Men’s Depression and Anxiety: Contributing Factors and Barriers to Intervention

Contributing Factors to Men’s Depression and Anxiety—Modifiable and Non-Modifiable

To address this health inequity, it will be beneficial to understand the state of the science relative to factors contributing to men’s depression and anxiety. Financial and economic issues have been linked to depression, substance use, and suicidal behaviors (Apesoa-Varano et al., 2015; Currier et al., 2021). A systematic review and meta-analysis found that unemployment was significant in poor prognosis depression while home ownership resulted in an improved prognosis (Buckman et al., 2022). Similarly, a lack of work was found to be a significant source of stress for African American men, specifically relative to being unable to support one’s family and having nothing to do, and led to depression, low self-esteem, suicidal ideation, and anger (Robinson et al., 2021). In another line of inquiry, Cole and colleagues point to the health implications of environmental risks including traditional (heavy pollutants, poor social conditions), transitional (decontamination, new amenities), new (gentrification, access to amenities), and emerging (displacement, climate-related risks, re-emergence of traditional exposures) exposures that lead to poor mental and physical health and to new patterns of health inequity (Cole et al., 2021). Furthermore, in a study of White non-Hispanic and Mexican-origin men aged 60 and older, 52% pointed to declining health, 48% to grief/loss, and 46% to children/extended family conflicts as contributing to depression (Apesoa-Varano et al., 2015). Finally, COVID-19 was found to be a significant factor disproportionately affecting young adults as well as Hispanic and Black persons. A comparison between the second quarter of 2019 and June 2020 revealed that symptoms of anxiety disorders and depressive disorders were approximately three times and four times greater, respectively, and suicidal ideation was also elevated (Czeisler et al., 2020).

Barriers to Mental Health Intervention

The literature documents several barriers to mental health intervention for urban, impoverished, racially/ethnically diverse men. First, in a broader exploration of medical mistrust as it relates to African American men’s preventive health care, the authors found that factors outside health care, such as everyday racism, were most predictive of this group’s service utilization—even more so than lack of health care insurance or access to care—and must be addressed in any quest for health equity (Powell et al., 2019). Specific to mental health intervention, age may be relevant although the literature is mixed with one study noting that younger men are reluctant to seek help (Lynch et al., 2018) and another indicating that older men were more hesitant (Parent et al., 2018). Fear of negative social ramifications of help-seeking and a clash with traditional masculine ideals were other barriers (Lynch et al., 2018).

The additive impact of race/ethnicity and potential barriers to help-seeking may be useful to consider as well. Initially, it is apparent that help-seeking follows unique patterns across racial/ethnic groups. For example, one study found that White participants sought mental health intervention more frequently than Black and Mexican American participants while Black participants sought help significantly more than Mexican American participants (Parent et al., 2018). As a potential elaboration on this, access to mental health services was found to be limited for Black men as a result of stigma, a culture of perceived self-sufficiency, and limited financial resources (Tchouankam et al., 2021). The intersection of race and stigma was also cited in several studies and concluded that mental illness stigma around common mental disorders is higher among ethnic minorities (Eylem et al., 2020; Wong et al., 2021). Interestingly, Lynch et al. (2018) documented stigma linked to the Catholic Church with its emphasis on help-seeking through prayer and confession. Furthermore, a state-wide mental health anti-stigma campaign revealed differential responses across racial/ethnic groups suggesting that efforts to combat a barrier such as stigma must be specifically tailored to the recipient group (Wong et al., 2021). Finally, an interesting dynamic was reported around race/ethnicity and poverty. Income–poverty ratio was unrelated to help-seeking among Mexican American men, negatively related to help-seeking among Black men, and positively related among White men (Parent et al., 2018).

In pursuit of mental health equity and expansion of the science, this study’s objective was to understand perspectives of urban, racially/ethnically diverse, impoverished men on contributing factors to depression and anxiety and barriers to intervention.

Research Questions

Study Design

Using community-based participatory research (CBPR) as the overarching framework, the current investigation utilized a qualitative design. Qualitative designs explore an entire phenomenon (Polit & Beck, 2021) which can be critical to understanding the complexities of a topic like men’s anxiety and depression. CBPR is a philosophy of inquiry that empowers community members to promote social change by identifying their most pressing health concerns and corresponding solutions (Minkler & Wallerstein, 2011). For more than 20 years, a Midwest baccalaureate department of nursing has structured their curriculum around CBPR so as to partner with three urban neighborhoods, create meaningful learning experiences in the neighborhoods, undertake research that benefits residents, and in this manner enhance neighborhood health and address health inequities (Zandee et al., 2015). This study is an element of the nursing program’s continuing commitment to CBPR. Ongoing community assessments and feedback from an existing, CBPR-derived Mental Health Ambassador program suggested that men’s mental health was a significant and largely unaddressed issue in these three communities. The community feedback led to this study on men’s mental health.

Focus groups served as the vehicle for data collection. Focus groups have been identified as an excellent way to understand the perspectives of as many neighborhood residents as possible (Cyr, 2019) while blending them with CBPR facilitates the acquisition of a collective perspective from a homogeneous community (Bush et al., 2019). The research team constructed a semi-structured interview guide that neighborhood residents then evaluated and piloted. The focus group questions explored two spheres: the conceptualization of contributing factors to men’s depression and anxiety and the barriers preventing men from seeking intervention for depression and anxiety.

Setting and Sample

Institutional review board (IRB) approval was granted for this study by the authors’ university on November 23, 2020, via project #20-032. The men were recruited from the three partner neighborhoods which are predominantly Black (52%), Hispanic (70%), and White (65%), respectively, and have 29% to 40% of residents below the poverty level (City Data, 2023). Eligible participants were male residents who were 18 years or older. A convenience sample of 50 men, ranging in age from 23 to 83 (mean age of 45.18 years), was assembled. Forty-six percent of the men were Black, 24% were White, 22% were Hispanic, and 8% identified as other. Thirty-six percent of the men reported annual incomes of less than $15,000, while 44% indicated that their educational level was 12th grade or less.

Procedures

Given COVID-19 considerations, the researchers conducted six Zoom focus groups during the months of June and July 2021. Consistent with neighborhood racial/ethnic demographics, two homogeneous focus groups were offered in each community. In the Hispanic neighborhood, one of the focus groups was in Spanish while the other five groups were in English. Facilitators were selected for their skill sets as well as their demographic match (gender and race/ethnicity) to the participants and were oriented to the project by a member of the research team. Six to 12 men joined each of the focus groups. Groups lasted about 90 min, and upon completion, each participant received a $30 gift card to honor his time investment. To remove barriers to participation, the research team offered devices and Zoom tutorials. Qualtrics was used to obtain informed consent and collect demographic information on each participant prior to commencement of the focus groups. The research team committed to sharing the findings with participants and soliciting their involvement in designing the solution.

Analysis

All focus groups were videotaped, transcribed verbatim, and validated by the researchers. The Spanish tape was transcribed by an undergraduate research assistant, who is fluent in Spanish, and a native Spanish speaker. For the purpose of situating verbal statements in their context, undergraduate research assistants took field notes during the focus groups. The process of thematic analysis was supported by NVivo software and the framework method for analysis of qualitative data in multidisciplinary health research (Gale et al., 2013). Data analysis occurred during the fall of 2021. Themes were labeled as such if they occurred in all six focus groups while subthemes had to have arisen in at least four of six groups. It should be noted that racism subthemes were called out even when fewer than four groups reported given that two of the six focus groups were conducted with White men who likely do not experience this phenomenon.

The research team was cognizant of the overarching importance of trustworthiness of the data. To that end, the researchers focused on credibility and dependability as essential to trustworthiness. Korstjens and Moser (2018) outlined numerous approaches to operationalize credibility. Accordingly, the researchers used several types of triangulation including data triangulation (collection of data on various days and at various times throughout the day), facilitator triangulation (three facilitators, under the direction of the two co-investigators, gathered data while a 4-person team participated in coding via independent and comparative/collaborative analysis), and method triangulation (recorded responses and corresponding field notes were assembled). The strategy of member check was implemented by sharing the saturated themes back to a subgroup of men from each neighborhood for confirmation. Dependability was assured by means of an audit trail (Korstjens & Moser, 2018). The team clearly delineated the study design, outlined processes for constructing the research questions, developed consistent procedures for data collection, and used the framework method (Gale et al., 2013) for the analysis of the resulting qualitative data.

Contributing Factors to Men’s Depression and Anxiety—Modifiable

The men identified three themes and three subthemes around modifiable factors that contributed to their experience of depression and anxiety. The first theme identified as a modifiable contributing factor to men’s depression and anxiety was cognitive health behaviors .

Clearly, the men were articulate about specific types of thought processes that contributed to their depression and anxiety.

The second modifiable theme identified as a contributing factor to men’s depression and anxiety was a social determinant of health— economic stability (Healthy People 2030).

Finances played a central, contributing role in the development of depression and anxiety and the lack of financial education appeared to further exacerbate the situation.

The third modifiable theme identified as contributing to depression and anxiety was also a social determinant of health— social and community context (Healthy People 2030)— interpersonal factors .

Multiple interpersonal factors, including upbringing and relationship conflicts, were identified by the participants as playing a role in their anxiety and depression.

Four of the six groups identified a subtheme around the modifiable causes of depression that falls under the social determinant of health— neighborhood and built environment (Healthy People 2030).

Neighborhood disparities and violent crime contributed to mental health issues for these men.

Four of the six groups identified an additional subtheme around the modifiable causes of men’s depression that falls under the social determinant of health— social and community context (Healthy People 2030)— gender expectations .

The men felt pressure to adhere to specific gender-based standards which contributed to their depression and anxiety.

The final modifiable contributing factor to men’s depression and anxiety was captured in a subtheme under the social determinant of health— social and community context (Healthy People 2030)— systemic racism . It should be noted that this subtheme was established by three of the six focus groups (rather than four of the six) but was recorded as a subtheme given that two of the focus groups were with White men who likely do not experience this phenomenon.

These respondents identified societal processes, racial targeting, and law enforcement-citizen encounters as major contributing factors to their depression and anxiety.

Contributing Factors to Men’s Depression and Anxiety—Non-Modifiable

The men identified one theme and one subtheme that were non-modifiable contributors to their depression and anxiety. The theme, expressed by all six of the groups, was that of loss .

These men experienced a staggering amount of loss that they attributed to their experience of anxiety and depression.

The subtheme in the area of non-modifiable contributing factors to men’s depression and anxiety was that of the COVID pandemic .

The pandemic appears to have exacerbated the mental health vulnerability of these men further.

Barriers to Mental Health Intervention

The men identified one theme and three subthemes related to barriers that they recognized around accessing mental health intervention. These barriers provide significant opportunities for intervention. The theme, identified by all six groups, involved stigma wherein culturally defined gender roles constituted a significant barrier to seeking assistance. This is an obvious corollary to the previously presented data on gender roles as a modifiable contributing factor to depression and anxiety.

The men cited stigma, linked to culturally inculcated implicit and explicit gender norms, that prevented them from acknowledging and addressing depression and anxiety.

The final three subthemes around barriers to mental health intervention were each identified by four of the six groups. Two of the subthemes relate to resource issues—the first being a lack of awareness of mental health resources.

Participants felt that mental health resources were not known and thus difficult for community members to utilize when needed.

The second resource subtheme is that of deficiency or lack of fit . This subtheme was identified by four of the six groups and again suggests an actionable area of intervention.

The participants were vocal about the fact that there were insufficient mental health resources and that some existing resources were ill-suited for segments of the population.

The final subtheme related to barriers to intervention is that of a lack of knowledge of mental illness . Four of the six groups spoke to this area that provides a call to action.

The men spoke of a striking lack of familiarity with descriptions, definitions, and symptoms of depression and anxiety that created yet another barrier to intervention.