October 2008     Volume 2    #3


HIFU or HYPE-U?
New therapy for advanced PCa to be tested
Male depression and prostate cancer
The WWPCC in Geneva


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Male depression under-diagnosed: Why should men with prostate cancer care?


Help investigate depression in men
Dr. John Oliffe and Kristy Hoyak of the University of British Columbia are interested in speaking with English-speaking men aged 65 or older who are diagnosed with depression or who self-identify themselves as depressed. If you want to help in this valuable research, or for more information, download a brochure.
Fewer men than women are diagnosed with depression. In developed countries, the ratio is 2:1. But men have a much higher suicide rate than women, four times higher, on average. This discrepancy got John Oliffe and Melanie Phillips, medical researchers from the University of British Columbia, thinking. Perhaps male depression was being under-diagnosed. The researchers collaborated to review the literature on male depression, and their recent article "Men, depression, and masculinities: A review and recommendations" is the result. (See an abstract of this article.)

But why should men with prostate cancer care about the possibility that male depression is under-diagnosed? One answer is that this under-diagnosis probably means there are prostate cancer patients experiencing psychological distress and slipping through the cracks of our mental health care system, men struggling to cope not only with their disease but also with depression.

Besides, prostate cancer is often diagnosed at a time when a man and his partner are experiencing considerable stress as a normal part of daily life. Men 60 to 75 may be coping with many traumatic events:
  • retirement, which men sometimes perceive as the loss of identity, status, and workplace friendships;
  • aging and its effects on strength, stamina, and overall well-being;
  • changes in relationships as a consequence of one partner's declining health, reduced virility or desire, or the need to renegotiate family roles; and
  • other more obvious stresses, such as trying to live on a fixed income or taking care of both aged parents and young grandchildren.
Add to these the anxiety of a prostate cancer diagnosis, and depression may result. "It can certainly take the gloss off retirement," Oliffe comments. He adds, "A man undergoing prostate cancer treatment who feels depressed may respond by saying ' I'll get through this myself ' or ' I'll just tough it out ' rather than by seeking help."

But what is depression?
How do you know whether you should look for help? Depression is usually diagnosed when a person reports experiencing symptoms that persist over two weeks or more. And these symptoms relate to mood, feelings, and behavioural patterns. In other words, there are no open wounds, no blood, no swollen or obviously infected body parts, and often no sharp or persistent pains. Given the considerable research suggesting that men are "strongly reluctant" to consult physicians at all and only "go to their doctor when they're extremely sick," it is not a huge leap to theorize that men may not schedule a visit to talk about their symptoms of depression.

And, according to Oliffe and Phillips, some of the generic criteria used to diagnose depression are "not sensitive to depression in men." The usual symptoms used to diagnose depression are
  • A persistent sad or "empty" feeling
  • Abrupt changes in appetite or weight
  • A loss of interest in activities that you usually enjoy
  • Feelings of pessimism, hopelessness, guilt, worthlessness, or helplessness
  • Fatigue or decreased energy
  • Changes in your normal sleep patterns, e.g., trouble getting to sleep, waking in the night, trouble getting out of bed in the morning
  • Confusion or difficulty concentrating, remembering, or making decisions
  • Irritability
  • Persistent thoughts of suicide or death
  • Minor physical discomforts, such as aches and pains, headaches, or an upset stomach
But men and women often manifest depression in different ways, according to the research. Of course, there are many individual and diverse manifestations of depression in both men and women. As Oliffe says, "It is difficult to get at the diversity while pointing at the typical patterns." Still, he continues, "Depression doesn't usually look the same in men as it does in women."

"Men typically arrive in the doctor's office miserable, angry, introverted, and uncommunicative; they don't usually arrive crying or expressing feelings of falling apart," states Oliffe. And research supports this generalization. Although men who are depressed may experience many of the symptoms already listed, their depression might manifest itself in other ways as well. The symptoms of male depression often include
  • Anger and frustration
  • Violent behaviour, aggression, or other difficulties controlling impulses
  • Alcohol or substance abuse
  • Risk-taking behaviours, such as reckless or drunk driving, binge drinking, or having extramarital sex
  • Escaping behaviours, such as over-involvement in work or sports
  • Isolation from family and friends resulting in impoverished relationships
  • Inability or unwillingness to express emotion or a kind of emotional numbness
  • Persistent thoughts of suicide
Why is male depression under-diagnosed?
We have already examined, briefly, two reason for the under-diagnosis of male depression --- doctors can't diagnose illnesses that aren't reported to them, and depression in men may look very different from depression in women. Other factors are at play, however. According to Dr. Don McCreary, co-chair of the Toronto Men's Health Network, "We have inculcated a culture in our society that men have to be tough, men have to be strong. Weakness is not considered to be masculine." Simply put, "real men" don't get depressed, and, if they happened to feel depressed, they would certainly not admit it to anyone or seek help. As Oliffe and Phillips explain, in a much more accurate description of the situation, "Both depression and seeking professional help for depression are not only at odds with masculine ideals, they are also explicitly situated as feminine affliction and action."

This view---that it is somehow not masculine to admit to being ill---has to change so that men can get the help they need and deserve.

What about depression and prostate cancer?
A small but growing body of research suggests that prostate cancer is associated with elevated rates of depression (Bennett & Badger, 2005). Some studies indicate that men generally report high levels of psychological stress about a month before and during the first stages of treatment for prostate cancer but that they report significantly less anxiety and feelings of depression about six months after treatment begins (Korfage et al., 2006). A few studies have found that men undergoing radiation therapy experience higher rates of depression than men treated by brachytherapy or radical prostatectomy (Hervouet et al., 2005). However, some researchers, after examining survey and questionnaire data, conclude that "psychological distress in men with prostate cancer ... is not very high" and that "most of the prostate cancer patients do not need special help from mental health professionals" (Hinz et al., 2008).

Nevertheless, a significant factor to consider is that research results concerning the level of depression or anxiety felt by men with prostate cancer are, of necessity, based on what men report. As we have seen, there are reasons for men to avoid reporting feelings that they may consider unmanly. As Oliffe says, "It is a brave person who concludes that men don't need professional help for depression with the male suicide rate what it is." He thinks that "fellas should be more disregarding of the stats" and more in tune with their feelings and experiences.

And prostate cancer, as well as its various treatments and their side effects, may leave men vulnerable to depression. "Men may experience prostate cancer as the first threat to their mortality," Oliffe explains. Fear of recurrence and regret associated with missed opportunities to seek medical help can further complicate men's feelings, as can temporary or more permanent treatment side effects, such as fatigue, incontinence, or erectile dysfunction.

Men on hormone therapy should be aware that some research links depression and minor changes in cognitive ability to androgen deprivation. A 2002 pilot study found that 45 men receiving androgen deprivation therapy as a prostate cancer treatment had 8 times the national rate when it came to the prevalence of a major depressive disorder (Pirl et al.). Recently, a report published in the July 28 online edition of Cancer concluded that "androgen depletion therapy can potentially have some subtle, adverse cognitive effects," including difficulty in remembering, thinking quickly, or holding several pieces of information in the mind at one time. (See an abstract of this article.)

The answer, of course, is not to avoid the treatment for prostate cancer that you and your doctors decide is optimal for you but to be aware of the possibility that you might experience depression or other forms of psychological distress and seek help.

Getting help
Your family doctor, oncologist, and urologist can be excellent advisors, guiding you to specialists in the treatment of depression. Many men receive help from the counselling services of their cancer centres or clinics. And, even if you live in a small town or in the country, your medical team can usually arrange for you to receive help from counsellors or psychologists in private practice in your area, from programs run by community health agencies, or from local hospital-based social work programs. And don't forget support groups, telecare programs, or employee assistance programs. Often, talking with another man who knows from experience what you are going through is a great first step to getting the help you need.

You may wish to do a little research on the topic of male depression. CPCN recommends the following websites:
The Canadian Association of Psychosocial Oncology
The Canadian Mental Health Association
Men and Depression, National Institutes of Mental Health (USA)
Beyond Blue: The National Depression Initiative (Australia)
Mensheds: Addressing Men's Health, Isolation, Loneliness and Depression (Australia)

References:
Bennett, G., & Badger, T. (2005). Depression in men with prostate cancer. Oncology Nursing Forum, 32(3), 545-556.
Canadian Mental Health Association. (n.d.). Men and mental illness: A silent crisis.
Hervouet, S., Savard, J., Simard, S., Ivers, H., Laverdiere, J., Vigneault, E., et al. (2005). Psychological functioning associated with prostate cancer: Cross-sectional comparison of patients treated with radiotherapy, brachytherapy, or surgery. Journal of Pain Symptom Management, 30, 474-484.
Hinz, A., Krauss, O., Stolzenburg, J.-U., Schwalenberg, T., Michalski, D., & Schwarz, R. (2008). Urologic Oncology, in press.
Hitti, M. (2007, June 20). Why men skip doctor visits. WebMD Health News.
Korfage, I. J., Essink-Bot, M.-L., Janssens, A. C. J. W., Schröder, F.-H., & de Koning, H. J. (2006). Anxiety and depression after prostate cancer diagnosis and treatment: 5-year follow-up. British Journal of Cancer, 94, 1093-1098.
Mahalik, J. R., & Rochlen, A. B. (2006). Men's likely responses to clinical depression: What are they and do masculinity norms predict them. Sex Roles, 55, 656-667.
Nelson, C. J., Lee, J. S., Gamboa, M. C., & Roth, A. J. (2008). Cognitive effects of hormone therapy in men with prostate cancer. Cancer, 133(5), 1097-1106.
Oliffe, J. L., & Phillips, M. J. (2008). Men, depression, and masculinities: A review and recommendations. Journal of Men's Health, 5(3), 194-202.

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