Men and mental health

On average, 13 men take their own life each day in the UK, and poor mental health in men is a key focus of this year’s Movember campaign. We look at the facts behind the gender gap

THE PATHETIC GENDER

As a fully paid-up, card-carrying male, it is not unusual for me to feel despondent when reading statistics about the health of my ilk. From birth the average UK male will live 79.2 years, compared to 82.9 years for the average UK female. For those who make it to age 65 a man can expect to live for a further 18.5 years whereas his sturdy woman companion can wallow in another 20.9 years of afternoon teas and Bargain Hunt.¹ Within this, depending on where in the UK you live (and, surprise, surprise, the south does much better than the north), a man can expect between 10 and 23 years of living with a disability. To restore the gender balance somewhat, a woman can look forward to between 13 and 30 years of living with a disability.²

Though mortality is affected by mental illness – the mortality rate among mental health service users is nearly four times the national average³ – it is unusual for the mental illness per se to cause death. The obvious exception is suicide, and of the roughly 5,700 suicides in the UK each year, over three quarters are male.⁴ Yet the main deleterious effects of mental illness fall short of death. For the individual it is the mental anguish, the inability to think straight, enjoy life, or engage in normal human relationships; the impact on normal activity, on self-esteem, on making the most of the available years, can make death seem a desirable alternative. For their families, it is the constant need for support and reassurance, of caring for the sick member who is unable to pull their weight. For society it is not just the healthcare costs, it is also the national economic cost through lost production, disability benefits etc., currently estimated at up to £100 billion a year.⁵

A community survey carried out in 2014 found that about one-in-six adults in England were currently suffering the symptoms of a common mental disorder (mainly anxiety or depression), and that of these about a third were currently in contact with mental health care services.⁶ From this survey more women than men were showing symptoms (one-in-five vs. one-in-eight), but this disparity may not be genuine. Around a third of men are reluctant to admit to a mental health problem or seek help for it,7 which may also mean that they are more reluctant to reveal their true feelings to an impertinent research worker.

On some other measures of mental illness, men do much worse than women. The suicide rate has already been mentioned. Three quarters of adults who ‘go missing’ and nearly nine in ten adults who sleep rough are male. Men are three times more likely than women to be addicted to drugs or alcohol – it is known that under duress men are more likely than women to go in for hazardous behaviour. Men are more likely to be detained under the Mental Health Act, and comprise 95% of the prison population,⁷ in whom the rates of psychiatric illness are notoriously high.⁸

It can confidently be concluded that in the UK the rates of common mental disorder between the genders are roughly comparable, but that men are less likely to present their problems to a healthcare professional. It is this reluctance to acknowledge the problem and seek care which makes men an ‘at-risk’ group, for whom increased awareness by healthcare professionals is appropriate if good care is to be delivered.

A general practice nurse may become involved in the mental health problems of men in several ways. Those who are operating a triage system may become involved when a man presents for the first time seeking help with his mental health symptoms, or if he or his family are seeking urgent care following a crisis. Also, patients with other ongoing illnesses are more likely to suffer from mental health problems, and since chronic disease management in primary care is now overwhelmingly the province of GPNs, the population under your care are at particular risk. Finally, patients may need a friendly and reliable source of information about their mental illness, and a GPN is an obvious early port-of-call.

TALKING TO MEN ABOUT MENTAL HEALTH

It appears likely that men under-report their mental health difficulties, which means that a key responsibility for primary care is to identify disorders when they are present, particularly in men. Following detection the treatment of all people is the same: the guidelines for treating depression and anxiety do not distinguish between genders, so that what works for women is also likely to work for men.

Men are less likely than women to be comfortable discussing their mental health, and this will result in them under-reporting their problems.⁹ Despite old evidence to the contrary, it is now apparent that men are just as verbally able as women,¹⁰ so having a problem with explaining their distress cannot be a reason for failure to present. But let’s get this in proportion – only a minority of men will want to keep their symptoms completely secret, but it may be that for men you may have to dig a little deeper to get at the information you need to make a diagnosis.

Involvement in risky behaviour may be an indication of mental illness. So be aware of the possible implications of resort to alcohol, drugs, gambling, violence and other crime, driving offences, risky sexual practices, arguments at home and abusive behaviour. This is not an argument to excuse bad behaviour because of mental illness, but if such an illness is present then it also has to be dealt with.

The possibility of a mental illness may first come to light through the concerns of other family members. When your patient is marched into surgery by his exasperated partner, usually on a Friday evening, you can be pretty sure something is going on over and above a row about what take-away to have tonight. Problems at work – poor performance, disciplinary problems, and excessive sickness absence – may also be indicators that there is a mental health problem.

As a mental illness is brewing, there will be a tendency by patients and their families to suppress it, to wish it away. Sooner or later the problem reaches a level when it is clear something is wrong. People with mental illness often only seek help when a crisis has occurred. In the scenario above, something will usually have happened to make the problem urgent, or have caused the carers to reach the end of their collective tether. This means that exploring the events will inevitably uncover a history of issues that previously have not resulted in a consultation. ‘Can of worms’ might sum this up quite nicely. Other crises might result in the involvement of the ambulance services, the local A&E department or the police.

As with all mental health issues the first consultation is crucial. The decision to consult a healthcare worker will not have been made without a great deal of thought, and your patient will see disadvantages as well as advantages in getting the problem out in the open. Enough time must be taken to gather sufficient information, and this will invariably be more than the standard 10 or 15 minutes. There is much to be achieved, especially as some sufferers and their family will be keen on an instant fix for their problems (even if they have been building up for years). A management plan may include referral to other agencies and the possibility of medication, and there is a need for follow-up. In some (rare) instances, especially if there is suicidal intent, an urgent referral or even an admission to the mental health services may be needed. All this needs to be done at the first consultation. If the time is not available there and then, an urgent plan for review is needed: if your patient feels that his cry for help has been blocked, then the truth may never emerge.

As well as making an assessment of the risk of suicide, there are issues around safeguarding which must be kept in mind. How vulnerable is your patient? Is there self-neglect? Are other family members, and particularly any children, at risk? This is particularly important if there are problems with violence or anger control. Has drug or alcohol use resulted in physical health problems which need to be addressed urgently?

As many men find physical complaints a more acceptable topic for discussion than mental complaints, there may be a tendency to present mental illness as somatic symptoms. In the case of depression, 25% of sufferers have some physical symptoms and in about 10% all the symptoms are physical.¹¹ Common somatic symptoms reported by patients with depression include headache, backache, persistent tiredness, sweating, palpitations, nausea and generalised body aches.¹² When physical symptoms are present there will be a natural desire on the part of the patient that they are not ‘dismissed’ as being ‘just nerves’, even if your patient has the suspicion that they might be the result of a mental illness. Other possible reasons for the symptoms may need to be explored first before a mental health diagnosis can be agreed.

DETECTING DEPRESSION

Depression and anxiety are the commonest of the common mental disorders, so it is appropriate to look in detail at diagnosis and management, and in particular how this may relate to male patients.

The severity of depression is based on the number, duration and severity of the symptoms. It is currently recommended that patients be asked these core questions:

• ‘During the last month have you often been bothered by feeling down, depressed, or hopeless?’
• ‘Do you have little interest or pleasure in doing things?’¹³

If you get an affirmative answer to either question, and if the symptoms have been present most of the time (most days) for 2 weeks or more, then move on to consider other symptoms:

• Fatigue/loss of energy.
• Worthlessness/excessive or inappropriate guilt.
• Recurrent thoughts of death, suicidal thoughts, or actual suicide attempts.
• Diminished ability to think/concentrate or indecisiveness.
• Psychomotor agitation or retardation.
• Insomnia/hypersomnia (sleeping too much).
• Significant appetite and/or weight loss.

This gives a total of nine symptoms. If five are positive, this confirms a diagnosis of depression. According to the details of the response to these symptoms, the severity of the depression can be determined:

• ‘Sub-threshold’ depression: Less than five symptoms present, but your patient wants something doing
• ‘Mild’ depression: No or few more than five symptoms present, and none causing significant functional impairment
• ‘Moderate’ depression: Symptoms are causing marked impairment of function, and some are severe
• ‘Severe’ depression: A full house of symptoms, many of which are causing significant impairment. ‘Significant’ means it stops you doing things, i.e. rather more severe than things just being more of an effort to do. It will be seen that this bar is set quite high, and only a minority, probably around a quarter, of primary care patients will meet this threshold.¹¹

TREATING DEPRESSION

The recommended treatment depends on the severity of the depression.¹³

Sub-threshold or mild depression

Specific treatment interventions have little to offer. A conversation about the nature and natural history of mild depression is often appropriate, and this can be reinforced by written material. You could do worse than recommend the NHS Choices leaflet on Depression, which offers sound advice, and also many links to other sources of information.¹⁴ Mild forms of depression usually resolve without treatment. Indeed there is some concern that using a medical diagnosis to explain the normal ups and downs of human existence does not help anybody, and runs the risk of patients being poisoned with medication which almost certainly will do no good, and might cause side effects.¹⁵

However, sometimes symptoms drag on (a threshold of two years is suggested13) after which intervention might be considered on a ‘try it and see’ basis. A referral to IAPT (Improving Access to Psychological Therapies) may be suggested, for low intensity psychological therapy, or group-based cognitive behavioural therapy (CBT).

Low intensity psychological therapy consists of self-guided or computerised CBT, group-based peer support and/or an exercise-based programme. Each of these strategies has disadvantages as well as advantages. CBT requires dedication as time and motivation must be found for regular treatment sessions, and homework has to be done. Many men would baulk at the idea of sharing their thoughts in a group of strangers, particularly if they are talking about what they regard as a weakness, and in any event some men may not have the confidence or words to use (depression saps your confidence and concentration).

Exercise appears to help significantly in depression, with an effect the same order of magnitude as antidepressants and psychological therapy.¹⁶ Sport-based exercise (particularly football) appears to have an especial usefulness for men.¹⁷ Getting fitter also mitigates against other causes of morbidity and mortality.

Moderate or severe depression

The treatment recommendation for this group is high intensity psychological therapy and medication. High-intensity psychological interventions include:¹³

• Group based CBT – usually consists of twelve 2-hour sessions over 8–12 weeks.
• Individual CBT – usually given over 16–20 sessions over 3–4 months. For people with severe depression, two sessions per week might be provided for the first 2–3 weeks of treatment.
• Interpersonal therapy – duration and number of sessions is similar to CBT.
• Behavioural activation – duration and number of sessions is similar to CBT.
• Couples therapy – usually consists of 15–20 sessions over 5–6 months.

Medication invariably means a selective serotonin reuptake inhibitor (SSRI), and the recommended ones are citalopram, fluoxetine, sertraline and paroxetine. If this is not the first episode of depression the choice can be guided by whatever has worked before. All SSRIs have side effects, the commonest being nausea, weight gain and sexual dysfunction (which may be another cause for reduced self-esteem).

Though recommended, there is much controversy about how effective SSRIs are for depression. A meta-analysis from 2017 found a slight benefit,18 but also remarked that much of the evidence was of relatively poor quality, and produced by people with a vested interest in selling more pills. Medication can take 2 weeks to show benefit, and up to 12 weeks to show the full effect (even when it is the right medication at the right dose).

DETECTING ANXIETY

Some men will come into a consultation and tell you they are anxious. Others will display the typical symptom pattern:¹⁹

• Restlessness
• Increased fatigability
• Irritability
• Heightened muscle tension (including chronic headache)
• Difficulty concentrating
• Sleep disturbance
• Palpitations.

This is a list of symptoms that may also be associated with physical illness, possibly severe. To someone who is already anxious the worry about being seriously or terminally ill is a further burden. The careful professional will give the patient enough time to get everything off his chest before reaching a conclusion on diagnosis. Often precautionary tests or investigations are needed before a diagnosis of anxiety can be reached.

MANAGING ANXIETY

Anxiety and depression can (and often do) exist together. For anxiety low and high intensity psychological interventions are recommended,¹⁹ the only difference with depression being that some patients with anxiety, as well as responding to CBT, also do well with relaxation therapy. Exercise is equally useful in depression and anxiety. The medications of choice are the SSRIs, and these can be considered for anxiety of all severities: it is ironic that drugs designed for depression are probably more useful in the treatment of anxiety.

CONCLUSION

Mental health problems in men seem to be just as prevalent as in women. Nevertheless, men are less likely to consult with their mental health problems, and less likely to engage in treatment. Accordingly a special effort may need to be made to secure a mental health diagnosis for men.

The treatments available are not gender-specific. However some men regard mental health services as geared more towards women than men,¹⁷ and it is feasible that this is indeed the case as the services deal with more women than men and so may well have a slight female slant.

Spending time at the first consultation is most important, and not just to secure safety (suicide risk, safeguarding). As a GPN you will almost certainly not be making management decisions alone, but will usually be sharing the case with a GP colleague: but when your patient turns back to you asking what treatment will involve then some idea about the current recommendations is useful.

The recommended treatments for the two commonest mental health disorders – depression and anxiety – are broadly similar, so if depression and anxiety co-exist, this need not prevent treatment. IAPT is a very useful resource. However ‘talking treatment’, particularly in groups, is not everyone’s idea of a good time and treatment may have to be varied to accommodate this.

See Optimising management of lont term conditions in pregnancy – Part 3: Mental health conditions

REFERENCES

1. Office for National Statistics. National Life Tables, UK: 2014-2016.

2. Office for National Statistics. Disability-Free Life Expectancy (DFLE) and Life Expectancy (LE) at birth by Upper Tier Local Authority, England

3. NHS Digital. Mortality rate three times as high among mental health service users than in general population. http://content.digital.nhs.uk/article/2543/Mortality-rate-three-times-as-high-among-mental-health-service-users-than-in-general-population

4. Office for National Statistics. Suicides in Great Britain: 2016 registrations. https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/suicidesintheunitedkingdom/2016registration

5. Mental Health Foundation. Fundamental facts about mental illness 2016. https://www.mentalhealth.org.uk/sites/default/files/fundamental-facts-about-mental-health-2016.pdf

6. NHS Digital. Adult Psychiatric Morbidity Survey: Survey of Mental Health and Wellbeing, England, 2014. http://digital.nhs.uk/catalogue/PUB21748

7. Men’s Health Forum. Key data: mental health. https://www.menshealthforum.org.uk/key-data-mental-health

8. Prison Reform Trust. Mental health care in prisons. http://www.prisonreformtrust.org.uk/ProjectsResearch/Mentalhealth

9. CALM. A crisis in modern masculinity: understanding the causes of male suicide. 2015

10. Shibley Hyde J and Linn MC. Gender differences in verbal ability: a meta-analysis. Psychological Bulletin 1988 Vol. 104 No. 1, 53-69.

11. Wright AF. DEPRESSION Recognition and Management in General Practice. Royal College of General Practitioners, 1993.

12. Wright AF. Unrecognised psychiatric illness in general practice. Br J Gen Pract 1996;46:327-8.

13. NICE/CKS. Depression. https://cks.nice.org.uk/depression

14. NHS Choices. Clinical depression. http://www.nhs.uk/conditions/depression/Pages/Introduction.aspx

15. Dowrick C & Frances A. Medicalising and medicating unhappiness. BMJ 2013;347:f7140

16. Kvam S et al. Exercise as a treatment for depression: A meta-analysis. J Affect Disord. 2016 Sep 15;202:67-86.

17. Men’s Health Forum. How to make mental health services work for men. https://www.menshealthforum.org.uk/sites/default/files/pdf/how_to_mh_v4.1_lrweb_0.pdf

18. Jakobsen JC et al. Selective serotonin reuptake inhibitors versus placebo in patients with major depressive disorder. A systematic review with meta-analysis and Trial Sequential Analysis. BMC Psychiatry. https://doi.org/10.1186/s12888-016-1173-2

19. NICE/CKS. Generalised anxiety disorder. https://cks.nice.org.uk/generalized-anxiety-disorder