A cardiac rehab team called Joe O’Brien with a problem.
A middle-aged man had come through their program after a sudden, severe heart attack — the kind nobody saw coming. He had a job. He had a family. On paper, by every visible measure, he was fine. As part of standard intake, the rehab team ran him through a depression screening.
He scored over 20 — a serious red flag. When they asked how he was feeling, he wasn’t vague about it. He told them he wasn’t sure life was worth living. He hoped he might just not wake up.
He had never been to therapy in his life, and he was ambivalent about accepting the referral.
O’Brien, manager of outpatient behavioral health at Inspira Health, quickly grew concerned.
“That’s the guy who slips between the cracks,” he said. “He has a job, he has a wife, he has kids — he appears to be okay. It’s almost like functional alcoholism. You can kind of get away with it, because, oh, he has a wife, he has kids, he has a job.
“Looks can be very deceiving.”
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The math on this isn’t subtle. In fact, it’s scary.
Men are three to four times more likely than women to die by suicide. Of the roughly 48,000 suicide deaths in the U.S. each year, about 80 percent are men. And the population O’Brien sees slipping through hardest isn’t teenagers, where awareness campaigns and school-based programs have made real inroads.
It’s men in their 40s and 50s.
“I feel like a 16-year-old today is more likely than a 53-year-old to start therapy,” O’Brien said.
That’s not because access has gotten worse. If anything, O’Brien says access to therapy has never been better — telehealth platforms, national networks, the ability to get matched with a provider without ever leaving the house. Access isn’t the problem anymore.
“I think there’s a bit of a marketing issue,” he said.
Look at what actually gets advertised to middle-aged men, O’Brien says, rattling off a list of issues you can find on numerous television commercials: erectile dysfunction pills, hair-loss treatments and muscle producers.
Emotional health gets treated as a separate category entirely — something that happens to other people. And the other sex. It seemingly is marketed almost exclusively toward women.
“Our emotional health is kind of like this bastardized version that just gets thrown over here,” he said. “Until we see it as integral to all the rest, I don’t think we’re ever going to really make a shift.”
It isn’t that women are more depressed than men, O’Brien is careful to note. It’s that women are more likely to take an antidepressant — and pharmaceutical marketing follows the people most likely to buy. The result is a quiet feedback loop: men rarely see themselves reflected in messaging about emotional health, so they rarely think it applies to them, so the marketing keeps targeting the audience that already responds.
The consequence, O’Brien said, is that a man’s first real contact with the behavioral health system is too often a crisis — a substance-use admission, an inpatient hospitalization, an emergency room visit after something has already gone seriously wrong. Rarely is it someone walking in and saying, “I’ve been feeling kind of crappy” before it gets that far.
“To me, that is the most normal and effective use of therapy — to do it more prophylactically, preventatively and just weave it into our wellness,” he said.
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How do men differ from women in this arena? O’Brien points to two big moments.
The first: How differently men and women tend to process the suicide of a public figure.
When a beloved male celebrity has died by suicide, such as Robin Williams in 2014, O’Brien said the instinct for many men is to look outward — to wonder what was going on with him, to treat it as a singular, almost unexplainable event, rather than to ask what it might mean about their own life.
Women, he said, tend to be more willing to turn that same question inward, try to learn from it.
“Men will probably see the completed acts of suicide as these isolated incidents that in no way, shape or form reflect back on them,” he said. “Whereas women may be more vulnerable with themselves and their emotions — what does this say about me, or what does this mean for me? Maybe I should talk to somebody.”
Then there is the differing approach to therapy.
When men do show up in his office, O’Brien said, they tend to want the same thing: a diagnosis, a fix, a linear path from problem to solution. The medical model. Tell me what’s wrong, tell me what to do about it, and I’ll go do it.
Emotional work doesn’t operate that way. O’Brien has learned not to say so on day one.
“Emotions are realities that we have to live with and manage,” he said. “They’re not problems to be solved.”
Tell a new client that directly in the first session, he said, and there’s a real chance he won’t come back — it sounds like a doctor who can’t fix the problem. So, O’Brien takes the long way around, letting men test the idea themselves rather than handing it to them outright.
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Older men present a particular challenge. They want physical solutions for what may be emotional issues, O’Brien said.
Chronic pain with no diagnosis, a stomach that’s messed up, a stiff neck that no doctor can explain. They want a tangible explanation, he said.
The reality is that the body can become the language for something that was never given a vocabulary anywhere else, O’Brien said.
It’s his job to try to put all the pieces together, starting with the emotional damage.
“Grief or sadness — when you try to grab it, there’s nothing there to grab,” he said. “It’s much more frightening, I think, to do the emotional work.”
The cardiac rehab patient never set out to talk to a therapist. He set out to recover from a heart attack. The screening just happened to catch what nothing else had.
That, O’Brien said, is exactly the challenge — finding the crisis before it manifests itself in another way.
For information about Inspira Health, go to inspirahealthnetwork.org.
