Men's Health

The Missing Link To Men's Mental Health Has Been Hiding In Plain Sight

For some men with depression, testosterone therapy might be the answer.

by Isobel Whitcomb
Ariela Basson/Fatherly; Getty Images

So you’re feeling worn down, listless, and blue. Or maybe you’re having trouble getting intimate with your partner or finding the energy to work out. You have a feeling you might be depressed — but before you ask your doctors about starting an SSRI, there’s another avenue to explore: Research suggests that for some men, low testosterone levels may be an important, under-treated depression culprit.

Testosterone is a chemical messenger essential to male development, primarily as an embryo in the womb and during puberty. But testosterone isn’t just responsible for sex characteristics. In cisgender men, this hormone signals the body to make new red blood cells, maintains muscle and bone health, and may even play an important role in the brain — including modulating the way neurons send and receive chemicals that balance our mental health.

“We used to think [testosterone] was just a sex hormone, but we’re starting to learn that there is actually this broader reach to it,” says Amin Herati, M.D., a urologist and director of male infertility and men’s health at Johns Hopkins Medicine.

“We used to think [testosterone] was just a sex hormone, but we’re starting to learn that there is actually this broader reach to it.”

This means that when testosterone levels inevitably dip — which they do by about 1% to 2% per year starting around age 40 — they affect the whole body. Although the process is natural and usually not a problem, it leads around one-third of men above the age of 45 to develop low testosterone levels (keeping in mind that “low” versus “normal” levels are tricky to define, and somewhat controversial). Men with low testosterone may lose body hair and muscle mass, or even develop brittle bones. They may experience a low sex drive. And then there are the mental health effects, like feeling depressed, Herati says.

A lot of what we know about the connection between depression and low testosterone is based upon studies examining the effects of testosterone therapy on mental health — and based upon these studies, the treatment does seem to help. Scientists pooled the results of 27 clinical trials, which included data from 1,890 men, and analyzed them together. The results, published in 2019 in JAMA Psychiatry, showed that men who took testosterone therapy were 2.3 times more likely to see a decline in their depression than those who didn’t.

Why the low testosterone-depression connection exists is uncertain. It’s possible that testosterone plays a role in dopamine and serotonin production, Herati says. Research in rodents and humans suggests that testosterone increases the brain’s ability to send and receive serotonin and even promote the growth of new brain cells.

Some researchers argue that the evidence for a connection between depression and low testosterone is shaky. And some studies have found that testosterone therapy may increase symptoms of depression for some men. In a study published in the Journal of Sexual Medicine, researchers looked at testosterone use, suicide attempts, and depression diagnoses in more than 18 million men. They found that testosterone-deficient men on testosterone replacement therapy were more likely to have depression compared to testosterone-deficient men not taking the therapy. But Herati points out issues with the study’s methodology — it’s possible the men taking testosterone therapy sought it out because they already were experiencing depression.

Why the low testosterone-depression connection exists is uncertain. It’s possible that testosterone plays a role in dopamine and serotonin production.

Anecdotally, Herati sees men with depression benefitting from testosterone therapy. So, should you get your testosterone levels tested if you’re feeling depressed?

Yes, Herati says — if you’re experiencing more than one symptom of testosterone deficiency, such as trouble maintaining erections, low energy, and hair loss.

“If those symptoms are present, then it’s a good idea,” he says. “I wouldn’t do it for depression only.” Doing so, Herati adds, would identify a lot of men whose testosterone levels are just temporarily and incidentally low, without any relationship to their mental health.

If you do start testosterone therapy, and are interested in starting a family and having more children, Herati recommends monitoring fertility because testosterone supplements can negatively impact sperm production. If you have low testosterone, whether or not you opt for replacement therapy, he also recommends going in for regular prostate exams. “There are studies that associate low-T men with a higher risk of developing prostate cancer or that prostate cancer acting more aggressively,” he says.

Finally, it’s important to view testosterone therapy not as a single solution but a boost to other self-care habits. “When people have normal testosterone, they’re exercising more, they’re having more intimacy with their partners,” Herati says.

In other words, it could be these behaviors that boost men’s mood, rather than the testosterone itself. “I wouldn’t say if you give a sedentary person testosterone, that their mood is going to get any better,” Herati says. “You really have to move everything in parallel.”