Background: Prostate cancer is a risk factor for major depressive disorder. Recent psycho-oncology research suggests a potential role for male-specific mood-related symptoms in this relationship. Gender socialisation experiences may reinforce men’s anger and emotion suppression responses in times of distress, and anger and emotion suppression may be implicated in pathways to, and maintenance of depression in prostate cancer.
Patients and Methods: Data were collected online from men with a self-reported diagnosis of prostate cancer (N=100; mean age 64.8 years). Respondents provided information regarding diagnosis and treatment, in addition to current experience of major depression and male-specific externalising symptoms.
Results: Prostate cancer diagnosis in the last 12 months occurred for 35.4% of the sample. Elevated major depression symptoms were observed for 49% of respondents, with 14% endorsing past 2-week suicide ideation. Parallel mediation analysis (99% CIs) controlling for prostatectomy and active surveillance indicated men’s emotion suppression mediated the relationship between anger and depression symptoms (R²=0.580). Trichotimised emotion suppression scores with control variables yielded a large multivariate effect (p< 0.001, partial η²=0.199). Univariate moderate-sized effects were observed for emotion suppression comparisons for symptoms of depressed mood and sleep disturbance, and a large effect observed for guilt-proneness.
Conclusion: Findings highlight the salience of anger in the experience of depression symptoms for men with prostate cancer. The mediating role of emotion suppression, which in turn was strongly linked to men’s feelings of guilt, suggests potential assessment and intervention targets. Future work should examine the role of androgen deprivation therapy and other treatments including active surveillance on the relationship between anger and depression in men with prostate cancer. Consideration of interventions focused on emotion processing skills in psycho-oncology settings may help reduce men’s reliance on emotion suppression as a strategy for coping with feelings of anger or guilt in the context of prostate cancer.

Keywords: prostate, depression, anger, emotion suppression

Men diagnosed with prostate cancer have a heightened risk for major depressive disorder,^1,2 with rates exceeding those seen in the general male population.^3,4 This finding has been linked to the unmet psychosocial needs of this population following diagnosis,⁵ in addition to prostate cancer-related symptoms,⁶ and treatment-induced side effects including sexual dysfunction and urinary incontinence.^7–9 Even those men on active surveillance are at high risk for depression¹⁰ whereby a decline in quality of life can be expected in the first 6 months following diagnosis.¹¹ Depression among men with prostate cancer is also associated with the loss of masculine identity.¹² Amid efforts to ensure depression does not by extension go undetected or untreated in men with prostate cancer,⁴ symptom screening is recommended.¹³ Such approaches are essential given men with depression have an increased risk of prostate cancer mortality¹⁴ and suicide.¹⁵

A diagnosis of major depression is made on the basis of the nine diagnostic criteria per DSM-5¹⁶ or ICD-10.¹⁷ There is growing concern that these diagnostic criteria may inaccurately reflect men’s experiences of mood disturbance, and therefore insufficiently identify men with an underlying mood disorder.^18,19 Studies support the existence of a phenotypic variant of depression in men,^20,21 characterised by externalising and atypical symptoms including anger,²² substance use,²³ risk-taking²⁴ and emotion suppression.²⁵ These symptom domains tend to be socially sanctioned for men as reflecting culturally informed and affirmed dominant Western masculine norms (as opposed to vulnerable emotions of sadness).²⁶ It is unclear whether this range of externalising and atypical symptoms reflect problematic coping strategies and a predisposing risk factor for depression in men, or should instead be considered part of the prodromal phase on a unique manifestation of depression in men. There is evidence suggesting that such symptoms may be a unique feature of men’s depression,²¹ especially in the context of recent depressogenic negative life events that may precipitate major mood disturbance.²⁷ Nonetheless, it is important to recognise that this research area is in a nascent stage and draws debate.²⁸

Regardless of the role of externalising symptoms in men’s depression, in the context of oncology––and prostate cancer more specifically––the emotion and expression of negative affect (such as anger) has been identified as particularly important.^29,30 Amid growing literature on the role of anger in other cancers, such as breast cancer,^31–34 recent calls have been made to further anger-based research in the context of prostate cancer.³⁵ Importantly, research has shown an association between morbidity and suppression of negative emotion^36–38 and a link has been reported between prostate cancer and suppression of anger,³⁹ though corroborating evidence at present is sparse.⁴⁰ While psychodynamic theory has long posited that anger turned inwards can precipitate depression,⁴¹ anger has largely been ignored by other treatment models in the conceptualisation and treatment of emotional disorders such as depression.⁴² This negligence has occurred despite the fact that anger predicts negative consequences, greater symptom severity and worse treatment response for such conditions.⁴³

In the context of potential linkages between anger and depression in men with prostate cancer, the present study explored five putative male-specific coping strategies (emotion suppression, drug use, alcohol use, somatisation, risk-taking) as parallel mediators⁴⁴ in the relationship between anger and symptoms of major depressive disorder. Consistent with previous research,^45,46 significant associations were expected between externalising and atypical symptoms of depression. Based on the findings of others,^36,39 it was hypothesised that emotion suppression would mediate the relationship between anger and depression, and that alcohol and drug use may also be implicated (as external coping strategies) in this relationship.

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