Research suggests men with depression are slipping through the cracks

Evelyn Lewin

6/04/2021 2:51:09 PM

Clinicians have been advised to be on ‘very high’ alert for depression in men, especially those who present to their GP frequently.

Man speaking to his GP.
Men are more likely than women to experience somatic symptoms of depression.

‘She’ll be right.’
‘Men don’t go to the doctor.’
‘Blokes don’t talk about it.’
When it comes to Australian men and their mental health, these are the kinds of stereotypical attitudes that have pervaded.
But new research, published in the British Medical Journal Open, shows that men not only go to the doctor, they do so in droves.
Yet despite seeking care from their GP, men with depression are slipping through the cracks, with only half of those experiencing symptoms receiving a diagnosis.
For the study, researchers monitored the healthcare habits of 1500 Australian men aged 35–80 for five years, and found that the majority visited their GP at least once a year.
The participants also filled in questionnaires about depression symptoms and the results showed that 46% of men with a high burden of depression symptoms went to their GP five or more times a year, compared to only 29% of those with minimal symptoms.
Researcher Gary Wittert is a Professor of Medicine at the University of Adelaide and Director of the Freemason’s Centre for Male Health and Wellbeing at the South Australia Health and Medical Research Institute (SAHMRI).
He told newsGP this research helps dispel the myth that Australian men do not see their GP.
‘Men do go to the doctor,’ he said.
‘Over 90% of the men in the cohort had been at least once in the previous 12 months.’
But, Professor Wittert was also disheartened to discover such high numbers of men with a high burden of persistent depression symptoms are not being diagnosed.
‘That’s an important point,’ he said.
‘Because the accusation is often that men with depression don’t seek help – but they clearly do and they’re clearly high users of services.
‘So seeking help is not a predictor of whether you get diagnosed with your depression.’
He says severity of depressive symptoms are also not a predictor of whether a man receives a diagnosis of depression.
Dr Caroline Johnson, a GP and senior lecturer in general practice at the University of Melbourne, is pleased such a high number of men are engaging with their GP, but notes the research focused only on men aged 35–80, and it may be that younger men are not so likely to attend.
Regardless, she says these findings fly in the face of the ‘usual mantra’ she hears about men not seeing the GP.
‘It’s pretty clear that one of the groups you most want to reach are going to the GP,’ she told newsGP.
‘So it’s a really good reminder that GPs are a key part of the mental health system.’
However, Dr Johnson is also dismayed that so few men with depression receive an appropriate diagnosis.
‘We don’t know what happens in the consultations and whether they disclose their mental health issues; that’s a crucial part of the puzzle,’ she said.
‘I’m a qualitative researcher and I think it’s very interesting to look at what’s actually happening inside the consultation.
‘I wonder how much of this can be attributed to patient factors, and how much are GP factors, and I suspect it’s both.’
The research found that those who do not receive an accurate diagnosis of depression end up using medical and prescription services more. This leads to increased Medicare and Pharmaceutical Benefits Scheme (PBS) costs, says lead author Dr Sean Martin.
‘Men with undiagnosed depression are spending an average of $872 per year on Medicare and $742 on the PBS,’ Dr Martin said.
‘This demonstrates that failure to diagnose depression results in a higher financial cost to the community, in addition to the personal cost to individuals.’
Professor Wittert believes there are a number of reasons why men may not receive an accurate diagnosis of depression when presenting to their GP.
Firstly, he says, research shows men communicate their experiences with mental health in a ‘different way’ to women.
Dr Johnson seconds that notion and says that in her experience, it is also ‘a bit more difficult’ for men to open up about their mood than women.
Professor Wittert agrees that men commonly experience depression differently than women, who often experience ‘traditional’ symptoms, whereas men are more likely to present with somatic complaints.
Men are also more likely to present with symptoms that do not fit diagnostic criteria for depression, but may nevertheless be manifestations of this condition.
‘Things like irritability, aggression and substance abuse, which don’t appear in the standard diagnostic criteria as indicating depression but are significant features of depression in men and highlight the difference between genders in how depression presents,’ he said.

Dr Caroline Johnson says the research is a good reminder to explore depression symptoms.
Poor mental health literacy in men may also contribute to their low rates of diagnosis, with Professor Wittert suggesting that many men may not know the symptoms of depression, so could attribute their symptoms to another cause.
Clinicians can compound that issue by diagnosing a different condition when a patient presents with a specific complaint, such as a sleep issue.
‘Often it gets diagnosed as other things, rather than depression,’ Professor Wittert said.
‘The message for now is for GPs to have a very high level of suspicion about men having depression.’
Dr Johnson agrees.
‘Even though the Red Book doesn’t recommend screening of every adult for depression, this [research] is a reminder that when people are coming to the doctor a lot, particularly men, you should think of asking a couple of quick questions like, “How’s your mood?” and “How are you currently enjoying the things you normally enjoy?”’ she said.
‘If you get a negative to either of those two questions, then the probability of depression goes up.
‘Our New Zealander colleagues tested adding the “help” question to the questions regarding mood and anhedonia: “Is this something you’d like some help with today?”
‘And they showed that adding this third simple question will help GPs to pick up the people who are most likely to have depression.’
Dr Johnson says asking those three questions does not take long.
However, she says bringing up the issue of mental health in a GP consult is not always easy.
‘It’s a completely different conversation in general practice if someone comes in and says, “I want to talk about my mental health” than if someone comes in and says, “I’m here about some scripts, my sore big toe and a medical certificate ”,’ she said.
‘If it’s going to be a hard conversation, if the person’s not openly volunteering that they’re feeling depressed and they’ve come in with something else, because of the way the MBS is structured and the time tiering of the way GPs are remunerated, it does create a disincentive for GPs to spend a bit more time exploring [mental health issues].
‘And I think every GP has been in that situation where they’re already running half an hour late and a man comes in who seems a bit irritable but just wants some scripts or some minor issue and they have that thought, “Will I go there? Will I explore mental health issues more when I’m already running late and I might not get anywhere?”.’
Dr Johnson says that when doctors are rushed, there may also be ‘collusion’ with the patient.
‘Someone will come in with something and the GP will say, “But you’re alright, aren’t you?”’ she said.
‘And the patient will say, “Yeah, of course I am”.
‘That kind of just agreeing with each other is a problem, rather than asking the hard questions.’
Dr Johnson says this research highlights the fact it is worth taking the time to delve further – especially in men who present to their doctor often.
Professor Wittert agrees, but stresses he is not ‘GP bashing’ nor implying GPs are doing a poor job of recognising mental health conditions in the first place.
‘It’s not the GP’s fault, and it’s not the men’s fault,’ he said. ‘It is [simply] a problem we need to work out how to solve.’
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