This study tested a priori hypotheses about sex differences in toughness, in treatment preferences, and in the relationship between toughness and treatment preferences. In support of these hypotheses, men scored higher on toughness and showed a greater preference to wait and see whether symptoms resolved before seeking treatment. As expected, an inverse relationship between toughness and preference for active treatment was confirmed.
These results support suggestions that toughness is a more salient norm for men and could explain their greater resistance to traditional or formal mental health treatment (28
). The toughness norm teaches children that asking for help implies weakness and leads to a loss of independence (25
To the best of our knowledge, this study is the first to investigate the role of the toughness norm in women’s treatment preferences. It is noteworthy that like men, women who scored higher on toughness were also less interested in seeking active treatment for depression. Nonetheless, 18% of the sex difference observed in preference to wait and see was mediated by toughness. Although other factors are likely at play, these findings support the position that sex differences in mental health help-seeking behavior can be explained, in part, by gender norms.
Notably reporting symptoms of depression was positively related to toughness. Those who present themselves as relatively tough may possess certain psychological characteristics that exacerbate depression and, perhaps, other mental disorders. Restricted emotional expression has consistently been linked with depression (43
) as well as other disorders such as alcohol and drug abuse that may mask depression (46
). “Tougher” individuals may also refrain from or delay seeking help and as a result may be expected to experience more severe symptoms because they are not receiving help. Having a greater likelihood of experiencing depression and an increased resistance to seeking treatment can place people at added risk (30
). Those most in need of treatment are often the least likely to seek help.
Clinicians, public health officials, and policy makers interested in encouraging treatment-resistant populations to seek help for mental disorders ought to address gender norms. Attempts to bring depressed people to services could address toughness in one of two ways—through cultural interventions designed to modify gender norms, thereby decreasing the level of “toughness” in society, or through social marketing interventions designed to frame help seeking either as an act of toughness or at least as a behavior that is not inconsistent with being tough.
Attempts to change norms would require an extensive, prolonged social investment and policy changes. In such an approach, public health messages could focus on prompting people to question whether they need to act tough. Schools could also implement programs to encourage children to be more open with their emotions and more comfortable seeking help. This goal may be attainable in the longer term but is unlikely to have immediate effects on health services utilization for depression. Moreover, just as any community intervention may have unintended consequences (48
), iatrogenic consequences are possible.
A more pragmatic approach that could pay off in the shorter term involves developing targeted messages that represent help seeking as an act of toughness or at least an act that is not inconsistent with being tough (27
). For example, the “Real Men. Real Depression” campaign communicated that it takes courage to seek help for depression (50
). The U.S. Air Force suicide prevention program also involved changes in norms of help seeking (51
). Recently, a public education campaign was launched to improve understanding among black women that the pressure they face to always appear strong to others does not preclude seeking help (52
When men and women believe that being tough and seeking help for depression are not mutually exclusive they may be more willing to seek treatment. Public figures who are often considered tough (sports figures, stars of action movies, military personnel) could be used as spokespersons in social marketing campaigns encouraging help seeking for depression (53
). The effects of such public admissions on treatment uptake now and in the future could be examined.
Seeking help for depression could be positioned as aggressive action that represents taking control of one’s life and going on the offense—in other words, as a way to defeat depression. If depression treatment is able to be reframed in that way, adherence to the toughness norm may actually prove to help people overcome depression. Finally, the theme of tough people, women and men, getting help for depression could be introduced into popular art forms such as television and movies through the strategy of “infotainment” (55
). These examples serve as templates for interventions to increase the acceptance of depression care. Again, we would be remiss if we did not acknowledge that this approach could have unintended adverse consequences (48
This study has four noteworthy limitations. First, the research design required participants to imagine they were depressed, but differences in capacity to imagine depression were not assessed; we do not have the data necessary to determine whether findings attributed to toughness are better explained by other variables, including individual differences in the capacity to imagine what it is like to live with depression (56
), in mental health literacy (57
), or in emotional intelligence (58
). Second, participants were asked to imagine having been diagnosed with depression but not told how long the depression might have lasted. It is possible that those preferring a wait-and-see approach simply imagined that they had been suffering for less time and, therefore, felt less concerned about their depression.
Third, this study reports analysis of cross-sectional data. As with any cross-sectional study, no firm causal conclusions can be reached. Finally, this study presents secondary analysis of an existing data set. The population and measures were not specifically selected to assess the questions asked in this investigation. Therefore, further research with a study designed to specifically test the hypotheses are needed before firm conclusions can be reached.
Future research should determine whether gender norms explain sex differences in other stages of health service usage, including symptom awareness (14
) and treatment adherence (59
). Research should also continue to explore the role of the toughness norm in women’s behavior, especially in relation to treatment-seeking behavior. From a public health perspective, the relationship between toughness and help seeking is perhaps best addressed among symptomatic people who have not previously been diagnosed as having depression or if they had received a diagnosis of depression had not been treated for it.