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One afternoon when I was a young doctor I was at a routine administrative meeting with a senior physician when he unexpectedly opened up to me. Overweight and red-faced, he paced his office smoking the cigarette he was seldom without. He started telling me of his concern for his daughter, whom he feared was an alcoholic. At the end of our conversation he commented on how physically tired he felt. There was something about his voice that made me hesitate at the door, wondering if I should ask more. But I decided it would be intrusive, even presumptuous.
I still regret that I was so timid. The next day I learned that he had lain down on the couch in his office after I left and died of a heart attack at age 58. I was the last person who ever saw him alive. I'll never know if I could have at least postponed that tragedy.
That experience and others I've had since with men who were patients or friends have made me think long and hard about how men process the inevitable pressures we all face and how their responses affect their health.
At a dinner party a few years ago I proposed to the men at the table that depression was more common among males than we were aware of. "Of course it is," one of them answered instantly. "That's why we die first."
He was referring to the well-known fact that men tend to predecease women by an average of five years. Over the 40 years that I have practiced medicine with special training in cardiovascular health I have tried to understand why this is so. Why, for example, are men about 10 years younger than women when they develop cardiovascular problems -- and also have their first heart attacks at an earlier age? Why, by the age of 45, are they significantly more likely to develop coronary artery disease (CAD)? I helped pioneer the discipline of gender-specific medicine to explore these differences and to ensure that medicine develops information that enables us to treat both sexes effectively.
The significance of one male-female difference that has become increasingly clear to me is that men are notably reluctant to discuss the emotional issues that often underpin health problems. For example, a male patient will come in upset that he has accumulated fat in his midsection and complain that he cannot lose the weight no matter how he tries. Upon examination it's found that he has high blood pressure and diabetes. There's no doubt he has physical ailments. But when I dig deeper and talk to him, I find that an underlying depression is at the root of his problems.
In fact, a growing body of research links depression to a host of illnesses including CAD, hypertension, diabetes, and stroke, as well as making people more susceptible to infection. Although experts maintain that only half as many men suffer from depression as women do, I am convinced that it is much more common in men than that. And the consequences of all this undiagnosed depression are huge. Depression itself can be lethal; men commit suicide four times more often than women. Perhaps the most significant connection is to coronary artery disease.
Being depressed can more than double a man's risk of developing CAD and can also make him more vulnerable to its deadly consequences. In fact, men diagnosed as suffering from major depression have three times the incidence of CAD, according to a study in the British Medical Journal. Interestingly, no research has proved that women with depression are at increased risk for heart disease.
Some explanations for this remarkably strong association: Depressed men smoke more, exercise less, and use more alcohol to alleviate emotional pain, all of which enhance their risk of heart disease. Patients who have both depression and heart disease have more cardiac rhythm disturbances than heart patients who aren't depressed. Depression also elevates the stress hormone cortisol, which impairs glucose metabolism, lowers levels of good HDL cholesterol, elevates triglycerides, and can eventually lead to diabetes, a disease that itself doubles the risk of CAD in men. And depressed people are also less likely to follow medical recommendations.
Why does such dangerous depression so frequently go undiagnosed in men? Because it's so easy to miss the symptoms. Women typically express their feelings to others and reach out for help. Depressed men often do neither. "I know what's wrong," male patients have sometimes said to me. "Talking about it won't help." Instead, these men may isolate themselves, withdrawing into TV watching or electronic games. They may self-medicate with alcohol or drugs. They can become irritable, aggressive, or uncharacteristically violent.
These are problems that can strain or break families. What's more, they can sneak up on men who were previously healthy and have had successful careers. Depression becomes more common as men age, in some cases possibly due to a decline in testosterone. Research shows that 12 percent of adults 65 years of age or over who are seen in primary-care settings have clinically significant depression. When it hits men in middle age, as it so often does, the behavior that results can be a huge shock as wives and children wrestle with watching a loved one morph into a stranger they barely recognize. It's important to understand how and why men become depressed and what those who love them can do to help.
The good news is that when I have been able to convince male patients to be treated for depression, their mood and productivity have improved. I also believe their risk of coronary artery disease diminished. Among the positive changes I have seen: One man's heart arrhythmia subsided; another improved his blood pressure and required less medication to control it. Several men returned to an active exercise program and improved their cholesterol because they lost weight. It's worth the fight to make these changes happen.
Since men are less likely than women to want to talk about their problems, treatment for men should focus less on exploring their feelings and more on constructing solutions, according to international suicide expert Keith Hawton, DSc, FRC Psych, professor of psychiatry at the University of Oxford, in England, and director of the university's Centre for Suicide Research.
First, of course, you have to get a man to recognize that there is a problem. If you notice an accumulation of changes that suggest that he might be falling into depression (see "8 Ways to Tell He's Depressed"), approach him and tell him you love him and think he might be suffering. Pick a time when your partner is not doing something else. Bedtime is a good option since you're under the cover of darkness and there are no distractions. Ask him to talk to his doctor. Listen to his answer. If he denies that anything is wrong, ask him specifically about the behavior you notice that is worrying you. Say something like: "I notice you're drinking more beer than you have in the past. Does it relax you? Does it improve your mood?" This is a far better way to approach him than with an accusatory, "You've been drunk every weekend this month! What's going on?"
Keep your questions brief and emphasize how much he means to you and to your children. If he refuses to take action, talk to his doctor yourself and ask what can be done to help him. If he absolutely refuses help and you're frantic, ask the doctor about an intervention, which can include having a counseling and treatment team come to your home, meet with you and your husband, and determine which services might be needed. This may work when nothing else does.
The right treatment for depression depends on the individual, of course. But here are some treatments that have worked particularly well with men, researchers and mental health experts have discovered:
Doctors also caution that medication doesn't work well for everyone. Another option that has made a comeback in recent years is electroconvulsive therapy, which now has fewer side effects than it once did.
Most of all, don't expect quick changes. Treating depression may help improve resistance to infection and reduce cancer and heart disease risk. But recovery from depression can take a long time and requires a great deal of support from you and your family. There will be bad days when it seems that there is no progress as well as the possibility that he will suffer regression or relapses. But eventually the better days will increase in frequency and his mood will finally lift.
Originally published in Ladies' Home Journal, June 2008.