Men's mental health: Connection to urologie health Andrew Matthew, PhD;* Dean Elterman, MDr 'Psychologist, Princess Margaret Cancer Centre, Department of Surgical Oncology, Division of Urology, Toronto, ON; 'Urologist, Toronto Western Hospital, Division of Urology, Toronto, ON

Cite as: Can Urol Assoc J 2 0 U ;8 (7 -8 ):S 1 53-5. h ttp ://d x.d oi.o rg /1 0 .5 4 89 /cu a j.2 3 1 2 Published online August 1 1,2 0 1 4 .

Abstract Historically, the specialty of urology has focused on single-system dis­ eases. In recent years, however, there has been increasing recognition of the interconnectivity between the various systems, such as cardio­ vascular disease, metabolic syndrome, erectile dysfunction and pros­ tate cancer. This constellation of disease/syndrome and dysfunction may place urologists at the centre of men's overall health concerns. As urologists considering taking on a leadership role in men's health, they should also consider their potential in helping men suffering from the significant burden of a mental health disorder. Urologists may have a unique opportunity to identify mental health issues in their male patients, influence healthy behaviour change, and successfully refer men, who might otherwise not seek help, to appropriate medical/ psychological care.

Men's mental health An estimated 3.4 m illio n Canadian men are currently living with mental illness.1 This number is likely an underestimation given that a large proportion of men experiencing symptoms of mental illness do not seek the help of a professional.24 This gap in care has grave outcomes as Canadian men are at least 3 times more likely to die by suicide than Canadian women5 - a figure that increases to 7 times among elderly men.6 Specific to uro­ logie diseases/disorders, such as urologie cancers, lower urinary tract symptoms and erectile dysfunction (ED), men experience elevated levels of anxiety and depression.7'8 For example, the risk of suicide in men with prostate cancer is over 4 times that of a similarly aged man w ithout prostate cancer.9 Patients with lower urinary tract symptoms (LUTS) experience elevated levels of psychosocial distress, w ith depression rates of 6% to 21% and anxiety rates of 3% to 10%.10 An estimated 10% of men with ED suffer from depression, and 2.5% to 37% suffer from anxiety.11 Given the relationship between mental health and

overall health-related quality of life, it is clear that increasing numbers of men in general, and men w ith urologie disease, are suffering a significant burden and that most of this burden remains untreated by healthcare professionals. Barriers to accessing mental health services include stigma, differences in expression of emotional problems (compared to women), maladaptive coping, and lack of awareness of support services in the community.

Stigma Results suggest that the most prominent barrier to seeking and accessing mental health services is stigma.12'13 Seeking mental healthcare services remains a secretive and shameful activity for many individuals.14 The anticipation of social consequences and discrimination is often enough to force men into silence. W hile mental health stigma is not exclusively a male issue, men face a disproportionate amount of stigma, which is often perpetuated by masculine ideals of strength and self-reliance. A firm belief in stoicism and the need to control emotions may lead some men with anxiety and depression to perceive emotional distress as shameful, and hide their symptoms from others.13,15

Differences in expression of emotional problems Another factor that may complicate seeking help involves the recognition that men's experience of mental illness may differ from that of w om en.16 For example, men are more likely to manifest depression as anger, aggression and violent behaviour rather than sad affect.17 Instead of exhibiting the traditionally viewed symptoms of depression, such as lack of sleep, energy and interest in activities, men often put on a tough exterior to mask their distress. Consequently, men may struggle recogniz­ ing symptoms as originating from a mental health condition. In fact, a recognized limitation of current epidemiologic estimates for mood disorders, such as depression, is that the estimates tend to miss the symptoms most frequently experienced by

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m e n .18 Even in the p rim a ry care setting, m en w ith m ild depres­

GPs o r o th e r health professionals w e re the m ost fre q u e n t and

sive sym ptom s are m ore lik e ly to be m isdiagnosed than w om en, p a rtic u la rly w h e n evaluate d b y m a le p ra c titio n e rs .19 In instan­ ces w h e re sym ptom s are a p p ro p ria te ly in te rp re te d , m en m ay

strongest sources o f in flu e n c e ."25 H e lp in g patients w ith m ental health p ro b le m s is n o t e n tire ly u n fa m ilia r te rrito ry fo r m o st u ro lo g is ts . For e x a m p le , fo r the

e x p e rie n c e d e n ia l o r u n d e r-e v a lu a te th e ir sy m p to m s .20 Such

p a tie n t w ith u ro lo g ic a l cancer, th e u ro lo g is t m ay take on th e

responses m ay cause m en to a v o id treatm ent, b e lie v e th a t the issue w ill go aw ay on its o w n , o r th in k th a t th e ir sym ptom s are

ro le o f screening fo r signs o f distress, p ro v id in g e d u ca tio n on th e ir diagnosis, tre a tm e n t and related-side effects, and o ffe rin g

n o t serious enough to w a rra n t professional a tte n tio n . S im ila rly ,

s u p p o rt th ro u g h re fe rra l to p s y c h o s o c ia l services o r s p e c ific re h a b ilita tio n p ro g ra m m in g . For men suffering fro m LUTS, the

m en m ay also be c o n c e rn e d th a t th e h e a lth c a re p ra c titio n e r m ig h t th in k less o f th e m fo r a s k in g fo r h e lp o r b e lie v e th a t

u ro lo g is t m ay p e rfo rm a fu n c tio n a l analysis to d e te rm in e the

ce rn s.12'20'21

im p a c t o f sym ptom s on d a ily life , o ffe r p ra c tic a l so lutions (e.g., Kegel exercises), and p ro v id e p sych o so cia l referrals to address

M a la d a p tiv e co p in g

issues re la te d to se lf-e ste e m o r in te rp e rs o n a l re la tio n s h ip s . F in a lly, fo r patients suffering fro m ED it is g e n e ra lly recognized

professional assistance w ill n o t be a ble to h elp w ith th e ir c o n ­

U n fo rtu n a te ly, this in itia l id e a liz e d m a scu lin e response to m en­ tal health pro b le m s can e v o lv e o ve r tim e in to adverse c o p in g b e h a vio u rs.22 W h e n faced w ith th e c h o ic e o f seeking he lp and the perceived change in m asculine id e n tity, men are m ore lik e ly to self-m edicate w ith illic it drugs, abuse a lc o h o l, w o rk exces­ sive ly o r p a rtic ip a te in in fid e lity .18 This m a n ife sta tio n o f e m o ­ tio n a l repression is deem ed by the man as m ore so c ia lly accept­ able than tra d itio n a l ch a ra cte ristics o f depression .23 H o w e ve r, w h e n these m a la d a p tiv e c o p in g m e ch a n ism s e v e n tu a lly fa il, m en are at risk fo r v io le n c e o r severe se lf-h a rm in g b e h a v io u r th a t m ay in v o lv e suicid e .

by th e u ro lo g is t th a t a b io p sych o so cia l a pproach is needed th a t goes b e yo n d th e p re s c rip tio n o f p ro -e re c tile agents to in c lu d e c o u n s e llin g on m odels o f in c o rp o ra tin g p ro -e re c tile agents in to regular sexual a c tiv ity . A c c o rd in g ly , th e u ro lo g is t m a y e x p a n d his o r her ro le in screening fo r signs o f distress (id e n tifica tio n ), in flu e n c in g behav­ io u r change, and fa c ilita tin g m e d ic a l and p s y ch o lo g ica l care, b eyond that d ire c tly associated w ith u ro lo g ie disease. C om m on p re se n ta tio n s o f m e n ta l h e a lth d is o rd e r in m en in c lu d e sub­ stance o r a lc o h o l abuse, m arriage/coup les troubles, w o rk stress­ es o r w o r k /life im b a la n c e s , o r a d ju s tm e n t to m a jo r life s ty le changes, such as re tire m e n t. Distress scre e n in g (e.g., P atient H ealth Q u e stio n n a ire -9 )26 and b rie f questions regarding relevant

L ack o f a w a re n e s s o f s u p p o rt services

life d o m a in s (e.g., w o rk , re la tio n s h ip , substance use, sexual fu n c tio n ) m ay h elp to id e n tify men suffering fro m m ental health

F in a lly , lo g is tic a l b a rrie rs m ay p re v e n t m en fro m a ccessing m ental health care. For exa m p le , n o t k n o w in g w h ic h services

p ro b le m s . S im ila rly , u ro lo g is ts m ay h e lp p a tie n ts engage in b e h a v io u r change th ro u g h th e ir in flu e n tia l ro le as healthca re professiona ls. T he p a tie n t's v is it to th e u ro lo g is t's o ffic e m ay

are a va ila b le , n o t k n o w in g h o w to access services and la c k in g tra n sp o rta tio n to reach th e service m ay all serve as barriers.24

T h e r o le

o f th e

u r o lo g is t in

m e n 's

m e n t a l h e a lth

G iv e n th e in te rc o n n e c tiv ity o f th e v a rio u s h e a lth issues th a t often c o n fro n t m en, it is im p o rta n t fo r urologists to re co g n ize th e ir role in d ire c tly or in d ire c tly (via referral) assisting men w ith a w id e va rie ty o f health issues, such as ca rd io v a s c u la r disease, m e ta b o lic syndrom e, ED and prostate cancer. If urologists are to c o n s id e r ta k in g on a le a d e rsh ip ro le in m e n 's h e a lth , th e y should also consider th e ir p o te n tia l role in h e lp in g men w h o are suffering from th e sig n ific a n t burden o f a m ental health disorder. For m a n y m en, visits to th e u ro lo g is t m ay be th e first reg u la r c o n ta c t th e y have w ith h e a lth care o v e r m a n y years o f th e ir lifespan. This p rovides a u n iq u e o p p o rtu n ity fo r the u ro lo g is t to id e n tify m en e xp eriencin g m ental health problem s, and e n c o u r­ age these m en to engage in h e a lth y b e h a v io u r a n d /o r access m ental healthca re services. In this regard, urologists sh o u ld not underestim ate th e ir in flu e n c e . In e x a m in in g those w h o ca rrie d th e greatest in flu e n c e in m en seeking m ental health support, C usack and colleagues c o n c lu d e d : "th a t in tim a te partners and

SI 54

p re se n t an o p p o rtu n ity fo r a "te a c h a b le m o m e n t"27 th a t can serve to m o tiv a te he a lth y b e h a v io u r change th a t c o u ld in c lu d e s o m e th in g as s p e c ific as s m o k in g cessation to s o m e th in g as b road as seeking h elp fro m a m ental health professional. The re la tio n sh ip betw een the u ro lo g ist and the p a tie n t th rough regu­ lar visits m ay also serve to h elp n o rm a liz e m ental health issues and c o m b a t stigm a. The u ro lo g is t can then a ct as a gatew ay to healthca re services th ro u g h a p p ro p ria te referrals. T hrough this ea rly and regular c lin ic a l c o n ta c t w ith m ale patients, the u ro lo ­ gist w ith th e general p ra c titio n e r m ay p la y an im p o rta n t ro le in risk re d u c tio n , p re v e n tio n and m ana g e m e n t o f th e p otentia l burd e n o f m ental illness. In ta k in g a page fro m the experiences o f general p ra c titio n ­ ers w o rk in g w ith th e ir patients w h o suffer fro m m ental illness, increased know ledg e and tra in in g in m ental health can go a long w a y (e.g., fu n d a m e n ta l tra in in g in distress screening, he a lth b e h a v io u r c h a n g e m o d e ls and m o tiv a tio n a l in te rv ie w in g ). R ich a rd s and c o lle a g u e s e x a m in e d th e a ttitu d e s o f general p ra c titio n e rs to w a rd de p re ssio n , as w e ll as th e ir c o n fid e n c e in b e in g a b le to assess and tre a t depression. T hey fo u n d that general p ra c titio n e rs w h o had tra in in g in m ental health w e re

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Men’s mental health

more positive in their attitudes toward depression and helping their depressed patients. General practitioners without mental health training reported insufficient knowledge about depres­ sion as a barrier to managing patients and their treatments .28 For urologists interested in advocating for men's overall health, training in mental health could be offered online or through workshops at provincial and national meetings or conferences.

8. 9. 10.

11. 12.

Conclusion 13.

Following a similar model of gynecology in women's health, urologists are positioned to offer a gender-specific approach to the health service delivery, government policy, research and advocacy. As urologists consider taking on a leadership role in men's health, they will need to consider their potential in help­ ing men with a mental health disorder. Urologists may have a unique opportunity to identify mental health issues in their male patients, influence healthy behaviour change, and successfully refer men, who might otherwise not seek help, to appropriate medical/psychological care. By taking on a leadership role in men's health, urologists have the potential to influence the lives of many men suffering from mental health problems through risk reduction and preventive measures.

14.

15. 16. 17. 18.

19. 20.

Competing interests: Dr. Matthew and Dr. Elterman declare no competing financial or personal interests. 21.

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22.

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Correspondence: Dr. Dean Eltermon, Toronto Western Hospital, 399 Bathurst St, Toronto, ON M5T 2S8; [email protected]

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Men's mental health: Connection to urologic health.

Historically, the specialty of urology has focused on single-system diseases. In recent years, however, there has been increasing recognition of the i...
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