One of the most well-established findings in the epidemiology of psychiatric disorders is that women have nearly twice the lifetime risk of developing major depressive disorder than men. Suspected contributors to this stark difference include: a biological susceptibility stemming from hormonal or other gender differences; reporting bias, with women being more likely to acknowledge and seek help for sad or negative feelings; greater vulnerability to depression as a result of higher rates of childhood sexual and other trauma or differential processing of stressful life events; and sociocultural factors relating to reduced options for career and self-fulfilment compared with men. The relative contribution of each of these factors to the differential in rates is unknown. ^{Reference Piccinelli and Wilkinson1}

This difference in incidence may well change in the coming decades. There are two major societal shifts underway that could increase rates of depression among men. These forces are already apparent in Western societies, and are likely to gain strength with future generations. First, societal expectancy norms of men to be tough, stoic and not show their feelings are being significantly eroded. Programmes involving famous, respected men publicly discussing their depression (e.g. Mike Wallace, Rod Steiger) and awareness campaigns such as ‘Men Get Depression’ (http://mengetdepression.com/) have had a significant impact in opening up the public space for men to feel able to endorse symptoms of depression.

Socioeconomic changes

A second major societal shift is the profound restructuring underway in Western economies. Traditional male jobs associated with manufacturing and physical labour are increasingly being outsourced to low- and middle-income nations or becoming obsolete through technological advances. In general, blue collar jobs are being replaced by service sector jobs. The recent recession afflicting Western economies serves as a harbinger of the economic future for men, especially for those with lower levels of education. Dubbed by some the ‘Mancession’, the economic downturn has hit men particularly hard, because of its disproportionate effect on traditional male industries, such as construction and manufacturing, although of course working women have also been affected. Roughly 75% of the jobs lost since the beginning of the recession in 2007 were held by men. ^{Reference Taylor, Fry, Cohn, Wang, Velasco and Dockterman2} Economic sectors staffed largely by women (such as healthcare and education) are among the few minimally affected by the current economic turbulence.

There is little reason to believe that traditional male jobs will return in significant numbers with economic recovery. Moreover, the difference between the genders in the pursuit of higher education suggests that the economic pressures on men will continue. In 2006, women received 58% of all undergraduate degrees and 60% of all Master degrees in the USA, and in England women are 25% more likely than men to attend university. ^{Reference Harrington, Van Deusen and Ladge3} University graduates are substantially less likely to be unemployed than those who do not enter or complete higher education, although the benefits of education on employment may vary by gender.

Furthermore, Western women are increasingly becoming the primary household earners, with 22% of wives earning more than their husbands in 2007, versus only 4% in 1970. ^{Reference Galinsky, Aumann and Bond4} Given that more women than men are attaining higher educational degrees, this trend will likely continue in the coming decades. When couples have children, economic imperatives are forcing men to play a greater role in child-rearing and housekeeping roles. This entails a changing self-identity. It is worth thinking about the implications for men's mental health that these economic and societal changes will bring.

Men's roles and sources of self-esteem

In contrast to women, who derive self-esteem largely from reflected appraisals, men attach greater importance to social comparisons, particularly with regard to their roles as providers and protectors of their families. ^{Reference Schwalbe and Staples5} Men traditionally have seen their contributions to child-rearing and household chores as necessary, albeit secondary contributions to help their spouse, and not necessarily intrinsically rewarding in themselves. Men's failure to fulfil the role of breadwinner is associated with greater depression and marital conflict. ^{Reference Crowley6} Men in dual-earner couples now report substantially higher rates of work–life conflict than women (59% v. 44% in 2008), reversing the 1997 rates (34% v. 41%, respectively). ^{Reference Galinsky, Aumann and Bond4} However, the breadwinner role can be conceived as a social construct, with men who conform to it experiencing reduced psychological distress through benefits to self-esteem. If this social construct is modified over time as more women become leading income earners for their families, men who do not occupy this role may experience less distress, as other arenas of self–other comparison become more socially salient. Self-perceived competence is important to the maintenance of self-esteem for both genders. ^{Reference Schwalbe and Staples5} Thus, the potential for development of depression from low self-esteem may hinge on how successfully men are able to carry out the functions of homemaker and primary caregiver to their children. How well men adapt to these new roles will be critical to determining whether these societal changes carry a negative impact for men's mental health.

There is certainly broad variability among both men and women in their innate child-rearing skills and ability to derive satisfaction from maintaining a household. However, data suggest that, in general, abilities required to relate to young children are differentially distributed between men and women, with females having significantly greater empathic, verbal and non-verbal cue-detecting skills than males. ^{Reference Rosenthal and DePaulo7} Preliminary neuroimaging studies suggest divergent neural-processing patterns in response to child stimuli between men and women, although these findings could derive from differing socialisation patterns, innate biological differences or a combination of both. ^{Reference Swain8} If these differences are rooted in biology, then most men placed in these roles will likely find it harder to fulfil the role of primary care provider to young (especially preverbal) children than most women. On the other hand, if these differences stem from socialisation, it may be possible to design programmes to enhance these skills in expectant fathers. Without such interventions, many men could find themselves in a dynamic where they feel overwhelmed, incompetent and possibly trapped in an unfamiliar domestic role, laying the groundwork for the development of depression over time. This loss of self-worth together with peer comparison (self v. other working men) may increase feelings of being a ‘failure’ and, consequently, the risk for depression. Additionally, there is an obvious potential for higher rates of substance misuse to accompany these psychological changes.

Another recent line of research has identified high levels of depression in men in the postnatal period. ^{Reference Paulson and Bazemore9} Some data indicate that testosterone levels in men drop in the months prior to and immediately after the birth of their child, although compelling evidence of this change as a causal mechanism for early fatherhood depression is lacking. Other research suggests that the dramatic marital and role changes that accompany parenthood exert strong psychological forces that may increase men's risk for depression. With men playing greater roles in parenting in the coming century, the prevalence of depression in men may correspondingly increase. Studies have repeatedly reported increased psychopathology and behavioural disorders in the children of parents with depression, whether father or mother. Thus, the risks of intergenerational transmission of the effects of paternal depression are significant.

Looking ahead

Western men, particularly those with low education levels, will face a difficult road in the 21st century. It may be more difficult, on average, for men to adjust to a domestic role than for women to adjust to a work role. Some may no doubt take exception to this argument. Many men excel in domestic roles already ^{Reference Harrington, Van Deusen and Ladge3} and more will find such a role rewarding, whether freely chosen or externally imposed. Some might argue that it is sexist to think that men face greater challenges than women in becoming homemakers and primary caretakers of young children. We are not arguing that men are incapable of taking on such roles, only that this dramatic role shifting and its associated strain could increase men's susceptibility to factors associated with the development of depression. Even if men's relative weakness in domestic arenas arises not from biology but solely from different socialisation patterns, then men in the changing economy will still face the same risks for depression that women faced in older economies: trapped in a family role from which they cannot escape because of an inability to find employment. Regardless of whether biological or social forces exert greater influence, men are likely to experience significant stress in these changing roles.

The evolving socioeconomic structure of Western economies provides fertile ground for researchers to specifically evaluate the impact of societal, psychological and biological forces on the aetiologies of depression within genders. Mental health practitioners should be aware of these forces at work in the lives of their patients, and be prepared to explore with them the meanings of these changes. Recent data from the World Health Organization suggests small declines in the gender difference in rates of major depression across younger versus older cohorts, associated with changes in traditional female gender roles. ^{Reference Seedat, Scott, Angermeyer, Berglund, Bromet and Brugha10} Perhaps the changing socioeconomic position of the West will lead to further narrowing of this difference, with prevalence rates of depression in men increasing while rates in women decrease. Such changes would bring a new perspective to the concept of gender equality.

Funding

B.W.D. is supported by National Institutes of Health grant .