Men are less likely to be diagnosed with depression, less likely to seek treatment, and yet also die by suicide at roughly four times the rate of women. Those three facts tell one story. Together they describe a system that misses depression in men and finds out too late.
We miss it because we’re looking for sadness. In men, depression often shows up as something else.
What depression can look like
The patients I worry most about aren’t the ones who come in crying. They’re the ones who come in for something else. The details below are composites, but every clinician will recognize them.
A contractor in his 40s comes in for his blood pressure. His wife made the appointment for him. He mentions he’s “short with the kids lately” and that a six-pack has become his nightly way to “shut his brain off.” He scores a 3 on the PHQ-2 yet calls it “stress.”
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A surgeon picks up every extra call shift. His colleagues see a workhorse. At home he’s asleep on the couch by 8 p.m. or awake at 3 a.m. He hasn’t laughed, at anything, in months. Work is the only place he still feels competent. He tries to never leave it.
A fifty-two-year-old buys a motorcycle, starts an affair, and gets two speeding tickets in a month. His friends joke about a midlife crisis. Nobody uses the word depression, including him. He’s able to laugh, but it doesn’t touch his eyes. No one calls that detail out.
A recently separated father blows up at his son’s Little League coach in front of all the families on the bleachers. He’s mortified afterward. He can’t explain it. He hasn’t slept more than five hours a night since spring of last year.
None of these men would answer yes to “Have you been feeling down or hopeless?” Irritability, drinking, overwork, risk-taking, and affairs are also, sometimes, symptoms. These men numb the pain more than they express it. They hide in plain sight. When researchers added anger, substance use, and risk-taking to the “standard” symptom list, men met criteria for depression at nearly the same rate as women.
The hardest presentation to catch is competence. The man who meets every deadline, coaches the team, and fixes everyone else’s problems? He doesn’t get asked how he’s doing. Competence is rewarded. It’s an excellent hiding place.
Our system waits for a patient who won’t show up
Depression care assumes a patient who will make the appointment, fill out the questionnaire, and describe his mood to a near stranger. Many men won’t. Some don’t have the words. Others have them and won’t say them. When they don’t show up, or show up and say “fine,” we chart it and move on. If a group of patients reliably slips past our screening? The problem is the screening.
Veterans carry the same script
Military culture prizes endurance, self-reliance, and, above all, finishing the mission. Those are the traits that keep depression out of sight. Add to this a culture where a diagnosis can be a career risk, and a treatment menu that starts with a medication they may have to disclose? Many capable people decide the safest move is to say nothing. As Veterans Day approaches, remember that silence isn’t wellness.
Three things to change on Monday
Ask different questions. “How has your mood been?” gets “fine.” Ask what men will actually report: “How’s your temper lately?” “How many drinks on a typical night?” “What time do you wake up?” “How many hours are you working?” “Taking more risks than usual?” Concrete questions don’t require a patient to name a feeling he may not recognize.
Treat reluctance as a symptom. Missed appointments, minimizing, and “patient declined” are often the illness talking. Depression tells people their suffering doesn’t count and that nothing will help. Follow up anyway.
Widen the menu. Medication and therapy should stay central. But if they’re the only doors? Some men will never walk through. Patients can’t choose treatments no one tells them about.
Beyond the next pill
For many men, the first antidepressant doesn’t do enough, and neither does the second. Roughly a third of patients with major depression don’t respond adequately to medication. The usual next step is another prescription, then another, each with its own trial period, side effects, and, for some patients, its own disclosure problem at work. Every medication switch takes months. For a man who barely made it to the first appointment, that often-futile cycle is often where we lose him.
We have options that aren’t a pill, and we should bring them up much earlier in the process, if not as one of the first options to consider.
Transcranial magnetic stimulation has been FDA-cleared for depression since 2008 and is well studied. Accelerated protocols compress treatment from six weeks to days. I’ve been an author of many such studies. Esketamine, given in a certified clinic under observation, can work within hours to days. Electroconvulsive therapy remains the most effective treatment we have for severe depression, despite its reputation. These are interventional treatments: They act on the brain directly, and most involve no daily pill at all.
The newest option moves brain stimulation into the home. In December 2025, the FDA approved an at-home brain neuromodulation headset, by prescription only under a physician’s supervision, for major depression that hasn’t responded adequately to one or more antidepressants. In its randomized, sham-controlled trial, 21.3 percent of patients reached remission at eight weeks, compared with 6.0 percent on the sham device. I have a stake in this one: I serve as chief medical officer of the company that makes it. I mention it here because the delivery model matters for the men in this essay. No daily clinic visits. No new prescription bottle. Treatment that fits into a life rather than taking one over. Treatment is private and preserves dignity.
None of these is right for everyone, and each has trade-offs in cost, access, and time. But a man who has quietly given up? He deserves to hear there are treatment options available he may not know about, and they aren’t another pill.
One question
At your next visit with a man who seems fine, skip “Are you depressed?” Try: “You seem stretched thin. How are you really doing?” Then wait.
Many of the men we lose were never asked in a way they could answer.
If you or someone you know is in crisis, call or text 988. Veterans and service members can press 1.
Owen Muir is a child, adolescent, and adult psychiatrist, a multiple-time founder, and chief medical officer of Neurolief. He is the author of The Frontier Psychiatrists, a bestselling Substack focused on innovation in psychiatry, neuroscience, and mental health. For the past four years, he has incorporated AI-enabled neuroimaging into clinical care.
He has served as a principal investigator for clinical research that contributed to efforts bringing multiple medical devices to new FDA-cleared indications. He practices medicine at MacMillan, Muir & Associates. His books include Thirty-Five Minutes: The Lindsay Clancy Mistrial and an After-Action Report for American Psychiatry and Inessential Pharmacology: A Frontier Psychiatrists’ Guide to Understanding Psychiatric Medications, and he is a coeditor of Adolescent Suicide and Self-Injury: Mentalizing Theory and Treatment.
Neurolief is a privately held medical technology company developing neuromodulation technologies that engage the occipital and trigeminal nerve pathways to treat major depressive disorder and migraine.
The company first commercialized its technology in migraine, where it holds regulatory approvals in the U.S., Europe, and Japan. It has since expanded into depression with ProlivRx, a first-in-class, FDA-approved prescription neuromodulation therapy delivered at home for adults with major depressive disorder who have not achieved satisfactory improvement with antidepressant medication.
ProlivRx addresses a widely known care gap for patients who have experienced antidepressant failure or inadequacy but have limited access to effective therapies that are only available in clinics or hospital settings.
Questions? Reach us through our website or at 844-277-6548.
