It is consistently reported that women have higher rates of depression than men. In the past, there was an assumption that women were more vulnerable to depression. However, higher rates of suicide for men than women in almost every country, and rising rates of depression for men in many countries, has led to the development of more sophisticated approaches to conceptualising gender differences in mental health [1, 2]. One approach focuses on the importance of socially constructed gender roles; in many societies, culturally dominant forms of masculinity emphasise strength, stoicism and emotional control, in direct contrast with femininity which is characterised by vulnerability and emotional expression [3, 4]. Thus, it is hypothesised that the ways that women express emotional distress mean that they are more likely to be diagnosed (and perhaps over-diagnosed) with depression, while men's lack of articulacy means their depression may be 'hidden' [5, 6].
Qualitative studies are necessary in order to explore how people perceive, construct and express depression (see, for example, [7–12]). Qualitative researchers have also sought to explore how people with mental health problems experience primary care. Mental health patients valued general practitioners (GPs) who knew them, listened to them and took their concerns seriously [13, 14]. The importance of continuity of care has been highlighted as patients have suggested that a long-standing relationship with a GP enabled trust to develop, prevented them having to repeatedly retell their stories and, perhaps most importantly, allowed them and health professionals to understand each other as people [14, 15]. Symptoms of depression also contribute to problems in accessing help; for example, lack of confidence and assertiveness, low self-worth and feelings of lack of entitlement to GP time and resources have deterred patients from raising concerns about emotional distress [10, 13, 14, 16]. Another frequently reported barrier to communication in primary care is that patients are uncertain about the nature of their emotional distress and lack the vocabulary with which to name and discuss their experiences [8–10, 13]. Karp  describes this period of 'inchoate feelings' as the beginning of the depression 'career' and argues that "part of the pain of depression is their (people with depression) inability to satisfactorily communicate what they are feeling, and the simultaneous failure of others to understand them" (p27). Even when patients had the vocabulary with which to explain their emotional distress, they were sometimes unsure whether their symptoms could be classified as forms of medically manageable illness which were suitable for discussion with a GP [10, 17]. Pollock  found that patients suppressed the expression of emotional distress during medical consultations because they were trying to 'maintain face' and conform to "the socially sanctioned role of the stoic, good and uncomplaining patient in order to retain the social esteem and good will of others" (p175).
Despite this increasing body of qualitative work, very few studies have compared the experiences of men and women. There is still relatively little discussion of men's mental health ; many studies concentrate solely on women (e.g. [20–23]), and those with mixed samples tend to include a much higher proportion of women than men (e.g. [10, 12, 16, 17]). Some studies do comment, in passing, on gender differences but do not explicitly set out to compare the experiences of men and women. For example, Rogers and colleagues  note that, while most of their respondents were reluctant to disclose to their doctor that they felt they couldn't cope, this reluctance was particularly evident in the accounts of the men, while Wittink and colleagues  found that only women in their sample expressed a belief that doctors were able to 'pick up' on depression without the patient having to be explicit about their emotions. Karp  has argued that future research should concentrate on how gender and other markers of social position influence meanings attached to depression, so that "proper respect can be accorded to both regularities in the illness experience and to the diversity of definitions that affect its course" (p27).
Two recent studies have explicitly compared men and women. They concluded that men and women experience depression in a similar way, but have different ways of manifesting and expressing their distress. Brownhill and colleagues  found that both men and women tried to avoid emotional distress by not thinking about problems, or by distancing and distracting themselves. Men were more likely to suppress emotions which then built up over time and were sometimes released in the form of anger or violence, while women were more prepared to release emotions early by crying and seeking help. However, this study used a convenience sample of teachers and students who discussed their experiences of being 'down in the dumps'. In contrast, Danielsson and Johansson  used a sample of people diagnosed with depression. They found that women verbalized emotional distress more readily than men (which may put them at risk of being over-diagnosed with depression), and men talked more easily about physical distress than about emotions (which may put them at risk of being under-diagnosed for depression). The authors concluded that men might 'retreat into silence' when faced with emotional distress and so clinicians need to listen to the 'avoided' and the 'unarticulated' (p176), rather than just what is expressed in words, in order to counteract stereotypes around gender and depression.
In this paper, we take a gender comparative  approach to exploring the mental health of men and women. We are aware that language in this area is problematic. Oakley  popularised the influential distinction between sex and gender in the 1970s, where 'sex' referred to biological differences between males and females (assumed to be universal and unchanging), and 'gender' referred to culturally constructed notions of masculinity and femininity (assumed to be highly variable). While this distinction has been useful theoretically, it is increasingly recognised as problematic (see Emslie et al  for a full discussion). For example, the biologically 'given' nature of sex has been shown to be more complex than previously recognised . It has also been argued that there is constant interaction between the biological and the social; biological 'facts' are socially constructed, while cultural views affect which 'facts' are selected and how much importance they are given [29, 30].
Recently, Annandale  has argued that we need to move towards a new system: "in which social (gender) and biological (sex) depend on each other for understanding just as much as before, but where the meaning of biological sex and the meaning of social gender, as well as the connections between them, are more fluid" (p88). Some might argue that in this analysis we are taking a 'sex comparative' approach as we compare groups of (biologically defined) men with groups of (biologically defined) women. However, we have chosen to use the term 'gender' as the term 'sex' still carries connotations of narrow biological differences and we wish to indicate the importance of socially constructed gender roles (while not denying the role that biology plays in mental health). Furthermore, we believe that experiences of talking about mental health problems would seldom be heard in a 'gender-free' way as the listener is likely, consciously or unconsciously, to interpret what is being said to them in the light of the speaker's sex and socially constructed scripts of gender appropriate behaviour.
Here, gender is conceptualised as a dynamic set of socially constructed relationships, rather than as a fixed and binary category . Conceptualising gender in this way disrupts the notion that 'masculine' and 'feminine' identities are stable characteristics of individuals, and problematises the notion of focusing exclusively on gender difference. Instead, we are also interested in exploring commonalities across men and women, and diversity among women and among men.
In this paper, we present data from in-depth interviews with 38 respondents who identified themselves as having had depression. In our analysis, we set out to compare the accounts of men and women: specifically, is there evidence that women are articulate about depression and men are inarticulate, and are there gender differences or similarities in the strategies which respondents described as useful in helping them to engage with health professionals?