be healthy

Some people might call you highly competitive. Some might call you superfit. But a growing number of doctors would label you something else: Depressed

In 1994, at the age of 33, Raymond Britt took up running. It made him feel good. In fact, the more he pushed himself, the better he felt. So each time he went out, he pushed a little harder. It seemed to put him above the turmoil of the world and afford him some relief. Relief from what -- that wasn't so clear. His life was good. He was a successful executive. He'd married his high-school sweetheart. He had beautiful children.

But there was something odd about it all. For one thing, he had no background as a runner. He'd been a powerlifter in his 20s, benching 315. But in the summer of '94, amid a hectic schedule, he happened to see a flier for the Chicago Marathon and was seized by the impulse to run it. Never mind that there were only a few weeks left to train. Never mind that he had never run more than 3 miles at a time. He thought, I can do anything for 5 hours and 30 minutes, which was the qualifying time to receive a finisher's medal.

He became obsessed with his training.

"I was excited, I was nervous, I was alive," he says. "My mother and my wife thought I was crazy." As he reached the 18th mile of the marathon, his hopes for a life-changing experience were shattered. Beating himself up both mentally and physically, he managed to drag his body over the finish line in 4 hours and 41 minutes, as he puts it, "alone, hurt, angry, unhappy."

Rather than recover, he went out the next day to punish himself and prepare for the next marathon.

Sex Differences
The study of how mental illness affects men and women differently is new and fraught with controversy. The first comprehensive survey was conducted between 1990 and 1992. Its aim was to estimate the general prevalence of mental illness.

The research, known as the National Comorbidity Survey, was repeated, in more depth and on a larger scale, between 2001 and 2003, under the auspices of the World Health Organization and with funding from the National Institute of Mental Health. The principal investigator is Ronald C. Kessler, Ph.D., a jolly-looking, bearded professor in the department of health-care policy at Harvard University.

The numbers seem to show that men and women suffer from various mental illnesses at about the same rate, with some notable variations and exceptions. One of the differences, long accepted as gospel by the psychiatric professions, is that twice as many women as men suffer from depression. Kessler says his numbers show that a woman is twice as likely as a man to have a single episode of major clinical depression in her life. After the first episode, however, men and women don't differ in the number of episodes they'll have during a lifetime, or in whether they'll have another episode. Only the first step differs, he says. Then the statistics flatten out to equal.

But if repeat episodes of depression are equal for men and women, doesn't it stand to reason that they may be having first bouts at the same rate? Maybe the discrepancy lies not in the number of men and women who are depressed, but rather, in how depression is expressed.

According to an increasing number of experts, the diagnostic tallies don't take into account the real experience of a lot of men like Britt. They also ignore the fact that women are much more likely to report depression and seek help. Men are more likely to try to fight through their depression, using strategies ranging from hard work to extreme exercise to drinking to violence. Nearly four times more men than women kill themselves.

When women become depressed, they tend to show the classic symptoms described in the psychiatrist's handbook the Diagnostic and Statistical Manual of Mental Disorders. They feel sad and tired, and lose interest in the pleasures of life. In short, women generally get depressed in just the way that most people, including psychotherapists, think about depression.

Men tend to get angry, and that anger expresses itself in a wide variety of intense activities, such as Britt's obsessive running. Some of these men even win marathons--on the streets of Chicago or in feats of work endurance--and look like heroes, which makes it even more difficult to diagnose their depression.

Britt says, "I've always thought Lance Armstrong suffered from depression and that's where his anger came from. I saw a lot of myself in him, the way he transfers anger into action. Depression leads some of us to fight as hard as we can against it. It makes you angry. I liked my anger. I got focused and felt better, like I was leaving turmoil in the dust. But it was temporary."

Because he think of the word "depression" as fitting the woman's profile better than the man's, doctors and therapists don't tend to recognize the disease as readily in men, and men don't talk about it. William Pollack, Ph.D., a professor of psychiatry at Harvard, estimates that 50 percent to 65 percent of men suffering from what they call "covert depression" aren't diagnosed.

It seems clear that men will do just about anything to avoid admitting to having the disease. They'd rather just suffer. Some of them would rather die.

Driven
Britt raced in Chicago the next year and qualified for the Boston Marathon. Still, he needed more. He entered the Chicago Triathlon that same year and nearly drowned. ("I was a terrible swimmer.") He returned in 1996, and did well. That only fed his craving. "I wanted to take everything to the next, most impossible level I could imagine," he says. He describes himself as "driven to the margin of terror."

By 1998, he had developed a set of rules for himself: more, harder, quicker, and farther away. Three Ironman races in 7 weeks. Roth, Germany, in July for Ironman Europe. Zurich in August for Ironman Switzerland, wife and 4-month-old baby in tow. Ironman Canada again in September. "Still not enough," he says.

In 1999: four Ironman races, a 50-miler, and the Western States 100. Seven days later, he ran two 5-Ks on the same day, for "pain as punishment and proof that I was okay. I could survive the day as long as I could channel my inner turbulence into power and aggression during training. The determination, the drive, kept me afloat."

In the following years, he broke 3 hours in the marathon, qualified for the Ironman World Championships three times, won awards, gained sponsorship, and was regularly published as a cardio guru. He was a champ, a role model. "How can this be a bad thing?" he asked. "And if I'm strong enough to outlast anything, aren't I strong enough to outlast life's challenges?"

Yet his world had begun to contract. He began intentionally doing reckless things. "I took risks riding my bicycle in traffic, running at night, fighting whatever was fighting me. It felt good to be fighting."

He couldn't run, bike, and swim all day. He had to work. He had a wife and kids. So he simply pushed that much harder. "My best performances came when I was ready to rip the top off the race course. I had very aggressive feelings. I just wanted to attack."

He was winning, yes, but he also required emergency medical attention after every event. He'd come in with his blood pressure reading 90 over 50 and required up to four IV bags of fluid to counter dehydration. That didn't seem odd to him, but his wife began to worry that he was trying to kill himself. He told her he was just pushing it. He eventually did 42 marathons, 27 Ironman Triathlons, and six ultramarathons in 11 years, covering 42,000 miles, the equivalent of running, swimming, and biking around the world 1 1/2 times.

The weird thing is this: Raymond Britt isn't that unusual. His distances aren't even that huge, compared with some guys'. And the mental illness he suffers from, which drove him to battle through all those miles, is not that uncommon among men.

Steven Imparl is a lawyer in Chicago, but a look at his résumé affords a glimpse into the frantic world of a man working very hard to compensate for depression. He graduated from high school in the top 15 of his class of 550 students. He received his B.S. degree with high honors. He became an information-technology specialist working for big companies, then went on to earn his law degree and start his own firm. Along the way, he studied French, German, Slovene, and Spanish. He learned classical guitar, studied Slavic and Balkan history, and sang barbershop harmony. And he somehow found time for power walking, inline skating, volleyball, and boxing. By the fall of 2001, he was so wound up, he could hardly sleep. He became more irritable, more easily angered. After nearly getting into a fistfight while walking down a street, he decided to seek help. But when the doctor told him he was suffering from clinical depression, Imparl refused to believe it. Admitting to depression is . . . well, it's like getting your period: Guys don't do it.

Once Imparl accepted the diagnosis, he performed like any true, overachieving depressed man would: Through a program of therapy and drugs, he got better, and then he founded a successful Web site, maledepression.com, for guys like him.

Raymond Britt's crash and burn came one day in November 2004, when he set out to run himself into the ground, to transfer the pain from his soul to his body. Many miles and hours later, he found himself bloodied, exhausted, and hypothermic, but he neither displaced the internal pain nor found relief. He was forced at last to face what he'd known for decades: Depression was rampant in his family. From an early age, Britt had been determined that he wouldn't succumb. He wouldn't be weak.

Because his father had medicated his own depression with alcohol, Britt had never taken up drinking. By the fall of 2004, his father had been in therapy for a while, and was encouraging Britt to seek help. Having experienced depression himself, he was able to see the disorder in his son. He sent Britt an e-mail with his doctor's name. And then he dropped dead.

It was a few weeks later when Britt hit the wall on his last desperate run. Then he collapsed into classic symptoms of depression, which is what happens when the strategy fails: "The weight felt so heavy that it was hard to physically move," says Britt. He found himself wishing he'd be in an accident that would put him in the hospital so that he could escape. "I wanted to be taken out."

That's the point at which depressed men can slip beyond fantasy into active thoughts of suicide. Some 31,000 people in the United States commit suicide each year. More than 24,000 of them are men. And that doesn't count the deaths from alcohol or drugs. In fact, some researchers are beginning to suspect that depression causes more deaths than auto accidents do.

Britt's fantasies of having an accident scared him. He went to see his father's psychiatrist. It didn't take the doctor long to diagnose his condition. (Q: "When were you last really happy?" A: "1975.") And yet, his denial of clinical depression was so strong that he sought a second opinion.

Maybe men need a different word for depression. Or maybe the brain researchers and psychologists simply need to redefine the condition so it includes the way men experience it, too.

Cultural Cover-Up
It's understandable that women are three times more likely than men to be treated for depression; our culture has put a feminine face on the disease, so women give themselves permission to feel it and to seek help for it. Pollack puts it this way: "We have in our society a feminized view of depression, coming out of a model of hysteria that dates back to Freud."

Terrence Real, author of I Don't Want to Talk about It, and a marriage and family therapist in Massachusetts, wrote, "There is a terrible collusion in our society, a cultural cover-up about depression in men." And part of the cultural influence involves the way men are taught from early childhood to be strong, silent, independent, and resistant to suffering. As Real puts it, "Men have about a milli-second's tolerance for feeling [this type of] pain, and then they spring into action. A flight from shame into grandiosity lies at the heart of male covert depression."

Another reason men leap into action, though, whether it's through intense exercise, overwork, pounding back martinis, or some other strategy, is that it actually does relieve the symptoms of depression, at least for a time. In fact, many therapists have begun using exercise as an adjunct to therapy, as explained in books like The Joy of Running, by Thaddeus Kostrubala, and The Exercise Prescription for Depression and Anxiety, by Keith Johnsgard. And research at Duke University confirmed their hunches in 1999.

But exercise in itself doesn't treat the underlying condition. In fact, books called The Joy of Working 80 Hours a Week and The Drinking Prescription for Depression might reach a wide audience, because those strategies can effectively mask depression for years. That is, they can sort of work.

Because at the heart of what Britt and Imparl were going through was a life filled with large stretches of no feeling at all. Britt says he was constantly running, "hoping that movement would help me discover something better."

Looking back on his decades of depression, Britt saw isolated flashes of happiness--the birth of his children, laughter, friendship--but they were, he says, "bright spots on what had been a more turbulent journey than I let myself admit. The moments of happiness sustained my denial of something I had only recently begun to consider an 'invisible load.'" In other words, he'd been swimming with an anvil, and he was sinking by imperceptible increments.

Conditioning
The social conditioning that leads to men's response to depression begins in infancy. Male babies receive less of every type of nurturing, including speech, touch, and comfort when they cry. And that is only the beginning of what will be, to one degree or another, a brutal upbringing for boys.

In the 1960s, the crusading social psychologist Jeanne Block and her colleagues explored how differently parents treat boys and girls. For instance, moms and dads encourage boys to be competitive and to achieve. They don't like them to show their emotions. They encourage them to be less dependent; mothers push them away. They punish them more than they punish girls. And they are unaware that they treat boys and girls differently.

By the time boys are on their way to the teenage years, the process of disavowing what they are is complete. The book A New Psychology of Men describes research in which people were asked what it means to be feminine or masculine. Women and girls defined themselves by the ways they were connected to others, and by citing qualities like being caring or compassionate. Men and boys defined themselves by negatives: They weren't weak, dependent, or connected to their mothers.

But there is not much in our cultural definition of what it means to be a man that is inherent in maleness. Children start off surprisingly alike, whether they're boys or girls. If there's a difference, it's the opposite of what the culture seems to expect: Boys are more sensitive. They give expression to their emotions more readily than girls. They affiliate with others in the same way as girls. Then someone starts telling them it's not okay to be that way. If you act like that, you're a pussy.

As Real and others have explained, it is through this process of denial that men are primed for depression. And it is the cultural necessity of carrying out and carrying on this process that makes it so difficult for them to recognize and admit to depression when it comes. They not only don't acknowledge it to themselves, they often don't display the symptoms that psychotherapists use to diagnose depression.

The cultural training that lays the groundwork for depression in men and for their denial of it later in life involves social isolation. That means telling people the truth about yourself and trusting that they'll do the same, a concept that seems terrifying to many men.

In one case, two friends knew each other for years, commuting together, talking every day, laughing together. They would not have said they were socially isolated, yet when they happened to run into each other in the same group meeting for men suffering from depression, they had to laugh: Neither one had ever admitted it to the other, even though they were both seeking treatment for it.

Social isolation is a well-known killer of mammals. Countless studies going back to the '50s show that contact, affection, emotional communication, and genuine closeness are necessary for mammals, including humans, to maintain our health. Isolation wreaks havoc on everything from the immune system to the cardiovascular system to the brain. Conversely, staying socially connected helps protect men from mental illness, including depression.

The new research done by Kessler and others shows that single men and women look no different when it comes to most kinds of mental illness. But when they get married, they veer off in different directions. "It's a very good deal to be married if you're a man," Kessler says. "It's associated with a dramatic improvement in mental health."

Perhaps because they are forced into solitude as children, men are not as good at being alone as women are. Because of early socialization, women are better at relationships--with children, friends, and relatives. In general, women have more friends than men and are closer to those friends. This, of course, is the direct result of boys' having independence forced on them early in life, when what they need is emotional and physical contact with others.

Socialization punishes women, too. When they have children, women's mental health suffers, while that of men doesn't change at all. That's because women, in general, take care of the kids. If there's trouble in the home, or work interferes with child rearing, they'll disproportionately suffer for it.

Women also worry more than men. They care about a larger group of people who just don't appear on the emotional radar screens of men. In marriage, men share in the joys and are often protected from the pain. Just as the man will go downstairs to investigate a suspicious noise, the woman plays the role of emotional protector.

Kessler uses this example: A wife reports (to the researcher) that she's very upset, because her daughter had an abortion and had to miss a number of days of school. The husband reports that his daughter had the flu and couldn't go to school. How could this be? The explanation is simple: The daughter got pregnant and went to her mother for help, saying, "Whatever you do, don't tell Dad." So the mother helped the daughter have an abortion and told the father the girl was home sick with the flu.

The result is that the husband is exposed to less stress, while the woman is exposed to more. Not only does she have to deal with the abortion, but she also has to lie to her husband and orchestrate the protection of that lie. But throughout, her connections are reinforced and affirmed.
The studies show that when a father dies, the children grow closer to the mother. They come around more. The mother has been maintaining those relationships all along, and they pay off in a crisis. Yet when a mother dies, the children come around less. That's because for years, when they called on Sunday, they talked to the mother, not the father. By filling the social role, the wife grows closer to the kids. That's why widowhood and divorce are so much worse for men. Their protection is ripped away, and they have no social network to catch them as they fall. The person who managed their emotional life is gone.
As Kessler puts it, "You can hire someone to do most of the things the husband does in a marriage. But you can never hire someone to do what the wife does." Men can change this situation and possibly protect themselves from depression later in life by expanding the depth and breadth of their social networks.

Recovery
After undergoing treatment for bipolar disorder and chronic depression, Britt went back to compete in all the events he had run so desperately in 2004, such as the Lake Placid Ironman. To his amazement, he recognized for the first time that the run took place in a glorious natural setting. "You're literally running through fields of green," he says. Later that year, he was competing in the Ironman Wisconsin, which he'd done in such a black mood the year before, and began to wonder, Why am I hurting myself? I don't need to hurt myself anymore. For the first time in his life, he walked for an hour during the event, feeling joyous.

Britt's compulsion to run began to fade. "My race performance declined by about 5 percent in the first half of last year," he tells me, "and it really tailed off by fall. I took most of early winter off, totally. It's a healthier me all around." In other words, he now runs for fun, something he was unable to experience before.

But recovery wasn't simple or easy. Early on, when Britt was first diagnosed, he spent much of his time searching for a single moment in each day when something good happened, something he could celebrate. Gradually, those moments grew larger and more frequent. "Now," he says, "the days are filled with not only great moments, but great minutes and hours. And those make up great days, great weeks, and even great months."

When men talk about depression, one of the recurring themes is how it sucks the color and flavor out of life. The birdsong that filled you with joy as a child has no effect at all. The people you love don't make your heart sing, even though you know they should. The colors of the world are tarnished and dull. Britt ran the Boston Marathon once again, and realized at the end that although he'd run it many times, he had literally never seen the finish line; he ran right through it and focused on the next thing. "Now I can see things I never saw before--colors, scenery, people," he says. "It's almost impossible to describe, except to say that it seems like the world has visually opened up."

Depression is well known for shutting down the senses, and when it lifted, Britt was so astonished at what was around him that he took up photography just to try to capture it all. "I never cared before. I never noticed the colors of a sunset. The electricity in a lightning strike. The glow of moonrise over a lake. They've always been there. But only recently have I begun to see them. And I am amazed."