“I also take my car to a specialist garage.” factors that facilitate treatment entry among men with depression: a qualitative study

2.1 Data collection

This study is part of the research project “Transformation of masculinity orientations and work-related attitudes among depressed men (TRANSMODE)”, funded by the German Research Foundation. The aim of this project is to investigate the manner in which gender roles evolve over time, as well as the influence of psychological and psychiatric treatment on this process. This study was approved by the ethics committee of Ulm University (Nr. 347/21). Semi-structured interviews with 60 men with depression were conducted between July and September 2023 by three experienced researchers (MS, GK, PN) via encrypted video calls. The research team consisted of one woman and two men. At the time of the interviews, all of them were working exclusively in psychiatric research: two of them with a background in sociology and one with a background in medicine. The average length of the interviews was 63 minutes. The interviews were conducted in German and later translated into English by the research team. In a second step, the translations of all relevant quotations for the analysis of treatment entry were reviewed by an external language editor in order to be able to conduct a qualitative analysis despite the translation. Prior to the interviews, all participants were informed about the study via phone by staff members, and signed a written declaration of consent. After each interview, a short documentary report was written. The interview guidelines were developed by three members of the research team and reviewed by academic peers in a qualitative research workshop. The guidelines aim to provide a comprehensive picture of the way men cope with their depressive illness after being admitted to treatment. They are divided into five topic areas: (1) treatment entry and subjective theory of illness; (2) process of treatment; (3) social environment and disclosure, (4) work and (5) gender and attitudes towards society. The present study is concerned with the men’s entry into treatment and their subjective theory of illness, with specific consideration reserved for supporting factors, barriers, and the role of patient’s social environment. With regard to the patient’s social environment, an occasional question about treatment entry was added after two test interviews. If other people were reported to be relevant for treatment entry, the interviewers then asked whether the said people had treatment experience, as this aspect was found to be significant in the initial interviews.

2.2 Sample

The sample for the qualitative study was drawn as a subsample of a larger quantitative study (N = 323) that was recruited from eight psychiatric clinics in southern Germany (53.5%), as well as via social media (38.3%), the German Depression League, newspapers, and radio. Selection criteria for the study were: identification as male, being aged between 18–65 years, having self-reported a depression diagnosis, and having received some form of treatment for depression from a psychotherapist/psychiatrist or other specialist in the last 12 months. Exclusion criteria were: a primary diagnosis of an addiction-related disorder, a lack of proficiency in the German language, and intellectual disabilities. All participants agreed to be contacted again for an interview. A total of 113 men were asked to participate in an interview in order to reach 60 interviews. The numbering was retained for continuous anonymization, which is why the transcripts were numbered between 1 and 113. In the quantitative study, a latent class analysis was performed, resulting in three classes based on masculinity orientations, work-related attitudes, and health behavior. For the qualitative interviews, approximately 20 representatives from each class participated in order to obtain a heterogeneous sample. Among the representatives of each class, men with the shortest treatment duration were selected. Since these participants had only recently begun treatment, they were able to provide detailed accounts of their experiences. The duration of treatment for the participants ranged from one month to a maximum of 30 months. Thirty-six men were receiving treatment for the first time. Participants’ age ranged from 19 to 63 years (mean age = 40.6). At the start of the study, 40 were employed, 12 were unemployed, and eight were unable to work. Twenty-three participants held a college degree, 25 had completed an apprenticeship, six were still in training or studying, and six had no formal qualifications. Twenty-nine participants were in a relationship, while 31 did not have a steady partner.

2.3 Data analysis

The analysis was conducted using qualitative content analysis according to Kuckartz [29, 30]. First, all interviews (n = 60) were coded on the basis of deductive categories from the guideline using MAXQDA software (MAXQDA2020, VERBI Software, Berlin, BE, Germany). For this purpose, nine interviews (15%) were coded independently by three researchers. The interdisciplinary research team has members with both a social science and medical background. In the next step, differences in the coding were discussed and adapted until consensus was reached. Using the resulting coding system, the remaining 51 interviews were coded by one person each and cross-coded by one other person. For the analysis of treatment entry, the categories “Motivations to seek treatment”, “Obstacles to seeking treatment” and “Importance of patient’s environment at the time of treatment entry” were further analyzed inductively by two authors, and, following consensual validation and based on the research question, the category system was developed for “Factors that facilitate treatment entry”.

3.1 Crisis situation leads to a willingness to change

The interviews show that the decision to start treatment is typically a response to severe suffering and depressive symptoms. A central motivation behind men seeking treatment is to change the level of suffering caused by their depression. To this end, they refer to specific symptoms that they would like to overcome, such as anxiety, insomnia, mood instability, and a lack of perspective. In addition, the respondents generally describe wanting to develop personally and improve their quality of life. Moreover, for several men, one reason for seeking treatment was to overcome suicidal thoughts:

“On the one hand, there was a very big trigger in December, when I uh began to feel suicidal (…) and then a kind of will to survive set in or, not quite that, but I then realized, no, I don’t want that and I have to change something, because otherwise everything will simply become very… intense.” (Interview_04)

In this case, the person only entered treatment at a time when their state of health was so severe that there was no other option left. The deterioration became the trigger for considering treatment as necessary and thus changed the way they had dealt with their depression up to that point. The high level of suffering and the pronounced symptoms the patient was experiencing before the start of treatment had become clear:

“But at some point, I couldn’t cope with the whole thing any more. That had already become apparent over the past year and I was becoming more and more, how should I describe it, mentally… “restricted” (…) I then just sat at home for two or three weeks and was crying and had no way out because I just couldn’t get out of this thought loop. That was the biggest motivation for me.” (Interview_14)

“The downward spiral just keeps on going.” (Interview_09)

“I was just experiencing very low points, where I was, where I had um very dark thoughts too.” (Interview_46)

The men’s reports point to a long process of symptoms worsening before a decision is made to enter treatment. Participants described obstacles to entering treatment as irrelevant after experiencing severe suffering and pronounced depressive symptoms. One participant reported that he started treatment despite stigmatizing attitudes in the family environment:

“I think there was definitely a lot of prejudice from how I was raised towards mental health treatment (…) And that didn’t necessarily make it easier for me. But I think at that point I was already in a place where I didn’t really care about any of that.” (Interview_46)

The interviewees report their entry into treatment after realizing that they themselves no longer know how to deal with the depression. One participant describes how entering treatment undermined the gender role expectations he had held for himself:

“And I realized that I needed help now, because as a man you always think, ha, you have to be strong, and yes, you can do it and you have to be careful and you have to do it for others and all that sort of thing. And that’s when I realized that I’d reached the point where I couldn’t go on any further. (…) That I couldn’t handle it on my own.” (Interview_101)

For another participant, the turning point for seeking help was reached when he noticed significant limitations in his previous work abilities. While he was “used to telling other people what to do” due to the leadership position he held in his professional environment, and his depression meant that he “was no longer capable of helping himself” (Interview_14). In both cases, depression led to a changed perception of the patient’s own agency. The motivation for seeking treatment was both being “unable to cope with this on their own” (Interview_16) and at the same time to be able to regain their pre-illness state of health. This motivation outweighed any prejudices towards the treatment, such as “being hypnotized by the psychotherapist(s)” (Interview_56).

3.2 Regaining agency

With the depressive illness restricting their agency, men hoped to be able to regain their agency by entering treatment. Accordingly, they emphasized their “intrinsic motivation” (Interview_33) for entering treatment. It was “the right thing to do” (Interview_69) with the aim of being “actively involved in escaping this situation” (Interview_54). As a result, the need for “external help” (Interview_29) or “outside help” (Interview_101) was explicitly emphasized. In this way, the individual’s own attitude becomes a facilitating factor that encourages them to seek professional treatment. In addition, from the perspective of many interviewees, very few men would actually seek professional treatment “out of their own free will” (Interview_64).

Nevertheless, it is emphasized that “capacity” (Interview_72) is required in order to commit emotionally and organizationally to the treatment. In addition, motivation to improve the crisis situation can be associated with the fear of not receiving adequate treatment or suitable therapists:

“How can I deal with this? Somehow by finding a point of view, uh, an approach to solving the whole issue (…) Hopefully they believe me. Hopefully. Hopefully the people I meet won’t be so prejudiced. Hopefully they have enough time [to understand my issues].” (Interview_72)

On top of this, some men claim that it was their own decision to seek professional help. This relates to the identification of symptoms, the organization of treatment entry, and the active participation in treatment:

“And that was the reason I actually looked up the phone number on Google, called up, and said: Hey there.” (Interview_103)

“It was already clear in my head that I HAD to do something to get out of this hole. (…). So I really wanted to actively get out of it and I also discussed it with the psychiatrist and he said, well, there’s the possibility of this home, uh, assistance, and after that I really sat down and tried to gain access to it immediately.” (Interview_54)

For these men, it does not seem possible to “deal” with depression on their own, however, they were able to “make the decision” to enter treatment. Thus, entering treatment on their own becomes an opportunity to re-claim agency in the context of the depressive illness itself. In their narrative, the admission to treatment then follows as a logical consequence in a process of rational consideration: “So in my case, the logical side of my brain had not yet been switched off” (Interview_14). “Not starting treatment would make no sense to me at all” (Interview_01).

3.3 Role of social environment

For many of the men interviewed, their social environment played a decisive role in them entering treatment. However, the nature of this role and its specific impact varied across participants.

3.4 Influence from healthcare professionals

Healthcare professionals motivated the interviewed men to make use of psychiatric and psychotherapeutic treatment. This is based on recommendations from general practitioners and cross-sectoral counseling centers, such as “the university” (Interview_33), “the school psychologist” (Interview_63), “the social counselor at work” (Interview_79), and pastoral care. General practitioners in particular are the first point of contact for men with depressive symptoms and psychological stress. They take on both a supportive and mediating role:

“Then it tended to be the case, the GP said, that the wife said that she could no longer deal with it on her own because she wasn’t an expert, she wasn’t a specialist and she would really like else someone to take a closer look at it (…) Yes, and then I it simply became clear to me: Okay this is how it is, and I want to move forward again. I don’t want to just, um, grope around in the fog forever.” (Interview_88)

This quote shows that the family doctor calls for “clinical-psychiatric” (Interview_88) treatment. As a result, a change in understanding is described and the advice is accepted and implemented. Another interviewee also reports that his sister and his GP initiated residential treatment after a “suicide attempt” (Interview_02). On the other hand, another participant reported that contact with a counseling center was sought “intrinsically” (Interview_33), which then referred the person concerned. For almost all of the consulted men, their social environment first urges professional treatment before contact is made with the GP or psychiatric specialists.

In addition, most interviewees expressed a fundamental trust in mental health professionals, which had a positive influence on treatment entry. The “professional(s)” (Interview_62) and “specialists” (Interview_101) are assumed to be able to provide specific support due to the fact of being “professional” and are seen as having the competence required to improve their own state of health:

“Now I have something I don’t know anything about, and so then you just consult with experts: it’s just like I always say, I take my car to a specialist garage when I have no idea what’s wrong with it, so I don’t fiddle around with it myself either.” (Interview_01)

This comparison symbolizes a rational and responsible approach to health. At this point, the participants contrast the competence and knowledge of the professionals with their own powerlessness in dealing with the illness. The responsibility for their state of health can be delegated to the professionals as experts, which, ultimately, is conducive to seeking treatment.

Equally, mental health professionals are seen as being outside of the men’s own social environment. Professionals thus offer a form of support that the men believe is not guaranteed in their private environment:

“Because no friend or family member can help you, you have to find someone who is a bit external and to whom you can tell anything or who can perhaps tell you something that you might not take so seriously if it were to come from a family member.” (Interview_91)

Moreover, the desire to gain information about the disease encouraged treatment initiation:

“And I think that was also important to me, to understand things in this way. Why am I like this? Why do I feel so down right now? (…) Because for me, depression isn’t like that, I don’t know, it’s not like I’m going to fall down at some point and break my arm. I think everyone, even if they don’t have medical expertise, have a kind of rudimentary understanding of this. But, but with depression I’ve always found that, I still don’t think it’s understand it completely, it’s not quite tangible for me.” (Interview_59)

This is where insecurities about their own emotional state and state of health became evident. The men hoped that professional treatment would help them understand and make sense of their condition. The desire for clarification is expressed both when their social environment demands treatment, when treatment successes have been experienced by other affected persons, and also in situations without external influence.