Psychosocial impact of androgenetic alopecia on men: A systematic review and meta-analysis

Figures & data

Figure 1. PRISMA diagram depicting the results of the systematic search strategy.

Table 1. Summary of sample characteristics, hair loss assessment and quality assessment.

Study	Location	Balding male participant characteristics (mean age and standard deviation)	Sample type	Hair loss/loss severity assessment^a	Quality (0–14)
Alfonso et al. (2005)	Germany, France, Italy, Spain & UK	729 balding men recruited via market-research or through “‘random digit dialling” (pg. 1830; n.r.)	Nonbiased representative	Self-reported; no measure	6
Bade et al. (2016)	India	200 dermatology clinic patients (M = 30.6, SD = 8.7)*	Biased convenience	Clinician assessed; Norwood Hamilton Scale (I-VII)	8
Budd et al. (2000)	France, Germany, Italy & UK	798 balding men recruited via their households (n.r.)	Nonbiased representative	Self-reported; categorical scale with seven responses (‘a full head of hair’ to ‘I am bald’); Norwoord Hamilton scale (I-VII)	6
Camacho and García-Hernández (2002)	Spain	100 dermatology clinic patients (n.r.)	Biased convenience	Clinician assessed; Norwood Hamilton Scale (II-VII)	5
Cash (1992)	US	103 balding men referred to the study via their hairdressers*	Nonbiased convenience	Self-reported, (adapted) Norwood Hamilton Scale	6
Cash et al. (1993)	US	60 dermatology clinic patients (M = 31.3, SD = n.r.)	Biased convenience	Clinician assessed; Norwood Hamilton Scale (II-VII)	7
Cash (2009)	US, UK, France, Germany, Spain, Japan & Korea	604 balding men who were interested in hair loss services/products recruited via market research (M = 37.1, SD = 6.6)	Biased representative sample	Self-reported; Norwood Hamilton Scale (II-VII)	8
Danyal et al. (2018)	Pakistan	60 participants likely recruited from authors’ institution*	Nonbiased convenience	Clinician assessed; Norwood Hamilton Scale (I-VII)	9
DeMuro-Mercon et al. (2000)	Norway	1,761 balding men recruited via their households (n.r.)	Nonbiased representative	Self-reported; categorical scale with seven responses (full head of hair-bald); Norwoord Hamilton scale (I-VII)	6
Franzoi et al. (1990)	US	52 balding men at a US airport (M = 43, SD = n.r.)	Nonbiased convenience	Self-reported	8
Ghimire (2018).	Nepal	120 hair transplant patients (M = 31.87, SD = 6.8)	Biased convenience	Clinician assessed	7
Girman et al. (1998)	US	Approximately 191 balding men^1 recruited via their households (n.r.)	Nonbiased representative	Self-reported; categorical scale with seven responses (full head of hair-bald); Norwoord Hamilton scale (I-VII)	8
Gonul et al. (2018)	Turkey	30 hair transplant patients (M = 23.47, SD = 5.79)	Biased convenience	Clinician assessed; Hamilton Norwood Scale (I-VI)	6
Gosselin (1984)	UK	204 dermatology patients (M = 35.14, SD = 11.04)*	Biased convenience	n.r.	6
Gupta et al. (2019)	India	200 dermatology patients (M = 32.0, SD = n.r.)	Biased convenience	Clinician assessed; Norwood Hamilton Scale (I-VII)	8
Han et al. (2012)	South Korea	998 dermatology patients (M = 41.70, SD = 5.5)	Biased convenience	Clinician assessed	6
Karaman et al. (2006)	Turkey	175 balding men^2 recruited from their workplaces (M = 34.82, SD = 9.62)	Unreported	Self-reported; Norwood Hamilton Scale (I-VII)	7
Kranz (2011)	Germany	160 balding men recruited from author’s university (M = 24.4, SD = 2.56)	Nonbiased convenience	Self-reported; Norwood Hamilton Scale (II-VII)	10
Liu et al. (2019)	China	875 hair transplant patients (M = 30.85, SD = n.r.)	Biased convenience	Self-reported; Norwood Hamilton Scale (I-V)	8
Lulic et al. (2017)	Japan, South Korea, Taiwan, Mexico & Brazil	835 balding men who had recently received hair loss services/products (n.r.)	Biased convenience	Self-reported	5
Maffei et al. (1994)	Italy	64 dermatology patients (n.r.)	Biased convenience	Clinician assessed; Norwood Hamilton Scale (III-VII)	7
Molina-Leyva et al. (2016)	Spain	190 hair loss forum users (M = 26.3, SD = 5.4)	Biased convenience	Self-reported; Norwood Hamilton Scale (I-VII)	8
Mubki et al. (2019)	Saudi Arabia	96 dermatology patients (n.r.)	Biased convenience	Clinician assessed; Norwood Hamilton Scale (I-VII)	10
Passchier et al. (2006)	Netherlands	160 non-hair loss dermatology patients*	Non-biased convenience	Clinician assessed; Norwood Hamilton Scale (II-V)	6
Passchier et al. (1989)	Netherlands	201 prospective or current minoxidil users (n.r.)	Biased convenience	Self-reported; Hamilton Scale (blaness pattern)	7
Passchier et al. (1988)	Netherlands	85 prospective or current minoxidil users (n.r.)	Biased convenience	Clinician assessed; Norwood Hamilton Scale (III or IV) and a balding patch of at least 2.5 cm in diameter	8
Rahimi-Ardabili et al. (2006)	Iran	128 dermatology patients (M = 25.8, SD = 4.4)	Biased convenience	Clinician assessed	10
Russo et al. (2019)	Italy	23 dermatology patients (M = 28.39, SD = 11.86)	Biased convenience	Clinician assessed; Norwood Hamilton Scale (I-VI)	6
Sawant et al. (2010)	India	37 dermatology patients*	Biased convenience	Clinician assessed; Norwood Hamilton Scale (IIa-VII)	7
Tabolli et al. (2013)	Italy	237 dermatology patients (M = 31.53, SD = 10.57)	Biased convenience	Clinician assessed; Norwood Hamilton Scale (I-VII)	7
Tahir et al. (2013)	Pakistan	53 dermatology patients (n.r.)	Biased convenience	Clinician assessed; Norwood Hamilton Scale (II-VII)	7
Tang et al. (2000)	Singapore	161 balding men recruited via their households (n.r.)	Nonbiased representative	Researcher assessed; Norwood Hamilton Scale (I-VII)	8
Tas et al. (2018)	Turkey	283 dermatology patients (M = 23.16, SD = 6.34)	Biased convenience	Researcher assessed; Norwood Hamilton Scale (II-IVa)	9
Van der Donk et al. (1991)	Netherlands	168 prospective or current minoxidil user (M = 35.0, SD = n.r.)	Biased convenience	Researcher assessed; Norwood Hamilton (III-IV) discernible balding patch on the vertex of no less than 5 cm and no more than 10 cm.	9
Wang et al. (2018)	China	340 dermatology patients^3 (n.r.)	Biased convenience	Researcher assessed; Norwood Hamilton (I-VII)	8
Wells et al. (1995)	UK	122 balding men recruited from UK public locations*	Non-biased convenience	Researcher assessed (full head, semi-bald, bald)	8
Yamazaki et al. (2011)	Japan	27 prospective or current minoxidil users (M = 33.8, SD = n.r.)	Biased convenience	Researcher assessed; Norwood Hamilton (II-IV)	8

Notes: n.r.= no information reported.

^aThe Norwood Hamilton Scale consists of images of balding men depicting different degrees of hair loss (Norwood) and different patterns of balding (Hamilton). Severity of hair loss is graded I = little or no hair loss to VII = severe hair loss.

*The following studies divided their balding male participants into subgroups: Bade into 1) older (>31 years n = 122) and 2) younger (21–3, n = 68); Cash (1992) into 1) modest balding (n = 63) and 2) extensive balding (n = 40); Danyal into 1) Mild-Moderate recession (n = 30, M = 22.3, SD = -) and 2) Moderate-Severe recession (n = 30, M = 23.97, SD = -); Gosselin into 1) weave (n = 103), weave-rejected (n = 50) & unconcerned (didn’t try weave n = 51); Passchier into 1) Completed questionnaire twice (current & retrospective views on hair loss; n = 80; age M = 48.0, SD = 18.2) and 2) Current questionnaire only (n = 80, age M = 50.0, SD = 18.0); Sawar into 1) young (15–26 years; n = 23) & older (26+ years; n = 14); and Wells into 1) semi bald (n = 60, age M = 36.1, SD = 13.2) and 2) severer bald (n = 62, M = 37.3, SD = 12.8)

¹The exact number of balding male participants are not reported in Girman et al. (1998). Authors note however that 30% of their male sample (total sample N = 273) were not balding.

²Some of Karaman et al. (2006) results are incomplete and only reported for both balding men (70% n = 175) and nonbalding men (30% n − 77) together.

³Fifteen participants (4%) in Wang’s et al. (2018) study were women (total sample N = 355) and their results are conflated with male AGA participants (n = 340).

Table 2. Summary of key findings in relation to the general mental health, anxiety, and depression of balding men. For a more detailed version please see a supplementary file here: https://mfr.osf.io/render?url=https://osf.io/4y2pc/?direct%26mode=render%26action=download%26mode=render.

Study	Measure	Sample/Comparisons (Balding unless otherwise stated)	Mean (SD)	Reported results	Interpretation in relation to clinical norms (see notes)
General Mental Health
Cash et al. (1993)	Psychosocial well-being^a	Men (n = 60)	4.52 (0.66)	Balding women had poorer psychosocial wellbeing; balding men no different from non-balding women	Not available
		Women (n = 96)	3.91 (0.92)
		Non-balding women (n = 56)	4.62 (0.92)
*Passchier et al. (1988)	DelftQuestionnaire^b	Men (n = 85)	13.4 (7.6)	No significant difference from norm (12.5)	As reported†
Maffei et al. (1994)	The Symptom Checklist-90 (SCL-90)^c	Men (n = 64) Women (n = 52)	GSI 3.18 (3.40)* GSI 5.72 (5.50)*	No interpretation given on this scale alone	Not available
Sawant et al. (2010)	Symptom Check List-90-R (SCL-90-R)^c	Younger men (n = 23)	GSI 3.01 (4.51)*	No significant differences between the older and younger group	Not available
		Older men (n = 14)	GSI 3.44 (5.4)*
*Tabolli et al. (2013)	Medical Outcomes Study Short Form-12 (SF-12)^d	Men (n = 237)	45.2 (10.5)	Non-balding men had the best mental wellbeing, and balding men had better wellbeing than balding women	Scores below 50 suggest lower mental wellbeing than for the average American
		Non-balding men (n = 108)	47.7 (10.5)
		Women (n = 114)	38.8 (11.2)
	General Health Questionnaire 12 items (GHQ-12)^e	Men (n = 237)	12.1 (5.3)	Balding women had higher mental distress than balding men, who had higher distress than non-balding men	Range 0–36; clinical cut-off 12^†
		Non-balding men (n = 108)	10.8 (5.2)
		Women (n = 114)	16.1 (6.5)
*Wang et al. (2018)	Symptom Check List-90-Revised (SCL-90-R)^c	Men (n = 335)	1.50 (0.46	Balding men significantly more distressed than controls on the global severity index (GSI)	Not available
		Non-balding controls (n = 406)	1.33 (0.40)
Anxiety
*Cash et al. (1993)	Self-Consciousness Scale^f	Men (n = 60)	8.47 (4.27)	Balding women had higher social anxiety, than balding men or non-balding women (who did not differ)	Balding men did not differ from group norms of 8.8 (4.3)
		Women (n = 96)	10.08 (4.64)
		Non-balding women (n = 56)	7.79 (4.16)
*Danyal et al. (2018)	Hamilton Anxiety Rating Scale (HAM-A)^g	Non-balding men (n = 30)	12.46 (1.63)	Men with mild-moderate hair loss (not severe) had higher anxiety than non-balding men	A mean of 20.23 indicates moderate anxiety
		Men mild-moderate hair loss (n = 30)	20.23 (1.40)
		Men moderate-severe hair loss (n = 30)	15.46 (1.08)
*Donk et al (Van der Donk et al., 1991).	The Self-Report Inventory of Social Anxiety & Assertiveness^h	Men (n = 168)	64.3 (17.6) (Discomfort)	No significant difference in social discomfort or frequency between balding men & group norms (66.9 & 112.6)	As stated^†
			110.5 (16.3) (Frequency)
*Passchier et al. (1988)	Self-Report Inventory of Social Anxiety & Assertiveness^h	Men (n = 85)	65.3 (21.2) (Discomfort)	There was no difference between balding men & group norms on social discomfort (66.9) or frequency (112.6)	As stated†
			112.9 ± 18.5 (Frequency)
*Rahimi-Ardabili et al. (2006)	Hospital Anxiety and Depression Scale (HADS)^i	Men (n = 128)	6.24 (3.17)	60.9%, 28.9% & 10.2% of sample showed normal, mild or moderate anxiety	Mean is within the normal range (0–7)^†
*Russo et al. (2019)	Trait Anxiety Inventory (STAI Y)^j	Men (n = 23)	42.8 (5.97)	Balding women had higher anxiety than balding men	Slightly elevated scores compared to norm (34.9); outside range for diagnosed anxiety (47–61)
		Women (n = 57)	49.4 (9.94)
	Social Phobia (SPS) for psychosocial anxiety^k	Men (n = 23)	18.0 (6.14)	Balding women have higher social phobia scores than balding men	Scores higher than controls (12.5); below clinical threshold for Social anxiety disorder (24)
		Women (n = 57)	25.4 (9.91)
	Social Interaction Anxiety Scale (SIAS)^l	Men (n = 23)	15.2 (4.07)	Balding women have higher social anxiety than balding men	Scores below control group mean (19.9), & cut off for social anxiety disorder (34)
		Women (n = 57)	21.5 (9.19)
*Tas et al. (2018)	Beck Anxiety Inventory (BAI)^m	Men (n = 283)	5.95 (3.83)	Women were significantly more anxious than men	Male mean well below the clinical threshold (11)^†
		Women (n = 70)	11.93 (4.85)
*Yamazaki et al. (2011)	State-Trait Anxiety Inventory (STAI)^n	Men (n = 27)	45.0 (11.5) State anxiety	Scores for healthy volunteers are state = 36.6 (8.88) & trait 38.5 (9.42)	Higher anxiety scores than norms for healthy volunteers^†
			45.5 (11.2) Trait anxiety
Depression
*Danyal et al. (2018)	Zung Self-Rating Depression scale (SDS)^o	Men no hair loss (n = 30)	38.43 (1.26)	No significant difference was observed in SDS scores between groups	Mean scores fall within the normal range (25–49)
		Men mild- moderate hair loss (n = 30)	38.3 (1.16)
		Men moderate- severe hair loss (n = 30)	35.3 (0.8)
*Rahimi-Ardabili et al. (2006)	Hospital Anxiety & Depres- sion Scale (HADS)^i	Balding men (n = 128)	4.04 (2.52)	n.r.	Mean score falls within the normal range (<7)
	Beck Depression Inventory^p		12.11 (7.50)	46.9%, 18.0% & 3.9% of sample were within ranges for normal, mild & moderate depression respectively	Mean score indicates moderate depression†
*Tas et al. (Tas et al., 2018)	Beck Depression Inventory^p	Men (n = 283)	8.82 (5.07)	Balding women more depressed than balding men	Scores fall within the normal range (<10) & well short of clinical cut off (17)^†
		Women (n = 70)	14.74 (4.44)
*Wells et al. (1995)	Beck Depression Inventory^p	Non-balding (n = 60)	4.78 (4.65)	There is an association between increasing hair loss and depression	Mean scores fall within the normal range (<10) & well short of clinical cut off (17)
		Semi-bald (n = 60)	6.28 (6.03)
		Bald (n = 62)	8.00 (6.19)
Self-Esteem
*Danyal et al. (2018)	RSES^q	mild to moderate hair loss	16.46 (1.7)	Men with mild-moderate or moderate-severe hair loss have lower self-esteem than non-balding men	Assuming scoring from 0–30 mean for all groups are in the normal range (15–25)
		moderate to severe hair loss	17.3 (1.0)
		men without hair loss	21.63 (0.7)
*Krantz (Kranz, 2011)	RSES	Men (n = 160)	4.08 (7.29)	As distress re: hair loss increased, self-esteem decreased	Mean fall below normal range (<15)
*Liu et al. (2019)	RSES	Pre hair graft	29.79 (5.75)	Balding men had higher self-esteem post hair graft, especially those with higher pre-operative self-esteem	Pre hair graft scores within the normal range (26–29); post-operatively within high self-esteem range (30–40)
		Post hair graft	31.35 (5.27)
*Tas et al. (2018)	RSES	Men (n = 283)	15.76 (5.33)	Men has significantly higher self-esteem than women	Men’s scores are within the normal range for self-esteem (15–25)†
		Women (n = 70)	11.57 (2.88)
Donk et al. (1991)	Dutch measure based on the RSES	Before use of minoxidil gel	35.8 (n.r.)	No difference in self-esteem before & after 6 months use of minoxidil gel	Not available
		After 6 months use of minoxidil gel	36.3 (3.7)
Passchier et al. (1988)	Dutch measure based on the RSES^r	Men taking minoxidil with controls	n/a	Men taking minoxidil showed greater improvements in self-esteem	Not available
Wells et al. (1995)	Modified version of the RSES^s	Bald (n = 62)	41.08 (9.99)	psychological distress to increase with increasing degrees of hair loss	Not available
		Semi-bald (n = 60)	41.75 (9.82)
		No hair loss (n = 60)	44.13 (8.90)
Cash (1992)	TSBI^t	No hair loss (n = 42)	n/a	For men distressed by balding (n = 103) self-esteem decreased as number of negative events re: hair loss increased	Not available
		Low hair loss (n = 63)	n/a
		High hair loss (n = 40)	n/a
*Cash et al. (1993)	TSBI	Men (n = 60)	58.8 (9.1)	Balding men had higher self-esteem than balding & non-balding women	Scores for all three groups were higher than norm for male undergraduates (40.45)
		Women (n = 92)	54.5 (11.6)
		Non-balding women (n = 56)	59.4 (9.1)
Gosselin (1984)	Items from Eysenck &Wilson (1976)	Retaining hair weave	19.49 (6.74)	No interpretation offered	Not available
		Tried/not retaining weave	17.12 (7.11)
		no treatment/concern	20.67 (6.50)

Denotes studies which studies using validated assessments that compare AGA men to non-AGA male participants or where there are published norms available that can be used for comparison.

^†Denotes studies which used clinical/population norms to aid interpretation of their results.

NB: References for all measures and for clinical interpretation of scores are included in Supplement S1. Paper by DeMuro-Mercon et al (2000) not listed in general mental health because they did not report the results of the mental health measures they used; Cash (1992) not listed in the anxiety summary because did not report means on the Self-Consciousness Scale; Carmacho & García-Hernández (2002) not listed as relied on a non-validated assessment of anxiety & depression interpreted from behaviour; Kranz (2011) used the RSES but did not report means or SDs for balding men so is not included here; Gosselin (1984) used items from a validated measure of self-esteem. *GIS scores calculated by averaging the means from the subscale means reported. However, it is not possible to offer a clinical interpretation because the raw scores reported in both papers include scores greater than 4 which do not reflect the scoring system for this measure.

^aQuestionnaire reported in Cash et al (1986) – no further information provided.

^bThe Delft Questionnaire (Appels, 1975) measures general psychological maladjustment.

^cThe Symptom Checklist 90 (SCL-90; Derogatis et al., 1973) & Symptom Checklist-90-Revised (SCL-90-R; Derogatis, 1973) are identical except adjusted wording on two questions: 90-items assessing psychological distress (somatization, obsessive – compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, & psychoticism); 5-point response (from ‘not at all = 0’ to ‘extremely = 4’); GSI (the mean score of all items) is considered to be the best representation of an overall psychological distress dimension.

^dMedical Outcomes Study Short Form-12 (SF-12; Ware et al., 1998): 12-items regarding health status; dichotomous (yes/no), ordinal (excellent to poor), or frequency (always to never) responses; a Physical Component Summary (PCS-12) & a Mental Component Summary (MCS-12) score; higher scores=better QoL; scores transformed (X = 50 & SD = 10) for comparison with American ‘standards’. Scores above or below 50 are above or below the mean of the general American population.

^eGeneral Health Questionnaire 12 items (GHQ-12; Goldberg, 1972)(): measures psychological distress & detects depressive or anxiety disorders; responses 0–3; range 0–36; higher = higher distress. Includes group norms.

^fThe self-consciousness scale (Fenigstein et al., 1975): 22 items (23 before revision by Scheier & Carver, 1985) assessing public self-consciousness [7 items], private self-consciousness [9 items] & social anxiety [6 items]; 4-point scale response (0=’Not at all like me’ & 3=’a lot like me’). Cash et al (1993) used 13 items (public self-consciousness & social anxiety). Only scores social anxiety reported here. Range 0–18; higher scores = greater social anxiety. Group norms from a student population are X = 8.8, sd = 4.3 for men (Scheier & Carver, 1985).

^gThe Hamilton Anxiety Rating Scale (HAM-A; Hamilton, 1959): 14 items measuring anxiety; five-point scale response indicating how disabling each symptom is; 0–4 (‘None’ to ‘Grossly Disabling’ respectively); range 0–56; higher scores = higher anxiety. Clinical interpretation: <7 no/minimal anxiety mild anxiety = 8–14; moderate = 15–23; severe 24 (Matza et al., 2010)

^hThe Self-Report Inventory of Social Anxiety & Assertiveness (IOA; Dam-Baggen & Kraimat, 2000 later the Inventory of Interpersonal Situations): two scales (‘Overall discomfort during contact with others’ & ‘Overall frequency of contact with others’); 35 items describing responses in social situations; 5-point response (1=no discomfort/I never do & 5=very much discomfort/I always do); range 35–175; higher score = higher anxiety. Group norms provided by author.

ⁱThe Hospital Anxiety & Depression Scale (HADS; Snaith, 2003): 7 items for anxiety, 7 for depression; 4-point response (0–3). For the Persian version anxiety/depression norms: normal (0–7), mild (8–10), moderate (11–15), & severe (16–21) (Montazeri et al, 2003).

^jThe Trait Anxiety Inventory (STAI_Y; Spielberger et al., 1983): 20 items assessing anxiety as a personality trait; 4-point response (1= ‘Almost Never’ to 4=‘Almost Always’); range 20–80; higher scores = greater anxiety. Clinical interpretation: working men = 34.9 (SD 9.2); typical scores for people with diagnosed anxiety 47–61 (1983 manual, Version Y p68).

^kThe Social Phobia Scale (Mattick & Clarke, 1998): 20-items assessing fear of being scrutinised or observed during routine activities; 5-point response (0= ‘Not at all characteristic or true of me’ & 4= ‘Extremely characteristic or true of me’); range 0–80; higher scores = greater anxiety. Clinical interpretation: 12.5 (11.5) = without anxiety (controls); 49.0 (15.6) typical of clients; >24 cut off for social anxiety disorder (Heimberg et al., 1992).

^lThe Social Interaction Anxiety Scale (SIAS, Mattick & Clarke, 1998): 20 items; 5-point response (0= ‘Not at all characteristic or true of me’ & 4= ‘Extremely characteristic or true of me’); range 0–80; higher scores = greater anxiety. Clinical interpretation: < 19.9 (14.2) + no anxiety (controls), 32.8 (14.8) typical of clients; >34 cut off for social anxiety disorder (Heimberg et al., 1992).

^mThe Beck Anxiety Inventory (BAI; Beck, Epstein, Brown & Steer, 1988); 21-items each with four statements describing increasing levels of severity & questions that quantify the physiological aspect of anxiety; range 0–63; higher scores = higher anxiety. Clinical interpretation, Turkish version: 0–7 = minimal anxiety; 8–15 = mild anxiety; 16–25 = moderate anxiety; 26–63 severe anxiety; cut-off for clinically relevant subthreshold anxiety is 11 (Ulusoy et al., 1998).

ⁿThe State-Trait Anxiety Inventory (STAI; Japanese version, Nakazato & Shimonaka, 1989): 20 items assessing state anxiety (i.e. fluctuating & context dependent), 20 items assessing trait anxiety (i.e. stable personality trait); 4-point response (1–4); higher scores indicate higher anxiety. Clinical interpretation: state and trait anxiety scores for healthy volunteers were 36.6 ± 8.88 and 38.5 ± 9.42, respectively.

^oThe Zung Self-Rating Depression scale (SDS: Zung, 1988): 20-items used to screen for depression; 4-point response (1=a little of the time, 2=some of the time, 3=good part of the time, 4=most of the time); range 25–100; high score = greater intensity of depression. Clinical interpretation: 25–49 Normal Range; 50–59 Mildly Depressed; 60–69 Moderately Depressed; 70 & above Severely Depressed.

^pThe Beck Depression Inventory (BDI; Beck et al., 1961): 21-items assessing symptoms of depression; 4-point response (0 = absent, 3 = severe); range 0–63. Clinical interpretation Turkish Version: 0–10 normal range; 11–16 moderate depression; 31–40 severe depression, & 40–63 very serious depression; cut-off 17 (Hisli, 1988). Persian Version: ≤ 9 = normal range; 10–15 minimal depression; 16–31 = mild depression; 32–47 moderate depression; > 47 severe depression (Montazeri et al., 2003).

^qThe Rosenberg Self-Esteem Inventory (RSES; Rosenberg, 1965): 10 items; 4-point response (0–3 or 1–4); range 0–30 or 10–40. Clinical interpretation: 15–25 (or 26–29) = normal range; below 15 = low self-esteem; above 25 (or 30–40) = high self-esteem.

^rDeveloped using factor analysis on a translation of Rosenberg’s self-esteem scale (Sanders, 1977); 9 items; 5-point response.

^sDeveloped from the RSES (Russell & Hulson, 1992): 10 items, high scores = high self-esteem.

^tThe Texas Social Behavior Inventory (TSBI; Helmreich & Stapp, 1974): 16 items; 5-point response (0–4); range 0–64; higher scores = higher self-esteem. No clinical cut-offs.

Figure 2. Meta- analysis male balding psychosocial impact studies using the BDI (Beck, 1967).

Figure 3. Meta- analysis of balding psychosocial impact studies using the DQLI (Finlay & Khan, 1994).

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Data availability statement

The authors confirm that the data supporting the findings of this study are available within the article (and/or) its supplementary materials which are available at the Open Science Framework (doi: 10.17605/OSF.IO/RZP47). These include the PRISMA study protocol of the systematic review and other associated files here: https://osf.io/rzp47/?view_only=ea64dbef 2787485a83e18ef0671721a7