HELP SEEKING BEHAVIOURS IN MEN WITH DEPRESSION:
IMPLICATIONS FOR PRIMARY CARE PRACTICE IN NORTHERN BC
by
Kristine Helen Rowswell
B.A., Queen’s University, 2010
B.Sc.N., Queen’s University, 2012

PROJECT SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS
FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING: FAMILY NURSE
PRACTITIONER

UNIVERSITY OF NORTHERN BRITISH COLUMBIA
August 2017
© Kristine H. Rowswell, 2017

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Abstract
Within North America, there is a consistent and discordant relationship between
men’s low rates of diagnosed depression and high rates of completed suicide. This
discordance has traditionally been explained as due to lower rates of help seeking in men
as compared to women, particularly for concerns around depression and emotional
distress. However, little information is available that provides primary care clinicians
with recommendations to address this important gap in care. Therefore, an integrative
literature review has been conducted in order to identify the factors that influence help
seeking for men with depression in primary care settings. The results are discussed
within the context of northern British Columbian primary care practice. In this study, ten
articles were reviewed utilizing Whittemore and Knafl’s approach to the integrative
literature review. Both grey literature and academic research were included in the
analysis. Results suggest that men’s experience of depression and their behaviours
around help seeking are complex, but are largely shaped by socially constructed ideals
that dictate and perpetuate hegemonic masculinities. These masculinities situate
depression and help seeking as ‘feminine’, and may discourage some men from seeking
help for their symptoms. Primary care practitioners working in northern British Columbia
are encouraged to be aware of the impact of gender norms on their male patients’ help
seeking behaviours. Recommendations for enhancing assessment and treatment of men
with depression are discussed, and specific strategies for the primary care setting are
presented.

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Table of Contents

Abstract

ii

Table of Contents

iii

List of Tables and Figures

v

Acknowledgements

vi

Glossary of Terms

vii

Chapter I: Introduction and Background
Introduction
Background
Etiology, Diagnosis, and Standard Treatments for
Depression
Geographical Context
Masculinities and Men’s Health
Criticisms and Cautions Around Gender-Based Research
Primary Care Practice in the North

1
1
5
5
7
9
10
12

Chapter II: Methods
The Integrative Literature Review
Literature Search
Inclusion and Exclusion Criteria
Preliminary Search
Secondary Search
Grey Literature
Data Evaluation
Data Analysis
Mitigation of Researcher Bias

15
15
16
16
17
18
18
19
20
20

Chapter III: Findings
Barriers to Help Seeking
Depression Isn’t Masculine
Expression of Non-DSM Symptomatology
Symptom Concealment
Perceptions of Treatment
Facilitators to Help Seeking
Reframing Masculinities
Reaching Critical Thresholds
Presence of Social Supports
Availability of Choice-Based and Action-Oriented Treatments

23
24
24
26
27
28
29
29
30
31
32

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Chapter VI: Discussion
Recommendations for Practice
Normalize Depression
Adapt Depression Assessment
Assess for Depression in Men with Non-DSM
Symptomatology
Promote Autonomy and Control
Frame Help Seeking as Positive
Provide Education About Gender and Depression
Involve Social Supports and Loved Ones
Create a Genuine Connection
Offer Action-Oriented and Solution-Based Treatment
Limitations and Future Directions

34
39
42
43
45

Conclusion

52

References

54

Appendices
Appendix A: DSM-5 Diagnostic Criteria for Depressive Syndromes
Appendix B: Literature Search Flow Diagram
Appendix C: Literature Matrix

59
61
63

45
46
46
47
47
47
48

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List of Tables and Figures
Table 1: Prevalence Rates of Depression and Anxiety in British Columbia and
Across Health Authorities

3

Table 2: Inclusion and Exclusion Criteria for Selection of Research Articles

17

Table 3: Barriers and Facilitators to Help Seeking and Recommendations for
Practice

41

Table 4: Facilitators to Help Seeking and Recommendations for Practice

42

Table 5: Adapted Depression Assessment for Male Patients

44

Figure 1: Map of Northern British Columbia

8

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Acknowledgements
I would like to thank my project supervisory committee members, Linda Van Pelt
and Jennifer Beaveridge, for your contributions to this project. Your unlimited support,
astute commentary, and sharp critique enhanced my level of inquiry.
Thank you to Nicholas Bartell, for your love, support, and advice as I wrote this
paper. Your endless encouragement means the world to me, and reminds me why I do the
work that I do. Thank you also to Michael Rowswell, for your valued perspective on a
topic with which I can never claim true expertise. Thank you to Mabel, for your sweet
and steady presence at my feet, and for urging me to get out of house when I needed it
the most.
Finally, and most importantly, my sincerest gratitude goes to all of the men who
participated in these studies and others like them. Thank you for sharing your experience
and enduring wisdom.

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Glossary of Terms
Cognitive Behavioural Therapy: a form of psychotherapy based upon the notion that
thought distortions and maladaptive behaviours play a role in psychological
disorders. The focus is on developing coping strategies and changing unhelpful
thoughts, beliefs, and attitudes. It is the most widely used therapy for treating
depression in adults.
Gender-Role Identity or Gender-Identity: a person’s deeply felt, inherent sense of being a
particular gender (male, female, genderqueer, gender neutral, etc.) and the actions
associated with that gender. The gender may or may not correspond to a person’s
sex assigned at birth.
Gender-Role Socialization: the cultural process whereby traditional gender roles are
normalized within a society. For example, in the West girls may be socialized to
be nurturing, emotive, and gentle, while boys may be socialized to be self-reliant
and stoic.
Help Seeking (or Help Seeking Behaviour): the problem-focused and intentional process
of seeking assistance for health problems. Help may come from a variety of
sources including health care professionals, counselors, and personal or social
supports.
Heteronormativity: a system of beliefs or a worldview that supposes heterosexuality and
the existence of gender binaries are normative and preferred within society.
Heteronormativity assumes, for example, that only men can be masculine, and
only women can be feminine. It is inherently linked to gender-role socialization
paradigms.

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Heterosexist Bias: usually in academic work, the conceptualization of human experience
in strict heterosexual terms. Consequences of heterosexist bias include ignoring,
illegitimizing, or derogating non-heterosexual orientations, lifestyles, and
experiences. The failure to account for non-heterosexual identities within
mainstream literature may render such experiences as invisible.
Masculinity: the qualities traditionally associated with men. These are often the product
of gender-role socialization.
Nurse Practitioners: registered nurses who have undertaken graduate studies and training
in order to practice autonomously and with the ability to conduct comprehensive
health assessments, make diagnoses, order and interpret tests, and prescribe
medications. They treat and manage common acute and chronic illness within a
holistic model of care.
Primary Care: first-contact care with a health care professional where the majority of
non-acute health problems are treated. It is the principal point of continuing care
and/or referral to specialist treatment.
Primary Care Provider: a health care professional, usually a general practitioner or nurse
practitioner, who provides primary care.
Primary Health Care: a broader concept that includes primary care, health promotion,
disease prevention, and population-level public health activities. All determinants
of health, including the social determinants of health, are addressed in this model
of care, and focus is placed on increasing equity and equality of health care.

1
CHAPTER I: INTRODUCTION AND BACKGROUND
Introduction
If I was a woman I’d probably go to the doctor and get some … antidepressants … but as
a man you just pull your socks up.
- Participant Quote, O’Brien, Hunt, & Hart, 2005
Popular stereotypes characterize men as reluctant to ask for help in daily life.
Common examples include a reticence to ask for directions when lost, to get help on a
household maintenance project, or to seek advice from a health professional when
unwell. The latter stereotype is supported by a large body of academic and clinical
literature, which demonstrates that men seek health care services at lower rates than
women (Yousaf, Grunfeld, & Hunter, 2015). Regardless of age, ethnicity, and social
background, men seek help less frequently than women, and it is thought that this plays a
central role in the lower life expectancy of men (Addis & Mahalik, 2003; Galdas,
Cheater, & Marshall, 2004).
In the context of depression and emotional distress, men are even less likely to
seek professional help than they are for physical symptoms (Yousaf et al., 2015). Of
particular concern is that research from across North America demonstrates that there is a
consistent and discordant relationship between men’s low rates of diagnosed depression
and high rates of completed suicide (Gagnon & Oliffe, 2015). Prevalence rates for
depression in women are about twice as high as they are in men, while suicide rates are
about four times higher in men than in women (Oliffe & Phillips, 2008). This
discordance is thought to arise from a complex interaction of socialized male norms and
identities, men’s limited help-seeking behaviours, gendered stereotypes of depression,

2
and inadequate screening tools in primary care that fail to identify gender-unique
experiences of, or attitudes toward, depression (Gagnon & Oliffe, 2015).
Depressive syndromes are associated with significant morbidity and mortality.
Depression is the leading cause of death and disability in persons aged 18-44 (Remick,
2002). It is estimated that 15% of patients with mood disorders will complete suicide and
as many as 66% of all patients who complete suicide have concurrent depression
(Remick, 2002). Depression is strongly linked with higher rates of symptomatic
cardiovascular disease and is also associated with a three-fold increase in work
absenteeism (Remick, 2002).
In northern British Columbia (northern BC or ‘the North’), aggregate rates of
substance use, mental health conditions, and suicide in men are higher than in women.
Overall morbidity and mortality are also higher than in the rest of the province (Northern
Health, 2011). However, when looking only at depression and anxiety, British
Columbian women have almost double the prevalence as men, in keeping with statistics
from across North America (Provincial Health Services Authority [PHSA], 2010).
Interestingly, while overall rates of depression and anxiety in the North are slightly
higher than the provincial average, prevalence of these conditions in Northern men is
slightly less than the rest of the province (PHSA, 2010). Compared to other regions, the
North follows Vancouver Island and the Interior in terms of depression prevalence, but
when broken down into sub-regions, BC’s Northwest has the second highest prevalence
of depression following the Okanagan (PHSA, 2010). In addition, men in the North tend
to rate their mental health as lower than men in other regions of BC (PHSA, 2010). This
information is summarized in Table 1, below.

3
Table 1
Prevalence Rates of Depression and Anxiety in British Columbia and across Health
Authorities
BC -

Northern Interior Fraser Vancouver

Island

Overall

Health

Health

Health

Coastal

Health

Total

21.8%

22.1%

22.6%

21.0%

18.9%

23.6%

Men

15.6%

14.1%

15.9%

14.7%

13.8%

16.3%

Women

27.9%

28.5%

29.3%

27.2%

23.8%

28.5%

Note. Table adapted from the Provincial Health Services Authority (2010)
summary report on heath conditions from regional, longitudinal, and gender
perspectives. Statistics were gathered from BC Ministry of Health Services data
from 2007/2008. Depression and anxiety was defined by ICD-9, ICD-10, or MSP
codes entered for either a single hospitalization or two or more clinical encounters
within the past 365 days.
In terms of help seeking, research demonstrates that people who live in rural
settings are less likely than urban residents to seek help for mental or emotional health
concerns (Wang, 2004). In the North, there is relatively low economic diversity as
compared to other regions in the province, and employment opportunities are largely
determined by the prosperity of the natural resources sector (Northern Health, 2011). As
a result, the majority of men are employed in a few resource sectors, namely mining, oil
and gas, forestry, and agriculture, where job security is tied to market forces that are
often volatile. Research demonstrates that men working in these types of male-dominated
occupations are more likely to suffer from depression than men who work in more
gender-balanced occupations. Moreover, these men report that expressing feelings of
depression is perceived as less acceptable as compared to many other workplace settings
(Coen, Oliffe, Johnson, & Kelly, 2013; Roche, Pidd, Fischer, Lee, Scarfe, & Kostadinov,
2016). In combination with limited health care provider availability, remote working

4
locations, and a socio-cultural milieu that discourages help seeking and the expression of
depression, Northern men face significant and multifaceted barriers to accessing mental
health care (Northern Health, 2011; Rosu, Oliffe, & Kelly, 2016).
There are sizeable bodies of literature that explore the lived experiences of men
with depression, the psychosocial factors that influence help seeking behaviours for
depression, and the general predictors of health service utilization in men. However, no
research has been conducted that unites these bodies of evidence to address how the
clinician can incorporate this information into practice. Given that primary care is often
the entry point, or even the central site, for mental health care services in the North, it is
vital that primary care providers have an evidence-informed approach to addressing
barriers to men’s help seeking. As such, this integrative literature review has been
conducted in order to answer the following questions: 1) “in northern British Columbian
primary care settings, what factors influence help seeking behaviours in men with
depression?” and 2) “what are the most effective strategies for the primary care
provider to use to encourage men’s engagement in depression care?”
In this paper, I will first discuss the biopsychosocial factors that are thought to
predispose certain individuals to depression. I will then briefly outline how depression is
diagnosed and treated in primary care in order to contextualize the issue to practice in
BC. Importantly, I will also explore how these factors intersect with one’s gender
identity and will briefly outline the limitations and cautions applied to gender-based
research. To provide further context, I will describe the role and scope of practice of
primary care providers in BC, including the role of nurse practitioners (NPs). An
integrative literature review on the factors associated with help seeking in men with
depression will be presented, and based upon these findings I will explore how a primary

5
care provider working in the North can improve men’s uptake of and engagement with
depression care. Finally, the limitations of this paper will be presented and I will
highlight areas for further research and consideration for practice.
Background
Etiology, Diagnosis, and Standard Treatments for Depression
Depression is thought to arise from a complex interaction of genetic,
psychosocial, developmental, cognitive, and neuroendocrine factors (Worthington &
Rauch, 2009). An exploration of the details surrounding these mechanisms is beyond the
scope of this paper, but it is generally accepted that genetic and environmental
interactions predict risk of depression better than either genetics or environmental factors
alone. Moreover, the degree to which each factor influences an individual’s risk is
unknown (ann het Rot, Mathew, & Charney, 2009). The following vignette illustrates
how these factors may interact to produce depression in an individual:
Mr Richards is a 39-year-old man who lives in Northeast BC. He works as a flyin-fly-out heavy machine operator for an oil and gas company where he works 2 weeks
on, two weeks off. He has a grade 12 education. He separated from his wife 2 years ago,
with whom he has two children. His wife has been reluctant to let him see his children for
recent ‘volatile’ behaviour. He has suffered from alcoholism for the past 5 years, and his
consumption has escalated in the past 18 months. His father also suffered from alcohol
abuse and was physically and emotionally abusive to him, his brother, and his mother.
His parents divorced when he was 12 years old. His mother suffers from depression and
anxiety. Recently, Mr Richards has become more socially isolated, he finds he cries
easily, and has been in two bar fights in the past 3 months. He does not have a primary
care provider and has not interacted with the healthcare system for over 8 years.

6
Cardinal features of depression include: alterations in mood, such as sadness,
avolition, or hopelessness; negative self-concept, guilt, or self-blame; and neurovegetative changes such as disturbed sleep, changes in appetite, or decreased energy
(Lam, McIntosh, Wang, Enns, Kolivakis, … & CANMAT Depression Working Group,
2016). While these symptoms are the most characteristic of depression, many patients
present with atypical manifestations that can complicate a timely, accurate diagnosis.
Moreover, multiple depressive syndromes are described in the psychiatric literature, and
depression often co-exists with other psychiatric and physiologic conditions. While no
single classification system is universally accepted, the Diagnostic and Statistical
Manual of Mental Disorders, fifth edition, (DSM-5) is the current standard of diagnosis
in Canada (Lam et al., 2016). Depressive syndromes and their diagnostic criteria
according to the DSM-5 are listed in Appendix A.
Depression is diagnosed when a patient’s history and physical examination is
consistent with one of the clinical syndromes described in Appendix A and secondary
causes of depression, such as medical conditions and substance use, are ruled out. A
number of validated depression questionnaires are available to supplement the clinical
examination and to assess responses to treatment over time, including the Beck
Depression Inventory, the Hamilton Depression Scale, and the Personal Health
Questionnaire-9 (Worthington & Rauch, 2009).
Patients with uncomplicated depression are typically diagnosed and treated by
primary care providers. The mode of treatment is dependent upon the severity of
symptoms, and can consist of psychotherapy, including cognitive behavioural therapy
and/or interpersonal therapy; antidepressant therapy; or a combination of both (Lam et
al., 2016). Lifestyle adjuncts such as regular cardiovascular exercise, a healthy diet, a

7
regular sleep schedule, attention to home and workplace stressors, and
reduction/cessation of substance use, are also important in the treatment of depression.
Returning to the vignette about Mr Richards, it would be difficult, if not
impossible, to determine if he is experiencing depression, anxiety disorder, a traumatic
stress disorder, bipolar disorder, or some combination of these syndromes, without a
comprehensive assessment. It would likely require multiple primary care visits to
develop a therapeutic relationship with Mr Richards and to establish an accurate
diagnosis. From there, it could take several months of psychotherapy and possibly
medication trials and dose titrations before an improvement in symptoms is seen. For the
primary care provider looking after Mr Richards, successful treatment is contingent on
him initiating help seeking, continuing to attend appointments, and being agreeable to
and capable of trying the treatment options available to him.
Geographical Context
Northern BC (the North) covers close to 600,000 km2, or about two-thirds of the
province, and has a population of 285,500 people. The population density is low, with
just 7% of BC’s total population (Northern Health, 2011). The largest city in the region is
Prince George, which has a population of approximately 80,000, and this is the health
care hub of the North (Northern Health, 2011). See figure 1 for a map of the North.
Because of low population densities, living outside of a regional centre in the North may
mean inequitable access to timely, comprehensive care, including specialist care. Towns
and cities in the North tend to be widely spaced and distances to access health care can
be a significant barrier, especially in the winter months due to poor driving conditions.
Moreover, travel to the closest primary or tertiary care centre can present significant cost
barriers (Wong & Regan, 2009). A number of communities in the North also experience

8
shortages of permanent primary care providers, meaning that wait times for primary care
appointments are considerable and continuity of care may be interrupted. Locum
providers are often utilized to bridge this gap in care, but studies report that this can
negatively impact patients’ relationship with their healthcare providers. Wong and Regan
(2009) report that in communities with inconsistent primary care providers, patients have
less trust and respect for their providers, have lower confidence in their treatment plans,
and as a result are less likely to adhere to follow up and treatment plans.
Figure 1. Map of Northern British Columbia

Note: This map depicts the Northern Health Authority. Communities with healthcare
facilities are represented and named. Reproduced with permission from
www.northernhealth.ca.

9
The resource sector drives the economy of the North and requires many men to
relocate from larger centers or work away from their homes for extended periods of time
(Northern Health, 2011). As previously mentioned, this type of work is associated with
higher rates of depression in men, as well as lower rates of seeking help for their mental
health concerns. When combined with geographic isolation, unsafe and costly
transportation, and lack of continuity in primary care, men in the North are at risk for
depression and for having limited ability to access care.
Masculinities and Men’s Health
An emerging body of evidence has linked men’s poorer health outcomes with
their avoidance of health-promoting beliefs and behaviours (Addis & Mahalik, 2003;
Hoy, 2012; Oliffe & Philips, 2008; Rochlen, Paterniti, Epstein, Duberstein, Willeford, &
Kravitz, 2010; Sierra-Hernandez, Han, Oliffe, & Ogrodniczuk, 2014). These health
patterns are thought to be the product of gender-role socialization paradigms that dictate
and perpetuate cultural norms and values (Addis & Mahalik, 2003; Courtenay, 2000). In
childhood and beyond, males and females are exposed to pervasive and dichotomous
attitudes about what it means to be a ‘man’ or a ‘woman’. Over time, these attitudes may
become internalized to our identities and our sense of who we ‘ought’ to be (Addis &
Mahalik, 2003). Gender, therefore, is constructed by various subjective and cultural
meanings that are shaped and maintained by people’s actions, and “does not reside in the
person, but rather in social transactions defined as gendered” (Courtenay, 2000, p. 1387).
These small-scale social transactions contribute to broader social and gendered
hierarchies, which over time become normalized and seen as the natural ‘order of things’
(Browne, 2000). When people behave in ways that are gender-congruent, they are
simultaneously sustaining and legitimizing the gendered status-quo, where patriarchal

10
structures situate most men in the West as privileged and dominant within a given
society.
The gender-role socialization paradigm perpetuates idealized male norms, also
termed ‘masculinities’ in the literature, which include notions of self-reliance, toughness,
physical and sexual prowess, and emotional stoicism1 (Addis & Mahalik, 2003; Hoy,
2012). These norms strongly influence a man’s relationship with his mind, body, and
health, and, importantly, the types of health behaviours he may or may not engage in
(Courtenay, 2000; Hoy, 2012). Masculinities become hegemonic when they represent
idealized notions of what a man ‘should’ embody at the expense of femininities or other
types of masculinities that are at odds with dominant male norms (Courtenay, 2000).
Unfortunately, many health-promoting activities are not congruent with hegemonic
masculinities, and as such these hegemonies act as cultural barriers to expressing
emotion, revealing pain, and acknowledging the need to seek help (Hoy, 2012). By
actively rejecting health-promoting behaviours, men are able to achieve these hegemonic
masculine ideals and thus avoid subverting their positions of power within a patriarchal
structure. As a result, they are rewarded with social acceptance and power (Courtenay,
2000).
Criticisms and Cautions around Gender-Based Research
Early research into men’s health has been criticized for focusing on the
differences between men and women’s patterns of health maintenance behaviours. This
focus does not account for the fact that there might be differences in help seeking
between men or even within an individual male. Addis and Mahalik (2003) contend that

1

It is important to note that this paradigm also produces idealized feminine norms that
can contribute to and maintain hegemonic discourses around women, women’s bodies,
and their health.

11
this ‘sex difference’ approach not only provides an overly simplistic explanation, but it
also “may implicitly support essentialist interpretations of gender” (p. 7). Essentialist
interpretations lead us to view particular attributes of a group as fixed and fundamental to
that group, and thus can lead to stereotypes that promote and sustain power inequities
(Courtenay, 2000). For example, if we view the concept of men’s help seeking as lower
than that of women without considering the nuances of inter-gender differences or the
intra-gender differences, we risk categorizing all men as stoic and resilient to illness.
This situates women and other men who are more likely to seek healthcare in a position
where they might be seen as weaker and more vulnerable, thus producing and
perpetuating a hierarchical and essentialist interpretation of gender.
Heterosexist bias is also important to acknowledge and address in gender-based
research. Herek, Kimmel, Amaro, and Melton (1991) of the American Psychological
Association define heterosexist bias as “conceptualizing human experience in strictly
heterosexual terms and consequently ignoring, invalidating, or derogating” (para. 1) nonheterosexual orientations or identities. Gender-based research that ignores the plurality of
sexual orientation or that uncritically adopts discriminatory perspectives may
unintentionally perpetuate a patriarchal heteronormativity within academia and the
greater society.
To avoid the sex-differences approach and heterosexist bias in gender-based
research, most authors today utilize the gender-role socialization paradigm, as explained
above, to discuss their findings. This approach takes into account how people may be
more or less willing to adhere to traditional gender norms depending on a particular
social context that reinforces or punishes a particular behaviour (Berger, Addis, Gree,
Mackowiak, & Goldberg, 2013). For example, heterosexual men who identify more

12
strongly with traditional masculine norms may be more willing to appear emotionally
vulnerable with a romantic partner who has reinforced (and not punished) this behaviour.
The gender-role socialization approach mitigates replication of gender binaries and
allows for a more nuanced interpretation of how men might negotiate their health while
considering their own gender role identity.
Primary Care Practice in the North
Primary care refers to health care services that are provided in a community
setting, and is often the entry point to the health care system. Traditional models of
primary care have been criticized for having a narrow focus on patient care, where
services are provider driven, individually focused, and based only upon clinical diagnosis
and treatment (Canadian Nurses Association [CNA], 2005). However in the past decade,
primary care services have evolved to focus on illness management, interdisciplinary
care provision, and patient-centered care (Hutchinson, Levesque, Strumpf, & Coyle,
2011). This model of care is termed ‘primary health care’, and is being utilized in many
communities in northern BC in order to improve access to and coordination of care, and
to support individuals and families by providing high quality longitudinal health services
(Northern Health, 2017). The majority of primary health care in the North is provided by
family physicians and nurse practitioners. The following section details the nurse
practitioner role in the North.
Nurse practitioners in BC are health care professionals prepared at the masters
level to provide high quality care with a scope of practice that involves “…the
autonomous diagnosis and treatment of acute and chronic illnesses, including prescribing
medications” (College of Registered Nurses of British Columbia [CRNBC], 2016, p. 6).
This scope also includes the ordering of laboratory and imaging tests, making referrals,

13
and consulting with medical specialists as deemed appropriate by the nurse practitioner
(CRNBC, 2016). Other direct and peripheral patient care activities that NPs provide
include counseling, health promotion, community-based wellness programming, and
advocacy work. At the time of writing, NPs are currently providing primary care in
several communities in the North, and are also employed in non-primary care settings
such as the BC Cancer Agency Centre for the North, rural emergency departments, and
First Nations Health Centres (Northern Health, n.d.-a).
In northern Canada and BC, NPs have a long legacy of providing high quality
care to underserved, hard-to-reach, and vulnerable populations (Browne & Tarlier, 2008).
NPs are mandated to provide care within a primary health care model, where health is
addressed holistically and is framed by a commitment to addressing individual and
community-level health and social inequities (Browne & Tarlier, 2008). Thus while the
NP role has a strong focus on providing biomedical care to individuals, its philosophical
underpinnings continue to align with that of nursing. That is, there is an emphasis on
providing holistic care that optimizes an individual’s or community’s health and well
being within the relevant social, geographical, and political context (Browne & Tarlier,
2008). A major thrust of NP practice is therefore to consider the myriad socio-structural
conditions that impact health, and to consider innovative approaches to providing care.
The issue of men’s depression and help seeking is intrinsically tied to sociopolitical structures that inform men’s perceptions of health, and the Northern context
places additional geographical, social, and economic barriers to men accessing timely
care. Moreover, the primary care setting is typically the initial and longitudinal site for
mental health care in rural settings. Considering this, understanding and addressing the
factors associated with men’s limited help seeking for depression aligns well with the

14
mandates of primary health care. For the remainder of this paper, I will use the term
primary care provider to refer to family physicians and nurse practitioners providing this
model of care.

15
CHAPTER II: METHODS
The Integrative Literature Review
The integrative literature review (ILR) is a particular review method that enables
one to synthesize literature from varied research methodologies, such as qualitative,
quantitative, and mixed-methods studies (Whittemore and Knafl, 2005). ILRs differ from
other forms of literature reviews in that their results do not rely solely on the combination
of objective statistical evidence, as in meta-analyses. Similarly, they do not necessarily
combine evidence from primary studies looking at a specific clinical question, as in
systematic reviews (Whittemore and Knafl, 2005). In contrast, an ILR may include data
from both empirical and theoretical literature. Therefore a concept, question, or
phenomenon can be examined more comprehensively and from the vantage point of
diverse perspectives (Whittemore and Knafl, 2005). This allows us to generate a holistic
representation of complex health and human experiences that are particularly salient to
nursing research and practice.
In this paper, I have followed Whittemore and Knafl’s (2005) methodological
approach to conducting an integrative review, which involves the following five steps: 1)
problem identification, 2) literature search, 3) data evaluation, 4) data analysis, and 5)
presentation. In the preceding sections of this paper I have outlined that the problem in
question is men’s limited help seeking for depressive symptoms. The present chapter will
address the second, third, and fourth stages of Whittemore and Knafl’s ILR approach. I
will also include a section to discuss my own researcher bias while performing this ILR.
The final chapter of this paper represents the fifth stage, or presentation, of the ILR.

16
Literature Search
The literature search for this paper began with identification of inclusion and
exclusion criteria for the literature to be collected. The criteria were selected in order to
ensure the full breadth of literature on the topic was identified, whilst maintaining a
relevant focus to the review. The literature search stage was therefore conducted in two
stages. The first step was to identify literature via traditional database searching, and the
second step was to identify literature via hand picking, identification of grey literature,
and networking approaches. At all points in the search process, attention to inclusion and
exclusion criteria was prioritized and irrelevant or redundant articles were eliminated.
The following section outlines the literature search process in detail.
Inclusion and Exclusion Criteria
The literature search for this topic was conducted to identify sources that
addressed factors that influence help seeking behaviours in men with depression in a
Northern, primary care context. Sources published between 2000-2016 were reviewed in
order to capture the full breadth and evolution of research on the topic. These dates were
selected because relatively little research has been published on this topic prior to 2000,
and the writing of this paper began in January 2017. English language publications from
North America, Australia, New Zealand, and Western Europe were considered to include
relevant sociopolitical and cultural study demographics. Study populations of men aged
19-64 were reviewed to capture working-aged men.
Older men and adolescents face different psychosocial circumstances that might
alter their experience of depression and approaches to help seeking (such as school,
retirement, or additional comorbidities associated with aging), and were excluded from
review. In order to keep the study focused, studies were excluded if they involved sub-

17
populations such as students, specific ethnic populations, or immigrants. Articles were
also excluded if they addressed help seeking for general or physical health concerns, or if
they included patients with depression and an additional mental or physical health
diagnosis. Finally, while First Nations and Aboriginal men in the North suffer
disproportionately higher rates of depression than non-Indigenous men, this health
disparity is associated with a complex colonial history and as such is beyond the scope of
this paper (Northern Health, 2015). For this reason, research that focuses on depression
and help seeking exclusively in this population was not reviewed. Inclusion and
exclusion criteria are summarized in Table 2, below.
Table 2
Inclusion and Exclusion Criteria for Selection of Research Articles
Inclusion Criteria
Published between 2000-2016
English language
North American, Australian,
New Zealand, Western
European publications
Study population age 19-64
Self-identified male
participants
Studies examining help
seeking behaviour in men
with depression

Exclusion Criteria
Help seeking within
specific sub-populations
Help seeking within
specific social groups
Depression comorbid with
other mental or physical
health conditions
Help seeking in men for
general or physical health
concerns
Study population
exclusively First Nations

Preliminary Search
To collect relevant academic literature, the CINAHL, Medline, psycINFO, Pub
Med, and Cochrane databases were searched. These were chosen for their comprehensive

18
inclusion of healthcare, psychological, and mental health journals. Keywords used in this
search included:
•

(men OR male OR gender)

•

(depression+ OR mental health)

•

(help seeking* OR engag* OR barrier* OR health service utili?ation)

•

(British Columbia OR north* OR rural)
Each database was individually searched by combining these keywords with the

Boolean operator “AND”. Inputting the above key words into the database search yielded
several hundred or several thousand hits. Filters were applied to each search to limit the
data ranges, age and gender of participants, and publication language as per the inclusion
and exclusion criteria. Article titles and abstracts were then hand reviewed for relevance.
Articles that addressed help seeking for depression in men within a Northern, rural, or
Canadian context were preferentially selected.
Secondary Search
In total, the preliminary search described above yielded four systematic reviews,
one meta-ethnography, and sixteen primary studies. The references from these articles
were reviewed and two additional systematic reviews were selected for consideration in
this paper. Duplicate publications were removed, and each article was read in full for
relevance to this research topic. Only articles that addressed barriers, attitudes, and
factors associated with help seeking in men aged 19-64 with depression or depressive
symptoms were included. See Appendix B for a flow diagram of this search.
Grey Literature
To find relevant grey literature, a Google search was conducted with the
keywords men and depression and British Columbia. With this search, the following

19
websites were identified and reviewed: UBC Men’s Health Research, Northern Health
Men’s Health Program, and UBC’s Men’s Depression “Help Yourself” campaign. From
these websites, a report was located on men’s health in the North published by Northern
Health but because it did not address help seeking or depression specifically, it was not
included in the analysis. Dr. John Oliffe, a nurse and researcher at the University of
British Columbia, was identified as co-authoring a number of seminal and geographically
relevant articles for this review. He was contacted by email in an attempt to locate
additional data sources or articles in publication. However, no literature was identified
from this strategy at the time of writing. This search is also depicted by a flow diagram in
Appendix B.
In total, 10 published works were included in this ILR and include: 1 systematic
review, 8 primary studies, and 1 meta-ethnography.
Data Evaluation
The data evaluation stage of the ILR involves “extraction of specific
methodological features of primary studies” in order to evaluate overall study quality
(Whittemore and Knafl, 2005, p. 549). Where possible, the literature collected for this
review was evaluated for methodological rigour utilizing recognized quality criteria
instruments. Depending on study type, the articles were individually evaluated using the
Critical Appraisal Skills Programme (CASP) systematic review checklist, the CASP
qualitative checklist, or the Quality Assessment Tool for Quantitative Studies (QATQS;
CASP, 2014; National Collaborating Centre for Methods and Tools, 2008). There is no
quality assessment tool available to evaluate meta-ethnographies, so the CASP
systematic review checklist was utilized for this paper. Where available, each article’s
rating is indicated in the literature matrix in Appendix C.

20
Data Analysis
According to Whittemore and Knafl (2005), data analysis begins with the process
of data reduction. In this stage, data are organized according to identified subthemes. In
this review, articles were organized by study type (systematic review, primary study,
meta-ethnography, and literature review). Factors addressing barriers and facilitators to
help seeking in men with depression were extracted and displayed in the literature matrix
(see Appendix C). Other features of the papers were detailed in the literature matrix to
identify study aims, context and sampling, and strengths/weaknesses.
The next stage of data analysis is data comparison (Whittemore and Knafl, 2005).
In this phase, the data displayed in the literature matrix were compared and contrasted in
an iterative manner to identify and critically examine common themes, relationships, and
contradictions. These results are outlined in Chapter 3: Findings.
The final stage of data analysis, conclusion drawing and verification, “moves the
interpretive effort from the description of patterns and relationship to higher levels of
abstraction…” (Whittemore and Knafl, 2005, p. 551). The discussion section of the paper
exhibits this process of abstraction and synthesis of literature. Here, common themes are
explored and it is considered how these findings relate to primary care practice in
northern BC. Contradictory findings are also discussed and areas of future research are
identified.
Mitigation of Researcher Bias
Finally, it is important to discuss how, as the sole author of this study, I may
introduce bias into the research. While this research has been conducted with the
assistance of an academic and professional supervisory committee, I alone conducted the
extrapolation and interpretation of data. As a female, cis-gendered, white, and middle-

21
class person, I have a particular epistemological stance that informed my a priori
assumptions about what I thought the research might say, and likely also the ultimate
conclusions I drew from the research. Having been exposed to primarily white,
heterosexual and cis-gendered men throughout my life, my perceptions about their
worldviews were almost certainly shaped by my personal relationships with these
particular individuals. Additionally, my project supervisory committee is composed of
two self-identifying white females. Together, these factors influence the interpretations
drawn from the data analysis.
My reasons for pursuing this research were shaped by my interest in gender
theory, as well as a troubling observation that mainstream literature over-emphasizes
research about women, women’s bodies, and women’s experiences in a variety of healthrelated areas. This concerns me not only because the scrutinizing of women’s bodies
sustains a problematic hegemonic discourse about women, but also because it obscures
the experience of men and establishes the male experience as the standard against which
others are compared.
While I was aware of issues around heterosexist bias and gendered hegemonies
prior to conducting this research, I had never tested my own ability to be critical when
handling research and synthesizing information to produce a unique body of work.
Conducting this research made me reflect on my own inherent biases and tendencies to
reduce or oversimplify human phenomena, which, in the field of psychology, is termed
social cognition. In research, this concept describes how authors may explain human
phenomena by invoking personal traits in the behaviours they observe in their subjects,
as well as by describing men’s and women’s patterns in essentialist terms (Proctor &
Capaldi, 2012). In order to minimize introducing this form of bias into this research, it

22
was vital that I be aware of how these assumptions, or hypotheses, might influence my
interpretation of the data. In order to mitigate this bias, triangulation2, disconfirming
evidence3, researcher reflexivity, use of thick rich descriptions, and peer debriefing were
all employed in order to enhance the validity and objectivity of my research.

2

The process of searching for common themes amongst multiple sources of information
to form themes or categories in a study (Creswell & Miller, 2000).
3
After establishing preliminary themes, the researcher searches back through the data for
evidence that is inconsistent with the themes (Creswell & Miller, 2000).

23
CHAPTER III: FINDINGS
The existing body of literature on help seeking in men with depression is
primarily composed of qualitative studies utilizing phenomenological and groundedtheory methodologies to generate data. Most participants in these studies were
Caucasian, low to middle income, and heterosexual. A small subset of the literature was
quantitative, using survey-based methodologies to examine overall population trends in
patterns of help seeking in men with depression.
Four (50%) of the primary studies included in this integrative literature review
(ILR) were conducted in the USA, three (38%) were conducted in Canada, and one was
conducted in Australia. The two systematic reviews included only studies from these
three countries as well. Overall, CASP ratings for the primary qualitative studies were
high. Of the two quantitative studies, one received a high QATQS rating while the other
received a low QATQS rating.
Full information regarding each paper’s sampling, methodology, key findings,
and strengths and limitations is outlined in detail in the literature matrix in Appendix C.
In addition, each paper’s CASP or QATQS quality and reliability ratings are outlined in
the literature matrix and can be referred to while reading this section.
Through an iterative process of data comparison and critical analysis of findings
from each of the studies included in this ILR, several themes clearly emerged. For the
purposes of this literature review, these themes have been classified as either barriers to
help seeking or as facilitators to help seeking. The themes classified as barriers to help
seeking included: 1) depression isn’t masculine, 2) expression of non-DSM
symptomatology 3) symptom concealment, and 4) perceptions of treatment. The themes
classified as facilitators to help seeking included: 1) reframing masculinities, 2) reaching

24
critical thresholds 3) presence of social supports, and 4) availability of choice-based and
action-oriented treatments. These findings are presented in the following section.
Barriers to Help Seeking
Depression Isn’t Masculine
The most common theme surrounding help seeking for men with depression was
the effect of masculine norms upon both men’s experience of depression and their
decisions about help seeking. Participants in both the Chuick et al. (2009) and Rochlen et
al. (2010) studies reported that having depression was not socially acceptable for men.
These participants suggested that there is a deep incongruence between the traditional
male role, having depression, and help seeking for depression. Men who voiced these
sentiments tended to endorse and identify with the traditional male norms of self-reliance
and control, and they felt their masculine identity was deeply threatened by both the
experience and the expression of depressive symptoms. Moreover, men in the SierraHernandez et al. (2014) interviews reported that depression interfered with their ability to
“do” masculinity. For these men, depression was consistently referenced as being in
opposition to their ability to succeed, their sense of control, their strength, and their
social engagement. Being known to have accessed professional help for support made
some men in this study feel that they would be viewed as weak or as transgressing
masculine norms (Sierra-Hernandez et al., 2014).
Participants in Johnson et al.’s (2012) discursive analysis of depression in men
voiced feeling a strong expectation that men should be able to deal with their problems
on their own, and it was also noted that their reluctance to seek help was fundamentally
based on a fear of being judged. Men in the Rochlen et al. (2010) study commonly
expressed that masculinity was not necessarily equated with happiness. As one

25
respondent said, “‘the definition of what it takes to be male doesn’t include necessarily
[being] happy. … so to not feel happy doesn’t necessarily seem like a problem’”
(Rochlen et al., 2010, p. 170). These participants also voiced concerns that aspects of a
man’s role can impede his ability to recognize and verbalize depressive symptoms
Seidler, Dawes, Rice, Oliffe, and Dhillon’s (2016) Results in Seidler, Dawes, Rice,
Oliffe, and Dhillon’s (2016) systematic review corroborated these concerns, finding that
over 80% of the studies they reviewed included themes wherein men expressed hesitation
to outwardly express their depressive experience. The authors suggested that help
seeking, therefore, may be impeded by cultural norms that obscure both the behavioural
and verbal expression of depressed mood in some men (Seidler et al., 2016).
Coen et al. (2013) conducted an exploratory-descriptive study in which men and
their partners in Prince George, BC were interviewed to determine depressed men’s
perceptions about northern masculinities and how they negotiated their illness within this
particular geography. The participants reported that the northern and rural context is
associated with strong traditional masculinities where the “idealized Prince George man
and the cold, rugged landscape merged and mirrored each other: the iconic male was
strong, indefatigable, [and] impenetrable” (Coen et al., 2013, p. 98). In keeping with
findings from the other studies, the men in this study reported that depression served to
marginalize them from the prevalent cultural norms because experiencing emotional
turmoil was inconsistent with the idealized ‘northern man’. Despite participants reporting
good local availability of sources to seek help, a critical public gaze and negative stigma
about depression in men were strong forces that discouraged help seeking (Coen et al.,
2013).

26
Expression of Non-DSM Symptomatology
A recurring theme in both the quantitative and qualitative literature is the
presence of non-DSM depressive symptoms exhibited by some men. For these men,
depressive episodes were characterized by increased interpersonal conflict, anger,
violence, substance use, working long hours, or binge-type behaviours with eating or
sexual activities (Chuick et al., 2009; Coen et al., 2013; Hoy, 2012; Rochlen et al., 2010;
Seidler et al., 2016; Sierra-Hernandez et al., 2014).
Call and Shafer (2015) conducted a quantitative survey-based study to examine
the difference in help seeking behaviours between men who exhibited established DSM-5
symptoms of depression and men who demonstrated non-DSM symptomatology (stress,
irritability, aggression, risky behaviors, hyperactivity, and substance use). Even after
controlling for a number of important factors that might influence a man’s ability to
access care, men who exhibited DSM-5 depressive symptoms were more likely to seek
help (OR 1.604, p<0.001) than men who exhibited non-DSM symptoms (OR 0.769,
p<0.001). The authors also reported that the odds of seeking help increased 60% for each
additional DSM-5 symptom exhibited, while the odds decreased by 23% for each
additional non-DSM symptom (Call & Shafer, 2015). Interestingly, survey responders
with non-DSM symptoms were more likely to initially seek help from a medical provider
than those with traditional symptoms. This is in contrast to findings from other studies
that suggest men with non-DSM symptoms tend to initially conceal their depression
(Chuick et al., 2009; Johnson et al., 2012). It is important to point out that this study used
secondary data from a USA-wide national survey, which limits the generalizability of its
results to the Canadian and northern context.

27
Participants in the Coen et al. (2013) study described how some men adhered
more strictly to traditional masculine norms or traits (termed monologic traits by the
authors) and others displayed more nuanced and flexible masculine traits (termed
dialogic traits). Men who exhibited monologic traits were more likely to experience
and/or cope with their depression through substance use or angry outbursts. Men who
identified with a dialogic masculinity were able to reframe gender norms and select
healthful monologic traits that accommodated their depression within their northern,
rural contexts. In a socio-cultural environment that celebrates a strong and stoic
masculinity, being able to selectively engage certain monologic traits mitigated social
marginalization and emphasized the “positive qualities and resourcefulness” (Coen et al.,
2013, p. 99) of a more traditional masculinity. These findings contrast somewhat with the
Call and Shafer (2015) research, which suggests that men with a more traditional
masculinity are more likely to exhibit non-DSM symptoms, and men with a less
traditional, or dialogic masculinity, are more likely to present with DSM-5 symptoms.
Coen et al.’s (2013) findings suggest that the mechanisms that drive symptomatology and
help seeking are complex, not necessarily predictable, and are strongly linked to the
socio-cultural milieu within which men live.
Symptom Concealment
Symptom concealment was reported in all but one of the qualitative studies and in
both of the systematic reviews as a barrier to help seeking. This barrier interfaces closely
with that of expression of non-DSM symptomatology. Men reported making attempts at
concealing their emotional distress through the non-DSM symptoms described above.
This concealment was done in order to avoid the stigma, judgment, and vulnerability
associated with having depression (Chuick et al., 2009; Coen et al., 2013; Johnson et al.,

28
2012; Rochlen et al., 2010). For these men, manifesting their emotional distress through
more traditional masculine behaviours was an important method of re-asserting their
male identities in the face of an experience typically associated with femininity, or even
weakness. Thus symptom concealment was described as an effort to maintain a sense of
control and self-reliance over their illness, reach a congruency between their emotional
distress and their masculine identities, and align a coping strategy with masculine
behaviours (Seidler et al., 2016; Sierra-Hernandez et al., 2014).
Perceptions of Treatment
A final barrier to help seeking reported in the literature was men’s perceptions
about the interaction and the treatment they might receive if they sought help from a
health professional. Men in the Berger et al. (2013) study reported fears that if they
sought help from medical professionals they would “simply be given a pill”. Taking
medication was often viewed as something that limited a man’s sense of autonomy and
control, and as such was felt to be incongruent with masculine norms (Berger et al.,
2013; Hoy, 2012; Siedler et al., 2016). The participants in the Rochlen et al. (2010)
interviews reported a perceived incompetence or ambivalence on the part of the medical
providers they had interacted with for their depression, as well as a sense of frustration
that drug therapy had seldom worked for them in the past.
Similar to other research studies, the Berger et al. (2013) interviews demonstrated
that, overall, depressed men were largely ambivalent to any form of help seeking
(medical, psychotherapy, psychiatric, or informal support). Men who adhered more
strongly to traditional masculine ideals (particularly the norm of self-reliance) had
greater negative perceptions about seeking help from medical doctors than men with a
more flexible masculine identity. Adherence to a traditional masculine identity was

29
associated with favoring forms of ‘talk therapy’, either with a psychiatrist or a counselor
(Berger et al., 2013). This study utilized one-way Pearson correlation analysis to
determine associations between objective scores for adherence to male norms and
reactions to different forms of help seeking. While the associations reported here were
statistically significant, it is unclear how clinically significant these relationships are.
Furthermore, 40% of participants had Beck Depression Inventory scores that indicated no
to mild depression; this limits the extension of these findings to men with more severe
depression (Berger et al., 2013).
Facilitators to Help Seeking
Though not as commonly expressed as barriers to help seeking, several
facilitators to help seeking are apparent in the literature on this topic. These factors, as
described below, emerged as common factors that facilitated men’s positive perceptions
about or actual engagement with help seeking for their depression.
Reframing Masculinities
The most widely reported facilitator to help seeking for men in these studies was
an ability to reframe their masculinity in order to make their depressive experience more
socially acceptable (Coen et al., 2013; Hoy, 2012; Johnson et al., 2012; Seidler et al.,
2016; Sierra-Hernandez et al., 2014). These men “did not abandon masculine ideals of
strength or self-reliance, but redrew flexible boundaries and reintegrated them to improve
treatment uptake and efficacy” (Seidler et al., 2016, p. 114). Men in Coen et al.’s (2013)
interviews who reported less difficulty with help seeking ascribed to a dialogic
masculinity whereby both traditional and normative masculine traits coexisted, as
described above. For these men, the purposeful selection of “healthful” monologic traits
during times of distress legitimized their help seeking efforts in spite of a social milieu

30
that strongly marginalizes men for having depression. The authors described “healthful”
traits as those that helped men “to maintain a foothold ‘in bounds’” of traditional male
norms, and which emphasized the positive qualities of these norms (Coen et al., 2013, p.
99). For example, one of the participants’ wives described how her male partner, who
had depression, found great meaning in caring for his family by fixing the car, chopping
wood, and building their house. These monologic frames of reference provided men with
a reassurance that they could still embody masculinity despite their depression. In other
words, depression and monologic masculinities were not conceived of as mutually
exclusive entities. Additionally, Hoy’s (2012) meta-ethnography found that men who
positioned help seeking as a “brave enterprise” or who framed depression as normal were
more likely to seek help than men with more fixed notions of masculinity (Hoy, 2012).
Reaching Critical Thresholds
For a number of participants in the studies reviewed here, a major trigger for help
seeking was reaching a critical point in their depressive illness whereby their symptoms
became so severe that they recognized the importance of seeking help. Chuick et al.
(2009) describes this process as “a cyclical, escalating pattern of depression” (p. 306)
whereby men who demonstrate non-DSM symptoms of depression (such as substance use
or aggression) suffer increasing emotional distress as a result of these maladaptive coping
patterns. This pattern is often fuelled by attempts to both be self-reliant and to hide
depression. However, after this period of trial-and-error to conceal their internal
conflicts, men either sought help on their own or after a significant other intervened and
supported their help seeking behaviours (Chuck et al., 2009). The men in the Johnson et
al. (2012) interviews and findings from Seidler et al.’s (2016) systematic review echoed
this process, reporting that help was sought once the need was urgent, there were

31
perceived life-threatening consequences, and when men’s internal resources became
depleted and they could no longer rely on their own coping strategies.
Rice et al. (2015) conducted a quantitative survey-based study examining the
relationship between the chronicity of depression symptoms and help seeking. The
authors reported that while rates of help seeking did not increase with longer duration of
depression, men were less likely to seek help the more severe their depression was. This
seems to contradict the aforementioned results in which more severe depression seemed
to be a trigger for help seeking. This study was of low quality and had several sampling
and methodological flaws which are described in Appendix C.
Presence of Social Supports
Though not as prevalent as the other factors outlined in this paper, the presence of
important social supports, either romantic partners or trusted professionals, was identified
by many men as an important facilitator to seeking help. All but one of the participants in
the Chuick et al. (2009) interviews reported that the presence of a supportive
interpersonal relationship helped to break the cycle of maladaptive coping and escalating
depression. Hoy (2012) and Seider et al. (2016) also found that men were more likely to
seek help with the support and advice from a close and trusted individual. Coen et al.
(2013) reported a similar finding wherein the men interviewed expressed a dialogic
masculinity that was “co-constructed, sustained, and most often performed within the
domestic sphere” (p. 100) with their female partners. According to the authors, this
allowed men to cultivate a more flexible masculinity and break with rigid gender roles.
Ultimately, this promoted adaptive coping patterns, including help seeking. The
participants in this study were all in current heterosexual romantic partnerships, limiting
or preventing generalizability of findings to single or non-heterosexual men.

32
As described above, participants who did contemplate or actually seek help
tended to reject pharmacologic therapy in place of various forms of counseling therapy.
Participants in the Johnson et al. (2012) study suggested that they were willing to speak
openly and at length about their depression with healthcare providers whom they felt
genuinely understood them as a person, and who validated their illness within the context
of their unique lived experience. For these men, a crucial prerequisite to trusting their
primary care provider was feeling listened to, validated, and understood. Seidler et al.
(2016) also highlighted these findings in their systematic review, stating “men prefer
non-threatening therapeutic relationships built on trust and defined by open, collaborative
partnership[s] over a paternalistic style” (p. 114).
Availability of Choice-Based and Action-Oriented Treatments
Help seeking was seen as more favourable to men when the treatments on offer
provided choice. Men’s narratives in the Sierra-Hernandez et al. (2014) interviews
suggest that seeking help for depression placed men at risk of losing their identities as
independent and competent men. For them, help seeking meant “forgoing highly valued
masculine ideals by relinquishing [one’s] independent efforts to overcome …
depression” (Sierra-Hernandez et al., 2014, p. 351). However, some men felt that
maintaining a sense of independence despite help seeking was possible as long as they
felt they could maintain control and autonomy in the situation. Results from the
systematic review by Seidler et al. (2016) suggested that men were more likely to feel a
sense of control while help seeking when their care provider provided them with choices
for care. In particular, these men preferred being given choices about various actionoriented treatments that focused on problem solving strategies, such as cognitive
behavioral therapy. It was also identified that men responded favorably to clinicians who

33
framed their depression as a medical problem (Seidler et al. 2016). For these men, a
medicalized explanation provided them with hope that their symptoms were fixable and
not an inherent part of them.

34
CHAPTER IV: DISCUSSION
Findings from this integrative literature review (ILR) demonstrate that men’s
experience of depression and their behaviours around help seeking are at least in part
shaped by socially constructed ideals that dictate and perpetuate hegemonic
masculinities. Importantly, however, the results from this ILR also clearly illustrate that
men experience and exhibit a spectrum of masculinities that interface with a number of
other factors to influence their decisions around help seeking (Coen et al., 2013; Hoy,
2012; Johnson et al., 2012). Masculinity is a fluid concept and is enacted differently
within various social, occupational, and personal contexts. The ability to re-negotiate
one’s masculine identity depending on a particular setting speaks to the plurality of
gender and gender-roles. In contrast to popular stereotypes that portray men as reluctant
to seek help because of their ‘manliness’, this research suggests that certain masculine
qualities might actually be positive predictors of help seeking (Hoy, 2012). It seems that
while hegemonic masculinities are probably a major influence on men’s help seeking,
they do not directly predict men’s behaviour.
Within Western and/or patriarchal societies, male characteristics such as stoicism,
power, and the ‘provider role’ are normalized. Men are thus socialized to be strong,
resistant to disease, and indifferent to mental or emotional troubles (Addis & Mahalik,
2005). However, established DSM-5 symptoms of depression such as sadness,
hopelessness, and guilt contradict these masculinities, and may instead be viewed by
some as typically feminine characteristics. Similarly, the literature reviewed in this paper
demonstrates that help-seeking behaviours align poorly with traditional masculine traits,
and as such are seen as a departure from masculinity. Therefore for some men, the
experience of depression, the expression of depression, and the activities involved in

35
seeking help might all be viewed as deeply incongruent with their core masculine
identities (Coen et al., 2013, Sierra-Hernandez et al., 2014). In an effort to re-align their
emotional state and outward activities with a normative interpretation of masculinity,
these men may be more likely to engage in coping behaviours that are more traditionally
masculine. Non-DSM symptoms, such as substance use, anger, violence, or excessively
working may be viewed as more socially acceptable, and also serve to conceal depression
and thus any perceived transgression of masculinity (Chuick et al., 2009; Coen et al.,
2013, Johnson et al., 2012; Rochlen et al.; 2010, Sierra-Hernandez et al., 2014). This
active rejection of health-promoting behaviours enables men to embody hegemonic
masculine ideals, maintain a masculine identity within a patriarchal structure, and
alleviate a distressing incongruence between their masculinities and their internal
emotional processes.
Interestingly, results from this body of literature also reveal that while men may
feel that emotions like sadness are un-masculine, the outward expression of happiness is
also incongruent with a male identity (Rochlen et al., 2010). As a result, men may
experience a profound and paradoxical tension in their experience with depression
whereby symptoms are simultaneously inconsistent with masculine identities and are
viewed as a natural experience for men. This may be a secondary mechanism for
symptom concealment and delayed help seeking in men. The expression of non-DSM
symptoms may not just represent men’s attempts at reasserting their masculinity, but may
in fact represent an additional idealized, hegemonic masculinity that becomes normalized
and possibly celebrated. Put another way, if traits such as anger or emotional stoicism
(and not, for example, happiness or emotionality) are considered the normative state for

36
non-depressed men as well, then hypermasculinity may be seen as the status quo
regardless of the presence of a mood disorder.
DSM-5 criteria for depressive disorders include symptoms of poor appetite or
overeating, insomnia or hypersomnia, fatigue, feelings of worthlessness or guilt, feelings
of hopelessness, and low self-esteem. Indeed, common and validated depression
screening tools used in primary care, such as the Personal Health Questionnaire-9,
involve asking questions about these very symptoms (Canadian Task Force on
Preventative Health Care, 2013; Kroenke, Spitzer, & Williams, 2001). For men who do
not experience or exhibit such symptoms, the diagnostic criteria and screening tools
likely lead to misdiagnosis or under-diagnosis.
Several of the research articles included in this review examined differences in
help seeking between men who endorsed either more or less traditional masculinities. As
previously mentioned, masculinity does not exist as a binary concept and this will be
discussed in later sections of this paper as a major limitation of this study. However, a
review of these findings is nevertheless important. Men who endorse and identify with
traditional male norms of self-reliance and control may be more likely to feel that their
depressive experience, and the act of help seeking, is in opposition with their masculine
identities (Call & Shafer, 2015). On the other hand, men who identify with a more
nuanced masculinity may more quickly engage in coping behaviours such as seeking
help from a social or professional support (Call & Shafer, 2015, Rice et al., 2015). The
principal mechanism underlying this process appears to relate to control. For some men,
avoidance of help seeking via symptom concealment and maladaptive coping strategies
was described as an important way of maintaining a sense of self-reliance over one’s
illness (Chuick et al., 2009; Johnson et al., 2012; Rochlen et al., 2010; Seidler et al.,

37
2016). Other men described how they reframed their perceptions about gender norms and
selected healthful masculine traits that accommodated their depression (Coen et al.,
2013; Johnson et al., 2012; Hoy, 2012). For example, the action of seeking help can be
viewed as matter of self-empowerment, because living with depression may impede a
man’s ability to fulfill his responsibilities for his loved ones, work, or other meaningful
entities in his life. Rather than seeing depression as something that makes one powerless,
overcoming it was instead constructed as a ‘heroic struggle’ from which one emerges as
a stronger person (Hoy, 2012). By actively making the decision to seek help in order to
sustain a masculine sense of identity, men can thus take control of their illness and
neither help seeking nor depression are seen as incongruent with masculinity.
Negative perceptions of healthcare providers, namely a general distrust or lack of
confidence that their treatments would be effective, is cited as a common barrier to men’s
help seeking (Berger et al., 2013; Rochlen et al., 2010). This presents another interesting
paradox where, despite tending to prefer treatments that are action-oriented and present
‘quick fixes’, many men avoid medical providers because they feel they would simply
suggest pharmacological therapy. Men viewed being offered medications as a
minimization of the severity of their condition, which they felt warranted more
substantive treatment (Berger et al., 2013; Hoy, 2012; Seidler et al., 2016). Moreover,
taking medication may be viewed as something that limits one’s sense of autonomy and
control, and as such is inconsistent with masculine norms. This paradox was not well
explained by the literature. However, many participants reported that one of the most
important triggers to help seeking was reaching a point in their depression when their
internal resources became depleted and they could no longer rely on their own coping
strategies (Chuick et al., 2009; Johnson et al., 2012; Seidler et al., 2016). It may be that

38
men who do seek help have reached a more severe stage of their illness where a critical
threshold of suffering is met, thus legitimizing help seeking efforts. At this stage of
severity, medication alone may be viewed as insufficient treatment.
This research also demonstrates that men have a preference for making a genuine
connection with their medical provider or counselor. A collaborative therapeutic
relationship was seen as crucial to maintain a sense of control and autonomy in a
situation often associated with powerlessness (Chuick et al., 2009; Hoy, 2012).
Therefore, having a relationship with a professional with whom men feel validated and
equal may pose less of a threat to one’s masculinity.
Men and their partners living in Prince George, BC reported that a more
traditional masculinity is idealized and normalized in the North. The economy in the
North is primarily driven by the natural resource sector, which is traditionally associated
with a male-dominated workforce and potentially physically dangerous working
conditions (Coen et al., 2013; Northern Health, 2011). Coen et al. (2013) argue that this
“performance” of resource based work, combined with a long history of gendered
employment, fosters the development of a particular masculine identity associated with
strength, endurance, and a strong work ethic. The archetype of the typical ‘northern man’
thus emerges as someone who embodies physical and mental endurance and who does
not experience or discuss emotional distress. This type of masculinity, therefore, is
positioned as normal, dominant, and desirable because it provides men with the
environment of the North (Coen et al., 2013).
While we cannot draw firm conclusions about cause-and-effect relationships, it is
worth considering that men who live in rural areas and/or who work in male-dominated
industries are less likely to seek help for mental health issues at least in part due to strong

39
socio-cultural forces that celebrate traditionally masculine men and marginalize or
exclude other men. It is unclear if this correlation is unique to rural versus urban areas.
Similarly, from the present research it is impossible to know what kind of relationship, if
any, exists between hegemonic masculinities and risk for depression. Nevertheless, the
findings presented here provide important insight to the factors that contribute to lower
help seeking in men living in this region and allow us to generate a set of
recommendations for primary care practice.
Recommendations for Practice
Based upon the aforementioned results, a set of recommendations has been
generated to assist primary care practitioners in the assessment and treatment of men
with depression. Men have general health needs that are distinct from those of women,
and their mental health needs are no exception to this. Current services are failing to meet
these needs, as evidenced by low rates of help seeking, mis- and under-diagnosis of
depression, and limited evidence to guide practitioners in how to most effectively care
for their male patients. Results from this research highlight that complex systemic and
sociocultural issues underlie men’s lower rates of help seeking. While a discussion of
strategies aiming to shift these dominant cultural norms and expressions is beyond the
scope of this paper, the results from this review nevertheless suggest that there are gaps
in the front-line delivery of depression care for men. Primary care practitioners therefore
have an important role to play in tailoring the care they provide to better meet the needs
of this population.
The recommendations presented here have been derived from the literature
reviewed in this paper. Since the majority of the participants in these studies lived
outside of northern BC, these recommendations do not solely apply to this geographical

40
setting. That being said, the recommendations have been made considering the
geography in the North and the resources available to patients and providers.
Men’s help seeking behaviours appear to be largely influenced by the impact of
gender role socialization paradigms, which celebrate and normalize masculine traits such
as emotional stoicism and self-reliance (Addis & Mahalik, 2003). The results from this
research demonstrate that perceptions around loss of autonomy and control shape many
men’s decisions around help seeking for depressive symptoms. Moreover, depressive
symptoms may be exhibited by masculine-specific behaviours, or simply concealed,
making identification of depression in men difficult. As such, the following strategies
aim to increase the clinician’s ability to identify depression in men, and to equalize any
real or perceived power imbalances between patient and provider. The recommendations
are summarized in Table 3 and Table 4, and are listed beside their corresponding barrier
or facilitator to help seeking, as discussed earlier in this paper. The recommendations are
also discussed in more detail in the proceeding section of text.

41
Table 3
Barriers to Help Seeking and Recommendations for Practice
Barriers

Recommendations

Strategies in the Primary Care
Setting
Depression Isn’t
• Normalize depression
• Discuss that depression is common
Masculine
but emphasize how each person’s
depressive experience is unique
• Describe depression as a disorder
primarily caused by a biochemical
imbalance in the brain, which has
been provoked by environmental
factors
• Utilize formal group visits or
informal men’s groups
Non-DSM
• Adapt depression
• Include additional questions about
Symptomatology
assessment
increased interpersonal conflict,
anger, violence, stress, substance
use, increased sexual activity, and
over-productivity at work/school
Symptom
• Assess for depression in
• Initiate depression assessment in
Concealment
men who report non-DSM
men who exhibit non-DSM
patterns of depression
symptomatology
• Consider screening asymptomatic
men who are at high risk for
depression*
Perceptions of
• Promote autonomy and
• Utilize communication strategies
Treatment
control
such as humor, empathy, reflective
listening, and frankness
• Encourage patients to have and
express opinions and preferences
about care
• Provide choices for care
• Review options collaboratively
Note. *Risk factors for depression in men include family history of depression,
unemployment/underemployment, social isolation, cardiovascular disease and other
chronic illnesses, and substance use (Lam et al., 2016).

42
Table 4
Facilitators to Help Seeking and Recommendations for Practice
Facilitators

Recommendations

Strategies in the Primary Care
Setting
Reframing
• Frame help seeking as
• Verbalize help seeking efforts as
Masculinity
positive
courageous, positive, and important
Reaching
• Provide education about
• “Many of my patients say their
Critical
gender and depression
depression affects their sense of
Thresholds
who they are, including who they
are as a man. How do you think
depression affects the way you see
yourself?”
Presence of
• Involve social supports and • Invite loved ones/support persons
Social
loved ones
to attend appointments
Supports
• Create a genuine connection • Be familiar with non-healthcare
resources available in the
community; discuss and refer men
as appropriate. For example,
websites, community groups, peer
supports
• Build a therapeutic relationship
• Listen to men’s stories
• Validate men’s experience and
feelings
Choice• Offer action-oriented and
• Provide choices for treatment
Based and
solution-based treatments
options, including pharmacotherapy
Action
and/or talk therapy, e.g. CBT
Oriented
• Brief action planning and
Treatments
motivational interviewing
• Specific goal setting activities
Note. CBT = cognitive behavioural therapy

Normalize Depression
The most common theme that emerged as a barrier to help seeking in this
research was that men often feel that depression and help seeking are not masculine.
However, this research also demonstrates that men are more likely to engage in help
seeking and adaptive coping styles when they feel that their depressive experience is
normalized (Hoy, 2012). Simultaneously acknowledging one’s individuality and

43
normalness within the context of depression may help patients feel validated in their help
seeking efforts. Having this discussion with patients may help to reduce a wider stigma
that depression is something ‘brought on’ by oneself, and at the same time acknowledges
the uniqueness of a particular man’s depression. In addition, it may help men to
understand that their depressive experience is not necessarily an inherent part of them,
and therefore is more amenable to treatment (Coen et al., 2013; Seidler et al., 2016).
Implementing formal or informal, activity-based group interventions in safe,
male-friendly spaces is another strategy to normalize depression. Groups allow men to
socialize, discuss shared experiences with depression, access support in non-medical
settings (which might be more acceptable to some men), and also address the stigma
around having depression (Northern Health, 2011; Rosu et al., 2016; Spendelow, 2015;
Wilkins, n.d.). There is also encouraging evidence that formal group-based medical visits
could enhance help seeking and engagement in men with depression (Cramer, Horwood,
Payne, Araya, Lester, & Salisbury, 2014; Northern Health, 2011; Spendelow, 2015; Rosu
et al., 2016). Existing examples of these types of groups include the Dude’s Club for the
urban Aboriginal male population in the downtown eastside of Vancouver, and Men’s
Sheds, which are peer-run groups located in communal work sheds where men can
complete woodworking projects, make music, or watch sports together (Gross, Efimoff,
Lyana, Lambert, Joweski … & Smye, 2016; Wilson & Cordier, 2013).
Adapt Depression Assessment
A key finding from this research is that the DSM-5 diagnostic criteria for
depression may not correspond well with the symptoms experienced by some men
(Chuick et al., 2009; Coen et al, 2013; Hoy, 2012; Rochlen et al., 2010; Sierra-Hernandez
et al., 2014; Seidler et al., 2016). Therefore, the commonly used screening tools and

44
assessments in primary care may have a lower sensitivity and specificity in detecting
depression in these individuals. When assessing men for depression, it is therefore
recommended to include additional questions about increased interpersonal conflict,
anger, violence, substance use, change in sexual activity, and increased concern with
productivity at work/school (Chuick et al., 2009; Cochran & Rabinowitz, 2003). An
example of an adapted assessment of depression is outlined in Table 5, below.
Table 5
Adapted Depression Assessment for Male Patients
PART I: Ask about DSM-5 Criteria Symptoms:
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Trouble falling asleep, staying asleep, or sleeping too much
Feeling tired or fatigued
Feeling bad about yourself or feeling guilty
Difficulty concentrating
Moving or speaking slowly, or feeling very fidgety
Thoughts of self harm or that you would be better off dead
PART II: Ask about Non-DSM Symptoms:
Increased conflict with others or increased fights, either physical or verbal
More anger or irritability than usual
Increased use of alcohol or other substances
Increased concern with productivity at work or school
Increased sexual activity, including high-risk sexual activities
Feelings of intense stress or burn out
Note. Table adapted from Cochran & Rabinowitz (2003). DSM-5 = Diagnostic and
Statistical Manual of Mental Disorders (5th Ed.).

45
Assess for Depression with Non-DSM Symptomatology
Current Canadian guidelines recommend against the routine screening of
depression for asymptomatic patients in primary care (Canadian Task Force on
Preventative Health Care [CTFPHC], 2013). Rather, assessment is recommended in
individuals who present with objective signs of depression, such as psychomotor
agitation or flat affect, and in those who present with DSM-5 symptoms, which are
outlined in Appendix A (CTFPHC, 2013). As the research in this paper suggests, men
may not present with clear symptoms of depression. They may conceal depressive
symptoms as a result of cultural prohibitions placed on men against expression of
emotion (Chuick et al., 2009; Coen et al., 2013; Johnson et al., 2012; Rochlen et al.,
2010). In addition, some men may have difficulty verbalizing their emotional distress, or
may use language like “stress” or “burn out” to articulate their experience (Hoy, 2012).
For men who do exhibit non-DSM symptomatology, as described previously, it is
recommended to initiate assessment for depression. Similarly, judicious use of
depression screening in asymptomatic men may also be considered in order to identify
high risk men who may be experiencing depression, but who do not verbalize symptoms
of distress.
Promote Autonomy and Control
An important barrier to help seeking reported in this research was men’s
perception that seeking care would reduce their sense of power, control and autonomy.
The primary care provider is encouraged to actively promote men’s autonomy and
control by leveling power differentials between him or herself and the patient (Hoy,
2012). Specific strategies for the primary care setting are outlined in Table 3.

46
Frame Help Seeking as Positive
This recommendation is based upon findings that men were more likely to seek
help when it is viewed as a positive way of enacting one’s masculinity (Coen et al., 2013;
Hoy, 2012; & Seidler et al., 2016). Verbalizing that a man’s help seeking efforts are
important, courageous, and positive may allow him to view help seeking not as a loss of
power, but rather as an action-oriented approach to regaining control (Ogrodniczuk,
Oliffe, Kuhl, & Gross, 2016). By helping to foster a flexible, individualized, and
contextually based masculinity, men may feel more comfortable seek help for and
engage in treatment for their depression (Sierra-Hernandez et al., 2014).
Provide Education about Gender and Depression
The literature suggests that gender-role identity may be one of the most important
factors in a man’s experience with depression and his decision to seek treatment (Chuick
et al., 2009; Coen et al., 2013; Johnson et al., 2012; Seidler et al., 2016). Helping men to
understand this process could provide them with the context necessary to better
understand their depression and encourage help seeking earlier in the course of the illness
(Chuick et al., 2009; Kilmartin, 2005). Importantly, it may also help to give men the
vocabulary necessary to communicate their emotional troubles (Kilmartin, 2005).
Inviting a man to reflect upon whether or not there is a dissonance between his sense of
masculinity and his depression may introduce a level of insight that is beneficial to
recovery (Rice et al., 2015). Within this recommendation is again the reminder that
primary care providers must recognize the diversity within and between men, and the
plurality of masculinity. Clinicians must not assume that all men will have a similar
experience with their depression and help seeking, and this recommendation provides the
opportunity to explore each male patient’s unique gender identity.

47
Involve Social Supports and Loved Ones
A key facilitator to help seeking for men with depression is the presence of a
support person who encourages help seeking and who provides them with a sense of
accountability for their depression care (Chuick et al., 2009; Coen et al., 2013).
Moreover, men may feel more comfortable seeking help from non-professional supports
where the perceived power imbalance is lessened or where there is a pre-existing and
trusting relationship. Supports may include informal social contacts, members of
religious organizations, or community organizations (Johnson et al., 2012). This
recommendation also serves to remind us as healthcare providers that medical and/or
professional services may not be the most appropriate or sole forums for depression
treatment for some individuals. Similarly, help seeking is not always located in medical
services, and it is important not to assume that these services meet the needs of all of our
patients (Johnson et al., 2012).
Create a Genuine Connection
The research demonstrates that men report a strong desire for a ‘genuine
connection’ with their care providers (Johnson et al., 2012; Seidler et al., 2016). Men
report being more likely to talk openly with healthcare providers whom they feel
understand the complexity of their lives and them as a person (Johnson et al., 2012).
Therefore, taking the time to listen to men’s stories in order to understand how their lived
experiences contribute to their depression may help to legitimize their depressive
experience.
Offer Action-Oriented and Solution-Based Treatments
A common barrier to help seeking cited in the literature was a fear that clinicians
would simply prescribe medication for depression, despite a strong preference for action-

48
based treatments. When questioned about preferences for whom to seek care from, men
typically reported preferring treatments utilizing talk-based therapies, either with
counselors, psychiatrists, or other clinicians. While there is no clear evidence to suggest
that a particular form of talk therapy is superior for unipolar depression in men, cognitive
behavioural therapy (CBT) is established as the most well-validated intervention for
depression in both genders (Spendelow, 2015). CBT may be preferable for men because
of its relative emphasis on practical and problem-based strategies. Clinicians who are
trained in CBT may utilize this form of therapy themselves, or can refer patients to
alternative professionals. Additional strategies to engage men in action-oriented
treatments, as identified in the literature, include providing concrete, specific goal-setting
activities, brief action planning, as well as progressive muscle relaxation and deep
breathing (Mahalik, Good, Tager, Levant, & Mackowiak, 2012).
Limitations and Future Directions
A major limitation to this integrative literature review is the external validity of
its findings to the northern British Columbian population. Five of the eight primary
studies were conducted in the USA, and only one of the three Canadian publications was
conducted exclusively in the North. While the results of these studies can be discussed in
the context of northern British Columbia primary care practice, direct explanations for
men’s help seeking in northern BC cannot be made based solely upon this research.
Similarly, the majority of the primary studies in this review utilized phenomenological
methodologies. Their findings are valid representations of the lived experiences of the
individuals in the studies, but they should not be used in isolation to generate
assumptions or predictions about all other men’s experiences. A number of the studies
included mostly Caucasian individuals, limiting generalizability to other ethno-cultural

49
backgrounds, which are widely represented in northern BC. As previously mentioned, an
important exclusion criterion for this paper was research that addressed help seeking or
depression in First Nations, Inuit, or Métis men. This was a purposeful exclusion because
the intersection of the historical, cultural, and geographic influences on these men’s
depression and help seeking behaviours is complex and deserving of its own dedicated
research. However, this also means that the findings in this paper cannot be validly
applied to this population.
Nearly all of the primary studies in this review utilized convenience sampling
methods, possibly introducing sampling bias into the results. Men with particular life
circumstances, personality types, or issues with access (physical, economic, or social
access) to academic research that prevented their participation are underrepresented in
these studies. It could be that men who are more willing to engage in interview-style
studies have particular qualities that influence their help seeking patterns, again limiting
generalizability to the greater male population. Moreover, few studies involving
interviews required participants to have a formal diagnosis of depression. It is possible
that some of the participants did not meet diagnostic criteria for depression and/or had
another mental health issue presenting with similar symptoms as major depression.
Further research is warranted that specifically examines the patterns of help seeking for
men with mild, moderate, and severe depression in order to accurately capture
differences in trends and preferences for help seeking and treatment styles.
The recommendations for primary care practice included in this paper were
developed based upon the findings from this literature review as well as their feasibility
to implement within the context of primary care practice in northern BC. It is beyond the
scope of this paper to discuss the relative effectiveness of these interventions and

50
recommendations. There is a paucity of research available that discusses the
effectiveness of the alternative models of care in depression care in the North. Therefore,
while the recommendations put forward in this paper have been developed considering
the best available evidence for this topic, their feasibility and efficacy in the population
in the North are unclear. An important area for future research should address the
effectiveness of these recommendations within the specific context of primary care
practice in northern BC. In addition, research that examines men’s perceptions about the
gender of their care provider might provide important insight to decisions around help
seeking.
A critical interpretation of the studies included in this review reveals that a
number of articles approached their research with a heteronormative frame of reference.
Most of the articles did not disclose the gender or sexual identities of their participants,
leading readers to assume they were likely heterosexual. This is a possible source of
heterosexist bias. For example, the Coen et al. (2013) article describes how participants
describe hegemonic masculinities to be produced by the celebration of the strong, stoic,
and unfaltering ‘northern man’. All of the men in this study were in current heterosexual
relationships, so it is impossible to know if this worldview is shared by nonheterosexually identifying men. This is problematic because the inclusion of
predominantly heterosexual worldviews in research may systematically obscure the lived
experience of men who identify as non-heterosexual, or non-cisgendered. Not only does
this limit generalizability, it may also inadvertently reproduce prejudicial attitudes into
research and knowledge dissemination.
A very important caveat to this research, and indeed any gender-based research, is
that results must not be interpreted as representative of all men’s experience. Similarly,

51
the results should not be conceptualized as essential differences between men and
women. It is widely accepted that gender exists on a spectrum, is socially constructed,
and is expressed in different ways at various times in an individual’s life. The majority of
the papers included in this review explained their findings by considering the plurality of
men’s lives and multitude of ways that depression and help seeking are experienced.
However, some did frame their findings around the differences between men with either
a more or less traditional masculinity. Failing to consider intra-gender or intra-individual
differences in such a dichotomous manner is erroneous, and runs the risk of creating and
sustaining stereotypes about men. This may reinforce power imbalances between groups
and individuals, thus perpetuating the very hegemonic masculinities this research is
attempting to expose. In addition, much of the research conducted to date regarding
men’s help seeking is framed around what is ‘wrong’ with men. Targeting pathology,
rather than highlighting the inherent richness and plurality of masculinities, only serves
to constrain and essentialize the experience of men. Attempts were made while
conducting this research to extrapolate and highlight the inconsistencies in findings in
order to underscore the variability within and between men. Nevertheless, more research
is needed that adopts a more nuanced and strengths-based model of men’s experience in
order to more comprehensively understand and improve mental health issues in this
population.

52
Conclusion
This study sheds an important light on the factors that influence help seeking
behaviours in men with depression within a primary care setting, and outlines novel and
evidence-informed recommendations to increase men’s engagement in depression care.
A key finding from this research is that for some men, depression and help seeking
patterns are largely informed by hegemonic discourses produced and sustained by
socially constructed ideals of masculinity. This idealized masculinity is a particularly
salient feature in Northern men’s constructions of gender and identity, where traits of
strength, stoicism, and endurance are celebrated and normalized. Depression and help
seeking are commonly associated with feminine traits, so for men who identify with
strong masculine ideals, exhibiting sadness, hopelessness, or anhedonia might be
perceived as incongruent with this type of masculinity. As a result, depressive symptoms
may be concealed by or expressed in more traditionally masculine activities, such as
anger, substance use, or binge-type behaviours. Of importance, however, is that this
process is almost certainly more nuanced than early researchers in the subject have
postulated. A large proportion of men identify with a flexible masculinity, and they may
be more likely to seek help for their depression. While this research has not been
designed to understand how to increase rates of help seeking for men with depression, it
provides a strong evidence base for how to engage men who are already seeking care.
These recommendations are based upon the notion that men’s limited help seeking is
often tied to feelings of loss of control and autonomy, and are aimed at structuring a
man’s sense of self and masculinity in order to encourage ways of ‘doing’ masculinity
that do not conform to typical hegemonic discourses.

53
Future research is needed on this subject, as well as men’s health in general, that
emphasizes the plurality of masculinities. Masculinities are not fixed; they are tested,
dynamic, and socially located in both time and space. The existing literature has
overemphasized the essentialist and static nature of masculinity, as well as the
differences in help seeking between men and women, and between ‘traditional’ men and
‘less-traditional’ men. This has led to the creation of an overly simplistic, homogenous,
and inaccurate picture of these men’s experiences. This research calls upon primary care
clinicians to be alert to how depression may manifest in some male patients, and to how
traditional primary care settings may not feel like welcome spaces for men. Moreover, it
sheds light on the invisible nature of men’s mental health issues despite, for some men,
their privileged positions in society.

54
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59
Appendix A: DSM-5 Diagnostic Criteria for Depressive Syndromes
Adapted from the Diagnostic and Statistical Manual of Mental Disorders, 5th Ed
Criteria for Major Depressive Episode (MDE):
1. ≥5 of the following symptoms have been present during the same 2 week period
and represent a change from previous functioning; at least one of the symptoms is
either 1) depressed mood or 2) loss of interest of pleasure:
• depressed mood most of the day, nearly everyday
• markedly diminished interest or pleasure in all, or nearly all, activities
• significant and unintentional weight loss/gain, or change in appetite nearly
everyday
• insomnia or hypersomnia nearly every day
• psychomotor agitation or retardation nearly every day
• fatigue or loss of energy nearly every day
• feelings of worthlessness or excessive or inappropriate guilt nearly every day
• diminished ability to think or concentrate, or indecisiveness, nearly every day
• recurrent thoughts of death, recurrent suicidal ideation without a specific plan,
or a suicide attempt or a specific plan for committing suicide
2. The symptoms cause significant distress or impairment in function
3. The episode is not attributable to the direct physiological effects of a substance or
medical condition
Criteria for Major Depressive Disorder (MDD):
1. Single - Presence of a single MDE
2. Recurrent – Presence of two or more MDEs separated by at least 2 consecutive
months in which criteria for MDE are not met
3. The MDE cannot be better explained by another psychiatric disorder, and there
can be no manic or hypomanic episodes
• Specifiers – MDD with: anxious distress, mixed features, melancholic features,
atypical features, mood congruent psychotic features, mood incongruent
psychotic features, catatonia, peripartum onset, seasonal pattern.
Criteria for Persistent Depressive Disorder (previously dysthymia)
1. Depressed mood for most of the day, for more days than not for ≥ 2 years
2. Presence, while depressed, of ≥2 of the following:
• Poor appetite or overeating
• Insomnia or hypersomnia
• Low energy or fatigue
• Low self esteem
• Poor concentration or difficulty making decisions
• Feelings of hopelessness

60
3. During the 2 yr period the person has never been without the symptoms in criteria
A and B for more than 2 mo at a time
4. The disturbance cannot be better explained by another psychiatric disorder, and
there can be no manic or hypomanic episodes
5. The symptoms are not attributable to the direct physiological effects of a
substance or medical condition
6. The symptoms cause significant distress or impairment in function

61
Appendix B: Literature Search Flow Diagram
Flow Diagram for Academic Literature Search

PsycINFO

Pub Med

Cochrane
Database

Total:
1,312

��������
������

Total:
959

Total:
86

After Inclusion/
Exclusion Criteria:
1 systematic
review; 4 primary
studies

After Inclusion/
Exclusion Criteria: 1
meta-ethnography; 1
systematic review; 5
primary studies �

After Inclusion/
Exclusion Criteria:
1 systematic
review; 3 primary
studies

After Inclusion/
Exclusion
Criteria: 0

CINAHL

EBSCO
Medline

Total: 891

After Inclusion/
Exclusion Criteria:
1 systematic
review; 4 primary
studies

4 systematic reviews
16 primary studies
1 meta-ethnography

Articles Identified from References List:
1 systematic review

Total After Duplicates Removed and Reading in Full for
Relevance:
1 systematic review
8 primary studies
1 meta-ethnography

62
Flow Diagram for Grey Literature:

UBC
Men's
Health
Research

Men's
Depression
Help
Yourself

Northern
Health
Men's
Health
Program

1 review
paper

0

��

After Reviewing for Relevance
and Inclusion/Exclusion Criteria:
No papers met criteria

63
Appendix C: Literature Matrix
Primary Studies
Authors,
Date
&
Title
Berger,
Addis,
Green,
Mackowiak,
& Goldberg
(2013)

Aim

Theoretical
Framework,
Methodology,
and Methods
Theoretical
Framework:
Qualitative

1) How do
men verbally
react to
mental health
labels and
Methodology:
different
Observational
forms of
help-seeking? Clinical style
Men’s
semi-structured
reactions to
2) How do
interviews and
mental
men verbally completion of
health labels, react to
Conformity to
forms of help different
Masculine Norms
seeking, and sources of
Inventory
sources or
help seeking (CMNI-55)
help-seeking advice?
advice.
Each participant
3) Is selfwas ranked on a
reported
5-point scale
adherence to regarding level of
masculine
acceptance of a
norms related mental health
to men’s
label and form of

Context/
Sampling

Data Analysis

New
England,
USA

Interviews
independently
rated by two
researchers
Men aged 19- according to the
77 with
RMHRS, an
depression or original
other nonobservational
psychotic
measure
mental health designed to
condition
assess men’s
verbal reactions
Convenience to mental health
sampling
labels and
different forms
N = 85
of help seeking
Adherence to
masculine
norms and
reactions to help
seeking
analyzed via

Key Findings re: Help
Seeking

Strengths and
Limitations

1) Medication was the most
strongly rejected help seeking
option. Psychotherapy found
to be most accepted form of
help seeking

Strengths
Greater ecological
validity to findings
because conducted in
clinical-style
interview

2) In simulated situations,
men responded most
positively to help seeking
advice given by a
psychotherapist as compared
to a doctor or romantic
partner.
3) Psychotherapy and
medication were negatively
associated with adherence to
masculine norms. Stronger
adherence to masculine ideals
(particularly those who
adhered strongly to the norm
of self-reliance) was
associated with greater

Congruence between
study aims, theoretical
framework, and
methodology
Limitations
40% of men
interviewed had
“minimal” severity of
depression based upon
Beck-Depression
Inventory
Bias wherein the
participant knows the
scenarios are

64
verbal
reactions to
different
mental health
labels, forms
of helpseeking, and
different
sources of
help-seeking
advice?

help seeking
(medication,
psychotherapy,
informal help
from family and
friends, or
“other”).
Men presented
with 3 different
scenarios of
actors
impersonating a
romantic partner,
a medical doctor,
and a
psychotherapist
who all suggested
mental health
treatment for their
condition.
Participants’
responses rated
on 5-point scale
for willingness to
seek each type of
help

one-way
Pearson
correlation
analysis.

negative perception of help
seeking from a medical
doctor

simulated so may not
represent true in-vivo
responses.
Limited external
validity because most
participants
Caucasian, low/lowmiddle class, many
unemployed, and all
residing in
northeastern USA.
Sampling bias due to
convenience sampling
CASP Rating: High

65
Authors,
Date
&
Title
Call &
Shafer
(2015)
Gendered
manifestations of
depression
and help
seeking
among men

Aim

To
understand
how help
seeking
behaviours in
men who
exhibit maletypical
symptoms of
depression
differ from
men with
more
traditional
symptoms
To address
from whom
men seek
help

Theoretical
Framework,
Methodology,
and Methods
Theoretical
framework and
methodology not
stated
Dependent
Variables: 1) men
who had ever
sought help for
depression, 2)
men who had ever
sought help for
another mental
health problem, 3)
men who had
sought help for
both, 4) where
men initially
sought help
(medical provider
[including
psychiatrist],
mental health
clinician, or other
professional)
Independent

Context/
Sampling

Data Analysis

Key Findings re: Help
Seeking

Strengths and
Limitations

Data source
from national
Comorbidity
Survey
Replication
from 20012003.

Logistic
regression
models used to
explore
relationship
between maletypical
symptoms and
odds of help
seeking for
depression

1) Men who exhibited more
traditional depressive
symptoms were more likely
to seek help (OR 1.604,
p<0.001) than men who
exhibited male-typical
symptoms (OR 0.769,
p<0.001).

Strengths
Controlled for
minority status,
marital status, parental
status, income,
religion, current
employment, and
region of current
residence

Nationallyrepresentativ
e sample
from the
USA
N = 2,296
Non-Latino
men aged 3055

Multinomial
logistic
regression used
to make
comparisons
between sources
of initial help
seeking for men
with maletypical
symptoms

2) The odds of seeking help
increased 60% with each
additional traditional
symptom
3) The odds of seeking help
decreased 23% for each
additional male-typical
symptom
4) Those with male-typical
symptoms were more likely
to initially seek help from a
medical provider than those
with traditional symptoms

Limitations
Data collected
between 2001-2003,
weakening temporal
relevance
Lacks information
regarding adherence
to masculine norms,
so we cannot
comment on how this
interacts with maletypical symptoms
Use of secondary data
analysis means that
not all constructs were

66
Variables: 1)
Index of
traditional
depression
symptoms based
upon the DSM
criteria, 2) Index
of male-typical
symptoms based
upon the
Masculine
Symptoms Scale.
Variables in the
scales were
measured either
‘yes’ or ‘no’ and
scored on a 9point scale for the
traditional
symptoms and a
6-point set for
male-typical
symptoms.

ideally fit for the
present study
Retrospective/lifetime
reporting of
depressive symptoms
may limit accurate
recall and results
CASP Rating: High

67
Authors,
Date
&
Title
Chuick,
Greenfeld,
Greenberg,
Shepard,
Cochran &
Haley (2009)

Aim

Understand:

Theoretical
Framework,
Methodology,
and Methods
Theoretical
Framework:
Qualitative

1)
Manifestation
s of
Methodology:
depression in Grounded Theory
men
A qualitative
2-step interview
investigation 2) Helpof depression seeking
in men
processes
3)
Experiences
with
treatment and
recovery

Context/
Sampling

Data Analysis

Key Findings re: Help
Seeking

Strengths and
Limitations

Midwestern
USA

Each member of
research team
took turns
transcribing
interviews
verbatim.
Grounded
theory approach
taken to coding
transcripts that
identified metathemes and
themes. From
here, theory was
derived and
articulated
through
selective coding
process: defined
the conditions in
which
depression was
experienced by
men, how they
coped, the
outcomes of
their coping, and

1) Cyclical, escalating pattern
of depression was present in
men who demonstrated
atypical symptoms (alcohol
or substance abuse, escalating
interpersonal conflict, and
anger management
problems). This pattern often
fueled by men’s attempts to
hide their symptoms of
depression

Strengths
Methodology allowed
for in-depth analysis
of men’s experience
with depression

Men 18-75
with dx of
and tx for
depression
within prior 5
years
Convenience
and criterion
sampling
n = 15 (1st
interview); n
= 7 (2nd
interview)

2) Access to treatment was
identified by all of the
participants as an important
factor in mitigating
depressive symptoms

Congruence between
study aims, theoretical
framework, and
methodology
Limitations
Sample homogenous:
Caucasian, middle to
upper middle class,
heterosexual
Socioeconomic status
enabled easy access to
health care and other
mental health
resources

3) Men made initial attempts
at addressing their negative
feelings in ways that
concealed their symptoms
from others: substance abuse,
Self-selected and selfinfidelity, avoidance, and
focusing excessively on work identified as having
unipolar depression
4) After a period of trial and

68
how they either
departed from or
continued in
their cycle of
depression.
In second
interview,
themes that
emerged were
presented back
to participants
and feedback
given for
accuracy.

error with temporary
measures (above) to conceal
internal conflicts, the cyclical,
escalating nature of
depression required external
intervention by a significant
other
5) Participants reported
depression as not socially
acceptable for men, it was
inappropriate for men to seek
help, support for men is
lacking, men who are
depressed are often perceived
as weak, and men felt social
pressure to hide negative
emotions.

Attrition between two
interviews leading to a
sampling bias
whereby resilient
participants were
overrepresented in the
second stage of the
study
CASP Rating: High

69
Authors,
Date &
Title

Aim

Coen, Oliffe,
Johnson, &
Kelly (2013)

Understand:

Looking for
Mr. PG:
Masculinities
and men’s
depression in
a northern
resourcebased
Canadian
community

1) How men
describe
Prince
George (PG)
2) What men
think are
masculine
ideals in PG
3) How
men’s
depression is
perceived in
PG
4) How
depressed
men relate to
PG masculine
ideals

Theoretical
Framework,
Methodology,
and Methods
Theoretical
framework:
Qualitative
Methodology:
ExploratoryDescriptive
Interpretive,
semi-structured
interviews
Couples were
interviewed
separately

Context/
Sampling

Data Analysis

Key Findings re: Help
Seeking

Thematic
analysis:
Initial deductive
Convenience approach taken
and snowball whereby
sampling
interview data
were
n=9
categorized
heterosexual based upon a
couples aged priori themes
26-44
(themes as per
‘aim’ column);
8 identified
this developed
as Anglothe dataset for
Canadian, 1
the inductive
as “other”
analysis. The
inductive
Participants
analysis
took 21-item involved
Beck
distilling the
Depression
dataset into
Inventory and micro-level
scored a
themes to
range of
identify patterns
mild,
and
moderate, to
relationships
severe
among them. A

Depression and happiness
framed as feminine/not
masculine.

Prince
George, BC

Northern environment
favours strong & stoic men
with an “indomitable work
ethic” and who engage in
labour-intensive work.
Seeking help for emotional
concerns seen as incongruent
with this collective identity
Wider stigma that depression
was something people
“brought on themselves” so
cure is to “go get a pill like
everyone else”
Northern, rural context
associated with traditional
masculine stereotypes
(monologic)
Marginalization of men who
identify with more nuanced
masculine identity (dialogic)

Strengths &
Limitations
Strengths
Congruence between
study aims, theoretical
framework, and
methodology
Good balance of direct
quotes and
interpretive narrative
Limitations
Small sample size and
unclear if data
saturation reached
Men who identified
with dialogic traits
were white-collar
workers and
comprised most of the
sample à ? sampling
bias and selection of a
non-representative
sample
Themes not reviewed
by third party but

70
depression

Authors,
Date & Title
Johnson,
Oliffe, Kelly,
Galdas, &
Ogrodniczuk
(2012)

Aim

To determine
how
participants
reproduced or
reconstructed
Men's
the dominant
discourses of discourse of
help‐seeking men’s help
in the context seeking for
of depression depression
and to

Theoretical
Framework,
Methodology,
and Methods
Theoretical
Framework:
Qualitative
Methodology:
Discourse
analysis
Semi-structured
interviews

Context/
Sampling
Vancouver
(n=20);
Prince
George
(n=10), and
Kelowna
(n=8)

final deductive
approach was
taken to fit the
micro-themes
into broader
conceptual
categories that
were integrated
with masculinity
frameworks and
relevant
research studies.

Data Analysis

Interview
transcripts were
mined for
instances in
which
participants
detailed
depressionConvenience related “help
sampling
seeking”.
Another subset
Men aged 24- of data was

Men who identify with
monologic masculinities were
more likely to conceal their
depression and engage
in/exhibit maladaptive coping
and atypical sx (substances,
anger).
Men who identify with
dialogic masculinities more
likely to legitimize alternate
masculine ideals, recalibrate
gender relations, and select
healthful monologic traits
Key Findings re: Help
Seeking
5 discursive frames
identified:

were discussed
amongst authors
All participants
heterosexual and in
current relationship,
which is known to be
a mediating factor in
depression
CASP Rating: High

Strengths &
Limitations

Strengths
Consistent with
discourse analysis, the
1) Manly self reliance –
study maintained a
invoked when men tried to
strong critical stance
position their depression as a throughout, and the
minor personal problem that
semi-structured
could be handled alone. Key
interview
feature that manly men don’t methodology was
seek help. Depression a
congruent with its
departure from masculinity so philosophical
avoiding help seeking
perspective.

71
determine if
there were
alternate
ways in
which they
framed their
help-seeking.

50

identified under
theme of
Depressive
“engagement”,
symptoms
where
elicited from participants
Beck
detailed
Depression
interactions with
Inventory
healthcare
(BDI).
providers. Texts
Patients self
were then
identified as
reviewed to
having
understand: 1)
depression.
the discursive
12 of the 38
frames that
participants
shaped the way
had not been men talked
formally
about help
diagnosed but seeking, 2) the
all met
nature and tone
criteria based of the language
upon their
used to describe
BDI score
help seeking and
how this relates
to perceptions of
gender, and 3) to
what extent men
reproduced or
resisted popular
discourses about
masculinities,
depression and

minimized additional
potential stigma.
2) Treatment seeking as
responsible, independent
action – action oriented
approach taken to help
seeking, but only after
internal resources had been
exhausted. Help seeking more
acceptable when a threshold
of pain or suffering was met.
3) Guarded Vulnerability –
while men talked about how
they were not coping, they
simultaneously recognized
their masculine ideals were
being threatened. Cautiously
seeking assistance, limiting
disclosure, and minimizing
the severity of depression
thus guarded their
vulnerability.
4) Desperation – help was
sought when the need was
urgent and there were
perceived life-threatening
consequences to not seeking
help. Language used invoked

Sufficient number of
quotations to support
the authors’
interpretations of the
text.
Limitations
Not all interpretations
were backed by prior
theory or literature
and the authors did
not remark on
researcher biases or
cultural stances
Individual outlying
experiences were
tenuously applied to
fit with the
overarching frames
mined from the data
analysis.
Convenience sampling
may lead to sampling
bias
Authors did not
disclose how they
handled potential bias

72
help seeking.

sense of drama and suspense
– privileges actions that offer
possibility of recovery or
preserving masculine ideals

in their interpretation
of the transcripts, nor
did they comment on
how disagreements in
interpretation was
5) Genuine Connection – men handled
were willing to talk openly
and at length about their
depression with healthcare
CASP Rating: Low
providers with whom they
felt genuinely understood
them as a person, the
complexity of their lives, and
their depression. Desire for a
collaborative partnership, not
be in a deferential position as
the patient.

73
Authors,
Date, &
Title

Aim

Rice,
Aucote,
Parker,
AlvarezJiminez,
Filia, &
Amminger.
(2015)

To examine
the
relationship
between the
chronicity of
depression
symptoms
and help
seeking.
Looked at
two
relationships:

Men’s
perceived
barriers to
help seeking
for
depression:
Longitudinal
findings
relative to
symptom
onset and
duration

1) Length of
depression
and attitudes
towards help
seeking
2) Previous
mental health
help seeking
efforts and
attitudes
towards help
seeking
barriers

Theoretical
Framework,
Methodology,
and Methods
Theoretical
framework and
methodology not
stated

Context/
Sampling

Data Analysis

Key Findings re: Help
Seeking

Strengths &
Limitations

Participants
were classified
Convenience according to
sampling via their PHQ-9
Facebook
Scores: no or
Longitudinal self advertisemild depression
report data
ment
(0-9) and
collected at two
depressed (>9).
points in time. At n=125 (82
They were then
T1, depression
metropolitan, grouped as
was assessed with 25 regional,
never being
PHQ-9
18 rural)
depressed, being
questionnaires
depressed only
and participants
Men aged 18- at T1, only at
were asked if they 67
T2, or at both
had ever been
T1 and T2.
treated for
Factorial
depression. At
multivariate
T2, an average of
analysis of
15 weeks later,
covariance was
PHQ-9 was
undertaken
completed as well
using the 5
as the Barriers to
BHSS subscales
Help Seeking
as dependent
Scale (BHSS).
variables.
This scale is
Independent
comprised of
variables

No significant effects were
observed for previous help
seeking for depression
No effect on help seeking
barriers based upon age

Strengths
Use of longitudinal
data

Australia

Comparison between
indicative diagnostic
groups

Men depressed at T1 and T2
had more perceived barriers
Limitations
to depression than men with
no or transient depression (for Incongruence between
study aims and
all subscales in the BHSS)
methodology. Aimed
Symptom severity correlated to explore attitudes
regarding help seeking
with more overall barriers to
but utilized survey
help seeking
data that was
interpreted
For men with depression at
quantitatively
T1 and T2, the most
commonly reported barrier
Relies solely on self
was “need for control and
report data
self-resilience”
Responses to the
BHSS collected at T2
only
Group sizes grossly

74
subscales: Need
for Control and
Self Reliance,
Minimizing
Problems,
Concrete Barriers,
Privacy, and
Emotional
Control.
Respondents were
ask to answer in
the context of
hypothetically
suspecting they
had depression.
Authors,
Date, &
Title

Aim

Rochlen,
Paterniti,
Epstein,
Duberstein,
Willeford, &
Kravitz
(2010)

Describe the
influence of
masculine
role
expectations
on:

Barriers in
diagnosing
and treating

1) The
recognition
of depressive
sx

Theoretical
Framework,
Methodology,
and Methods
Theoretical
framework and
methodology not
stated
Data collected via
focus groups in 3
sites (see
context/sampling)
Researchers who

included men
who had
previously
sought help or
not, and the four
depression
groups outlined
above.

unequal (80 had no
depression, 9 had
depression at T1 and
T2)
Selection bias due to
sampling technique
Responses based upon
hypothetically
suspecting they had
depression
QATQS Rating: Low

Context/
Sampling

Data Analysis

Key Findings re: Help
Seeking

Strengths &
Limitations

3 sites across
the USA:
NY, TX, CA

Recordings were
transcribed and
reviewed for
accuracy. Codes
were applied to
each transcript
based upon
concepts of role
of masculinity,
men’s
characterizations

1) Incongruence between
male role, depression, and
treatment. Aspects of the
male role may interfere with
men’s experience of
depression and help seeking
patterns (happiness not linked
to masculinity, depression
dialogue ‘feminine’)

Strengths
Congruence between
study aims and
methodology

Convenience
and
purposive
sampling
(selected zip
codes for
desired SES)

2) Male-type or masked

Reasonably diverse
and representative
sample of men
Majority of
participants had

75
men with
depression

2)
Appropriate
help seeking
behaviours
3) Reactions
to maletype/masked
depression
4) Reactions
to depression
treatment

had expertise in
sociology,
psychology, and
medicine
developed
questions.
Questions were
tested in pilot
groups in each
study site.
Questions asked
about: 1) unique
obstacles to
depression
recognition and
help seeking, 2)
messages
received that
contributed to
those barriers, 3)
thoughts,
reactions, and
experiences to the
concepts of
masked or maletype depression

Low/lowmiddle
income men
24-64 with
self-reported
personal or
family hx of
depression
80% had
sought
treatment for
emotional or
mental health
concerns in
the past year
n = 45

of depression,
help seeking,
and treatment.
Coders
discussed these
categories and
came to a
consensus on
recurrent
themes,
conceptual
descriptions, and
illustrative
examples from
focus group
responses. To be
considered a
salient aspect of
men’s
discussion, a
theme had to
appear in two or
more groups. An
external coder
reviewed
preliminary
codes.

depression: Endorsement of
men’s alternative or
unrecognized experience of
depression (looking good and
remaining in control,
covering up depression with
substances or other
problematic, compulsive
behaviours, self-mask/refusal
to recognize depression)
3) Reactions to treatment and
treatment providers
a) Barriers: perceived
incompetence or
ambivalence, frustration
toward drug treatment,
preference to solve on their
own
b) Benefits: efficacy of
treatment, focused time to
address problems,
reframing depression as a
medical condition

recently sought help
for mental health
concern, likely
improving the
accuracy and salience
of their responses
Limitations
Many participants had
very severe
depression, others also
had comorbid bipolar
disorder and substance
abuse. May impact
generalizability of
results
Self-identification of
depression may mean
that participants had
certain characteristics
that differ from men
who did not
acknowledge
depression dx and
who avoid seeking
help
Focus groups can lead
to “group think”,
where themes may

76
seem more robust than
if interviews were
done individually
All facilitators were
white academics; this
may bias the
responses based upon
power dynamic
CASP Rating: High

77
Authors,
Date, and
Title

Aim

Sierra
Hernandez,
Han, Oliffe,
Ogrodniczuk
(2014)

Investigate
the
corresponden
ce of the five
socialpsychological
processes
proposed by
Addis and
Mahalik4
(2003) to the
actual help
seeking
experiences
of depressed
men.

Understanding HelpSeeking
behaviours
among
depressed
men

Theoretical
Framework,
Methodology,
and Methods
Theoretical
Framework:
Qualitative
Methodology:
Interpretivedescriptive
Individual indepth semistructured
interviews
conducted, with
questions
corresponding to
each of Addis and
Mahalik’s five
socialpsychological
processes.
Participants took
BDI to score their

4

Context/
Sampling

Data Analysis

Key Findings re: Help
Seeking

Strengths &
Limitations

Vancouver,
BC

Interview
recordings were
transcribed and
reviewed for
accuracy.
Transcripts
were read for
instances where
participants
described
depression
experiences.
This became the
parent code,
from which a
coding schedule
was developed
where data was
assigned to one
of Addis &
Mahalik’s
processes.
Recurring,

Interview data from all
respondents corresponded
with three of Addis and
Mahalik’s processes (see
points 1-3 below), and over
half of respondent’s endorsed
two of their processes (see
points 4-5 below).

Strengths
Congruence between
aims and methodology

Convenience
sampling
(postcards
and
brochures
distributed at
outpatient
psychiatry
clinics and
UBC)
Participants
were English
speakers who
had sought
help for
depression
and had
received a
formal

Including men who
have an established
diagnosis of
depression and who
have sought help may
1) Is the Problem Normal?
provide important
All men perceived depression insights to this
as common among men, but
experience
concluded that disclosure or
Limitations
acknowledgment is socially
prohibited because of social
Men who have already
and self-pressure to conform sought help may have
to masculine norms.
different
characteristics than
Participants reported both
men who have not
DSM criteria symptoms and
sought help, limiting
other characteristics,
including social withdrawal, the generalizability of
this data
irritability, binge-type
behaviours (eating, sex)

Addis and Mahalik’s (2003) five proposed mechanisms though which masculinity influences help seeking include: 1) the perceptions of the normativeness of the
problem, 2) the ego centrality of the problem, 3) the opportunity to reciprocate, 4) characteristics of the social groups to which individuals belong, and 5) perceived
loss of control.

78
depression at the
time of the study.

diagnosis of
depression
n=13 men
Primarily
heterosexual, white,
employed
and well
educated

converging, and
contradictory
patterns were
distilled, along
with illustrative
examples of the
data. Crossanalysis was
then undertaken
to generate key
concepts that
were found both
within and
across data. An
external judge
reviewed coding
and concept
analysis.

2) Is the Problem a Central
Part of Me? Respondents
suggested that depression
interfered with their ability to
conform to masculine norms
and to “do” masculinity,
which appeared to be a
central part of their identities
as men. Depression was
consistently reported as
interfering with their ability
to succeed, sense of control,
strength, and social
engagement.
3) What Can I Lose if I Ask
for Help? Seeking help was
viewed as a loss of
independence, control, and
sense of masculine identity.
Respondents tended to prefer
self-management approaches.
Some men felt that if they
had a choice in seeking help,
this could maintain a sense of
control and ultimately afford
greater autonomy.
4) Will I Have the
Opportunity to Reciprocate?

Non-longitudinal data
does not allow for
interpretation of how
these factors might
change over time
Sample homogenous:
white, employed, well
educated
CASP Rating: High

79
Men were reluctant to
reciprocate support despite
recognizing its positive
effects.
5) How Will Others React if I
Seek Help? Being known to
have accessed professional
help or support from others
made some men feel they
would be viewed as weak or
as transgressing masculine
norms. When seeking help
was disclosed, it was done
discreetly or purposefully
within a social context felt to
be more accepting, as in
educated communities.

80
Systematic Reviews
Review
Authors,
Date, &
Title

Aim

Hoy, 2012 Describe
men’s
Beyond
perspectives
men
on
behaving
psychologic
badly: a
al distress
metaand help
ethnoseeking in
graphy of order to
men’s
inform best
perspecpractice and
tives on
policy,
psychogenerate
logical
new theory,
distress
and identify
and help
gaps in
seeking
knowledge

Type of
Review,
Methods &
Quality
Assessment
MetaEthnography
Systematic
search of
electronic
databases
including:
MEDLINE,
Web of Science,
CINAHL, Social
Science
Scholar’s Portal,
and Google
Scholar.
Quality
assessment done
via 12-item
checklist. Key
papers identified
based upon
contextual
richness and

Study
Types,
Dates &
Number

Context

Key Findings

Qualitativ
e

Psychological
distress,
excluding
schizophrenia

1) Men’s general
understanding of the concept of
psychological distress – men
are uncomfortable with the
term depression; instead use
terms “stress”, “distress”, or
“burnout”. Men aligned
depression with feminine
qualities or personal weakness.

Studies
published
between
1993-2010
51 studies
n =1477
men

Majority
from
North
America,
Australia,
and UK

2) Perspectives on causes of
distress: the social explanation
reigns – financial concerns,
poverty, unemployment,
stressful working conditions,
and social isolation were the
main causes of distress quoted
by men.
3) Symptoms and experiences
of psychological distress –
most common symptoms
reported were of feeling lonely
and alienated. Other common

Strengths & Limitations

Strengths
Inclusion of perspectives of men
from minority cultural groups,
including rural men, African
American men, and gay men
Congruence between study aims
and choice of meta-ethnographic
methodology
Limitations
No search for unpublished works,
grey literature, non-peer reviewed
literature, non-English
Single author
Quality assessment subjective and
unclear if quality assessment tool
was validated
Thematic analysis poorly described
and subjective

81
potential for
contribution to
the synthesis.
Data examined
for common
themes, which
were Hoy’s
interpretation of
the study
author’s
interpretation.
Subthemes
mined from this
data, and finally
studies were
examined to
look for
reciprocal and
refutational
characteristics.

symptoms included: somatic
complaints and anger.
4) Coping – 63% of studies
described men undertaking
‘maladaptive’ coping: avoidant
measures such as alcohol,
drugs, risky sexual behaviour,
or work. 45% mentioned the
‘adaptive’ coping styles: social
connection, re-establishing
control, coming to terms or
finding meaning in their
personal experiences, and
harnessing traditional
masculine traits to help and
cope.
5) Help Seeking – Barriers:
social stigma, fear or
apprehension about health
professionals giving
medication and loss of control.
Facilitators: having a trusting
relationship with someone who
encouraged help seeking,
positioning help seeking as
“brave”, and positioning
depression as “normal”.
6) Perspectives of men from

Interpretation can only be based
upon the quotes the original authors
choose to publish
CASP Rating: Low

82
different communities – for
rural men, the masculinity
inherent in farming profession
provides these men with power
and influence in their
communities and homes, but in
bad times, these men suffer
extreme stress and their
masculine ideals prevent them
from acknowledging problems
or seeking help.
Review
Authors,
Date, &
Title

Aim

Seidler,
Dawes,
Rice,
Oliffe, &
Dhillon
(2016)

Rigorously
collate and
present
finding
from the
existing
literature
related to
the role of
masculinity
on men’s
help
seeking for
depression

The role
of
masculinity in
men’s
help
seeking

Type of
Review,
Methods &
Quality
Assessment
Systematic
Review
Adherent to
PRISMA
guidelines.
Studies
identified
through
MEDLINE,
PsycINFO,
SCOPUS,
CINAHL, Web

Study
Types,
Dates &
Number

Context

Qualitativ
e (n=17)
and
quantitativ
e (n=18)

76%
(n=28)
from US
or Canada

Studies
published
between
1995-2015
Total
number of
participant

14 from
university
population
s, 14 from
general
communit
y setting,
10 from
primary

Key Findings

1) Quality Assessment:
Qualitative studies showed
moderate to high
methodological rigour.
Quantitative studies were of
low to moderate quality.
2) Themes Identified (in order
of occurrence):
i) Impact of masculinity on
depression symptoms –
Incongruence between
depressive symptoms and
masculine ideals lead to fears

Strengths & Limitations

Strengths
Highlighting poor quality of studies
serves to create strong
recommendations for future
research
Rigorous application of PRISMA
guidelines
Limitations
Possibility of publication bias,
since studies with positive findings
are more likely to be published

83
for
depresssion: A
systematic
review

and provide
recommend
-ations for
future work
in the area.

of Science, and
Proquest
Central, as well
as through
manual
searching of
reference lists
Thematic
analysis done in
three stages
synthesize the
qualitative
studies: 1) free
line-by-line
coding of each
study’s findings,
2) codes were
organized into
relevant areas or
“descriptive”
themes, 3) six
“analytical”
themes
developed
Quality
assessment
included risk of
bias in sampling
and

s = 8146
men and
women

care
physician/
outpatient/
hospital
setting, 2
from
online
social
networkin
g sites

of “otherness”. These fears are
proposed to increase severity
of symptoms.
ii) Difficulty communicating,
recognizing and understanding
depression – men are socially
conditioned not to engage in
emotion-based communication,
and help seeking is hindered by
a limited vocabulary. Typical
depressive symptoms not
interpreted as signals of mental
illness by men.
iii) Impact of masculinity on
help-seeking - Men tended to
engage in treatment only when
internal resources become
depleted and depressive
symptoms severe
iv) Type of therapy and
therapist preferred – most
preferred action-oriented
interventions based on problem
solving strategies, as in CBT
but not other forms of “just
talking” therapy. Preference for
therapeutic relationships built
on trust and defined by open,
collaborative partnerships
v) Masculinity and
maladaptive coping styles –

Choice of search databases may not
have been exhaustive
The relative importance of the
themes derived in the thematic
analysis of qualitative studies are
not necessarily reflected in the
number of studies reporting similar
findings
Possibility of subjectivity in quality
assessment
Poor overall quality of studies
(particularly quantitative) may
diminish application of the findings
CASP Rating: High

84
measurement
using “preformulated
rating criteria”.
Inter-rater
reliability was
excellent
(k=0.92)

social withdrawal, substance
abuse, risk-taking behaviour,
anger-fuelled conflict,
increased work hours were
used to cope with depression
instead of seeking help. These
coping tactics were believed to
be more masculine
vi) Reshaping and reframing
masculinity – Reframing
traditional masculine ideals
towards more fluid
masculinities allowed men to
better express, understand, and
accept their depression