To the Editor, The review paper by Liyam Eloul, Amaal Ambusaidi and Samir Al-Adawi ‘Silent Epidemic of Depression in Women in the Middle East and North Africa Region’ published in the April 2009 issue of SQUMJ1 is an interesting discussion of depression in women in the Middle East and North Africa (MENA) region. The authors provided a balanced and well articulated discussion of the factors that may play a role in the development of depression in women such as the higher exposure to postpartum depression, changing roles of women due to modernisation and some local sociocultural practices, not related to Islam as a religion. However, it is important to pay attention to the fact that modernisation has not only affected the mental health of women in the MENA region. Rather, modernisation and changing family life have also influenced women’s mental health in Western countries as evidenced by the increased depression rates for women.2,3,4 In addition, social and cultural forces in the region and elsewhere have played a role in the increasing depression rates for men, too. Several studies have shown that there is an increased risk of depression in younger cohorts of both men and women.5,2 In addition, the prevalence rates of depression have actually increased for both genders of younger cohorts.2 Data showed that they are experiencing an earlier onset of depression, although sex ratios were indistinguishable.2 Despite the increase in depression rates, men’s lower reported rates of depression compared to women may not be an accurate estimation of the prevalence of depression among men. Therefore, rates of depression for men may be much higher than what is reported in different studies. Two important factors may be related to the lower reported depression rates for men.6 The low reported rates of depression may be an indication of the insensitivity of the diagnostic tools utilised to measure depression.7 Diagnostic measures focus on the expression of emotion and the identification of the self-inefficiencies in the persons diagnosed with depression, all of which are in strong agreement with the feminine qualities of self-expression, as opposed to men’s who, when depressed, are three times more likely to display inappropriate anger outbursts compared to women.8 These anger outbursts are supposed to be the result of unexpressed emotions.9 Another reason for the low reported rates of depression of men appears to be their unwillingness to seek mental health services when needed, especially in mild-moderate depression.10 Admitting signs of mental illness is considered to be against the legends of masculinity that place special importance on ignoring symptoms of sickness in the hope that symptoms will go away.11 This is because masculinity requires men to demonstrate to people that they are “tough” and that they exemplify “manhood”.12 That is why future studies have to be extra sensitive when reporting on men’s depression given the complexity of the interaction between the cultural and psychological dimensions of depression. Zena Al-Sharbati Department of Behavioral Medicine, College of Medicine & Health Sciences Sultan Qaboos University, Muscat, Sultanate of Oman Email: zenam@squ.edu.om SQU Med J, December 2009, Vol. 9, Iss. 3, pp. 359-360, Epub. 19th Dec 2009 Received - 10th Oct 09 رد: وباء االكتئاب الصامت لدى املرأة يف منطقة الشرق األوسط و مشال أفريقيا Re: Silent Epidemic of Depression in Women in the Middle East and North Africa Region letter to editor Write Effectively A quick course for busy health workers 360 | SQU Medical Journal, December 2009, Volume 9, Issue 3 References 1. Eloul L, Ambusaidi A, Al-Adawi S. Silent Epidemic of depression in women in the Middle East and North Africa Region. SQU Med J 2009; 9:5-15. 2. Weissman MM, Leaf PJ, Holzer CE. III, Myers JK, Tischler GL. The epidemiology of depression: An update on sex differences in rates. J Affect Disord 1984; 7:179-88. 3. John CL, Tepperman L, Wilson SJ. The futures of the family. New Jersey: Prentice Hall, Englewood Cliffs, 1995. 4. Niemi RG, Mueller J, Smith TW. Trends in public opinion: a compendium of survey data. New York: Greenwood Press, 1989. 5. Simon GE, Vonkorff M, Ustun TB, Gater R, Gureje O, Sartorius N. Is the lifetime risk of depression actually increasing? J Clin Epidemiol 1995; 48:1109-18. 6. Oliffe JL, Phillips MJ. Men, depression and masculinities: A review and recommendations. J Mens Health 2008; 5:194-202. 7. Rutz W, Walinder J, Von Knorring L, Rihmer Z, Pihlgren H. Prevention of depression and suicide by education and medication. Impact on male suicidality. An update from the Gotland study 1997. Int J Psychiatry Clin Pract 1997; 1:39-46. 8. Brownhill S, Wilhem K, Barclay L, Schmied V. Big build: hidden depression in men. Aust N Z J Psychiatry 2005; 39:923-31. 9. Winkler D, Pjrek E, Kasper S. Gender-specific symptoms of depression and anger attacks. J Mens Health Gend 2006; 3:19-24. 10. Sharp MJ, Heppner PP. Gender role, gender-role conflict, and psychological well-being in men. J Couns Psychol 1991; 38:323-30. 11. White P, Young K, McTeer W. Sports, masculinity, and the injured body. In: Suso D, Gordon F, Eds. Men’s health and illness: Gender, Power and the Body. Thousand Oaks, Ca: Sage Publications Inc., 1995. pp.158-82. 12. Courtenay, WH. College men’s health: an overview and a call to action. J Am Coll Health 1998; 46:279-90.