Psychosocial health screening and recognizing early signs of psychosocial distress

Healthy Aging in Men series

Psychosocial health screening and recognizing early signs of psychosocial distress Keywords Mental health Doctor–patient relationship Mental wellness Stigma Depression Substance use

Sanford Herman and Richard Sadovsky Abstract Mental health issues are a common cause of psychosocial distress in men over the age of 55, and are a common cause of disability due to problems of disturbance of mood, substance use issues, and cognitive difficulties. The physician’s ongoing relationship with the older male patient is highly personal and enables the clinician to key in on events and changes in his life that may predispose to mental illness. Doctors have the opportunity to reduce long-term disability and suffering caused by mental and emotional distress through early recognition and anticipation of common mental health problems. ß 2010 WPMH GmbH. Published by Elsevier Ireland Ltd.

Cognitive difficulties

Sanford Herman, MD SUNY Downstate Medical Center, Brooklyn, New York, USA Richard Sadovsky, MD, MS SUNY Downstate Medical Center, Brooklyn, New York, USA E-mail: [email protected]

Online 8 February 2010

Mental health issues are a common cause of distress and disability in men over the age of 55 [1]. Problems are frequently caused by (1) disturbance of mood, (2) substance use issues, or (3) cognitive difficulties. Often, these three overlap and it becomes difficult to determine the root cause of the problem. A comprehensive approach is required to assess each distinct problem area and to outline an effective course of intervention. The physician’s ongoing relationship with the older male patient is highly personal and enables the clinician to be sensitive to events and changes in his life that may predispose to illness. Early recognition and the anticipation of common mental health problems provide the doctor with the best opportunity to reduce long-term disability caused by mental and emotional distress.

Setting the stage for early recognition Well before diagnostic or treatment issues can be addressed, it is necessary to assess a patient’s ability to discuss pertinent mental

ß 2010 WPMH GmbH. Published by Elsevier Ireland Ltd.

health issues. For some patients, this may come easily. However, for many men, especially those who may not be psychologically minded, discussing these issues may represent a challenge for the physician. Setting the proper tone with the older male patient serves to maximize the yield of useful history and lays the groundwork for effective treatment. Discussions about healthy aging begin with the establishment of a therapeutic alliance with the patient (Table 1) [2]. This means that the physician aligns with the patient in a caring and compassionate manner for the purpose of helping the patient deal with any difficulty at hand. Both physician and patient are vital members of the same team, each with a distinct role in the relationship. On the one hand, the physician is the recognized expert on the medical and psychosocial aspects of care and contributes this expertise to the team. On the other hand, the older male patient is the recognized expert on his personal experience with his symptoms, complaints or issues. Each member of the team relies on the other’s expertise. Each needs to communicate openly with the other and share pertinent informa-

Vol. 7, No. 1, pp. 73–82, March 2010

73

Healthy Aging in Men series Table 1 Setting the tone for a collaborative doctor–patient relationship Establish a therapeutic alliance Create a compassionate, non-judgmental atmosphere Clarify the role of both the doctor and the patient in the relationship, expectations and limitations for each Recognize the patient as expert on his experience of his problems Give license to discuss issues of concern Open lines of communication

tion in a comprehendible and understandable manner. Yet, the role of setting the ground rules for the relationship rests with the physician. A condescending, judgmental approach by the physician will result in a patient who does not share what the physician needs to know to properly help the patient. However, a physician who conveys the message that everything that the patient has on his mind is valid and important will give license to the patient to open up and discuss issues that may have been felt previously to be uncomfortable or even embarrassing. It is well documented in multiple past studies that men of all ages and ethnicities are reluctant to seek help for medical concerns (Table 2) [3]. The refusal to seek help for mental health issues is even greater and presents a special challenge. Only one third of all mental health out-patient visits are made by men [4]. Much of this behavior is learned over the course of a man’s lifetime. Society re-enforces certain male stereotypes through books, film, and television. Masculinity is identified with being physically and emotionally tough and independent. Acknowledging the need for help is equated with vulnerability and is felt by many men to be a sign of weakness. Real emotions are buried lest they be misperceived by others and cause embarrassment. Crying is Table 2 Why dealing with mental health issues among men is difficult Reluctance to seek any kind of medical help in general The particular stigma of mental illness Need to overcome a lifetime of learned behavior to avoid emotional issues Attitudes reinforced by stereotypes in popular culture and media Fear of being seen as vulnerable and weak

74

7, No. 1, pp. 73–82, March 2010

something real men are just not supposed to do [5]. The stigma of mental illness that exists is yet another barrier to men seeking help. All too often, well-meaning family members and friends will ignore important warning signs of mental illness, such as changes in behavior or increased substance use. They may accept a disability such as cognitive dysfunction as being normal or an accepted part of aging. Individuals with severe depression are treated as if they have control over their moods. The physician is in a unique position to counter inaccurate stereotypes surrounding mental illness and dispel much of the stigma. A direct, informative approach and reassuring attitude is often successful. A first step in this method is for the physician to reframe the concept of mental illness into mental wellness when dealing with the male patient. This approach de-emphasizes the negative illness connotation and regroups concern for mental health with other positive aspects of healthy living (Table 3). An example of this approach would be to say, ‘‘I’m here to take care of all of you – your physical, mental and emotional wellbeing. They are all interconnected and all important to me.’’ Another useful way to combat stigma is to medicalize mental illness. With this approach, mental illness is not seen as some sort of mystical or esoteric condition that is difficult to comprehend or seen as a personal flaw. Rather, it is conceptualized as a medical illness that affects an important organ in the body – the brain. Just as there are medical illnesses that affect vital organs in the body like the heart or kidneys, there are a wide range of common medical illnesses that can affect the brain. These kinds Table 3 A primary care approach to mental health issues Assess the patient’s ability to discuss and deal with pertinent mental health issues Frame the discussion in terms of mental wellness instead of terms such as mental illness that might have a negative or frightening connotation. Characterize diagnosable psychiatric conditions as medical conditions affecting an organ in the body called the brain. Emphasize that these conditions are common and widespread with the biggest problem being lack of awareness and recognition.

Healthy Aging in Men series of medical illnesses operate on the same basic principles as medical illnesses affecting other vital organs. This theme can be taken further. For example, just as no one willingly opts to have a medical illness affecting a major organ in the body, so too, nobody chooses to have a medical illness affecting the brain. Thus, the notion of ‘‘just snapping out of it’’ makes as much sense as telling someone with high blood pressure to ‘‘just snap out of it’’. Yet, this is exactly what many well intentioned but misguided friends and relatives will tell a loved one suffering from a depressive illness. Finally, just as the treatment for someone with a medical illness affecting the heart is usually a combination of medication and therapy (e.g., diet, exercise, stress reduction, etc.), so too for the individual with a medical illness affecting the brain, a combined approach of medication and some form of therapy works best [6]. This makes sense as the expression of most medical illnesses is a combination of genetic vulnerability and environment. For the susceptible heart patient, managing environmental factors such as diet and exercise can help modify the risk or course of heart disease. For the individual at risk for a medical illness affecting the brain, psychosocial interventions and other forms of non-medication treatment can likewise modify the disease expression accordingly. Doctors can exert a positive influence on the older male patient by emphasizing a preventive approach to mental health. Most individuals with mental health issues are usually seen first by their physicians with complaints about sleep, pain or malaise being common. Recognition of sub-optimal functioning by the physician is also an important clue. Neglect of family responsibilities, household chores or financial obligations should be investigated further. In 1967, psychiatrists Thomas Holmes and Richard Rahe investigated over 5,000 medical records in an effort to establish a relationship between stress and medical illness. They developed a measure called the Social Readjustment Rating Scale [7]. Common life events were given a value in Life Change Units (LCUs) relative to the amount of stress they caused. Death of a spouse was deemed the most stressful of all life events and was given a score of 100 LCUs. Also ranking high was retirement, illness and

Table 4 Commonly occurring events in older men as rated by the Holmes–Rahe scale Life events

Life change

Death of a spouse Death of a close family member Personal injury or illness Retirement Change in health of family member Sexual difficulties Change in financial state Spouse stops work Change in living conditions

100 63 53 45 44 39 38 26 25

units (LCUs)

Source [7].

change in financial situation, events that commonly occur in older men (Table 4). A score of 300 or greater was thought to reflect an increased risk of medical illness. Although this scale did not look specifically at the risk of developing a psychiatric illness, such as mood disorders or substance use, it is easy to infer that with stressful life changes these might occur more often. Recognizing this allows the physician to adopt a proactive approach to mental health issues, especially when the provider is aware of stressful life changes in a man’s life. Simple questions are often the best at recognizing emerging mental health issues. In response to known stressful events such as retirement or a change in financial situation, questions such as ‘‘So what plans do you have when you retire?’’ or ‘‘How will you spend your free time?’’ or ‘‘How is your retirement likely to affect your lifestyle?’’ may be asked. These are often useful in eliciting subtle signs of anxiety or depression related to the change. Loss of self-esteem related to a change in life situation can often lead to use of substances. Questions such as ‘‘Do you find yourself drinking more lately?’’ might be used to open up a discussion on substance use. When specific questions related to life changes do not produce any yield or when there are no obvious red flags of note, non-specific and open-ended questions are often helpful. General inquiries such as ‘‘How are you sleeping at night?’’, ‘‘Tell me about your appetite’’ or ‘‘How would you rate your overall stress level?’’ will frequently reveal underlying problems. Even in the absence of specific symptoms related to life changes or particularly stressful

7, No. 1, pp. 73–82, March 2010

75

Healthy Aging in Men series situations, a proactive approach by the physician will help direct the older male patient to resources in the community that may be useful in warding off future mental health problems. For the recently retired male patient, the suggestion of using one’s expertise in community service or by volunteering might be welcomed as a means of staying productive and enhancing self-esteem. Physicians need to recognize that a large percentage of their older male patients do not live in a psychosocial vacuum. Many have involved spouses, families and friends. With the patient’s permission, these individuals should be included in the assessment process and are a valuable source of information. Often, the older male patient will paint a rosy picture of good adjustment and contentment to his doctor. However, when a family member is asked to corroborate the information, a totally different picture emerges. Many patients put up a stoic front to their health care provider and do not wish to appear weak in their eyes. Others may feel that they are imposing on their doctor with the burden of their troubles. Clinicians, too, send messages to their patients through their conscious or non-conscious communication, both verbal and nonverbal. This is termed counter-transference [2]. All too often, physicians may feel that they will open up a situation they are not equipped to handle if they raise the issue of mental wellbeing. This may be due to time constraints of their practice or just the feeling of being unable to deal with the torrent of issues that may emerge. Often, it’s just sometimes easier to rationalize and pretend that mental health issues do not exist, thus ignoring obvious clues of distress. Physicians need to be continually aware that everything they say or do has therapeutic significance for their patient. Likewise, omissions, be they conscious or unconscious, can have the same impact. Finally, a physician’s body language is likely to be read by the patient and interpreted accordingly. Patients are adept at recognizing when a physician is uncomfortable with a given subject or is feeling too rushed to give the matter the attention it deserves. Likewise, they will open up about the most sensitive matters if the physician’s body language is consistent with the question being asked.

76

7, No. 1, pp. 73–82, March 2010

Depression Not recognizing a patient’s distress can be disastrous. Depression is highly prevalent in adult males (7–12%) with much higher rates for the medically ill [8]. Up to 75% of patients who commit suicide will see their doctor within 1 year of their deaths and 45% within one month [9]. Picking up on the clues a patient provides can be lifesaving (Table 5). There is no evidence that inquiring about these issues ever precipitated a suicide. On the contrary, presenting an openness to discuss mental health issues is almost always perceived favorably by patients and gives them an opportunity to get important feelings off their chests. While physician sensitivity to mental health issues in older males is necessary for quality care, clinicians often feel they are inadequate to make a diagnosis of a mental disorder in the absence of any standardized lab test. Fortunately, numerous well validated screening tools exist [10–14]. The Patient Health Questionnaire (PHQ)-9 (Table 6) is a quick tool for diagnosing depression in a medical setting as well as monitoring response to treatment [15]. It is self-administered by the patient but clinician scored. It is based on the DSM-IV-TR diagnostic criteria for depression [16]. It is useful in assessing symptoms and functional impairment in depression as well as in tracking the response to treatment. In the shorter PHQ-2, patients are asked to rate if they have had little interest or pleasure in doing things over the previous 2 weeks or if they have felt down, depressed or hopeless. It is also well validated [17]. Once diagnosed in an older male patient, successful treatment of depression can have a tremendous impact on the quality of life and lead to feelings of happiness and wellbeing. However, depression is often a complex condiTable 5 Hints and clues of potential suicide risk History of any previous attempt Feelings of despondency or total hopelessness Concurrent use of alcohol Presence of command auditory hallucinations Poor family or psychosocial support Recent losses (spouse, job) Increasing age and worsening health During the initiation of treatment (when energy level may be better but depressed feelings are still there)

Healthy Aging in Men series Table 6 Patient Health Questionnaire (PHQ)-9

Source [15].

tion with many different facets requiring a comprehensive approach. When a diagnosis of depression is suspected, there are four essential elements that must be considered. Often, these elements are interconnected so an organized, step-by-step approach is advocated. The first element of greatest concern is patient safety. In men, suicide rates increase after age 45 with older white males being at highest risk [2]. Indeed, the two factors associated with successful suicide are increasing age and physical illness. Simple questions that validate patient’s feelings are useful in eliciting suicidality. An example may be, ‘‘When people tell me they feel the way you do, they often have thoughts of no longer wanting to live or even doing something to harm themselves. Is this you?’’ Proactive screening for suicidal thoughts, initiation of treatment, psy-

cho-education and timely follow-up can minimize suicide risk. If suicidal thoughts persist, then a referral to a psychiatrist may be indicated, especially if the individual possesses a weapon or is actively drinking. The second essential element to be assessed is the presence of psychosis. Of individuals with depression, 15% also experience psychotic features such as delusions or hallucinations with older individuals being particularly susceptible [18]. Simple questions such as, ‘‘When people feel the way that you do, they often report hearing noises or voices in their heads. Sometimes they hear the doorbell or phone ring and nobody is there. Is this happening to you?’’ may help improve recognition. The addition of an antipsychotic agent is usually necessary to achieve successful resolution of psychotic symptoms.

7, No. 1, pp. 73–82, March 2010

77

Healthy Aging in Men series The third essential element to be assessed is a history of at least one previous manic or hypomanic episode. This automatically changes the diagnosis from depression to a diagnosis of Bipolar I or Bipolar II, respectively. Treatment with an anti-depressant alone may precipitate a switch to a full-blown manic or hypomanic episode. The Mood Disorder Questionnaire (MDQ) is a simple 5-question tool that is useful in eliciting a history of Bipolar Disorder in a clinical setting [19]. Finally, depression should never be thought of as just a single illness to the exclusion of other psychiatric conditions. In fact, the opposite is frequently true. Depression is often seen co-morbidly with other anxiety disorders such as Panic Disorder, Obsessive-Compulsive Disorder (OCD), Social Anxiety Disorder and Generalized Anxiety Disorder [20]. Substance use disorders may be especially common and are often used as a means of self-medication by those with mood disorders [21]. If multiple conditions are present, then each disorder must be listed separately and treated accordingly. Fortunately, it is often possible to treat depression and anxiety disorders with the same medication although dosing may differ depending on the conditions being addressed.

Substance use disorders The older male patient is often at risk for developing a substance use disorder or continuing with an older one into his senior years [22]. Alcohol remains the most common and problematic substance used. In a study of 1,155 older men, 10.4% reported that they had been ‘‘heavy drinkers’’ in the past [21]. Older men were found to be twice as likely to consume alcohol compared with older women and are up to six times as likely to be considered problematic drinkers [23]. For many older men, the pattern of alcohol use is established earlier in life and the rate of alcohol consumption may actually increase as men age [24]. Tolerance for alcohol and other substances declines with age. Elderly men’s brains are particularly sensitive to the toxic effects of alcohol. This is due to the decrease in extracellular fluid and increase in the percentage of body fat as people get older. Compounding this is the decrease in the number of brain cells as people age creating a higher ratio of alcohol to

78

7, No. 1, pp. 73–82, March 2010

brain cell despite a similar amount of alcohol consumed. One consequence of these age-related changes is an increase in the severity and duration of cognitive problems in areas such as memory, abstraction, visuo-spatial and problem-solving skills. These deficits are often subtle and do not meet the full criteria for dementia. Nevertheless, they may greatly impact an older man’s ability to function and, ultimately, his quality of life. Unfortunately, the effects of drinking on cognition are often minimized or ignored by both patient and family [25]. Older men often fail to accurately report the extent of their drinking to their physician, even when asked directly [26]. This may be for several reasons including outright denial, trivialization or even difficulty in remembering secondary to the use of alcohol itself. Some may think of wine or whisky as containing alcohol but not beer. However, if the question is re-phrased to include beer, a significant positive response may be elicited. Many individuals are simply not aware that the average can of beer contains the equivalent of one shot of straight whisky. Compounding the problem of getting a good history from the patient is the underreporting of alcohol use by significant others or family. Often the problem is rationalized with the thinking that ‘‘he’s earned it’’ or ‘‘he’s entitled to drink a little now and then to help him relax or fall asleep’’. It is easy to see how even physicians who are meticulous in getting a good history of alcohol can be misled. This need for physicians to be compulsive in getting a history extends to inquiring about other substances as well [27]. Older individuals are also known to abuse a wide range of other drugs. These include illicit substances such as cannabis, amphetamines, opiates, streetbought benzodiazepines and cocaine. Use of these is often begun by men earlier in life and carried with them into their later years, often secretly. As the population ages, use of illicit substances is likely to become more and more widespread among older men. In addition to alcohol, individuals using opiates or benzodiazepines are at risk for going into withdrawal when hospitalized or suddenly unable to obtain the substance they are dependent on. Another major category of concern is with prescription medications and over-the-counter preparations [28]. Elderly patients often see

Healthy Aging in Men series Table 7 The CAGE test C - Have you ever felt you should cut down on your drinking? A- Have people annoyed you by criticizing your drinking? G - Have you ever felt bad or guilty about your drinking? E - Eye opener: Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover? Source [30].

multiple physicians for multiple medical problems and have ready access to a wide variety of prescribed medications. Furthermore, over-the-counter preparations are easily available and are used by the elderly for sleep problems, relief of pain or enhancement of mood. These preparations may contain antihistamines, anticholinergics, caffeine, aspirin

or non-steroidals. Overdose or misuse can result in cognitive difficulties, mood problems, delirium, falls, and a wide range of toxic reactions. Problems can also occur with well intentioned individuals who misuse medications by taking inappropriate doses or combinations of medications. Another common problem is that medications for pain or sedative–hypnotics are frequently shared among family members. These represent a hidden risk to the geriatric patient. Screening and counseling for substance use issues is an essential part of health care for the older male patient. There are many simple, easy to use screening tools available like the AUDIT C [29] and CAGE [30] (Table 7), questionnaires that take little time to administer in an office setting. Their simplicity and high yield makes them valuable instruments for alcohol screening. The Drug Abuse Screening Test (DAST) (Table 8) [31] is a comprehensive 20-

Table 8 DAST (Drug Abuse Screening Test) 1. Have you used drugs other than those required for medical reasons? Yes No 2. Have you abused prescription drugs? Yes No 3. Do you abuse more than one drug at a time? Yes No 4. Can you get through the week without using drugs (other than those required for medical reasons)? Yes No 5. Are you always able to stop using drugs when you want to? Yes No 6. Do you abuse drugs on a continuous basis? Yes No 7. Do you try to limit your drug use to certain situations? Yes No 8. Have you had ‘‘blackouts’’ or ‘‘flashbacks’’ as a result of drug use? Yes No 9. Do you ever feel bad about your drug abuse? Yes No 10. Does your spouse (or parents) ever complain about your involvement with drugs? Yes No 11. Do your friends or relatives know or suspect you abuse drugs? Yes No 12. Has drug abuse ever created problems between you and your spouse? Yes No 13. Has any family member ever sought help for problems related to your drug use? Yes No 14. Have you ever lost friends because of your use of drugs? Yes No 15. Have you ever neglected your family or missed work because of your use of drugs? Yes No 16. Have you ever been in trouble at work because of drug abuse? Yes No 17. Have you ever lost a job because of drug abuse? Yes No 18. Have you gotten into fights when under the influence of drugs? Yes No 19. Have you ever been arrested because of unusual behavior while under the influence of drugs? Yes No 20. Have you ever been arrested for driving while under the influence of drugs? Yes No 21. Have you engaged in illegal activities to obtain drugs? Yes No 22. Have you ever been arrested for possession of illegal drugs? Yes No 23. Have you ever experienced withdrawal symptoms as a result of heavy drug intake? Yes No 24. Have you had medical problems as a result of your drug use (e.g., memory loss, hepatitis, convulsions, or bleeding)? Yes No 25. Have you ever gone to anyone for help for a drug problem? Yes No 26. Have you ever been in hospital for medical problems related to your drug use? Yes No 27. Have you ever been involved in a treatment program specifically related to drug use? Yes No 28. Have you been treated as an outpatient for problems related to drug abuse? Yes No Source [31].

7, No. 1, pp. 73–82, March 2010

79

Healthy Aging in Men series Table 9 Clues to identifying substance abuse in older men

Table 10 Comprehensive screening and work-up for dementia

Previous history of substance abuse Family or social network involved in substance use Recent loss, social isolation or poor psychosocial support High degree of life stress Access to prescribed painkillers, sedative–hypnotics or anxiolytics Heavy reliance on over-the-counter medications

Mini Mental State Examination [34] Vision and hearing testing Review of all prescribed and over-the-counter medications CBC, electrolytes, vitamin B12, folate, ESR, glucose, calcium, phosphorous, magnesium, LFTs, TFTs, BUN, creatinine, triglycerides, RPR, UA Toxic drug screen EKG CT scan or MRI

question self-administered test that extends beyond alcohol use to include screens for excess or non-medical use of prescribed medications and over-the-counter drugs. This makes it an especially useful screening tool for older men. However, ultimately, the biggest help in making a diagnosis is a sensitivity to the issue of substance use and a heightened awareness of risk factors in a patient’s life (Table 9).

Cognitive problems Cognitive problems, regardless of their source, remain perhaps the most difficult mental health area to manage in the older male patient [32]. Unlike mood disorders and substance use disorders where, despite denial, there may be some underlying awareness of the problem at hand, with cognitive deficits, individuals may be completely unaware of any problem. The clinicians may feel overwhelmed by the challenge of dealing with the problems that cognitive issues bring. Often, it is the physician who must take an active role in preventing a cognitively impaired individual from driving. On the surface, this may rob the older male patient of his autonomy, independence and self-esteem. However, ultimately, the intervention is for the patient’s own safety and for the safety of the public. In dealing with the issue of cognition, the physician can help on several levels. Screening the older male patient for cognitive deficits should be done on an annual basis after about age 60. Dementia affects approximately 3–11% of patients over age 65 and 25–47% over age 86.The incidence of dementia doubles every 5 years after age 65 [33]. The most popular and easy to use tool is the Mini Mental State Examination [34]. It is a 30-point scale used to estimate the presence or severity of dementia.

80

7, No. 1, pp. 73–82, March 2010

Early recognition is essential, especially as not all forms of dementia are irreversible. Prescribed medications as well as over-thecounter sleep preparations frequently contain anti-cholinergic compounds that can cause cognitive dysfunction. Vitamin deficiencies such as B12 can mimic dementia. Visual and hearing problems can be another cause [35]. Finally, many patients suffering from depression may appear to have dementia. They may complain of poor concentration, memory impairment and other indicators of cognitive dysfunction as part of their symptom picture. Pseudo-dementia is the term used to describe this phenomenon [36]. With prompt and effective treatment of the depression, the cognitive deficits usually abate. However, the clinician needs to be on particular guard after the resolution of the mood symptoms as research has shown that a significant number of these individuals go on to develop a full-blown dementia several years later [37]. Encouraging the older male patient to have regular medical check-ups can usually pick up many of these problems in their early stages. If dementia is suspected, a more extensive workup can be initiated (Table 10). If irreversible causes of dementia are suspected, then the physician can be instrumental in helping the older male patient and his family outline an effective long-term plan of care. Inherent in this is the effort to keep him active and functional for as long as possible.

Encouraging an active lifestyle Finally, the physician can have an enormous impact on the older male patient just through the spoken word. Encouraging an active,

Healthy Aging in Men series Table 11 Evidence-based recommendations for physicians treating older men Establish a therapeutic alliance with the older male patient [38] Focus on mental wellness as part of a comprehensive approach [39] Screen for depression [10–17] Screen for substance abuse [29–31] Screen for cognitive problems [34] Setting goals and encouraging an active lifestyle [40]

robust lifestyle and setting goals can help keep the individual involved in the outside world and help keep his mind active. Simple recommendations about diet and exercise are likely to be heeded when coming from a physician. Likewise, suggestions for activities like volunteering, senior centers, social clubs or religious organizations may present opportunities for involvement. Studies have shown that a productive and busy mind can help forestall the

development of mood and cognitive problems and lessen the need for reliance on external substances such as drugs and alcohol. Basic questions such as ‘‘So tell me, what have you been up to lately?’’ or ‘‘Have you thought about keeping yourself busy with new things now?’’ can be effective in stimulating such a discussion. Healthy aging in men can be achieved through awareness, anticipation, and intervention in a timely manner. In summary, physicians are in a unique position to influence the older male patient to adopt healthy lifestyle changes while at the same time, being on the lookout for impending problems that might impact his mental health wellbeing. This is done by creating a climate of openness, support and collaboration with the patient. With this approach, problems involving mood, substances or cognition can be recognized in their earliest stages and an effective treatment implemented (Table 11).

References [1] Blazer DG, Steffens C. Textbook of Geriatric Psychiatry. Fourth Edition. Arlington, VA: American Psychiatric Publishing; 2009. [2] Sadock BJ, Sadock VA, Ruiz P, editors. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry/IX. 9th Edition. Baltimore: Lippincott Williams & Wilkins; 2009. [3] Broom A, Tovey P, editors. Men’s Health; Body, Identity and Social Context. London: John Wiley & Sons; 2009. [4] Vessey J, Howard K. Who seeks psychotherapy? Psychotherapy 1993;30(4):546–53. [5] Addis M, Mahalik JR. Men, masculinity, and the contexts of help-seeking. Am Psychol 2003;58(1):5–14. [6] Pampallona S, Bollini P, Tibaldi G, Kupelnick B, Munizza C. Combined pharmacotherapy and psychological treatment for depression: a systematic review. Arch Ben Psychiatry 2004;61(7):714–9. [7] Holmes TH, Rahe RH. The Social Readjustment Rating Scale. J Psychosom Res 1967; 11(2):213–8. [8] Robins LN, Locke BZ, Regier DA. An overview of psychiatric disorders in America. In: Robins LN, Regier DA, editors. Psychiatric Disorders in America: The Epidemiologic Catchment Area Study. New York: Free Press; 1991. p. 328–66. [9] Luoma JB, Martin CE. Contact with mental health and primary care providers before suicide: a review of the evidence. Am J Psychiatry 2002;159:909–16.

[10] Montgomery SA, Asberg M. A new depression scale designed to be sensitive to change. Br J Psychiatry 1979;134:382–9. [11] Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry 1961;4: 561–71. [12] Zung WWK. A self-rating depression scale. Arch Gen Psychiatry 1965;12:63–70. [13] Yesavage JA, Brink TL, Rose TL, Lum O, Huang V, Adey M, et al. Development and validation of a geriatric depression screening scale: a preliminary report. J Psychiatr Res 1982–83;17(1):37–49. [14] Hamilton M. A rating scale for depression. J Neurol Neursurg Psychiatry 1960;23:56–62. [15] Kroenke K, Spitzer RL. The PHQ-9: a new depression and diagnostic severity measure. Psychiatric Ann 2002;32:509–21. [16] American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: Fourth Edition – Text Revised. Washington, DC: American Psychiatric Association; 2000. [17] Kroenke K, Spitzer RL, Williams JB. The PHQ2: validity of a two-item depression screener. Med Care 2003;41(11):1284–92. [18] Swarz CM, Shorter E. Psychotic Depression. New York: Cambridge University Press; 2007. [19] Hirschfeld RMA, Williams JBW, Spitzer RL, Calabrese JR, Flynn L, Keck Jr PE, et al. Development and validation of a screening

[20]

[21]

[22]

[23]

[24]

[25] [26]

[27]

instrument for bipolar spectrum disorder: The Mood Disorder Questionnaire. Am J Psychiatry 2000;157:1873–5. Hirschfeld RMA. The comorbidity of major depression and anxiety disorders: recognition and management in primary care. Primary Care Companion. J Clin Psychiatry 2001;3(6):244–54. Colsher PL, Wallace RB. Elderly men with histories of heavy drinking: correlates and consequences. J Stud Alcohol 1990;51: 528–35. D’Archangelo E. Substance abuse in later life. Can Fam Physician 1993;39:1986–8: 1991–1993. Atkinson RM. Substance abuse. In: Coffey CE, Cummings JL, editors. Textbook of Geriatric Neuropsychiatry. 2nd Edition. Washington DC: American Psychiatric Press; 2000. p. 367–400. Liberto JG, Oslin DW, Ruskin PR. Alcoholism in older persons: a review of the literature. Hosp Community Psychiatry 1992;43:975– 84. McMahon AL. Substance abuse among the elderly. Nurse Pract Forum 1993;4:231–8. McInnes E, Powell J. Drug and alcohol referrals: are elderly substance abuse diagnoses and referrals being missed? Br Med J 1994;308:444–6. Thibault JM, Maly RC. Recognition and treatment of substance abuse in the elderly. Prim Care 1993;20:155–65.

7, No. 1, pp. 73–82, March 2010

81

Healthy Aging in Men series [28] Abrams RC, Alexopoulos GS. Substance abuse in the elderly: over-the-counter and illegal drugs. Hosp Community Psychiatry 1988;39:822–3: 829. [29] Bush K, Kivlahan DR, McDonell MB, Fihn SD, Bradley KA. The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Arch Internal Med 1998;158(16):1789–95. [30] Ewing JA. Detecting alcoholism: the CAGE questionnaire. JAMA 1984;252:1905–7. [31] Gavin DR, Ross HE, Skinner HA. Diagnostic validity of the Drug Abuse Screening Test in the assessment of DSM-III drug disorders. Br J Addiction 1989;84(3):301–7. [32] Boustani M, Peterson B, Hanson L, Harris R, Lohr KN, U.S. Preventive Services Task Force.

82

7, No. 1, pp. 73–82, March 2010

Screening for dementia in primary care: a summary of the evidence for the U. S. Preventive Services Task Force. Ann Intern Med 2003;138:927–37. [33] Bachman DL, Wolf PA, Linn RT, Knoefel JE, Cobb JL, Belanger AJ, et al. Incidence of dementia and probable Alzheimer’s disease in a general population: the Framingham study. Neurology 1993;43:515–9. [34] Folstein MF, Folstein SE, McHugh PR. Minimental state: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189–98. [35] Larson EB, Reifler BV, Featherstone HJ, English DR. Dementia in elderly outpatient: a prospective study. Ann Intern Med 1984; 100:417–23.

[36] Emery VO, Oxman TE. Update on dementia spectrum of depression. Am J Psychiatry 1992;49:305–17. [37] Alexopoulos GS, Young RC, Meyers BS. Geriatric depression: age of onset and dementia. Biol Psychiatry 1993;34: 141–5. [38] Safran DG. Defining the future of primary care: what can we learn from patients? Ann Intern Med 2003;138(3):248–55. [39] Price JR. The Wellness Book. Carlsbad, CA: Hay House, Inc; 1998. [40] Glass TA, de Leon CM, Marottoli RA, Berkman LF. Population-based study of social and productive activities as predictors of survival among elderly Americans. BMJ 1999;319(7208):478–83.