Men, Depression, and the Symptoms We Miss

From irritability to substance use, male depression presents differently — and the mental health system is only beginning to catch up.

Psychologists such as myself have long been aware of a quiet asymmetry in who seeks help and who does not. Women come. Men, by and large, do not, or do so less — or if they do, they arrive late, reluctantly, and often through a side door.

That side door is frequently couples therapy.

A recent article in The New York Times — "What Psychologists Want Men to Know About Mental Health" (subscriber access required) — covers familiar ground: men are less likely to seek mental health care, take longer to improve when they do, and are more likely to drop out of treatment. The piece points to socialization as the primary culprit — boys absorbing early lessons that asking for help is weakness, that self-sufficiency is the measure of a man. This is true, as far as it goes. But it doesn't go quite far enough.

What socialization doesn't fully account for is the interior life — the unconscious dynamics that make the consulting room feel not just unnecessary to many men, but unsafe.

Therapy asks something that cuts against everything many men have learned about survival: it asks them to depend on another person. To not know. To be seen in their uncertainty and stay in the room anyway. For men who grew up learning that vulnerability invites punishment — from a critical father, an absent mother, a peer culture that rewarded toughness — the therapeutic relationship itself becomes a place of anticipated danger. The resistance isn't simply pride. It's a psychic self-protection organized around old relational experiences, a part of them that expects the therapist to confirm what they already fear: that what's inside is too much, or not enough. This is transference, and it operates long before a man ever sits across from a clinician — in the moment he considers calling and puts the phone down, in the deflecting joke when someone suggests he talk to someone.

The article notes that depression in men often presents as irritability, risk-taking, anger, or physical complaints rather than sadness. Clinically, this rings true. It also reflects something about what happens when a person has never been given a vocabulary for pain beyond the ones that they were permitted. Anger moves through the world in ways that grief cannot. What looks like a mood problem is often, underneath, an attachment problem.

Which is part of why couples therapy serves as such an important — if rarely acknowledged — point of entry. A man who would never call a therapist for himself will sometimes come for his relationship. The frame changes the meaning: he's not the one who needs fixing, he's doing something for someone else. That small shift can be enough to get him in the room. And once he's there, something can begin.

What tends to happen, when the conditions are right, is that the permission he never quite gave himself gets discovered rather than granted. He finds, sometimes to his own surprise, that it's possible to speak about what's been difficult — and that the room holds it without judgment or alarm. That experience, repeated, is often where the real work starts.

The Times piece notes that three times as many men sought mental health help in 2023 as in 2014. Progress, genuinely. But the more interesting clinical question is what made the difference for those men — what finally made it feel possible. That answer is rarely a public health campaign. It's usually a relationship: a partner who asked, a friend who went first, a therapist who didn't make him feel like a patient before he was ready to be one.

The men still outside aren't, for the most part, indifferent. They're cautious in ways that make a great deal of sense given their histories. Meeting that caution with curiosity rather than urgency tends, in my experience, to get further.