Is it Different for Guys?

Men are less likely to get treatment for psychiatric disorders, more than half of those who seek help are women.
Men are less likely to attempt suicide. 
But men have three times the number of completed suicides than women: they choose more lethal methods.


Are men different?  


Here's the beginning of the Mission Statement from a site called Mantherapy.org:


Working aged men (25-54 years old) account for the largest number of suicide deaths in Colorado. These men are also the least likely to receive any kind of support. They don’t talk about it with their friends. They don’t share with their family. And they sure as heck don’t seek professional treatment. They are the victims of problematic thinking that says mental health disorders are unmanly signs of weakness. And I, Dr. Rich Mahogany, am dedicated to changing that.

Part of a multi-agency effort, including the Colorado Office of Suicide Prevention, Carson J Spencer Foundation and Cactus, Man Therapy™ is giving men a resource they desperately need. A resource to help them with any problem that life sends their way, something to set them straight on the realities of suicide and mental health, and in the end, a tool to help put a stop to the suicide deaths of so many of our men.


So went to ManTherapy and listened to Dr. Rich Mahogany (I think he's an actor, the site says he's not a real therapist), I surfed around his office where there's  a dead creature with antlers on the wall, seating that's from a baseball stadium, and I took part of his symptom checklist test (it's not the M3).


The site feels like a parody of all things masculine.  I'm not a man -- so I'm not sure how to call this -- but I think if I were a distressed man, this wouldn't make me feel more comfortable getting help.  It's not that listing resources might not be useful, but I just wasn't sure.  If you feel like checking it out, surf over to Mantherapy and tell me what you think. 

Can We Teach People How To Avoid Mental Illness?

Prevention is an interesting word in psychiatry. It's hard to prevent mental illness-- we believe a lot of it is about genetics-- and when we think about prevention, we think about things like avoiding drugs and excess alcohol, getting enough sleep, growing up in a kind, safe, and loving environment with a reasonable amount of stability. Those are good things. When it comes to preventing Post-Traumatic Stress Disorder, we think about avoiding trauma, to the extent that we are able. Roy has written about the hypothetical idea of giving people medications to prevent the hard-wiring of traumatic memories and we talked about it in our My Three Shrinks Podcast #46 :Fugetaboutit!

But can you teach people not to get ill -- an insurance plan, if you will, or extra-protection-- before they get exposed to extreme trauma? Can you teach them not to get depressed? Not to get PTSD? It's a great idea, but as far as I know, people vary in their vulnerability and resilience, perhaps even tempermentally, and I'm not aware of research that shows you can teach people resilience in the fact of horror. It doesn't mean it can't be done, it just means I don't know of any research proving it. And if you can teach this, I want to be in the class, and I'd like to invite all the folks who live in the inner city to join me.

So Benedict Carey writes in today's New York Times about how the military intends to require emotional resiliency training for every soldier. Wow!

The new program is to be introduced at two bases in October and phased in gradually throughout the service, starting in basic training. It is modeled on techniques that have been tested mainly in middle schools.

Usually taught in weekly 90-minute classes, the methods seek to defuse or expose common habits of thinking and flawed beliefs that can lead to anger and frustration — for example, the tendency to assume the worst. (“My wife didn’t answer the phone; she must be with someone else.”)

Carey goes on to note:

“It’s important to be clear that there’s no evidence that any program makes soldiers more resilient,” said George A. Bonanno, a psychologist at Columbia University. But he and others said the program could settle one of the most important questions in psychology: whether mental toughness can be taught in the classroom.

So what's the downside? I'm not sure there is one-- except the price tag-- $117 million dollars for an unproven experiment? Couldn't we do some pilot studies first? Obviously I'm a bit of a skeptic-- perhaps we can teach people to be more adaptive in mildly stressful places, but I'm wondering if anything shields you from the extremes and the trauma our soldiers experience in combat. Funny to be spending so much for an unproven intervention in an arena where there aren't funds for treatment of those who give so much and come back so damaged.

Shoveling Up the Mess

This went out on a mass email. I liked it and I decided that since the author wants it disseminated, he wouldn't mind being made a Guest Blogger:

According to a report CASA issued this morning, federal, state and local governments spend almost half a trillion dollars every year -- almost 11 percent of their total budgets -- as a result of alcohol, tobacco and other drug abuse and addiction. The worst part is that, for federal and state spending, about 95% of that money is spent "Shoveling Up" the mess created by a failure to provide enough money for prevention and treatment.

That's right. Out of every dollar federal and state governments spent on substance misuse in 2005 (the latest data available), 95 cents paid for the enormous burden of this problem on health care, criminal justice, child welfare, education, and other programs. And only 2 cents were invested in prevention and treatment programs that could reduce many of these costs -- and save lives.

This huge waste of money is hidden in many different budgets, so most of our elected officials don't have a clue about how much alcohol, tobacco and other drugs really cost taxpayers, and how little governments spend to effectively address the problem. Maybe if they knew, they might do something. You can tell them.

Please do two important things today:

• See detailed expenses for Massachusetts and download the report.
  
  
• Send a message to your governor and state legislators urging them to review and act on the report.
  

Our researchers studied all federal, state and local budgets for 2005 using careful, conservative methods to determine how much of each major budget category was directly linked to substance misuse. For example, they determined how much of each state's Medicaid and other health care expenses were due to one of over 70 medical diagnoses that are caused or made worse by alcohol, tobacco and other drug abuse and addiction. They did the same for criminal justice, welfare and other key government budgets. They also identified all government spending on prevention, treatment and research, regulation of alcohol and tobacco products and drug interdiction.

When the numbers are added up, the total is really shocking: 467.7 billion dollars. Spending less than 2% of the federal and state costs for prevention and treatment, and more than 95% shoveling up the mess, is upside down public policy that wastes billions in taxpayer dollars at a time when resources are scarce, and results in untold human suffering.

Our leaders need to make new investments in prevention and treatment now to reduce the awful burden that untreated tobacco, alcohol and drug problems place on our budgets -- and our citizens.

Please act today.

Sincerely,

David L. Rosenbloom
President and CEO
The National Center on Addiction and Substance Abuse at Columbia University

P.S. Please forward this important message to your friends and colleagues today.

Should You Shrink Your Prostate?

Okay, bear with me here while I have a brief fantasy about being a urologist.

New York Times reporter, Gina Kolata writes in "New Take on a Prostate Drug, and A New Debate" about the pros and cons of asymptomatic men taking a medication to decrease their chances of getting prostate cancer. She notes that screening tests reveal cancers (and therefore have surgery and other treatments) that might not prove to be lethal--- some prostate cancers are slow growing and might be better left undiscovered.

With finasteride, as many as 100,000 cases of prostate cancer a year could be prevented, said Dr. Eric Klein, director of the Center for Urologic Oncology at the Cleveland Clinic.

Dr. Howard Parnes, chief of the prostate cancer group at the National Cancer Institute’s division of cancer prevention, also is convinced. “There is a tremendous public health benefit for the use of this agent,” he said.

While it might seem convoluted to offer a drug to prevent the consequences of overtreatment, that is the situation in the country today, others say. Preventing the cancer can prevent treatments that can be debilitating, even if the cancers were never lethal to start with.

“That’s the bind we’re in right now,” said Dr. Christopher Logothetis, professor and chairman of genitourinary medical oncology at M.D. Anderson Cancer Center. “Most of the time, treatment wouldn’t help and may not be necessary. But the reality is that people are being operated on.”

Kolata goes on to talk about whether all men should take the medication as prostate cancer prophylaxis. She says an early study showed that while it shrunk prostates and decreased the rate of cancer diagnosis overall, among study participants there was a slight increase in the percentage of aggressive tumors found, and initially there was concern that the drug was causing aggressive tumors, rather than just unmasking them.


So why does this Shrink Rapper want to blog about prostates? As I read Gina Kolata's article, I thought about ClinkShrink's post, An Ounce of Prevention where we talked about the theoretical option of treating people at risk for a psychiatric disorder who may never develop one. It seems we do this all the time-- how many people take Lipitor or other statins who might never develop coronary artery disease? How many people with osteoporosis are given medications who might never break a bone without it, who might break bones even with them? Oh, and if you're male, and therefore at risk for Prostate Cancer, now there's something else to think about. There is, after all, iodine in our salt and fluoride in our water. Maybe it's not all bad?

An Ounce Of Prevention

In medicine, therapeutic interventions tend to fall into one of three classes. Tertiary prevention means doing something to reduce the impact of symptoms in a disease that already exists. Secondary prevention is when you try to catch the disease at an earlier stage, either before symptoms develop or before they become severe. Routine blood pressure checks are an example of secondary prevention because blood pressure measurement catches hypertension (hopefully) before complications like stroke or heart disease develop. Finally, primary prevention is when you do something to keep the disease from starting to begin with. Routine pap smears are a primary preventive measure for cervical cancer---the idea is to catch abnormal cells before they transform into cancer.

So how does this all apply to psychiatry?

It's relevant because, unfortunately, in our specialty right now almost all interventions are tertiary interventions. We see patients after a disease has developed, when they are bothered enough by their symptoms (or their families or employers are bothered enough) to make them seek treatment. By the time they come to treatment they have often already experienced some type of morbidity, either in the form of time lost from work or impaired social functioning, or even impaired physical recovery as in the case of hospitalized medical patients with untreated depression.

There have been some secondary prevention efforts. Every October there is a national depression screening day, when health fairs offer evaluations for clinical depression in addition to other general medical assessments. Internists, family practitioners and other primary care providers are starting to include screening for mental disorders as part of routine health care.

The area where psychiatry is still grossly lacking, mainly because of our still-meager understanding of the basic causes of mental illness, is in primary prevention. Simply put, we just aren't very good yet at preventing psychiatric illness.

We do our best primary prevention when the psychiatric disorder is the result of an identifiable physical cause. We can prevent cognitive impairment and lowered IQ by checking babies for hypothyroidism and children for lead poisoning. You can prevent HIV psychosis by preventing the spread of HIV and keeping the disease under control to delay or prevent dementia. General paresis, or dementia due to advanced untreated syphillis, is pretty much gone now due to the invention of penicillin.

Unfortunately, we still don't know how to prevent schizophrenia or bipolar disorder. We may be about to find a way to prevent clinical depression, at least in some patients. The Associated Press today summarized the findings of an article in this week's issue of JAMA regarding the prophylactic use of an antidepressant in post-stroke patients. One hundred twenty-seven stroke patients were divided into three groups: one treated with escitalopram, one given therapy and one group given a placebo. The escitalopram group was significantly less likely to develop clinical depression over the course of the year following stroke than either of the two control groups.

Now I'm waiting for a study to see if prophylactic antidepressants are useful in other at-risk groups, like heart attack patients, who are also prone to clinical depression in the months following the attack.

It's only one study, but it's a start.
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And now : an intrusion from Dinah. I've decided I like putting my comments on the front of the post.

So here's the problem with preventative psychiatry in it's infancy. In the studies above, the issue is one of Risk. I don't know that I'd want to take a medication (with all the risks, side effects, possible adverse reactions, and the question of the unknown longterm or short term effects) for a condition that one is at Risk for. Invariably, some people will be exposed to medications who would never develop the targeted illness. It's a hard sell for me, unless the risk is 100 per cent.

I think we like to think maybe if an illness is caught early in it's course, then it won't get as bad, or at least the symptoms can be treated earlier. This is one rationale for on-going psychotherapy in people who want to be seen between episodes: that therapy may prevent future episodes, may give people tools to prevent relapse, and that the subtle signs of illness may be caught sooner before they become full blown episodes.

Thank you for letting me join in here.