Am Fam Physician. 2000;62(1):117-124
This is Part II of a two-part article on health issues in men. Part I, “Common Genitourinary Disorders,” appeared in the June 15 issue (Am Fam Physician 2000; 61:3657–64).
During screening examinations and, when appropriate, other health-related visits, family physicians should be alert for signs and symptoms of common psychosocial disorders in men. Health issues of concern include alcohol and substance abuse, domestic violence, midlife crisis and depression. Alcohol remains the most abused drug in America. The highest rates of alcohol abuse are in men 25 to 39 years of age, although alcoholism is also a considerable problem after 65 years of age. Disulfiram and the opioid antagonist naltrexone are the two medications currently labeled by the U.S. Food and Drug Administration for the treatment of chronic alcohol dependence. Like alcohol abuse, domestic violence is a sign of psychosocial distress in men. Domestic violence may be a problem in up to 16 percent of marriages. Most men move through the midlife period without difficulty. Major depressive illness occurs in about 1 percent of elderly men, whereas minor depression or subsyndromal depression affects 13 to 27 percent of older men. Selective serotonin reuptake inhibitors have become first-line therapy for depression.
Psychologic well-being and effective social functioning are important to men of all ages. Often, men begin to have difficulties in these areas without clearly understanding that a problem is emerging. In particular, the family physician should remain alert for signs and symptoms of substance abuse, domestic violence and depression.
Male patients with psychosocial dysfunction frequently mention vague complaints that do not easily fit into diagnostic categories. A compassionate, trusting physician-patient relationship can facilitate the discovery of psychosocial dysfunction and the implementation of appropriate treatments.
Alcohol and Other Substance Abuse
The prevalence of drug, steroid and alcohol abuse has continued to increase at an alarming rate since the early 1990s. Recent studies indicate that 24 percent of eighth graders and 38 percent of 10th graders admit to using illegal substances in the previous year.1 A reported 5 percent of 12th graders use marijuana daily.1 From 5 to 11 percent of adolescent males report use of anabolic steroids.2
Compared with women, men are at greater risk for alcohol abuse, with the highest rates of abuse occurring in men between 25 and 39 years of age.5 Unfortunately, alcohol abuse and dependence are not limited to the younger male population.
Alcohol abuse is estimated to have a lifetime prevalence of 4 to 8 percent in the general population. It is a problem in 14 percent of men more than 65 years of age and in 1.5 percent of women in the same age group. Alcohol-related problems are present in approximately 14 percent of elderly patients seen in emergency departments, 20 percent of elderly patients admitted to acute care hospitals and 40 percent of elderly patients admitted to psychiatric hospitals.6
The rate of alcohol-related hospitalizations in the United States is comparable to the rate of myocardial infarction. These hospitalizations are responsible for more than $230 million in health care expenditures annually.6
In 1995, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) published its definitions of moderate and at-risk adult drinking.7 The NIAAA defines moderate adult drinkers as persons who consume a number of drinks per day that places them at low risk for alcohol-related problems. In contrast, at-risk adult drinkers consume alcohol at a rate that puts them at risk for long-term alcohol-related complications.8 Alcohol abuse and dependence are best defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).9 Summary definitions of moderate drinking, at-risk drinking and alcohol abuse and dependence are provided in Table 1.8
Screening for alcohol abuse should be included in the annual health assessment. Family physicians should remain alert for signs and symptoms of substance abuse, which include vague physical complaints, relationship discord, weight gain or loss, school difficulties, depression, work difficulties, financial problems and injuries such as falls and boxer's fracture (i.e., fracture of the metacarpal neck with volar displacement of the metacarpal head caused by striking a hard object with the fist). A detailed family history regarding alcohol abuse disorders should also be obtained.
Family physicians can easily incorporate the CAGE questionnaire into their medical practice as a screening test for alcohol abuse and dependence. This tool is estimated to be 85 percent sensitive and 89 percent specific in identifying patients who have an alcohol abuse disorder.5 However, this four-question test has not always been helpful in identifying men who are at risk for problem drinking.
Another screening tool, the Alcohol Use Disorder Identification Test (AUDIT), contains 10 questions.10 Three of the AUDIT questions are directed at identifying current alcohol intake.
A highly useful and rapid screening tool for alcohol abuse disorders and at-risk drinking can be created by combining parts of the CAGE and AUDIT questionnaires (Table 2).5 An additional alcohol-screening test that has been validated in the geriatric population is the Michigan Alcohol Screening Test (MAST-G).6,11 This test is shown in Figure 1.11
Any patient with signs and symptoms of alcohol abuse or a positive screening test for alcohol abuse disorder or at-risk drinking should receive counseling and assistance appropriate for alcohol abuse. The “Four-A Model” (Ask, Advise, Assist and Arrange) is a useful approach to problems related to alcohol.
Multiple treatment programs are available, including outpatient programs (such as the 12-step program of Alcoholics Anonymous), day treatment programs, programs for hospitalized patients and residential treatment programs. No program has provided outcome data that indicate its clear superiority in decreasing recidivism rates for alcohol abuse.6
Disulfiram (Antabuse) and naltrexone (Trexan) are the two medications currently labeled by the U.S. Food and Drug Administration for the treatment of chronic alcohol dependence. Studies indicate that naltrexone may be the more effective agent.
Disulfiram interferes with the metabolism of alcohol by acting as a reversible inhibitor of the enzyme alcohol dehydrogenase. Inhibition of alcohol dehydrogenase allows the metabolite acetaldehyde to accumulate. Acetaldehyde causes tachycardia, nausea, vomiting and dyspnea. Disulfiram promotes abstinence by acting as an aversive agent once alcohol is consumed.12 Unfortunately, the efficacy of this agent in preventing recidivism of alcohol use has yet to be established. One randomized, controlled trial conducted by the Department of Veterans Affairs in 605 men found no significant improvement in abstinence rates among men treated with 1 mg per day of disulfiram, 250 mg per day of disulfiram or placebo.13 Because disulfiram is associated with an increased incidence of hepatitis, routine monitoring of liver enzyme levels is necessary during therapy.12
Naltrexone, an opioid antagonist, exerts its effect by blocking alcohol-induced release of dopamine. Through this mechanism, naltrexone reduces the pleasurable side effects of alcohol consumption and reduces cravings for alcohol.12 Numerous randomized, controlled trials have shown therapeutic benefits from naltrexone therapy, along with an improved abstinence rate compared with placebo.14,15 Naltrexone is usually given in a dosage of 50 mg per day for the first 90 days of abstinence, although dosages ranging from 25 to 100 mg per day have been used.12 Side effects of naltrexone include nausea, headache and anxiety. In higher dosages, naltrexone can cause hepatotoxicity, but this adverse effect is uncommon when recommended lower dosages are used. Nonetheless, liver function should be monitored in patients taking naltrexone in any dosage.
Although screening tools have not been established, family physicians should incorporate questions about narcotic and steroid use into their medical practice. It is helpful to have prearranged contacts (e.g., Narcotics Anonymous and other treatment programs) within the community so that patients can be referred for counseling and treatment.
Domestic Violence
Domestic violence is a major cause of morbidity, mortality and disability in the United States. A 1985 national survey found that 16 percent of married couples reported one or more episodes of physical violence in the preceding year.16 However, few family physicians screen patients for domestic violence or the tendency to perpetuate violence.
In domestic violence episodes, the majority of assailants are men 18 to 35 years of age. Most of these men use alcohol or drugs on the day of the assault. Unemployment appears to correlate with the incidence of domestic violence. A recent study found that approximately one third of assailants were unemployed.17
Because family physicians care for all members of the family, they can often recognize patterns of abuse, as well as risk factors in the assailant. Physicians should have a heightened clinical awareness for investigating and reporting possible domestic violence. In addition, they should routinely screen male patients by asking if they ever feel the urge to strike out at a family member when they are angry or frustrated.
When domestic violence is discovered, interventions are directed at ensuring the immediate safety of the victim and family, providing stress management and encouraging relationship counseling. Treatment programs exist for assailants and victims of domestic violence.
Midlife Crisis
The literature reveals very little scientific evidence for the existence of a male midlife crisis, or “male menopause.” However, in the transitional period between 40 and 60 years of age, men become aware that they are aging, that life is finite and that death will occur at some point in the not too distant future. During this time, men must also deal with family changes (e.g., empty nest syndrome), retirement, physical decline, unfinished tasks and plans, and the loss of parents, friends or even a spouse.
Rather than being a time of crisis, midlife should be viewed as a normal developmental change, part of an “endless circular process of beginnings, fulfillments, endings, and self-renewals that proceed as we transform and evolve.”18(p1301)
A 1994 study of 350 men between 30 and 60 years of age found no evidence of a peaking of midlife concerns during this time period.18 In an earlier study, it was discovered that divorce, job disenchantment and depression occurred with approximately equal frequency throughout a man's adult years.19 If there is any true pathology, it is found in men who are overly neurotic, who present with low morale, high anxiety and a sense of inadequacy and resentment, and who have a diagnosis of adjustment disorder.
The authors of this article believe that the concept of male midlife crisis is outmoded and is not supported by behavioral science. All men make transitions psychologically and behaviorally as they age. Most men make this transition smoothly and without difficulty. However, if male patients appear to have particular difficulty with this transitional process, counseling by the family physician or a psychologist is certainly in order. Referral for psychiatric help can be beneficial for the occasional patient who is experiencing extreme difficulty.
Depression and Suicide
Depression is the most common psychiatric disorder in the elderly. Approximately 1 percent of community-dwelling elderly men have major depressive illness, and from 13 to 27 percent have “minor depression” or “subsyndromal depression.”20,21 The prevalence of major depressive disorders ranges from 5 to 50 percent in men and women who are institutionalized or have other medical illnesses.20,21 Depression is two to three times more common in women than in men, but men are more likely to commit suicide. Unrecognized or undertreated depression unnecessarily increases suffering and health care utilization, and decreases functioning and quality of life.
Risk factors for depression in men include previous depressive episodes, family history of depression, comorbid medical illness, medications (i.e., beta blockers, histamine H2-receptor antagonists, methyldopa [Aldomet], benzodiazepines, reserpine [Serpasil] and barbiturates), alcohol abuse, lack of social support, recent life stressors, single marital status and physical disability. Advancing age itself is not a risk factor.
The most frequent symptoms of depression are persistent sleep disturbance, fatigue, multiple somatic complaints, a change in bowel habits and weight gain or loss.21,22 The classic presentation of a depressed mood is less common in the elderly than in younger persons. Persistent sleep disturbance has been found to be highly associated with depression in community-dwelling elderly men and women.21 Office screening for depression can be conveniently performed using the Beck Depression Inventory or another depression scale.
Selective serotonin reuptake inhibitors (SSRIs) are now used as first-line therapy for depression. These agents, which include fluoxetine (Prozac), sertraline (Zoloft) and paroxetine (Paxil), are effective in 65 to 75 percent of patients with depression. The SSRIs have a wide therapeutic index and a low potential for seizures. However, a clinical response may not become apparent until an SSRI has been taken for four to eight weeks. Common side effects include nausea, agitation, insomnia and sexual dysfunction. SSRIs do not have the significant cardiovascular, anticholinergic and sedative side effects that can occur with tricyclic antidepressants, and they are relatively safe when consumed in overdose.22
Other treatment options include psychotherapy and electroconvulsive therapy. Good sleep hygiene, regular exercise, minimal alcohol and medication use, and good nutrition are other key measures in the treatment of depression. The option of psychiatric referral should be entertained if a patient has accompanying psychosis or suicidal ideation or if depression is refractory to treatment. Early involvement of psychiatrists and other mental health experts has been shown to be cost-effective and to result in improved outcome.22
Because of their shorter half-lives, sertraline and paroxetine are favored over fluoxetine for the treatment of depression in elderly men. Other medications for the treatment of depression include tricyclic antidepressants, bupropion (Wellbutrin), trazodone (Desyrel), monoamine oxidase inhibitors, lithium and stimulants. Venlafaxine (Effexor) and nefazodone (Serzone) are newer antidepressants that are being used with increasing frequency in elderly patients with depression. Detailed discussions of these agents are beyond the scope of this article. Because most of these agents have higher side effect profiles than SSRIs, they should not be considered as first-line therapy.
Suicide is a significant concern in depressed men. In particular, elderly white men have six times the suicide rate of the general population.21 From 1980 to 1992, the suicide rate increased 9 percent in persons 65 years and older, and increased 35 percent in persons 80 to 84 years of age.21 The likelihood of a suicide attempt resulting in death is highest in the elderly, increasing from 200 attempts for every one death in young adults to four attempts for every one death in the elderly.23
Family physicians are in a pivotal position to identify elderly patients who are at risk for suicide. Data indicate that 75 percent of elderly suicide victims had visited their primary care physician within the month of their death, and 33 to 39 percent had seen their physician within the week before death.21,22
The most important risk factor for suicide is an active episode of depression. If a patient also has active psychotic features, the risk is increased fivefold. Other risk factors for suicide include male gender, social isolation, alcohol abuse, chronic pain and disability, organic brain syndrome and lack of social support.22
Depression is an insidious and common finding in elderly men. Early recognition, diagnosis, treatment, follow-up and support are critical to a successful outcome. With early intervention, unnecessary morbidity and mortality can be prevented, and function can be improved.