Research reportDevelopment and preliminary validation of the male depression risk scale: Furthering the assessment of depression in men
Introduction
The established 2:1 incidence rate of major depressive disorder (favouring females) remains poorly understood (Möller-Leimkühler and Yucel, 2010) and belies the fact that in comparison to females, males are four times more likely to die by suicide (Centers for Disease Control and Prevention, 2010). To address the issue of men's suicide, peak representative bodies and public health researchers continue to call for improved assessment and treatment of depression in men (e.g., American Psychological Association, 2005, Pitman et al., 2012).
Males are known to respond to negative emotional states with elevated levels of substance use and externalising behaviours such as aggression and risk taking (e.g., Cochran and Rabinowitz, 2000), and there is growing suggestion that generic diagnostic criteria which exclude such behaviours inadequately identify males experiencing underlying affective disorder (e.g., Cochran and Rabinowitz, 2000, Cochran and Rabinowitz, 2003, Hammond, 2012, Pollack, 1998, Rochlen et al., 2010). The expression of externalising depression symptoms is theorised to result from socialisation processes and associated conformity to masculine norms emphasising male autonomy, stoicism and invulnerability (Rutz, 2001), where anger is the only negative emotion that men are socially permitted to exhibit (Fields and Cochran, 2011). In particular, externalising symptoms are hypothesised to occur in males who are unable and/or unwilling to disclose or demonstrate typical depression symptoms out of fear of being viewed as weak, inferior or vulnerable (Cochran and Rabinowitz, 2000, Cochran and Rabinowitz, 2003, Hammond, 2012, Pollack, 1998, Rochlen et al., 2010).
The Gotland Male Depression Scale (GMDS; Zierau et al., 2002) was the first screening instrument designed to assess both typical depression symptoms (e.g., depressed mood, hopelessness, fatigue, indecision, and sleep disturbance) and theorised masculine congruent externalising depression symptoms (e.g., irritability, aggression, impulsive behaviour and problematic alcohol use). To date, such gender-specific externalising symptoms have been largely overlooked in the depression-related medical literature (Rutz and Rihmer, 2009), but are consistent with men's qualitative reports of depression (e.g., Oliffe et al., 2010, Rochlen et al., 2010).
While the GMDS has been instrumental in precipitating a burgeoning of research into men's mental health, it has been widely criticised for its psychometric shortcomings and limited clinical utility (e.g., Ajayi, 2011, Grace et al., 2013, Diamond, 2008, Levin and Sabacora, 2007, Magovcevic and Addis, 2008, Martin, 2010, Melrose, 2010, Stromberg de Sousa Soares, 2013). Studies have repeatedly failed to validate the hypothesised a priori factor structure of the GMDS (e.g., Innamorti et al., 2011, Möller-Leimkühler et al., 2007, Möller-Leimkühler and Yucel, 2010, Rice, 2012), and research findings related to sex and gender role differences central to the theoretical underpinnings on the GMDS have been inconsistent (Fields and Cochran, 2011).
In response to the shortcomings of the GMDS a range of additional male specific depression rating scales have been published (e.g., Brownhill et al., 2003; Diamond, 2008, Martin, 2010). Unfortunately these scales also lack scientific rigour – relying either on inadequate psychometric development processes (including small validation samples), or binary response formats that preclude the use multivariate statistical validation. The one exception to this is the psychometrically rigorous Masculine Depression Scale (MDS; Magovcevic and Addis, 2008). Regrettably, however, due to the use of a relatively small validation sample (N=102), initial factor analysis of the MDS items failed to adequately differentiate sub-domains of externalising responses into various factors, resulting in a relatively lengthy scale comprising only two subscales (e.g., internalising symptoms – 33 items, externalising symptoms – 11 items).
Although some case study reports suggest that externalising depression symptoms are significant in the presentation of men's depression (e.g., Kantor, 2007, Rutz and Rihmer, 2009, Rabinowitz and Cochran, 2008), this notion currently fails to rest on a strong empirical foundation (Addis, 2008). Clinicians and researchers have astutely critiqued the adequacy of the diagnostic criteria for major depressive disorder in relation to gender related constructs and men's externalising responses, and interested readers are directed to this commentary (e.g., Addis, 2008; Fields and Cochran, 2011; Möller-Leimkühler et al., 2004, Wilhelm, 2009). Regardless however, innovative approaches are required to improve detection of suicidal people in general (Linehan, 2008), and in men in particular (Rutz and Rihmer, 2007), and it is possible that modifications to assessment procedures may assist to identify potentially high-risk (e.g., suicidal) men (Wide et al., 2011). While there is general agreement that researchers and clinicians should actively assess men's depression symptoms within the context of cultural norms related to masculinity (e.g., Hooper et al., 2012), the field currently remains without a brief psychometrically rigorous male-specific rating scale assessing depression risk that is both multidimensional (e.g., comprising subscales assessing multiple symptom domains), and specifically designed to assess externalising depression symptoms. The present studies were purposively designed to fill this research and assessment gap.
Study 1 aimed to refine a large item pool and evaluate initial scale factor structure. The Male Depression Risk Scale (MDRS) was expected to report a multidimensional structure with satisfactory preliminary internal consistency. Study 2 sought to (i) further refine and validate scale structure using confirmatory factor analysis, and (ii) evaluate MDRS scores according to sex and self-reported masculinity. Given externalising depression symptoms are hypothesised to have particular salience for stoic and traditional men (Rutz and Rihmer, 2009, Zierau et al., 2002), an interaction was expected between greater conformity to masculine norms (e.g., greater adherence to emotional control, self-reliance, and pursuit of status) and biological sex. It was predicted that greater conformity to masculine norms would correspond to significantly higher MDRS scores in males relative to females.
Section snippets
Scale development process
Thorough review of the relevant research literature led to the identification of nine broad symptom sub-domains relevant to men's experiences of depression (Rice, 2012). These nine domains, similar to those identified by Magovcevic and Addis (2008) were operationalised as anger (cognitive awareness of, or expression and escalation of anger); aggression (behaviours displaying physical or verbal aggression); distraction and avoidance (behaviours that may be used to distract from, or avoid dealing
Participants
Given the MDRS was primarily designed as a screening tool for men in the wider community (e.g., men from a non-clinical sample), a community cohort was targeted for sampling. Data was collected from a community sample of 386 males (M=32.74 years, SD=12.58) using an online questionnaire (see Table 1 for sample characteristics).
Procedure
Ethical approval was provided for this study by the Australian Catholic University Human Research Ethics Committee (V2010 47). Participants were recruited via paid
Study 2 – confirmatory factor analysis
It is recommended that scale developers perform confirmatory factor analysis (CFA) in a separate sample when seeking to validate new assessment instruments following exploratory factor analysis (DeVellis, 2003; Worthington and Whittaker, 2006). In Study 2 CFA proceeded on the basis of the second-order (e.g., seven subscale) factor structure identified in Study 1.
Discussion
The present research was undertaken with the goal of developing and validating a brief male-specific depression risk rating scale sensitive to externalising depression symptoms. Externalising depression symptoms (such as anger, substance abuse and risk-taking behaviours) have received increasing research and clinical attention as potential markers of depression in men who adhere to masculine norms (e.g., American Psychological Association, 2005, Fields and Cochran, 2011).
In addressing the
Role of funding source
The funding source (Australian Commonwealth Government) provided a Postgraduate Scholarship with stipend to fund the principal author in undertaking this research.
Conflict of interest
Nil conflicts of interest declared.
Acknowledgements
The authors are grateful to Prof. John Ogrodniczuk for his helpful comments related to this research and Daniel Moore for assistance with data collection.
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The principal author was supported by an Australian Postgraduate Award provided by the Australian Commonwealth Government.