strategies in the survey. Openness to seeing a health professional is perhaps surprising, given previous reports that men can have negative attitudes towards help-seeking.[10,11,48] However, previous work has found that people rate GPs and counsellors as likely to be helpful for mental health disorders[29] and given that a majority of men in the sample had previous experience with depression, it is possible this contributed to their openness to seeking help.[49]

Clinical and Public Health Implications

Clearly, stressful events contribute to both depression risk and depression symptoms, yet experiencing stressful events is not always controllable. The present results are therefore important in providing insights into factors men can control, namely their choice and use of effective self-help strategies. The findings thus give rise to several important implications for clinical and public health practice.

Firstly, health professionals, families and friends supporting and treating men at risk of depression should note that while certain prevention strategies were significantly related to lower depression risk, the same strategies used for management were not significant predictors of fewer depression symptoms. Therefore, it is crucial to help men to match their use of strategies to different mental health aims. For example, diet, exercise, achievement and 'reframing' strategies were all important tools in preventing depression among 'at-risk' men in the absence of clinically significant symptoms. However, once symptomatic, men reported that managing symptoms through the use of cognitive reframing strategies was important – with the caveat that exercise may have a dose–response relationship with depression[50] and is thus important throughout all stages of care.

It may also be important to consider a man's level of conformity to traditionally 'masculine' belief systems. While the present survey did not assess men's gender role conformity, it is clear from previous research that adherence to masculine norms can influence men's attitude towards help-seeking,[11,51] and can affect which strategies they use in times of distress.[8,52] Furthermore, adhering to masculine norms may be especially important to younger men.[53] Thus, developing an understanding of the relative importance of 'masculinity' to an individual's identity may significantly assist in successfully supporting men to self-manage their depression.

With regard to public health messaging, it may be prudent to publicise firstly men's use of and openness to using many different strategies. The men in this study used, on average, 16 prevention strategies and 14 management strategies, while 'taking time out' was the most common regularly-used management strategy. It would appear that it is important to men to be able to choose from a range of social, emotional, practical or problem-solving strategies at every level of symptom severity. Future public health campaigns targeting men could focus on encouraging men to try out new strategies that other men have found useful by publicising some of the strategies reported here. Secondly, public health messaging could emphasise that men make important distinctions between prevention and management when it comes to their mental health, with an emphasis on recognising when it is important to have some 'time out'. This may be an important message for men who are not in contact with health services. Hearing that other men use many different positive strategies to self-manage their mental health, and who also value the importance of taking time out during tough times, could help to normalise such self-care behaviours for men in the community.

Future public health and awareness campaigns might also highlight that men report being open to using 'non-traditional' strategies such as meditation, or finding a mentor, and that these types of strategies are worth trying, to see if they are useful. In this way, the present results may help to inform social-norm based education and health campaigns, by conveying simple messages about the positive strategies used by men to prevent and manage feeling "flat or down". The messages should highlight that men generated the strategies, use them and find them helpful. The information may help to give other men fresh ideas, or convince men to try positive strategies when previously they may have favoured unhelpful coping mechanisms. Simply hearing that other men consciously invest in preventing poor mental health could be a powerful message.

Limitations and Future Research

Among Australian men in 2007, the prevalence of a depressive episode in the previous 12 months was 3.1 %.[54] Despite our efforts to publicise the study widely throughout Australia, in this sample, the majority of men were currently at-least mildly depressed (68 %), were also tertiary educated (84 %) at higher rates than the general population[55] and lived in metropolitan areas (80 %). Given these considerations, there may be further positive strategies used by men that haven't been represented in our survey and the results may not generalise to all men. In addition, regular use of a strategy was chosen as the unit of analysis, based on the assumption that regularly used strategies represent what is in a person's behavioural repertoire. However, we also acknowledge that some strategies may be effective with only occasional use. Future research would benefit from examining the best conceptualisation of 'frequency of use' and 'number of strategies used' as indicators of effective strategy use in men with depression. In addition, given the cross-sectional nature of the data presented, future research should consider using prospective studies to determine possible causal relationships between use of particular strategies and severity of depression symptoms.

Despite these limitations, it is worth noting that the study attracted a large sample of men across Australia, from a population who can be reticent about discussing their mental health. The results are therefore important in confirming earlier findings[19] and are vital to providing new insights into an under-researched area, namely, the positive things men do to prevent and manage their mental health.

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