Young White Men & Missed Mental Health Diagnoses

We’ve all heard about the higher incidence of mood disorders (depression, anxiety etc.) in women and chances are we’ve all seen this reflected in the dominance of female clients who present seeking help but what’s this really telling us?  Many of us are aware that men are more likely to ‘self-medicate’ with alcohol and other substances, as a maladaptive way of dealing with the psychological stressors, however, the lesser talked about fact is that substance induced (i.e. cannabis etc.) psychotic disorders are significantly more prevalent in men and occur at younger ages than women (Bogren et al 2010) and substance use & abuse is commonly not sufficiently explored or adequately diagnosed in general practice amongst male patients.  Oh dear…what else do we need to know?

The results of a large English survey on mental health and help-seeking behaviour published in 2005 found that men were less likely than women to say that they would seek help (OR=0.78, 95% CI 0.72–0.88,P<0.001). The preferred reported source of help was friends or relatives with 63.1% saying they would seek help from this source.  In addition to this and somewhat, more alarmingly, the WHO reports that “doctors are more likely to diagnose depression in women compared with men, even when they have similar scores on standardised measures of depression or present with identical symptoms.”  https://www.who.int/mental_health/prevention/genderwomen/en/ So even when males do finally present for help, often, the mental health problem is being overlooked or missed.

One theme that keeps coming up in research is the ongoing associated stigma for men with mental health issues.  A study published in 2008, conducted by two National Institute of Mental Health postdoctoral fellows in mental health care policy at Harvard Medical School, investigated the effect of gender, race and socioeconomic status on psychosocial barriers to mental health care and found that white males were most likely to mistrust the mental health care system and were also likely to perceive mental illness as a stigma and therefore avoid formal mental health care https://www.sciencedaily.com/releases/2008/09/080908125123.htm

In my practice we actually have a high proportion of males presenting with mental health concerns, admittedly, our practice specialises in this area so that may be a key reason for this and in many instances the appointment has been instigated or driven by a concerned mother, a wife etc.  Regardless, I’ve found that many men really struggle & it’s made somewhat more complicated by the role they are expected to play in society. I think the key message is not to reinforce gender based stereotypes on our patients, have the confidence to explore mental health with male patients, their vulnerabilities, concerns etc. as much as you would your female patients. Make sure you thoroughly assess their substance use and take heart there is a lot we can do for these individuals, the first step is recognising there’s a problem.

Rachel will be speaking on Young White Men & the Mental Health Challenges They Face at the MINDD International Forum in Sydney June 14-15th.  For more information and bookings check out: https://mindd.org/forum/mind2014.html

What a difference a Doctor makes!

Be warned…whinge ahead! One of the things I’m asked most often by naturopaths is about my experiences & interactions with doctors regarding shared care of patients.  The question typically arises because they’ve been on the receiving end of less than ideal situations.  We’ve probably all been there at some point.  My usual optimism tells me that if we keep building the bridge by ensuring our communication is professional, accurate, respectful and always in the patients best interests, eventually we’ll bring the detractors around and those who make it clear they’ll never come around reveal themselves to be ill-equipped for shared care. Over this last week I’ve had a nasty reminder of the latter!

Here’s the scenario: I recently started seeing a female patient in her late 50s who has had unresolving diarrhoea for 3 months.  Multiple trips to the GP and investigations revealed no explanation, however, the diarrhoea was severe, unprecedented and deeply concerning to my patient.  After much discussion I organised a CDSA for her, the results of which confirmed extensive infection with Dientamoeba fragilis.   This parasite is a well-known established cause of diarrhoea and its eradication is associated with resolution of these issues.  There were also high levels of two gram negative bacteria which can be commensals (non-pathogenic, not infrequently found in human GIT), however, their population should be kept in check:  Klebsiella pneumonia & Citrobacter freundii.   As both of these bacteria are notorious for developing antibiotic resistance I did what I thought was best and communicated the findings of these results (plus copies) as well as a review paper from a mainstream scientific journal on Dientamoeba fragilis to her doctor in case we needed to pursue medical treatment of the parasite.  Now this is where the drama begins.  Did I mention this patient also suffers from anxiety?  Upon receiving my communication, her doctor wildly informs her that Klebsiella pneumonia is lethal! Potentially true if found in your respiratory system, however, absolutely not in the GIT.   He says has no idea about what I’m talking about (true!), with the suggestion that I don’t either & refuses to treat her.  Understandably, I receive frantic calls from a very upset patient concerned about the lethal bit!  What do you say?  Here’s what I said: Unfortunately this GP has simply demonstrated his ignorance about GIT microflora.  K. pneumonia is nasty in other parts of your body but quite common in the gut.  I can send you some information about this to reassure you. In the meantime let’s get you in to see someone who actually knows something about GIT pathogens.

A week later after the same patient sees the GP I referred her to (who received the same referral letter and information) I receive an email from him saying essentially: Thanks for sending this patient and the information.  According to the Centre for Digestive Diseases I think we can treat the parasite if necessary without risking resistance with the gram negative bacteria, however, right now she seems to be doing really well on the herbal anti-microbials you’ve prescribed so let’s delay any medical intervention unless really necessary.  I’ll see her again in 3 weeks and keep you posted.

Let’s just recap…this is a regular GP with the same training as her original one the difference is he has an open mind and takes the time to keep abreast of new information in order to offer his patients the best care. In the space of one week and two GPs I’ve gone from ‘mad fish-slapping dangerous naturopath’ to a welcome & respected contributor in patient care.  A good reminder that if you’ve done your best in terms of establishing good communication with doctors and other carers and they seem unable to respond in a way that has the patients best interests at heart…find another doctor! Ok – I’m done now 🙂

Keep an eye out for high prolactin

Seeing female patients with anxiety/depression, irregular menstrual cycles and perhaps marked PMS?  How about male clients with decreased libido, low measurable testosterone and perhaps even impotence or infertility?  All of these signs and symptoms could actually be the result of elevated prolactin. 

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Why aren’t they doing what I told them to?

Our patients are faced by more health & nutrition messages via multiple mediums than ever before yet escalating rates of obesity & lifestyle related disease highlight the failure of these. It would seem behavioural psychologists are right when they assert that information does not change behaviour in the majority of people.  Therefore if we too simply add to our patients’ information overload, we’ve missed the point. One of my favourite & at the same time terrible illustrations of this was when I walked into a local café and saw a man sitting at a table by himself having just finished a cup of coffee and something sweet.   On the table next to his coffee was a very recognisable ‘prescription’ from a naturopath he’d obviously just been to see.

It read:

  • Reduce coffee
  • Reduce sugar
  • Reduce fat
  • Increase exercise

Oh the power of such words!!  If we spit out advice/instructions/directives at our patients, even with all the best intentions, we seem to make very little progress or only create short-term change.  In contrast, if we take the time to focus in on each change we wish the patient to make, individualise the approach and solutions then we may have only given them a small fraction of the ‘advice’ we ultimately want to but at least this time it’s actually met it’s mark and created life-long healthy habits.

An understanding of the components behind successful behavioural change (readiness, empowerment, barrier identification & resolution etc.) is essential to improving patients’ health & wellbeing.  If you want to hear  more about how to successfully promote behavioural change in your patients follow this link https://rachelarthur.com.au/product-category/premium-audio/   to a premium audio download I recorded on this topic last February.  I really believe it can make the difference between success and failure with individual patient’s treatment & the success of your practice overall. Enjoy and remember more information isn’t the answer!

The Canary in the Mine – Assessing Androgens in Men

Often I find practitioners are a bit mystified by the male hormonal milieu and their skills at interpreting androgen results are patchy compared with their confidence in female hormone investigation.  Yet, just like in females, understanding the sex hormones is a critical part of the whole health puzzle in our male patients – leading us to a better understanding of possibly the cause of their presentation (impaired motivation and mood, subfertility or infertility & osteoporosis etc.) or perhaps the consequence of unhealthy behaviours & other health risks (e.g. obesity, excess alcohol, chronic inflammation etc.).  The natural decline in androgen levels with ageing (so called andropause or PADAM) gets talked about a lot but when does it start (typically in the 4th decade), why does it happen (primarily due to reduced number, function & responsivity of testicular secretory cells) & how low does it go? Is it possible for men to age and not become hypogonadal in the process?  Well the answer to the last question is emphatically, ‘Yes!’ according to Australian research.  Often, however, I’m finding younger males with very low testosterone levels which require thorough investigation to determine any direct cause. When none emerge, we are left with the ‘canary in the mine’ scenario, whereby testosterone production, not considered essential for survival, will be sacrificed when the organism is ‘under threat’.  To hear more about how to comprehensively assess & interpret androgens, the real causes and consequences of low testosterone and some treatment suggestions check out the following premium audio https://rachelarthur.com.au/product-category/premium-audio/

Numb feet reveal deeper woes

Mid-40 female presents with acute onset pain in both feet and hands. Questioning reveals that she has experienced episodic numbness in her feet over the past 2 years.  Patient suspects gout but blood urate levels are normal and patient’s diet and lifestyle not ‘typical’ of the gout sufferer (high alcohol and meat intake, central adiposity etc.)

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Identifying & Addressing the Marked Stress Response in Drug Withdrawal

A current patient is a 20+ year old male who is trying to recover from a heroin addiction.

Having been on the methadone program for the last 7 months and only having ‘used’ once or twice during this time, he is doing well.  He has managed to get down to just 25mg/d of methadone which is typically the final dose before stopping altogether.

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Coeliac disease presents as behavioural problems

Recently I started seeing an 8 year old girl diagnosed with ODD and ADHD as well as impaired IQ at 6yo. 

Notable features include:

  • She has variable bowel and bladder control – often coming home from school with wet pants and a Bristol type 1 stool in her underwear.  She increasingly complains of abdominal pain and an itchy bottom in spite of being ‘wormed’.  (more…)
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