Analysis of the 'Real Men, Real Depression' Public Health Campaign as it Relates to Health Communication

Runninghead:REALMEN REAL DEPRESSION ANALYSIS
Analysis of the ‘Real Men, Real Depression’ Public Health
Campaign as it Relates to Health Communication
Danielle Hoyt
Bryant University

REAL MEN REAL DEPRESSION ANALYSIS
Analysis of the ‘Real Men, Real Depression’ Public Health Campaign
Introduction
Major depressive disorder is the clinical diagnosis for what is more widely known as
depression. It is a mood disorder "characterized by sadness and a loss of pleasure, with multiple
cognitive, behavioral, and somatic symptoms, and impaired functioning” (Parritz & Troy, 2014,
p. 214). It affects both women and men; people of all ethnicities, races, and national origins;
adolescents, adults and the elderly; and people of all walks of life. It is a prevalent mental illness
with a long history. And despite knowing all of this, the vast majority of the public dialogue
regarding depression centered on women. That is, until the ‘Real Men, Real Depression’
campaign rolled out in April of 2003 and changed the way people saw depression.
Background
Symptoms
Major depressive disorder, or depression as it is more commonly referred to, is an
episodic psychiatric disorder that afflicts 7% of the United States population annually (American
Psychiatric Association, 2013, p. 165). As a mental disorder recognized by the American
Psychiatric Association (APA), the diagnostic criteria for Major Depressive Disorder is listed in
The Diagnostic and Statistical Manual 5th Edition (DSM-5). As it is an episodic disorder, a
diagnosis may be applicable after one or more depressive episodes. A depressive episode
consists of a period of at least two weeks during which the individual exhibits at least 5 of the
symptoms, one of which must be symptom 1 or 2. The symptoms are as follows: (1) Depressed
mood, (2) Loss of interest or pleasure in all, or almost all, activities, (3) Significant weight loss
or gain or an increase or decrease in appetite, (4) Insomnia or hypersomnia, (5) Psychomotor
agitation or retardation, (6) Fatigue or loss of energy, (7) Feelings of worthlessness or excessive

and inappropriate guilt, (8) Diminished ability to think or concentrate, and (9) Suicidality
(includes recurrent thoughts about death, suicidal ideation, or a suicide attempt) (APA, 2013, p.
160-161). A full listing of the diagnostic criteria laid out in the DSM-5 may be reviewed in
Appendix A.
With the symptom profile of each episode consisting of any combination of 5 or more of
these symptoms, there is no one face of depression. Adding to the complexity of the diagnostic
criteria is the variability in severity. The criteria require the symptoms to cause significant
disruption in some area of life functioning. However this is not as simple as it may seem, as
‘significant disruption’ looks very different from person to person. In addition, depression is a
disorder that can affect any one of any race or gender at any point in their lifetime. This
complexity is often overlooked, especially in media representations of the disorder.
Prevalence in Males
Although stereotyped as a feminine disorder, depression is known to affect 1 in 10 men
during their lifetime (Orengo, Fullerton & Tan, 2004, p. 24). The stereotyping of depression as a
woman’s disease is also supported by the fact that the prevalence rate within women is 1.5 to 3
fold higher than that of men throughout the lifespan after age 13 (APA, 2014, p. 165). Despite
the higher prevalence in women, at least six million men experience depression each year
(National Institute of Mental Health, 2003). These statistics may be even higher, as many men go
undiagnosed for a variety of reasons. In general, men are far less likely than their female
counterparts to “recognize, acknowledge, and seek treatment for their depression” (NIMH,
2006). Additionally, the symptom profile for depression in males can make it difficult for even
healthcare providers to diagnose the disorder. Men are more likely to present with somatic
complaints at first, such as fatigue, weight changes, and sleep disturbances (Rochlen, Whilde,

&Hoyer, 2005, p. 189). In fact, the typical male presentation is so different than the typical
female presentation that a revision of the DSM diagnostic criteria has been proposed to create a
subtype of major depressive disorder called MDD-male type (Rochlen et al., 2005, p. 189). No
such revision has yet been made, but the proposals for such changes do promote the idea that
men’s experience of depression may be qualitatively different than that of women, and the
diagnostic tools in use may not be sensitive enough to those differences (Rochlen et al., 2005, p.
189).
Despite the differences in evident symptom profiles, it has been found that the course of
the disorder is no different between genders. A longitudinal study consisting of men and women
who at the beginning of the study were presenting with their first major depressive episode,
followed the course of their disorder over 15 years. It found no significant differences over the
years between the genders in “overall time to first recurrence, the time to recovery, or the
number or severity of recurrences of depressive episodes” (Simpson, Nee, & Endicott, 1997, p.
636).
Older Males. Older men are one subgroup that prompts a closer look, as they are at
heightened risk for depression. There are multiple reasons for this increased threat. The first is
that depressive episodes have the effect of lowering ones threshold, such that once someone has
one, a second comes on much easier than the first, and the third even easier than the second and
so on. The older an individual is, the more likely it is that they have experienced a depressive
episode at some point in their life, therefore older men have an increased likelihood of having a
decreased threshold. Additionally, older individuals are more at risk for stressful life events that
may trigger depressive episodes, such as the death of a spouse, retirement, or the onset of a
physical illness. Furthermore, older men have been found to report having fewer friends and

impaired social networks that do not shelter them from the impact of such stressful life events
(Orengo et al., 2004, p. 25). Depression in older men may be even more difficult to diagnose
than in younger men as their symptom profile tends even further towards somatic complaints,
and these may be slightly different than those of younger individuals (Orengo et al., 2004, p. 25).
The profile might include symptoms such as apathy, increased appetite, low, libido, agitation and
anxiety, mood swings, anger and/or medical non-compliance (Orengo et al., 2004, p. 25). Most
of these are not depressive symptoms in and of themselves on a definitional level, but rather
require a closer look to see that they do imply a connection to the diagnostic criteria. For
example, a lowered libido might be indicative of a loss of interest in previously pleasurable
activities. However, complicating matters further is the issue of older males’ heightened risk for
other, physical ailments that can present similarly to the somatic symptoms of depression. Older
men have also been found to mask their depression through the abuse of drugs and alcohol or
other compulsive behavior, which may make it difficult for health care providers to pick up on
underlying depressive symptomology (Orengo et al., 2004, p. 25). Furthermore, although men in
general have a suicide completion rate 4 times that of women (NIMH, 2003), older white men
are at the highest risk of suicide and are “more likely to resort to violent means of attempting
suicide, such as using a gun” (Orengo et al., 2004, p. 26).
Treatment
Because depression is quite prevalent, and has been a recognized mental illness for many
years, much research has been done with regards to its treatment. Therefore there are many
possible treatment options for a depressed individual. The most common treatments are talk
therapies and medication, and the majority of the time a combination of such therapies is
employed. Complementary approaches such as acupuncture and herbal remedies are often

suggested, and alternative approaches such as electroconvulsive therapy may need to be used for
more severe or persistent forms of depression (Major Depressive Disorder, 2009). The
effectiveness of these various techniques depends on the person and their specific presentation of
the disorder, so it is critical that the therapeutic approaches be tailored to fit the individual’s
specific needs. The overall effectiveness rate for those who seek treatment for their depression is
an astonishing 80%, much higher than many other mental illnesses (National Institute of Mental
Health, 2003).
The Real Men, Real Depression Campaign Significance
This paper will focus its attention on a specific health campaign conducted by the
National Institute of Mental Health (NIMH) called ‘Real Men, Real Depression’ which brought
attention to the issue of male depression. Prior to this campaign, there had never been a health
campaign concerning depression in men, making it the first campaign of its kind. Although
women do have a higher incidence rate of depression throughout the lifetime, men have a much
higher suicide completion rate (NIMH, 2003). Men are often a neglected audience when it comes
to mental illness, especially with depression. This may be influenced by mainstream culture’s
emphasis on tough masculinity where men must be seen as strong, and depression implies a
weakness and a need for assistance.
The timing of this campaign is also significant. The campaign materials officially rolled
out starting in 2003, but the campaign began as a reaction to the September 11, 2001 series of
terrorist attacks (NIMH, 2003). The incidence rates of post-traumatic stress disorder, depression,
and other such disorders dramatically rose in the wake this tragic event, especially for those
directly involved in the terrorist attacks and the direct aftermath. This forced such mental health
issues to come to the forefront of the nation’s attention.

Analysis
The “Real Men, Real Depression” effort was a public health awareness campaign for
depression in men. The organizer of this campaign was the National Institute of Mental Health
(NIMH), one of 27 components of the National Institutes of Health (NIH) which is a part of the
Department of Health and Human Services (DHHS) for the United States Federal Government.
This campaign had real men tell the story of their experience with depression in an effort to
make people aware that men can become depressed, and that asking for help when they do does
not mean they are weak. It directly addresses both the issues surrounding recognition of male
depression and the stigma surrounding this particular aspect of mental illness.
Goals and Objectives
The goals and objectives of the campaign are many. The primary message is that it takes
courage to recognize that you as a man have depression and to then ask for help to deal with it.
Therefore, their foremost goals involve increasing public awareness (for men, their loved ones,
and their caregivers) of what depression might look like in order to increase recognition of the
disorder. From there, another objective is to encourage men to ask for the medical help, and
therefore receive the potentially life-saving and definitively life-altering treatment they need. The
NIMH also aims to address the stigmas against mental illness, depression specifically, and men
showing ‘weakness’ in asking for help. Additionally, they aim to be multiculturally sensitive,
incorporating individuals from many walks of life and of various ethnic backgrounds. They also
have many materials available in multiple languages, specifically English and Spanish.
Techniques Employed
This campaign used a multitude of different media channels to disperse their message.
The most prominently used format were the 30 second film interview PSAs aired on television.

The voice recordings of the same PSAs were also broadcast on the radio, and the video versions
have since been posted to the NIMH Youtube page. Other channels included print based PSAs,
an interactive website, posters, pamphlets, fact sheets, in depth brochures, and even powerpoint
presentations and other materials that other institutions and organizations can use to give
presentations on the subject (NIMH, 2005; NIMH, 2007).
Strengths
One of the major strengths of the ‘Real Men, Real Depression’ campaign is the sheer fact
of its existence. Up until that point there had not been any public health campaigns that
specifically addressed the issue of men with depression. This was an area that needed emphasis,
and this campaign truly brought male depression out of the shadows of stigma and into the
spotlight of attention.
Another advantage of this campaign made obvious in the above section is their use of
multiple channels to disseminate the message. This diversity of media channels was important as
their target audience was a diverse group of people who crossed age, occupational, geographic,
ethnic, and class lines.
Speaking to an audience this diverse could be quite difficult, but the NIMH handled it
quite well. The spokespeople chosen to tell their personal testimonials of their experiences with
depression represented the variability in who depression can affect – old and young and
everything in between, Asians, Hispanics, Native Americans, Caucasians, African Americans, a
variety of occupations ranging from stereotypically manly careers like the military to other walks
of life like writers, lawyers, and a U.S. diving champion. This diversity is essential to a campaign
that aims to reach out to all men who may not seek treatment for their depression, as that group is
just as diverse if not more so. If the audience members do not identify with the person they see or

hear in the PSA, they are far less likely to pay attention to it or recognize the message as
applying to themselves (J. Volkman, personal communication, April 20, 2016). This campaign
offers a wide range of people for the audience to potentially connect and identify with, thus
increasing the likelihood that the message will be received and interpreted as applicable to them.
Not only did the campaign have diverse individuals appear in the materials, they
were truly multiculturally competent in doing so. They incorporated men of many races, as stated
above, and of varying ages (college student to retiree). Each of these men directly addressed the
obstacles they faced specific to their cultural background, when appropriate. For example, the
Asian man spoke about the fact that Asian families tend to avoid discussion of mental health
issues, and the Latino man addressed how Hispanic families share decision making and how his
family members’ reactions were of critical importance. This is important to note because
Hispanic individuals are twice as likely to display depressive symptoms than non-Hispanic white
individuals but a staggering 54% of Latino men who have had a depressive episode do not
recognize that they have had a mental health problem (NIMH begins public education effort on
Latino men and depression, 2005, p. 4). This is exacerbated by the severe stigmatization in the
Hispanic community of mental illness as a woman’s experience, encouraging a silence among
Latino men regarding mental illnesses of their own such as depression (NIMH begins public
education effort on Latino men and depression, 2005, p. 4). This particular testimonial helps
convince them that depression happens for real in men and it takes courage to seek treatment.
They also address the unique issues faced by people of different age groups, having a
young college student, a middle-aged father, and an older retiree all speak about their
experiences at that stage in their life. The retiree is especially important for the campaign to have

included, since that population is at a heightened risk for depression, missed diagnoses, and
suicide completion.
Lastly, it is clear that the campaign organizers followed the ideal outline of planning their
campaign prior to its implementation. The materials are very well tailored to their target
audience of ‘manly’ men who otherwise would not consider getting help for depression. In fact,
a study found that men who had a negative attitude about seeking help and had rigid gender role
beliefs, which is essentially the high belief that men should behave differently than women,
preferred the ‘Real Men, Real Depression’ campaign materials over gender neutral materials
(Kersting, 2005, p. 66). This same effect was not seen in men in general, so the materials did
appeal specifically to men who would most need the message (Kersting, 2005, p. 66). This could
be due to their infusion of cultural norms within the messages. Each personal story ends with a
sense of triumph and hard-fought victory. Even the campaign slogan “It takes courage to ask for
help” evokes the connection to mainstream understandings of masculinity and the norms of
retaining mental and physical prowess in all areas. This feeling of ‘fighting’ illness is not only
prevalent specifically to males, but in the U.S. and western culture in general, as can be seen by
phrases such as battling cancer. (du Pré, 2014, p. 167).
Limitations
Although this campaign does have many strengths, there are some areas for possible
improvement. The first is that although the messages do educate the audience on what depression
might look like in men, and discourages the stigmatization of males with mental illnesses, there
is not much information given as to what these men should do with this newfound knowledge, or
where they could go to get more information. The end of the televised PSAs do have a screen
saying to contact a healthcare provider and providing the web address for the NIMH’s Men and

Depression page. However, it is quite brief, lasting only 2 seconds, and is almost too blurry to
read. Men are less likely to recognize for themselves that their symptoms are rooted in
depression, so it is important that healthcare providers be able to elicit that kind of information.
Men being able to recognize their own depression and directly address it with their healthcare
provider would help to decrease the number of depression cases that go undiagnosed and
therefore untreated. Despite this weakness, the NIMH Men and Depression webpage (which
includes the ‘Real Men, Real Depression’ campaign materials) still reached 8 million people by
2005 (Rochlen et al., 2005, p. 186). The NIMH seems to have made good use of key words, as
the Men and Depression webpage is also the first link on a Google search of “men with
depression” and “depression in men”, and makes it on the first page of a Google search of many
other possible search phrases on the topic.
Another limitation of this campaign is that they did not do much to keep up the campaign
at all. The webpage is buried in the NIMH website, making it difficult to find from the NIMH
home page itself, however of course you could easily find it in a quick Google search as
mentioned previously. They also have done very little to keep up with the times. 12 of the video
PSAs were put on the NIMH’s Youtube site, but not until 2013, a decade after the initial
campaign roll out and 8 years after the creation of Youtube. Other than that, none of their other
pages on social media platforms contain any mention of the campaign or related materials. They
have moved on to other campaigns, understandably, but this is clearly still a large societal issue.
The gender-based differences in prevalence, symptomology, and suicide rates cited previously
are from the DSM-5, which was revised, updated, and released in 2013.
A final limitation of this campaign was that they did not use the marketing mix as it
relates to social marketing as well as they could have. With regard to the product, they explained

some aspects quite well, and others not as much. It is clear that they want to increase awareness
of what male depression looks like. However, it is not totally clear to the audience what specific
behavior they should be enacting. After researching the campaign, it is clear that the desired
behavior is to recognize the signs of depression and to speak with a healthcare provider about it,
but that is not clearly emphasized by the materials. They do a fairly decent job of depicting the
price aspect, clearly laying out all the negative impacts depression had on the spokespeople’s
lives and all the positive effects that they experienced after addressing that disorder. Similar to
the product, the place was unclear. Since it was not made evident that the goal was to speak with
a healthcare provider, it is not clear that the place would most likely be in a healthcare setting.
However, anyone can recognize the symptoms of depression at any time or place during every
day life. The last piece of the mix, the promotion, was actually a strength for the campaign. The
use of personal testimonials was a persuasive tactic, and the placement of the one line slogan on
every campaign material and their use of a variety of media channels combined to make the
message widely disseminated and easily remembered (Edgar, Volkman, & Logan, 2011, p. 238-
2243).
Reflection
The ‘Real Men, Real Depression’ campaign overall was a huge success story. Their use
of the 7 step model to health communication campaign creation is evident in the effectiveness
the materials had with their specific target audience. There are many lessons to be learned from
this campaign that can be applied to future public health efforts, especially in the sphere of
mental illness.
Future public mental health campaigns should follow the NIMH’s lead with regard to
addressing stigma. The U.S. culture stigmatizes mental illness, and this is a huge barrier to
treatment for those who need it. The NIMH’s ‘Real Men, Real Depression’ campaign did a good

job of taking an enormous issue, and tackling just one piece of it at a time. It did not try to cure
the entire population of all stigma against mental illness in general. Instead, it worked to change
just one aspect of such stigma: the negative views of men having depression and of them asking
for help overcoming it.
Another great thing this campaign did was to address health literacy, or more specifically
mental health literacy. This is especially important for mental illnesses due to the abundancy of
misconceptions about it. According to the World Health Organization, health literacy is defined
as “the cognitive and social skills which determine the motivation and ability of individuals to
gain access to, understand and use information in ways which promote and maintain good
health” (du Pré, 2014, p. 135). Essentially, it is the degree to which individuals can obtain,
process, and understand the basic health information and services they need to make appropriate
personal health decisions (J. Volkman, personal communication, February 16, 2016). The main
issue this campaign addresses is a gap in the available public health information. This was the
first public health campaign of its kind, and little had been done previously to provide men and
their loved ones with information about how male depression may present and what it means, or
what to do about it. This information gap affects health literacy in that if the information is not
available to be obtained, there is no way people could understand the health issue. And if the
audience does not understand what a health issue is, that affects how it should be presented in the
campaign. Additionally, the belief perseverance phenomenon, which is people’s tendency to
continue holding on to their original beliefs even when faced with evidence to the contrary,
complicates this education. The phenomenon is strongest with beliefs that are deeply entrenched,
which occurs for things people have ‘known’ from a young age or that have been repeated many
times by various sources. Both of these are true of stigmas against mental illnesses in general,

and are also true of stigmas against men asking for help. This issue combines both of those
challenges and addresses the unique intersection of the two. It would be good for future
campaigns to use this as a guide to determine what issues and what aspects of those issues would
their message have the most beneficial effect on.
The ‘Real Men, Real Depression’ campaign also directly addressed many of the cultural
issues that often come up in issues of mental health. Their spokespeople as well as what those
people focused on in their testimonials held true to their cultural beliefs, values and customs.
They also displayed multicultural sensitivity in creating Spanish versions of many of the
campaign materials. In future campaigns it will be increasingly critical to remain multiculturally
competent and sensitive to multicultural issues. The U.S. is still a very diverse country, and the
entire world is becoming ever more globally connected.
Although the NIMH’s campaign had many strong points, there are a few additional
factors future campaigns should take into consideration that this campaign did not do a great job
of. First, changing times should be addressed, especially if the campaign extends for a long
period of time. This campaign officially ran from 2003-2005, so social media was not needed at
first. When the campaign launched, the biggest social media platform in existence was
Friendster, and no one had been using it for any sort of marketing purposes. However, in the
course of their campaign, both Facebook and Youtbue were created and became popular with
both the public and marketing professionals. Since then many other social media platforms have
become popular as well. The video PSAs do appear on the NIMH Youtube page as of 2013, but
there is no mention of the campaign or materials on their Google+, Facebook, or Twitter
accounts. Future campaigns should definitely at least look into using social media platforms,

making sure to consider factors such as whether their target audiences uses such channels, and if
so for what, as well as the appropriateness of the content of the campaign being on social media.
Additionally, the ‘Real Men, Real Depression’ campaign gave very little information
about the role of patient-provider communication. The only mention was the brief visual saying
to contact your healthcare provider. However, the role that this type of communication plays in
people’s health is immense, as it is the communication that occurs in the official healthcare
setting. If people understand they may have depression, but do not change their patient-provider
communication style and content, and still do not directly address those concerns with their
healthcare provider, then no measurable changes will occur in the outcomes. This is an important
area for any future public mental health campaigns to explicitly address.
Conclusion
The NIMH’s ‘Real Men, Real Depression’ campaign marks a landmark moment in the
public dialogue regarding depression. They were the first to directly and publicly address the
issue of male depression, and in doing so they helped to lay the foundation for public mental
health campaigns of the future. Not only did they change the public dialogue about depression
and attack a certain aspect of the stigma surrounding mental illness, they have also created a
successful campaign that can serve as a guide and model for similar campaigns going forward.

References
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental
Disorders (5th ed.). Washington, DC: Author.
du Pré, A. (2014). Communicating about health: Current issues and perspectives. 4th edn.
New York, NY: Oxford University Press.
Edgar, T., Volkman, J., & Logan, A. (2011). Social marketing: Its meaning, use, and application
for health communication. In T. Thompson, R. Parrott, & J. Nussbaum (eds.), Handbook
of health communication, 2nd edn. London: Routledge, pp. 235-251.
Kersting, K. (2005). Men and depression: Battling stigma through public education. Monitor on
Psychology, 36(6), 66.
National Institute of Mental Health (2003). NIMH launches First public health education
campaign to reach men with depression. Retrieved from http://www.nimh.nih.gov/news
/science-news/2003/nimh-launches-first-public-health-education-campaign-to-reach-men-
with-depression.shtml
National Institute of Mental Health (2005). Men and depression public service announcements
(PSAs). Retrieved from http://www.nimh.nih.gov/health/topics/depression/men-and-
depression/public-service-announcements/index.shtml .
National Institute of Mental Health (2006). Men and depression: Background on education
materials. Retrieved from http://www.nimh.nih.gov/health/topics/depression/men-and-
depression/background-on-education-materials.shtml
National Institute of Mental Health (2007). Publications about men and depression. Retrieved
from http://www.nimh.nih.gov/health/topics/depression/men-and-depression/publications-
about-men-and-depression/index.shtml
NIMH begins public education effort on Latino men and depression. (2005). Mental Health

Weekly, 15(42), 4.
Orengo, C. A., Fullerton, G., & Tan, R. (2004). Male depression: A review of gender concerns
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United States: Wadsworth Cengage Learning.
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doi:10.1001/archpsyc.1997.01830190059006

Appendices
Appendix A – DSM-5 Major Depressive Disorder Diagnostic Criteria
A. Five or more of the following symptoms have been present during the same 2-week
period and represent a change from previous functioning. At least one of the symptoms is
either (1) or (2).
1. Depressed mood most of the day, nearly every day
Note: In children and adolescents, can be irritable mood
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day,
nearly every day
3. Significant weight loss when not dieting or weight gain, or decrease or increase in
appetite nearly every day
3.1. E.g. a change of more than 5% body weight in a month
3.2. Note: In children, consider failure to make expected weight gain
4. Insomnia or hypersomnia nearly every day
5. Psychomotor agitation or retardation nearly every day
5.1. Observable by others, not merely subjective feelings
6. Fatigue or loss of energy nearly every day
7. Feelings of worthlessness or excessive or inappropriate guilt nearly every day
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day
9. Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a
suicide attempt or specific plan for committing suicide
B. The symptoms cause clinically significant distress or impairment in social, occupational,
or other important areas of functioning

C. The episode is not attributable to the physiological effects of a substance or to another
medical condition
D. The occurrence of the major depressive episode is not better explained better by
schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder,
or other specified and unspecified schizophrenia spectrum and other psychotic disorders
E. There has never been a manic episode or a hypomanic episode

Analysis of the 'Real Men, Real Depression' Public Health Campaign as it Relates to Health Communication

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Analysis of the 'Real Men, Real Depression' Public Health Campaign as it Relates to Health Communication