Male madness

Case report: Tom: A 59-year-old male with a sick days issueA 59-year-old male presents to you saying, “I was forced by my boss to take medical sick leave as I’m missing too many days at work.” On review, you find that he is struggling with motivation, cognition and energy. His sleep is disturbed and he is much less hungry than usual. He has started isolating himself from his usual social activities (hockey and curling) and has been calling in to work “sick” a few days each week. He admits to drinking more than usual and on his own, which was never his usual pattern. He even tried some cannabis gummies, without success. “I feel like shit most of the time and I am really angry at everyone and everything. I not going to talk to a shrink and I’m not taking any happy pills that I’ll need for the rest of my life. My buddy thinks I should take the same T boosters he’s on. Just give me a few weeks off work before I lose my job and I’ll take care of things on my own.” Sound familiar? While there are many questions to be explored and clinical work up to be completed, my impression is that lab investigations will be normal. I am considering a diagnosis of MDD (major depressive disorder) and want to set out of therapeutic plan which he might reject. Why is he likely to be difficult? Is men’s mental health that much different than dealing with mental health in women? Is this worthy of being its own topic with unique approaches and therapies? More times than not the answer is: Yes!This article is not meant to advance the cliché that all men are ultra-masculine and the same. There are many bell-shaped curves which define a wide continuum of characteristics, but let’s not get too caught up in these murky grey weeds just yet. Accepting there is a spectrum, what’s the definition of “masculine” and how do its features differ from the “feminine” traits? Masculine characteristics: Physical strength and toughnessEmotional control and stoicismSelf-determinationLeadership and authorityRisk-taking and adventureProcreationProtectionismRead: Dr. Ted Jablonski: Why ban medical care?Commonly recognized traits associated with femininity are nurturance and compassion which could include caring, empathy and supportiveness, emotional expressiveness incorporating sensitivity and vulnerability, subtlety, gentleness, cooperative and collaborative focus, passive/submissive roles, modesty, humility, sensitivity to social norms, physical grace and beauty and “female intuition.” Seems to me the feminine side of things is more complex and nuanced. Compared to the feminine side, masculine traits are inherently problematic when it comes to managing mental health. A man may present late if at all, dismiss his diagnosis and refuse collaborative therapies. Venus and Mars are not alright tonight. While women have higher rates of the majority of mental illnesses, men also struggle with depression, anxiety and higher rates of substance abuse, PTSD and suicide. Men with mental health problems are just as ill, but less likely to be diagnosed. So what is the pragmatic approach that will be more successful for men?The new rap is rapport: We need to build some rapport and create a safe and non-judgemental space for conversation. Allow men to show their emotion and be vulnerable. Address stigma proactively and be quick to normalize and validate the patient’s symptoms and concerns.Think big picture—size matters: Use screening tools such as PHQ-9 and GAD-7 questionnaires. Evaluate job stress and socioeconomic pressures, relationship and family issues. Assess views of societal expectations and coping mechanisms used.Screen, screen, screen: Screen for substance use in a non-judgemental manner. Screen for suicide always. Men are much less likely to communicate their desperation and their suicide attempts are often more successful.Guys love customization (and, of course, tools): Custom multi-modal therapies are commonly needed. Many men don’t like to talk. So sometimes a wider scope of therapies need to be tried including behavioural activation, CBT, motivational interviewing, solution-focused therapy and group therapy. There is a place for pharmacologic intervention but be careful particularly of the use of SSRI (or lower dose SNRI) due to the potential sexual side effects relating to serotonin. One bad experience might turn a man off pharmacologic treatments forever. In keeping with behavioural activation, regular exercise can be extremely helpful in the management of mood and anxiety and should not be underestimated. Encourage communication with family and encourage healthy connections and social supports.Knowledge is power: Encourage proactive psychoeducation about signs and symptoms of mental illness. Educate about job stressors and unrealistic expectations. Language matters and the learning of new skills to manage challenges more positively may be more powerful than just fixing something broken.It takes a village: Encourage the use of community resources. There is a flourishing community of male mentors, peer support, and men’s support groups in most communities. Guys helping guys be healthier. We can collaborate with these groups and with other medical professionals to build a strong, resilient and supportive community around these patients.Follow-up: Incorporate follow-ups and checks during routine care. Good health takes time and the effort involved in achieving mental wellbeing is substantial. Guys shouldn’t have to wait for a crisis to deal with the ongoing maintenance of good mental health. So back to our patient Tom . . .I incorporated a number of the steps above and we quickly found some common ground that he was comfortable talking about. He got more than a few things off his chest. I did use the PHQ-9 and GAD-7 screens and together we created a plan of attack based on his scores. The initial plan did not involve medication but was otherwise comprehensive and assertive so that all time off work for illness had a purpose and direction. In the end, he said “I think you are the first doctor I can actually talk to about things that have been bugging me for a long time. Thanks, doc.” A small win that I will build on at his next visit. He better show up!In conclusion, men can be their worst enemies when it comes to health issues. We need to recognize and address the barriers that toxic masculinity can engender in providing care for men. Thankfully, we can have significant positive impact on their health if we are proactive, empathetic and appreciate the unique challenges they face. MDs can help overcome the stigma of “being a man,” by providing the necessary tools to improve their mental well-being. All of us will benefit, no matter where we are on the gender spectrum. Dr. Ted Jablonski is a performing artist and writer who has retired his family practice to focus on sexual medicine and transgender health in Southern Alberta with two feet still on the front-line trenches of acute primary care.

Male madness

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