with Clifford M. Singer
George Vaillant, a psychiatrist who has studied men’s aging, notes that “aging well” may seem like an oxymoron.1 But he recognizes that aging is a complex process of adaptation and development as much as decline. We have all seen older men coping with severe challenges with inspiring grace. What accounts for some men’s remarkable ability to maintain a sense of calmness through adversity? What psychological characteristics contribute to satisfying adaptations to old age? What are the psychological challenges for men as we age? In this chapter we’ll begin with an overview of brain aging, since that is intimately related to a man’s behavior, thinking, and feelings. The next focus is on the psychology of aging, including an overview of personality development and a look at the major themes affecting men’s emotions in middle and old age. A review of the major mental disorders of late life follows, and we end with some strategies for successful adaptation by men as they grow older.
It has long been thought that aging brings a steady, determined decline in all aspects of brain function. As is often the case, reliable data are inconsistent with widely held assumptions. At about age 30, when the myelination (or insulating) of the brain’s long communication tracts is finally complete and the frontal lobes are fully formed, our brain structure is mature. Contrary to folk wisdom, once the brain is mature, there is no gradual decline in the number of brain cells (neurons). Brain researchers have learned that if we do not have a disease that causes neurons to die, then nearly all of the neurons remain healthy until we die.2 What does change as we get older is the thinning of the fatty sheath (or myelin) coating of the nerve axons (or the white matter)3 and shrinking of the synapses between brain cells, as well as some shrinkage of neuron size (or the gray matter).4 These changes slow the flow of information from one area of the cerebral cortex to another. The result is a slowing of instance processing speed and of memory recall, which begins in the fourth decade of life with healthy aging. The change is only measurable in milliseconds. In fact, the performance decrement is so subtle at first that it is obvious only at the highest levels of performance demands, such as in Olympic and professional athletes and, famously, among physicists. The history of science is populated by figures having their “blockbuster” insights as young adults.
Here’s the good news about brain aging. The old beliefs were that the brain is a static organ, unresponsive to events, with a fixed structure and with cell populations that are unable to repair or reproduce. These beliefs are now dead, pushed aside by the findings of brain research. There has been a torrent of evidence coming from modern neuroscience that the brain can grow and adapt in late life. The growth of new brain cells, the formation of new synaptic connections between those brain cells, and the acquisition of new knowledge and skills are common in older adults. True, these processes are slower and not as effortless as in youth, but they do occur. The mechanisms that promote adaptability and growth in the human brain are not as strong in older adults. Learning requires more repetition and practice. Functional imaging studies demonstrate that the brain has to work harder in older adults to achieve the learning performance of young adults. Memorization tasks cause the brains of middle-aged and older adults to recruit more help from the frontal lobes, bringing greater awareness and focus to learning efforts. This process is sometimes referred to as “top-down processing,” as it is reliant on the frontal lobes or “higher brain centers.” Even when brain injuries occur, there is slower healing and less complete recovery in older adults than young people, but improvement and repair do occur. In experiments with research animals, experiences and novel situations have been found to stimulate neuronal growth in the old as in the young.5 The growth and adaptation of brain cell circuits to stress, injury, and new demands is called neuroplasticity.6
There is an equivalent to neuroplasticity in the body. Called myoplasticity, it is the ability of muscles to adapt and respond to stress, injury, and new demands. The fact is that our muscle strength and endurance are less at 50 than at 20. The adaptation of muscles to stress and workload, as in weight lifting, takes more time and may not yield the same large, hard muscle mass as years before. This doesn’t mean that older muscles don’t respond well to exercise and performance demands. Even modest increases in demand result in improved strength and performance in 90-year-olds. The same is true of our aging brain.
In old age, our brain still responds to increased demands. It just does so less swiftly than at age 30 and with less potential peak performance. Once this is understood and accepted, we can come to terms with the changes in memory and attention that accompany aging (see chapter 13 for more details). With patience, persistence, and mindfulness, we can achieve high levels of intellectual and creative activity. Knowing this, you may be less likely to shy away from mental challenges that may be frustrating at first but even more satisfying in the end. The satisfaction of achievement, in this case, is even sweeter with the awareness that the effort itself provokes growth and renewal in the brain.7
We live in a culture where the masculinity code tells us to strive to be the “big wheel” and, if need be, “give ’em hell.”8 We are competitive. We learn to crave power and status, thinking that this is the way we attract fame, ensure the survival of our offspring, and secure the essentials of life. In adolescence, our competitiveness may be expressed through sports and academics or played out in more direct ways through attempts to stand out in social situations or through physical aggression and violent confrontation. As adults, the workplace is our coliseum.
The need to maintain a stable sense of identity often faces new challenges as we transition through our middle ages and early older adult years. Sometimes the challenge comes from a sudden and unexpected event, such as an injury, a disabling illness to a partner or wife, or being laid off from a job we expected to have the rest of our life. Sometimes it comes gradually as we begin to recognize the aging of our bodies. We may notice that young women no longer glance our way as we pass. Our first experiences with erectile dysfunction (ED) or long intervals before our next feelings of arousal raise fears that sex will never again be fun for us or satisfying for our partners. Young people, men and women, suddenly seem so full of enthusiasm, energy, quick wit, and the latest knowledge of the field, and they are suddenly your colleagues or even your supervisors. Your children may be grown and appear to be less dependent on your skills or wisdom. Your spouse or partner may be achieving success in his or her career and earn more than you do. You may even feel a little more vulnerable and have a keen awareness that you cannot always control events. These are heavy things for us to cope with.
The saving grace for many of us is that we move away from trying to be the big wheel. As we age, wisdom, increasing confidence, and the way the natural decline in reproductive hormones affects our body tend to move us toward new masculinity plateaus. If things go well, we may become more compassionate and collaborative. Those of us who allow ourselves to grow emotionally become secure enough to acknowledge our shortcomings and wise enough to depend on others to help compensate for them. We even become more accepting of flaws in others. The end result is that the drive to compete quite commonly declines in the hierarchy of personal goals as the typical man ages. In fact, researchers in Oregon have found that risk-taking behavior and the desire to enter into competition to achieve bigger payoffs appear to peak in the fifties and then begin to decline (especially for men).9 Of course, for the hard-driving elite, it may be a different story.
Erik Erikson, a mid-twentieth-century psychoanalyst, conceived of human psychological development as sequential chapters of life, each unfolding under the influence of biology and culture. His stages of development, beginning in infancy, are dependent on the successful negotiation of the major developmental task of the previous stage.10 For example, the task of forming a stable sense of who we are and how we behave as (young) men is the major psychological milestone of adolescence (ages 12–20); Erikson did acknowledge that working through each stage may take years longer for many people. He referred to the tensions during this period of life as “identity versus role confusion,” and he thought that the formation of a predictable, consistent identity is essential for the successful negotiation of the stage of “intimacy versus isolation.” People, and perhaps men in particular, can create and tolerate intimate relationships only when they feel confident in their own identity and self-worth. In order for us to give love, we must feel worthy to receive it in turn.
To succeed in adult relationships, he argued, we must feel comfortable with the reciprocity of relationships, being willing to rely on others as they rely on us. This is not so easy for men who are apprehensive to ask for help from others or who do not even know what they need from others. There may be denial of needs and exaggerated expressions of independence. Men may feel excessively burdened by meeting the most basic needs of a partner and seek escape by addictive behavior, such as drinking, overworking, compulsive exercise, or spending long hours on the Internet. Of course, everyone needs alone time away from family and friends. Those who can’t negotiate the balance of intimacy and isolation may become too detached from others, increasing their risk of depression and health problems later in life.
In the sequence of psychological stages that Erikson conceived, the capacity for intimate relationships sets the stage for adulthood (ages 35–65). This “middle” period of life pivots on what Erikson called “generativity versus stagnation.” He believed that in adulthood men will strive to build a legacy, something of lasting value for the benefit of the next generation. Without this sense of purpose, we may feel stagnant or “go through the motions” without really caring about outcomes or having a sense that what we do matters. It is during this phase that most men strive to create financial stability for themselves and their loved ones, raise children, mentor young colleagues, and achieve what they hope to achieve in life. We also grow to be more forgiving of ourselves and others in the effort to get along. We may learn to take fewer risks because there are more people counting on us and what we provide, emotionally and materially.
Men of all ages can be preoccupied with thoughts of strength and success, failure and mortality, but these themes reemerge as among the strongest late in life. Erikson called this life stage “integrity versus despair.” The terms refer to the psychic struggle of later life, in which we must come to terms with the life we have lived, for better or worse. By “integrity,” Erikson meant coming to feel that our life has followed a story line true to a person’s heart and values: a feeling that life has been worthwhile and fulfilling, and we come to accept without fear that death will occur probably in the not-too-distant future. “Despair,” of course, is the opposite pole. It could be a belief that not much good has come from your life and there is little to be done about it at this point. Such feelings can leave us mired in regret and paralyzed by demoralization. Or there could be isolation and bitterness from a grim perception that the world is changing for the worse and we can either passively resign to “let the fools have it their way” or fall into a paranoid state in which others are seen as different, dangerous, or just inferior. Of course, we all know people at both extremes of “integrity versus despair,” and we certainly know whom we’d rather invite over for Thanksgiving dinner.
Erikson’s model provides a useful framework for thinking about the changing challenges of life as we age, and it is supported by research. Various studies indicate that there are certain competencies most relevant at different life stages, and good outcomes are dependent on achieving those milestones in our lives. For middle-aged and older men, the quality of our lives is said to hinge on generativity versus stagnation and integrity versus despair. Erikson also believed that there is value in the ability to balance the various developmental challenges over our lifetime. Balancing is a skill that allows us to deal with the apparent paradox that exists between developmental challenges (e.g., integrity versus despair). Learning to balance challenges effectively reflects what Erickson called wisdom. Of course, many people consider this model oversimplified and culture specific. As Erikson even cautioned, any attempt to define discrete developmental stages can’t be taken too literally since our lives do not follow linear trajectories.11
The psychology of men’s aging will influence any relationship that spans the years of middle and old age. The identity issues and lifestyle changes surrounding retirement and “empty nesting” can challenge men and their partners. These later life stages usually mean that more time is spent together and there are fewer distractions from the marital relationship. This may be an opportunity to regain intimacy and friendship. Many long-term relationships and marriages thrive when the children are grown and work demands lessen. Two people can again focus on their own and their partner’s needs and their relationship. There may be a sense of reacquaintance between two partners, or even learning new things about each other. But if your relationship is empty or dysfunctional, there will be increased stress. If partners do not share interests, they may live “parallel” lives, each pursuing their own interests, activities, and friends. Such relationships would not be fulfilling for some people, but they can meet the needs of more independent sorts, particularly if they find mutual satisfaction in family gatherings or a few shared friendships. Divorce is not unusual at this stage of life, when partners confront the realities of a relationship held together by forces outside of themselves.
When two men are partnered, these issues may be amplified by each partner’s struggles with similar identity challenges. As men see themselves or their partners aging and losing “sex appeal,” impulses to reexperience youthful exuberance may expresses themselves through affairs with younger partners, second or third marriages with a partner half their age, or attempts to stop the time clock with plastic surgery, hair coloring, cosmetic dermatology, and the like. Whereas attempts to look more youthful may have healthy origins, attempts to actually be healthy through diet and lifestyle changes will yield greater happiness in the end. Moreover, to accept a partner’s aging, men are challenged to find “beauty within” their partner—to adjust notions of beauty to accommodate aging faces and bodies and the elegance not found in simpler features of youth.
If you think of your main contribution to a relationship, marriage, or family as bringing in the money, midlife unemployment or forced retirement can be especially stressful for your ego above and beyond the very real financial stresses these events bring. If your partner relies on your strength and mechanical skills around the house, physical or mental disability can deprive you of an important source of your self-esteem within the relationship. People in these situations run the risk of losing their sense of purpose in life, which can be very demoralizing and lead to the unmasking of self-doubt and insecurity.
Luckily, most men and their partners adapt. For instance, you may assume more kitchen responsibilities and revel in praise for your newly developed cooking skills. Or, you may start a new hobby, such as landscape painting or furniture making. These new talents redefine you within the family or neighborhood as the “artist in residence.” Those of us who are fortunate enough to have grandchildren can find new life in experiencing this still-uncharted relationship. Less happily, men may transition into being a caregiver for a spouse with a terminal or chronic disease. Although this experience imposes enormous physical and emotional burden, there can be a sense of fulfillment that brings forth the most loving and generous aspects of ourselves.
Meeting the challenges to late-life relationships with partners and spouses may yield enormous benefits. Experience, common sense, and research studies tell us that happiness is based on successful relationships. Social isolation and stressful relationships are associated with poor health, alcohol abuse, and premature death. It is telling that there is a gender difference in the willingness of people to remarry following divorce or widowerhood in later life. A higher percentage of men than women choose to remarry, and the period of time remaining single is shorter for men. Of course, this may just be due to the fact that it is easier for men to remarry later in life because there are more available women than men. But there are clearly other factors. The majority of men have spent little time living alone since they were young adults, and it is more stressful being alone. There is overwhelming evidence that good marriages and positive relationships sustain men’s lives.12
People in the United States are increasingly mobile. We voluntarily move hundreds or thousands of miles for a job, an education, love, or warmer weather. The disruption created by such moves in our social lives can have unforeseen consequences, because for many of us our daily connections to people who matter are fewer as we grow older. There are certainly ways for those of us who have never had children, who have lost our children, or whose children and grandchildren live far away to meet the need to feel included. One way men can feel appreciated is by contributing to the welfare of younger non-kin through teaching, foster care, and other volunteer work. Men can also maintain family ties at a distance through phone calls, video chats, social networking sites, e-mail, texting, and travel. Indeed, many men who are parents or grandparents appreciate the peacefulness of distance and the convenience of electronic communications such as Skyping.
One of the most challenging aspects of aging for many men is the transition from work to retirement. For some men work is a means to an end; it is a source of income to support the family and finance our true interests, such as sports, travel, and hobbies. If they are financially able, retirement isn’t a loss. For other men, work is an end in itself, and success in our career may be the major source of our identity and self-esteem. These men may delay retirement or avoid it altogether. Even so, for the majority of men, retirement, once entered, ends up being maneuvered successfully, with minor if any enduring negative effects on their self-esteem, the quality of their personal relationships, or their physical and mental health. Seemingly quite resilient and adaptive, the majority of men don’t let leaving their day-to-day involvement in their work community, minor disabilities, reduced income, or even widowerhood impact their satisfaction with life and self-esteem in significant ways. Only significant disability that directly impacts our ability to function independently on a daily basis has been repeatedly shown as strongly related to declines in our personal sense of worth and well-being.13
Self-esteem is the idea that you matter and that you are “good enough.” If you do not think that this is the case, your self-esteem has room to improve.
There are data to suggest that men who stay active in their occupations later in life are healthier and live longer than those who retire early.14 Of course, such findings may be explained, at least in part, by the obvious reality that healthier men are able to work more years. Nevertheless, a sense of purpose is essential to happiness, and people who devote their lives to their work may face a struggle to find that same sense of purpose outside the workplace. Men who have cultivated interests, volunteer activities, and friendships outside of work fare much better with retirement. Researchers find that men’s self-esteem can peak at or near retirement age; further, men with better education, income, health and employment status, and happy marriages report higher levels of self-esteem as they age,15 until physical health affects independence.16 Without new interests or postretirement involvement, our self-esteem and overall psychological health are threatened. There is compelling evidence that working after retiring postpones poor health outcomes and improves psychological health.17
Even those men who stay on in the workplace will face challenges to self-esteem as they experience erosion of influence or work skills. We have all seen the sad image of the aged business owner who refuses to let go and allow the next generation to take over the reins. Although without doubt these men may have true wisdom and sound judgment, they may not realize that the best mentors keep a distance and allow younger colleagues to gain confidence in their own abilities. The inability to let go and welcome the challenge that comes with life transitions is the “stagnation” that Erikson was referring to, in contrast to the “generativity” of true mentorship. As difficult as it may be, those of us who move on and develop new interests in late life are all the better for it.
Serum testosterone levels begin to decline at around 40 years of age and do so at a rate of about 1 percent per year, so that, on average, men 75 years of age have lost about one-third of the testosterone levels they likely had as young men.18 As in all things, levels of testosterone are highly variable from one person to the next, but it is estimated that 20 percent of men in the 60–80 age group have below-normal levels. Many of these men will experience low libido and erectile dysfunction (ED). Although testosterone replacement can help with libido, it often does not affect ED. Mild to moderate ED is experienced by 52 percent of men over 40. Of these, fewer than 10 percent will have low testosterone levels.19 There are many men therefore who experience normal or mildly reduced libido and some degree of ED, situations that also negatively affect self-esteem, confidence, and the quality of sexual relationships. Fortunately, many men adapt to these changes without much trouble. If you are married or partnered, remember that your spouse may also be experiencing similar changes and having to deal with fluctuating levels of sexual desire. Explorations of physical intimacy not dependent on erections may be very satisfying and fun. Medications and techniques to enhance erectile function can be used to the satisfaction of both partners. Many men report an appreciation for feeling a sense of freedom from intrusive thoughts of sex and welcome the greater appreciation of the nonsexual elements of their relationships with women.
Illness and disability are difficult for anybody to adjust to, but they may be more troubling for men. A man’s ego can be very reliant on projecting an image of strength and independence. Health issues of greatest concern to men include ailments that risk compromising independence and quality of life.20 As a result, for some men illness represents weakness. Dependency on others during illness can also threaten a man’s need to be independent and feel self-sufficient. A consistent research finding is that men’s self-ratings of their health tend to take their lifestyle and mortality risks into account, and in fact men’s self-ratings of health are better predictors of their mortality.21
Not only does positive self-esteem reflect our health status, but it can improve our health. Men participating in health surveys and rating their health as “poor,” “fair,” or sometimes just “good” have a significantly higher risk of mortality than those who considered their health “excellent.”22 The point is that our sense of our health is a strong predictor of our acquired mortality risk. Men in good health know it and feel better about themselves, which is a good reason to eat well and stay active. Equally impressive, positive self-perceptions about growing older actually improve our health and increase longevity.23 Perception is powerful.
Anxiety about aging and dying (called “death anxiety”) may challenge your self-esteem and can be activated by initial experiences of serious health conditions in yourself or your contemporaries. Many of us remember the first time we heard of someone our age dying of a heart attack. “I’m too young to start losing friends to heart disease” is a common thought. Little wonder that when heart disease (or any other disabling chronic illness) is first experienced, there is a higher risk of developing depression after the event, though sometimes not until months afterward. Rather than letting their family and close friends know about the struggles and anxieties they are facing, most men keep it all to themselves. This “suffer silently” strategy of internalizing stress increases our risk for depression and suicide.
Men are four times as likely as women to actually take their own lives, and almost three-quarters of men who commit suicide have seen a physician within a few weeks of killing themselves. They actually sought help but probably never asked aloud for the help they so wanted. Perhaps they were seeking relief from pain and sleeplessness—but guys do not talk directly about that stuff. It is also easy to imagine a scenario where the man anticipated positive news but left the physician’s office with a feeling of hopelessness regarding a newly diagnosed medical condition that may mean he will never have the same life he had come to expect. Whatever the circumstances of that final doctor visit, men, on average, do not adapt as well as women to declining physical capacity, and they are more likely to keep their vulnerable inner lives hidden. The traditions of men’s vulnerabilities being hidden from public display may be one reason older men, especially white men, have the highest suicide rates of any age group in our society. The suicide may not be a reaction to actual pain or disability, but to meaning of the diagnosis. One of the most challenging things for men with a life-threatening chronic illness is to maintain a sense of purpose in life—to be able to contribute and not be dependent on others.
A man ending his own life by choice could be interpreted as his final insistence on control of personal destiny. Viewed in this way, suicide in the face of an unacceptable quality of life may be an act of empowerment and maintaining dignity. By comparison, men who choose to face chronic illness and their disability with some form of acceptance are equally powerful, representing “grace under pressure.” These men continue with life, perhaps because they find pleasures in the smallest corners of life.
Faced with spousal or partner loss, men experience an array of emotions, including anger, shock (especially if the death is unexpected), profound sadness, numbness, and feelings of dismemberment.24 They exhibit intense feelings of restlessness, impatience, frustration, wanting to give up, and sleep deprivation, as well as increases in anxiety, drinking, and smoking and decreases in appetite, all of which are now considered to be behaviors that mask their understandable underlying depression.
Widowerhood is not a well-charted territory, but it is well known that men’s experiences pose serious challenges to their identities. For many men, the loneliness and emptiness experienced reflect a loss of the taken-for-granted security that being married and being a husband (or partner) provided. Many men undergoing spousal loss regard themselves as independent and as a resilient “sturdy oak” in the face of emotional challenges.25 Yet most men are absolutely unaware of how socially and emotionally dependent they are on their wife/partner. Their marital relationship provided them with a sense of normalcy, stability, and having succeeded as a man. These emotional responses are not unlike those of grieving fathers who must live with the loss of a child.
No matter what type of loss, men tend to control their emotions. Some men express their emotions more openly than others. But they typically hold back and cry less openly. Widowers, more often than not, will channel their energy into active coping and problem-solving strategies like work, physical activity, or addressing disruptions in the household. At other times they may prefer to be alone with their thoughts, reflecting their quiet ways to cope with their new situation. Men usually express their feelings of grief in solitary ways, but this should not be construed as any less intense than a woman’s grief. These patterns suggest that while some responses may be more typical, any one widower’s experience can be somewhat unique as well.
Not surprisingly, adaptation to loss varies from individual to individual. The most difficult times are usually the first 6 months to a year, yet some men adapt more quickly. Some methods associated with more successful adaptation include keeping busy with meaningful activity (such as work), having adequate support and ability to do things with others or to share feelings, and a sense of retaining control.
Is there a clinical entity called “Depression” that exists somewhere within a person, much like a cancer tumor can be located within the body? No, not at all. There is increasing evidence that there is no coherent entity we can call depression.26 It’s not whether you have “it.” Rather, men can be more or less depressed, ranging from debilitating severe depression to just “feeling down.” Signs and symptoms of depression include doubting our own confidence in our decision making, feeling as if we are “hitting the wall” way too often, feeling apart from things even when with people, being no longer interested in succeeding, and saying that we prefer quiet time when in fact we just do not want to engage ourselves in social activities.27 Men who strongly adhere to the masculine norms to be in control of their destiny and are quiet about their feelings will most often mask their depression through grouchiness and heavier drinking.
Striving to remain respected, a middle-aged or older man ultimately will find the generation behind him rising up. At first he might add more hours to keep up; consequently, his sleep may become restless, his easygoing demeanor turns edgy, and his unflappable disposition percolates into irritability. His emotional responses and behavior suggest he is experiencing depression, but he and his partner are more likely to label his mood as irritation or anger. He isn’t likely to turn to friends to talk; instead, he keeps his distress to himself and uses swearing, a sport, alcohol, or pounding a wall or the steering wheel as a response to being distressed. He isn’t likely to cry; he’s more likely to yell. And his loved ones will rarely acknowledge his pain directly.
When Silence Hurts
Partners of depressed men often express fear that naming the man’s condition will only make matters worse. It is better just to “get on with it” and “not dwell on the negatives.” But when we minimize a man’s depression, for fear of shaming him, we collude with the cultural expectations of masculinity in a terrible way. We send a message that the man who is struggling should not expect help. He must be “self-reliant.”
Source: Real, T. (1998). I don’t want to talk about it: Overcoming the secret legacy of male depression. New York: Simon & Schuster, p. 38.
Clinicians working with men who have mental health troubles have increasingly argued that there is collusion in Western societies that covers up the depression men feel.28 Men’s depression becomes “masked” when men follow masculinity norms and convert their worries and sad mood into somatic symptoms such as digestive disturbances or the fatigue and muscle tension that accompanies negative mood and/or anxiety. Somaticizing is what men (are supposed to) do, and it is not surprising that men are three times more likely to complain about gastrointestinal symptoms but three times less likely to seek help for “depression” than women. Depressed men have learned not to reveal sad feelings. A man might cry, but in a private place where others never witness the sadness and pain.
Hundreds of studies indicate that adult men are half as likely as women to divulge their depression in ways that correspond to the symptoms physicians expect. Even when men disclose their suffering to family members, they are still twice as reluctant to seek a professional’s help for their depression.29 Unfortunately, men’s unrecognized and untreated depression ruthlessly increases suffering and adds to the risk of death from many causes—in particular death from cardiovascular disease and suicide. The chart provides an overview of the signs and symptoms of men’s depression.
In addition, Western cultures normalize men’s heavier drinking as “self-medication.” The message heard is that men are expected to manage their feelings by themselves. Even the 1990s Seagram’s VO advertising slogan “It’s what men do” encouraged men to think of having a few drinks. Equally disturbing, older men are expected to “slow down,” and signs of their depression such as fatigue, sleepiness, and a decrease in mental agility will be misinterpreted as age related. Depression-related symptoms coexist with other medical illnesses and disabilities, often causing doctors and family to misread men’s depression as evidence of medical problems. The result, all too often, is that what we feel is never investigated.
A lingering emptiness or sadness isn’t normal no matter what your age, and when we misread depression, effective treatment gets delayed, if even provided. Too few people appreciate that depression is perhaps the most frequent cause of suffering among middle-aged and older men. Too few people recognize that depression need not have “the big D”; rather, it is a persistent negative mood (whether anger or sadness) that undermines quality of life.
DEPRESSION-RELATED SYMPTOMS IN OLDER MEN
Emotional/mood symptoms |
Cognitive symptoms |
Physical/behavioral symptoms |
Sadness |
Hopelessness |
Low energy and initiative |
Irritability |
Excessive guilt |
Altered sleep |
Anxiety |
Slowed thinking |
Altered appetite |
Apathy |
Reduced motivation |
Self-neglect |
Chronic anger |
Memory impairment |
Decreased immunity |
Lack of pleasure from usually enjoyable activities |
Thoughts of death and suicide |
Increased cardiac mortality risk |
Most older men have at one time or another been temporarily immobilized by depression. By age 65 it is estimated that about one-half of all men in the United States have experienced at least one depressive episode lasting 2 weeks or more. Their unshakable depressed mood or markedly diminished interests in most of their normal activities are key signs of clinical depression.30 Furthermore, statistical patterns reveal that on average one in seven men age 60 and older will be living with a major depressive disorder and his suffering will remain untreated. Current estimates tell us that 16–18 percent of men age 60 and older are depressed, but these estimates fail to accurately count the true prevalence of depression, because only one-half of the middle-aged and older men with severe symptoms ever seek help from their physician or will be pushed toward a physician by a family member. This leaves about half of men living with depression undiagnosed and untreated.31
When these symptoms are present most of the time for a period of at least 2 weeks, major depression is likely the cause. You may not experience all of these symptoms. Older men may not experience low mood or sadness, for example, or changes in sleep patterns and appetite. These symptoms may come and go, but many could be present at least in mild if not severe form. The symptoms listed are not exactly those within the diagnostic criteria for major depression as presented in the Diagnostic and Statistical Manual of Mental Disorders (DSM), but they nevertheless are depression-related symptoms that strongly warrant our attention, especially for older men.
To understand depression, remember that all of our thoughts and feelings are generated by the electrochemical processes within the brain and affected by brain health. It is also essential to remember that although the mind is the brain’s creation, it is also its master. The brain is a dynamic organ that responds to the thoughts and feelings we create. Our thoughts and experiences shape the brain through what is called neuroplastic response. Joyful experiences, secure relationships, fulfilling work, lifelong learning, and intellectual activity systematically structure the brain to reduce our risk of both depression and dementia in old age. By contrast, threatening and painful experiences actually alter brain structure and function and increase our risk for depression later in life.
Many people think that you can always “think” or “will” your way out of depression. This is true to a degree. Psychotherapy, spiritual practice, enjoyable activities and hobbies, art, music, friendships, and close family ties all can help your recovery from depression and reduce the risk of relapse.32 However, once depression becomes severe enough, our thinking becomes impaired because our brain structure has changed. Medical and mental health professionals call this state “major depression.” You might have heard it referred to as “clinical depression” because of the need for clinical intervention.
In major depression, brain function is impaired by changes in the structure of a fatty sheath (or myelin) coating of the nerve axons (the white matter) and the synapses between brain cells (the gray matter). Physical functions such as sleep, appetite, immune response, and metabolism become deregulated. There is ample evidence that major depression accelerates physical and cognitive decline. The longer the depression stays, the harder it can be to come out of it. Complicating this, certain age-related diseases of the brain such as a stroke or Parkinson’s disease affect mood and the expression of emotions (affect). When major depression is associated with brain disorders, it can be especially severe and recovery tends to be less than optimal, with residual symptoms and high risk of relapse.33
Depression can have organic roots as much as it is based on social experiences. Many of the medications older men take can cause or worsen their depression, as noted in the insert. Major depression and some other mood disorders, such as bipolar disorder, also tend to run in families. Genetic risk factors have been identified. Having a parent with a mood disorder such as major depression increases your own risk for several reasons, including genes and early life experiences. Having a parent with bipolar disorder, with intense “highs” and “lows” in their life history, is an even greater risk factor for a man’s mood disorder. The natural history of depression is highly variable, and the condition may spontaneously remit within weeks or months. The longer a man remains in a depressed state, the higher the risk of him developing chronic symptoms of depression. In depressed men, the stress hormone cortisol may continue to be secreted even though the levels of the hormone are already high in their body. Once the depression disappears, cortisol levels return to normal.
The duration and severity of depressions are predictive of relapse risk. The more time you remain in a depressed state, the higher your risk of developing a recurrent illness with little or no connection to life events. There may not be any obvious “cause” for becoming depressed once you have developed this form of depressive illness. “I don’t know why I’m feeling so out of it” is a common thought. In other cases, men may assume that the cause is a current stressor they are experiencing even though that stress may be something they could easily cope with when they are feeling well. Treatment of depression with medication, talking therapies, and cognitive and behavioral therapies can be helpful for most men. Milder depressions frequently run their course and spontaneously remit or resolve with positive life changes and implementing new and more positive health and lifestyle habits.
Medications That Can Cause or Worsen Depression
• Blood pressure medication (clonidine)
• Beta blockers (e.g., Lopressor, Inderal)
• Sleeping pills
• Tranquilizers (e.g., Valium, Xanax, Halcion)
• Calcium-channel blockers
• Medication for Parkinson’s disease
• Ulcer medication (e.g., Zantac, Tagamet)
• Heart drugs containing reserpine
• Steroids (e.g., cortisone, prednisone)
• High-cholesterol drugs (e.g., Lipitor, Zocor)
• Painkillers and arthritis drugs
Source: Helpguide.org (2011). Depression in older adults and the elderly: Recognizing the signs and getting help. http://helpguide.org/mental/depression_elderly.htm.
Although depression can be severely disabling, most men manage to endure repeated episodes of it and lead productive, inspiring lives. Abraham Lincoln is one of the most well known of these men, but the list is long. At least one Lincoln biographer has speculated that despite the suffering and paralysis of depression, the experience of illness may bring emotional depth and compassion that enhances a person’s other attributes of greatness which are then expressed when the depression is in remission.34
There are three “cousins” of depression which men need to be aware of. Dysthymia is chronic, long-term sadness, sometimes called a chronic type of minor depression. It may begin in childhood and become a defining feature of a man’s personality. It can also develop over time as a result of repeated loss, disappointment, loneliness, and hardship. Typically, a man with dysthymia will feel little sense of joy or optimism. He may respond warmly to pleasant events, compared to a person with major depression, but his feelings of happiness are fleeting. The physical and cognitive symptoms of depression, such as changes in appetite, sleep, or energy or a deep sense of despair, are not usually present. If they do occur, major depression may have developed.35
Moods Related to Depression
Bereavement and grieving
Dysthymia
Demoralization
Apathy
Demoralization is another cousin, but it is purely situational and lacks the intensity of depression. If you are a demoralized person, you have given up trying to improve a difficult situation. “Burnout” is one form of demoralization (see chapter 5). As men age, they may lose zest for life, interest in work, or passion in their marriage. They “sleep walk” through life and feel as if nothing they do really matters. Men who are depressed are often demoralized too.
Apathy is yet another syndrome that can look a lot like depression. Apathy is a state of uncaring indifference. There is a profound lack of motivation, similar to the absence of goal-directed behavior among men with damage to the frontal lobes of the brain. Apathy in older men is usually associated with cognitive impairment caused by cardiovascular and brain diseases. The brain diseases that produce apathy also result in dementia. Alzheimer’s disease, the most common cause of dementia in men, produces apathy that is progressively more severe and disabling in that men will lose the desire to do things even before the disease affects their cognitive ability to do them.
Should You Consider Taking an Antidepressant?
While medications can help relieve the various symptoms of depression, they should not be seen as a cure. Furthermore, it is important to know that they come with risks—both physical and psychological. It is essential that you weigh the advantages and disadvantages of taking antidepressants, so that you can make an informed decision about whether a particular medication is right for you.
Bereavement and grieving are common in late life as we experience the loss of loved ones and friends. Bereavement may look and feel similar to depression and can certainly affect a person’s health and function, but it is not depression. Loss of appetite, difficulty sleeping, problems with concentration and memory, and an overwhelming sense of loneliness and despair are symptoms that bereavement and depression have in common. However, grieving as a result of a loved one’s death has a clear cause, and it typically lessens gradually over several months. Sometimes, with the loss of a child, spouse, or partner, the grieving may persist indefinitely under the surface. It is when excessive guilt, hopelessness, impaired function, or suicidal thoughts persist after several months of grieving that you should seek special help.
Anxiety is the most common symptom of psychological depression; however, in generalized anxiety disorder there is a high level of anxiety almost all the time, regardless of circumstance. Phobias and posttraumatic stress disorders are examples of anxiety disorders in which overwhelming fear or panic can be triggered more by perceived than actual danger. A social anxiety disorder is a condition in which someone becomes anxious and extremely self-conscious around other people, particularly strangers, and stays in the backdrop of social situations or avoids them altogether. Obsessive-compulsive disorder can be a disabling form of anxiety disorder in which any disruption of routine, ritual, or order becomes intolerable. These conditions typically begin early in life. Anxiety disorders beginning in late life, however, are usually due to depression, medical disorders, neurologic diseases, or medications. Escalating or new-onset alcohol abuse can indicate a newly developing or worsening anxiety disorder or depression.
Bipolar disorder is a distinctive mood disorder affecting about 2 percent of the adult population,36 and its onset occurs earlier in men than in women.37 It is characterized by discrete periods of depression followed by excessive energy, intense and dramatic reactions to events, rapid and excessive speech, decreased need for sleep, getting involved in many new and unrealistic ventures, impulsive behavior such as overspending and sexual indiscretions, driving too fast, and disinhibited behavior that may be uncharacteristically offensive or arrogant. When elevated, men may be euphoric, but often with much irritability. In severe form, exaggerated beliefs and grandiose delusions can form. The “manic” episodes may occur several times a year or may be experienced only once or twice in a man’s lifetime. Debilitating depressions also typically occur in bipolar disorder. The frequency of episodes may increase as men age.
Bipolar disorder tends to present in young adulthood but may develop before that. However, it is often diagnosed for the first time in middle age or old age, and in these cases symptoms have usually been present years before the diagnosis. Less severe forms of the illness are much more common, with the low- and high-energy periods having symptoms with much less severity. Both severe and milder forms of the “bipolar spectrum” can show seasonality, with high-energy times (mania or the less severe hypomania) coming in spring and fall. Treatment of these cyclical mood disorders relies primarily on “mood-stabilizing” medications, and in most cases people do well. Nonmedical treatments are very helpful as well. Counseling, sleep hygiene, managing stress, and proper diet can be helpful. If a person does not stick with treatment, the social consequences can be devastating and include divorce, loss of career, bankruptcy, substance abuse, and legal problems. This illness has an increased risk for cognitive impairment and possibly dementia.38
Schizophrenia is a chronic mental illness that manifests in abnormal thinking and sensory perceptions. The delusional thinking can include auditory hallucinations, and the disorder may cause major disability through impaired executive functions such as muted motivation, poor judgment and insight, and underdeveloped interpersonal skills. Schizophrenia usually develops in adolescence or young adulthood and is more common in men. The onset of schizophrenic-like symptoms among older men is often due to medical issues, neurological problems, or severe mood disorders. Men with schizophrenia from the baby-boom generation have additional health problems because of their high rates of cigarette smoking and neglect of physical health care. They grow older in poorer health and with fewer financial and social resources. Many middle-aged and older men with schizophrenia are winding up in nursing homes, which may provide food, warmth, basic care, human contact, and safety but leave much to be desired in terms of cost to society and quality of life for the person with the illness.
Attention deficit disorder (ADD) is typically considered a disorder of childhood, and many people do “grow out of it” as they enter adulthood. The progressive development of the brain’s frontal lobes through adolescence and young adulthood allows better focus and impulse control. It is the motor restlessness or extraneous movements (“hyperactivity”) common to the condition that prompt the name attention deficit hyperactivity disorder (ADHD). Restlessness is not always a sign, and it can be suppressed through growth and development of the frontal regions of the brain. However, inattention, forgetfulness, impulsive behavior, and poor organizational skills may affect a man’s occupational and social functioning during his entire life. Chronic lateness, procrastination, impulsive decision making, and disorganization take their toll on relationships and careers. Many men with ADD or ADHD may not have the diagnosis or realize the severity of their problem until mid- to late adulthood.
ADD and ADHD represent an extreme on the spectrum of individual differences in ability to focus, organize, and prioritize. When adult men with ADD or ADHD come to realize that they have the disorder, they can change their lives for the better, especially with effective treatment. You can use stimulant medications, such as methylphenidate or dextroamphetamine, and psychotherapy and life coaching to help simplify and prioritize are also very helpful.
If you are adapting well to later life, you are likely to be balanced and flexible in your thinking and attitudes, make decisions that are based more on reality and less on fear, may be less anxious and therefore more even-tempered, may be less competitive and more nurturing, and may be more generous with your time in teaching and helping others. If this sounds like you, you can expect that others will more likely view you as being wise, because you maintain active social roles as a mentor or leader. Of course, underlying these idealized traits of later-life maturity are states of mind that may take decades to master. To better understand the mental attitudes that facilitate adaptation to old age, we conclude by examining three concepts.
Change is inevitable; human relationships and living circumstances rarely last a lifetime. The Buddhist concept of impermanence is useful to consider: acceptance of change and the transient nature of life’s circumstances can lead to greater appreciation of the present moment and ability to adapt. When we embrace the inevitable—our changing health, the loss of someone or something we cherish—we are more likely to take full advantage of what we have. For a man to appreciate the finality of life is to understand how precious every day is in whatever form, for there is always something to be savored. As we age, we may be more apt to appreciate a day without pain, or another day with a spouse recently diagnosed with cancer. With time, we learn many lessons of impermanence. Studies of men’s aging indicate that healthy adaptation to impermanence is influenced by how well a man applies these lessons, and it does seem that older men learn to avoid situations that distress them or make them sad.39 When we fully accept mortality and the transient nature of being, we will be better prepared for whatever may come. For example, if you live long enough or develop certain disabilities, you will likely have to give up driving. For men who are city dwellers or those with family nearby, this transition may be barely noticed. For men living independently in rural and suburban settings for whom driving is crucial to remaining independent, being able to adapt to the loss of driving privileges requires a willingness to change habits. Spending time with others, especially friends, as you accept rides may make you wonder why you didn’t share trips to the grocery store, club, and church earlier. If we anticipate changes and can be psychologically ready for them, the transitions will be accomplished with a lower risk of depression.
Acceptance of change will better enable you to “roll with the punches” and tolerate the fickle nature of fate. Conversely, the more reliant you are on things staying as they are, the more you are at risk of depression if you lose the person to whom you are most attached or move from the place with which you most identify. A man’s ego (or sense of self) must conform to unfolding realities, even if they are unexpected. Winning a large sum of money in a lottery or later-life grandparenthood can be as stressful and identity changing as selling the home your children grew up in. Men who score high on measures of adaptability and “ego flexibility” are at lower risk of depression as they age. They are able to adjust to changes with less disruption to their happiness, pride, and sense of purpose in life. Older men who have been able to develop flexibility are able to maintain a more positive perspective.40
Although the ability to adapt to circumstances of life is important to aging well, there is another side to this. It is also important for men to maintain some continuity of ego (or sense of identity). Your values, ties to family and friends, long-time possessions, and unique life story can be critical to happiness. In therapy groups of older adults, a popular activity is to promote life review and reminiscence. The creation of a coherent life story can restore a man’s feeling of comfort and improve his morale by encouraging recognition that there has been much consistency in his beliefs and behavior through the years.
As we age, we transition to many new life chapters—from retirement, to living with chronic disabilities, to leaving behind a community to move to better climates or be closer to children and grandchildren. In these cases, we must be strong enough to maintain our sense of self among the new realities of life. Maintaining hobbies, becoming closer to our spouse or partner, staying in touch with friends, or maintaining some connection to our work or recreational interests can all be very comforting during periods of transition.
Memory Boxes
In some long-term care facilities, there are often “memory boxes” hanging outside the doorways of the residents’ rooms. The memory boxes generally contain photographs and mementos evocative of different periods in the residents’ past. These displays can help people with dementia remember themselves and help ground them among the disjointed, confusing experiences of their daily lives.
No less important, they give the paid caregivers an extended view of the residents’ lives, allowing them to see that the disoriented, forgetful person under their care was once a star of the high school football team, a gifted musician, a loving husband, a skilled carpenter, a scholar of history, a captain of the local police force, or a favorite uncle. These fragments of our life stories are woven into an identity that men can carry into old age as refuge from the sometime disruptive effect of widowerhood and loss of friends, home, and health.
The transitions through middle age and into later life present many challenges to men. Few people will negotiate these years without some unexpected and unwanted changes. Yet, we have within us the capacity to meet these challenges and thrive in the last decades of our lives. Even in late life, our bodies, brains, and spirit retain the ability to change and evolve in ways that can bring us contentment and increased receptivity and deep appreciation for those moments of real joy that may come at any time.