By V. Peer. Seattle University. 2019.
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A1C: Your result will tell you what your average Next test: blood glucose level was for the past 2 to 3 months. Creatinine: At least once a year, get a blood test to Next test: check for creatinine. Dental exam See your dentist twice Date: a year for a cleaning Result: and checkup. Next test: Pneumonia Get the vaccine if you Date received: vaccine are younger than 64. After 3 years, people in this group lost about 5 to 7 percent of their body weight by eating a diet low in fat and calories and getting more physical activity. This modest weight loss cut their chances of getting type 2 diabetes by 58 percent compared with people in the placebo group, which received information only. Department of Health and Human Services National Institutes of Health and the Centers for Disease Control and Prevention and includes over 200 partners at the federal, state, and local levels, working together to reduce the morbidity and mortality associated with diabetes. Established in 1978, the Clearinghouse provides information about diabetes to people with diabetes and to their families, health care professionals, and the public. The aim of the Received 20 April 2014 present article was to provide an up-to-date review of the literature dedicated to the question of Received in revised form 8 January 2015 burnoutdepression overlap. A total of 92 studies were identied as informing the issue of burnoutdepression overlap. Available online 17 January 2015 The current state of the art suggests that the distinction between burnout and depression is conceptually fragile. Empirically, evidence for the distinctiveness of the burnout phenomenon has been Depression inconsistent, with the most recent studies casting doubt on that distinctiveness. In conclusion, the epistemic status of Review the seminal, eld-dominating denition of burnout is questioned. It is suggested that systematic clinical obser- Stress vation should be given a central place in future research on burnoutdepression overlap. Lastly, lack of professional efcacy includes feelings of inadequacy birth of the burnout construct in the 1970s. In what is generally consid- and incompetence associated with loss of self-condence. To our knowledge, no structured clinical interview has been advanced the view that burnout and depression () are distinct, albeit developed for the assessment of burnout. Although the burnoutdepression fatigue in burned out individuals do not differ from those reported in pa- overlap has been reviewed and discussed in the past (see also Maslach tients with major depression or anxiety disorders and may therefore not & Schaufeli, 1993), important work has been dedicated to this issue in be relevant to the understanding of the specic pathological processes the last decade (e. Cortisol is the end product as well as a key effector of the neuroendocrine stress response. It has been involved in general patho- Many conceptions of burnout have been proposed during the last genesis, due to its systemic effect on the organism (Hellhammer & four decades (e. Exhaustion refers to the feelings of being proach allows for a quantication of burnout and situates the aficted emotionally drained and physically overextended; energy is lacking and individual on a continuumthe individual experiences burnout to a 30 R. A categorical approach allows for a qualication of the need to clarify the nosological status of burnout in relation to phenomenonburnout is either present or absentthat is particularly depression. Theendstageoftheburnoutprocess is regarded as the clinical form of burnout (see Schaufeli & Enzmann, 1. However, no binding diagnostic criteria are available for identifying The concept of depression is deeply rooted in the history of medical cases of burnout (Weber & Jaekel-Reinhard, 2000). The emergence only appears as a factor inuencing health status and contact with of the modern concept of depression is linked to the rise of psychiatry health services(codedZ73. This state of affairs has led burnout researchers cal purposes (Ingram & Siegle, 2009). A diagnosis of major depressive episode requires at least two adjustment, and fatigue disorders (e. Nevertheless, burn- disorder and has been associated with appetiteweight decrease out has been increasingly regarded as a serious burden for working indi- and insomnia whereas atypical depressiona subtype of depression viduals, organizations, and society as a whole (Maslach et al. At an occupational level, burnout has been associated with absen- weight increase and hypersomnia (American Psychiatric Association, teeism (Ahola et al. Among self- Today, burnout has become a privileged construct in the study of report inventories, the Center for Epidemiologic Studies Depression ill-health at work. Self-report inventories syndrome (Weber & Jaekel-Reinhard, 2000), contributing to deni- are notably employed for investigating subclinical forms of depression tional ambiguity, and resulting in diagnostic noise vis--vis depres- or grading the severity of depressive disorders once formal diagnoses sion. Several authors, indeed, have warned against the use of the have been established. Depression has been examined in various con- burnout label in medical settings in the current context of diagnostic texts, including the occupational context (Adler et al. Burnout seems to be both predicting and predicted by depressive symptoms, ronment and actively neutralizing stressors is a key pathogenic factor in following a circular causal pathway. The extent to which job-specic and generic factors discriminate burnout from depression is unclear. History of clinical depression is a risk factor for both new depression and burnout. Sapolsky (2004) afrmed that it is impossible to understand either the biology or psychology of major depressions without recognizing the critical role played in the disease by stress (p. In the burned out at work and functioning well in another domain, whereas United States, 17% of adults experience at least one episode of major depression would inevitably impregnate every situation of an depression during their life (Kessler et al. This view, which is nearly as old as the burnout construct, has been widely adopted across the main conceptions of burnout (e. Despite its remarkable inuence, however, the idea of a scope- In the present article, the issue of the burnoutdepression overlap is based distinction between burnout and depression is problematic rst addressed from a theoretical viewpoint through an analysis of the in several respects. First, if conceptualizing burnout and depression way the added value of the burnout construct has been presented and on a continuum (one is more or less burned out; one is more or less justied so far (for an overview, see Table 1). In the second part of the depressed), it should be noted that the early stages of the depression paper, ndings from empirical studies that examined the link between process can be domain-specicfor example, job-relatedlike the burnout and depression are synthesized in order to determine whether early stages of the burnout process (e. Throughout the paper, future avenues of inves- and develop as occupational stress unfolds and intensies. Second, if adopting a categorical, all-or-nothing approach to burnout and depres- 2. Method sion (one is burned out or not; one is depressed or not), it is worth observ- ing that clinical burnout is pervasive in nature like clinical depression. A systematic literature search was carried out in PubMed, Indeed, the state associated with clinical burnout (e. The systematic search was accompanied of a hand search based on the literature referenced in the retained articles. A total of 92 studies were included, divided into 67 cross-sectional studies (Table A. Conceptual and theoretical considerations At the heart of the distinction between burnout and depression lies the idea that burnoutat least initiallyis job-related and situation-specic whereas depression is context-free and pervasive (e. Following this line of reasoning, Table 1 Overview of the conceptually-examined overlap between burnout and depression. In a dimensional approach, it is unclear how burnout as a process is conceived to differ from a process of depression. In a categorical approach, it is unclear how burnout as a state is conceived to differ from a state of depression. Associating burnout with a job-related scope does not guarantee its nosological distinctiveness with respect to depression. The largely atheoretical origin of the burnout construct seems to be still an obstacle to its differentiation. The arbitrariness surrounding the eld-dominating denition of burnout is fundamentally problematic. Third, attributing a given condition or disorder to a specic environments (Schonfeld, 1991) or even to afrm that the state of domain (e.
Denition Inability to achieve or sustain a sufciently rigid erection Complications r in order to have sexual intercourse purchase super p-force oral jelly 160mg overnight delivery. Occasional episodes Recurrent balanitis may occur due to secretions col- of impotence are considered normal discount 160mg super p-force oral jelly, but if erectile dys- lecting under a poorly retractile foreskin super p-force oral jelly 160 mg on line. Balanitis function precludes more than 75% of attempted inter- causes pain and a purulent discharge super p-force oral jelly 160mg for sale. Also called male If apoorly retracting foreskin remains retracted after sexual dysfunction. Incidence/prevalence r Phimosis increases the rate of penile cancer by at least This has been underestimated in the past, due to the 10-fold. With Management greater understanding, increased availability of treat- Symptomatic phimosis is treated by elective circum- ment and more widespread discussion of the problem, cision. Circumcision is not required in asymptomatic 40% of men aged 40 are recognised to have some degree young children, unless for religious reasons. In cases of of sexual dysfunction, increasing by approximately 10% acute paraphimosis, the band is excised under general with each decade. Aetiology The cause is pyschogenic in 25% of cases, drugs (25%) and endocrine abnormalities (25%). The other 25% are Epididymal cysts caused by diabetes, neurological and urological/pelvic Denition disease. Epididymalcystsareuidlledswellingsconnectedwith Psychogenic causes can be divided into following: the epididymis that occur in males. If the uid contains r Depression, causing loss of libido and erectile dys- sperm, it is called a spermatocele. Barbiturates, corticosteroids, phenothiazines 5phosphodiesterase), so increasing the ability to gen- and spironolactone may reduce libido. Recreational drugs such as co- 1 hour before sex, and its effects last for 4 hours. Its caine and hallucinogenic drugs can cause impotence vasodilation effects can cause headache, dizziness, a with long-term use. Auto- r Penile self-injection with vasoactive drugs such as pa- nomic neuropathy is also an important factor. There r Vacuum devices can be used to suck blood into the isalsoareexarcatS2S4whichmeansthatgenitalstim- penis and then a ring is applied at its base to main- ulation increases vascular ow. Ejaculation is not possible with these any level can therefore interfere with sexual function. Clinical features r Psychological counselling is useful for those with a Some features in the sexual history, medical history or psychological cause. Completelossof erections, including nocturnal erections, suggests a neu- rological or vascular cause. Sudden loss of sexual func- Genitourinary oncology tion without any previous history of problems, or major genital surgery, suggests performance anxiety, stress or Kidney tumours loss of interest in the sexual partner. Ability to generate an erection, but then inability to sustain it may be due Benign tumours are commonly found incidentally at to anxiety or to a problem with vascular supply, or nitric post-mortems or on imaging. It is important to r Renal adenomas are derived from renal tubular ep- take a drug history and enquire about possible features ithelium. Tumours less than 3 cm in diameter are ar- of depression, smoking, alcohol or drug abuse. Microscopically they giomyolipomas, but there is also an increased risk of contain only large well-differentiated cells with papillary renal cell carcinoma. Malignant tumours r Clinical features The most common is renal cell carcinoma (8590% Presenting symptoms may include haematuria, fever, in adults). These share the same pathology as in dromes are relatively common: bladder cancer. Adenocarcinoma of the kidney, which arises from the r Polymyalgia-like symptoms with aching proximal renal tubular epithelium. Many patients remain asymptomatic until advanced lo- Prevalence cal disease or metastases develop, so may present with 2% of all visceral tumours; 8590% of primary renal the symptoms of complications and increasingly lesions malignancies in adults. On examination, occasionally a palpable loin mass Age may be found and lymphadenopathy, hepatospleno- Increases with age, most over age 50 years. Predisposing factors include smoking, carcinogens such as asbestos and petrochemical products, obesity and ge- netic factors. Complications Prognosis Local spread especially into the renal vein, and may grow If conned to renal capsule 10-year survival is 70%. Tumour poor if metastases present, 25% of patients present with may also spread into neighbouring tissues, such as the metastases and they have a 45% 5-year survival. Bladder cancer Denition Investigations Bladder cancer is the most common urological malig- Urinalysis shows haematuria in 40%. A solid tumour >3cmisdiagnostic, but sometimes a cyst is seen which needs to be differentiated Incidence/prevalence between a simple benign cyst, a complex cyst or solid Common malignancy; 1 in 5000 in United Kinddom. Management Surgical removal is the treatment of choice for those Aetiology without metastases (if there is a single metastasis this There are several risk factors for the development of can be resected along with the primary tumour). In the past, radical nephrectomy with removal of r Exposure to certain carcinogens and industries cause the kidney, perinephric fact, together with the ipsilateral as many as 20% of cases. Aromatic amines, or deriva- adrenal gland and hilar and para-aortic lymph nodes tives, which are strongly carcinogenic are commonly was routinely performed. Some now perform either total found in the printing, rubber, textile and petrochemi- nephrectomy (without removal of the adrenal or lymph cal industries. Genetic: Macroscopy r Through polymorphisms of various cytochrome P450 Low-grade tumours have a papillary structure and look enzymes, some individuals appear to oxidise ary- like seaweed. Higher grade tumours lamines more rapidly, which makes them more prone appear more solid, ulcerating lesions. T3 Deep muscle involved, through bladder wall Radiotherapy, for example for pelvic tumours, pre- (mobile mass). It is thought that in most cases, the bladder and ureters G2 Moderately well differentiated. Adenocarcinoma arises from the urachal rem- Investigations nants in the dome of the bladder. Whilst all these symptoms are most commonly be performed from the bladder upwards. Pain may be felt in the loin when there is ob- Depends on stage: struction, or suprapubically if there is invasion through i TisorTa, and T1 are initially treated by cysto- the bladder wall. Follow-up 3 months later has a 50% re- Prostate cancer currence rate and regular follow-up is needed, usu- Denition ally for 510 years. In Geography males it is possible to use a piece of ileum to form Varies by population (90x). Most common in Afro abladder substitute substitution urethroplasty be- Caribbeans, common in Europe, rare in Orientals. Morbidity results from radiation cystitis and proctitis leading to a small Pathophysiology brosed rectum. In females radiation vaginitis and/or The cancer is commonly androgen-dependent, but anasensatevagina,andinmalesimpotenceoccursdue there is no evidence that its growth is driven by a to nerve damage. However, popu- r Chemotherapy is increasingly used with surgery, or lation studies have shown that men with higher testos- may be used alone as a palliative measure. Neoad- terone levels appear to be at greater risk of prostate juvant chemotherapy (i. Depends on stage and grade at presentation and the age r In most cases it is diagnosed either on rectal exam- of the patient. Recurrence is common and may be of ination as the nding of an asymmetric prostate, a a higher grade (25%). T1 has an 80% 5-year survival and diagnosed because of the nding of a raised prostate T4 has 10% 5-year survival (but very age dependent). Macroscopy Management The tumours usually are in the peripheral zone of the This depends on the tumour staging, grade and also on prostate and appear as hard yellow-white gritty tissue the patients age and co-morbidity, as many of the treat- (see Table 6. Organ-conned, low-grade disease: r These tumours tend to grow slowly, in older patients Microscopy (>70 years) and those likely to die of co-morbidity be- Most are well differentiated and consist of small acini fore the cancer causes signicant symptoms or metas- in a glandular pattern. However, rad- Gleason score: The biopsy material is examined under ical surgery is a major operation, with a 60% incidence a microscope and a Gleason grade 15 (grade 1 being of impotence (compared to 16% preoperatively) and most differentiated, grade 5 the least) is assigned to the anincreaseinurinaryincontinence.
It is also useful order super p-force oral jelly with amex, but generally less effective for and functional impact on the individual purchase discount super p-force oral jelly on-line. This is mainly due to detrusor instability/over- 30% of women <65 years but only up to 5% of men <65 activity cheap super p-force oral jelly 160mg with amex. Rates are much higher in certain settings such as care of r Overow incontinence is continual or unprecipitated the elderly institutions (up to 45%) and psychiatric care leakage without urge cheap super p-force oral jelly. Bladder outow obstruction may lead Age to overow incontinence due to bladder decompen- Increases with age. Rare causes include spinal cord compression affecting the sacral segments (S2, 3 and 4) or the conus medullaris. F > M Acomprehensive examination is important and can avoid the need for specialist tests. It is important to as- Aetiology sess uid balance, mobility, cognitive ability and relevant Incontinence has been associated with many conditions neurology. Toremaincontinentthere r Avoiding diary is useful to record the time, volume must be: and relevant events, e. This is due to poor sphincter func- Stress incontinence: Initially non-surgical options tion. Systemic or topical oestro- r Inspinalcordcompressionemergencydecompression gen therapy may be of benet. Ring tions intermittent self-catheterisation is the preferred pessaries are useful for those with uterine prolapse. For vaginal cys- Urinary tract infections toceles (where the bladder herniates into the vaginal canal), a transvaginal approach may be used to re- pair the cystocele but this is generally less effective. In females, vaginitis is another syndrome Urge incontinence: unlike stress incontinence, be- which commonly overlaps. Surgery (clam cystoplasty to increase the size of the blad- Age der using bowel) is rarely successful. In patients with cognitive awareness of bladder Sex lling and the ability to independently toilet, bladder F > M training is used to learn methods of deliberately sup- pressing the urge to pass urine. In patients without cognitive awareness or lack of motivation to remain Aetiology dry, scheduled or prompted voiding reduces the num- Most frequently due to bacteria, in particular E. These and Histoplasma capsulatum), parasites (the protozoan tend to cause a dry mouth and may cause constipa- Trichomonas vaginalis and the uke Schistosoma haema- tion and/or urinary retention. Pathophysiology Combined stress and urge incontinence may be treated r Bacterialvirulencefactors:Criticaltothepathogenesis with behavioural therapy with or without medical ther- of bacteria is adherence to the uroepithelium as infec- apy. Surgicaltreatmentappearstobelesseffectivethanin tions ascend from the urethral orice to the bladder pure stress incontinence. A culture is regarded as Urine itself is inhibitory to the growth of normal uri- 5 positive if >10 of a single organism per mL. Further investigations are required in children Clinical features (see page 268), males and females with recurrent infect- Acute cystitis typically presents with dysuria (a burning ions. Macroscopic haematuria is not uncommon, although this should Management prompt further investigation for any other underlying Empirical antibiotic therapy is used in symptomatic pa- disease such as urinary stones or a bladder malignancy. Both Intravenous antibiotics should be used in those who are pyelonephritis and prostatitis may be due to ascending systemically unwell or those who are vomiting. Quinolones such present nonspecically with fever, falls, vomiting, or as ciprooxacin are useful as resistant E. Macroscopy r Intravenoustherapyisoftenwithacephalosporinwith The urine is cloudy due to the pyuria (pus cells) and or without gentamicin. Over time, recurrences can cause chronic sistance, and some centres advise a cycling regime, e. If there is any evidence of obstruction this requires rapid drainage Aetiology (see page 256). Management Mild cases may respond to oral antibiotics as for urinary Pathophysiology tract infection, but many require intravenous therapy Predisposing factors to ascending infection include suchasgentamicinandciprooxacin. Antibiotics should be tailored to the sensitivity stasis due to obstruction, dilatation or neurological and specicity, and continued for 1014 days (longer causes and reux. Clinical features Fever >38C, rigors, loin pain and tenderness with or withoutlowerurinarytractsymptoms. Denition An abscess that forms in the kidney, or in the perinephric Macroscopy/microscopy fat,astheresultofascendinginfectionorhaematogenous The kidneys appear hyperaemic, and tiny yellow-white spread. These have become less common, due to more spherical abscesses may be seen in the cortex. Aetiology Complications r As with other urinary tract infections, the most common Gram negative septicaemia causing shock is uncom- organisms are E. Necrotic renal papillae due to inammatory thrombosis of the vasa recta, can be Pathophysiology shed, causing obstruction and acute renal failure. Commonly the infection ascends via the lower urinary r Recurrent infections cause renal scarring and im- tract to cause pyelonephritis. U&Es and creatinine (assess hy- kidney into the perinephric fat, or by direct haematoge- dration and renal function). It In reux nephropathy, the papillae are damaged, and the may not be possible to differentiate it from a renal calyces become dilated and clubbed. However, hypertension Antibiotic choice is as for pyelonephritis, until culture may lead to damage to the single functioning kidney. In large abscesses (>3 cm) medi- cal therapy alone is often insufcient, and percutaneous drainage or even partial or total nephrectomy may be Clinical features required. The term should largely be replaced by reux nephropathy, the Macroscopy most common form. The kidneys are smaller than normal, with an irregular, blunted, distorted pelvicalyceal system and areas of scar- Incidence/prevalence ring 12 cm in size. Accountsforabout15%ofcasesofend-stagerenalfailure and is an important cause of hypertension in later life. Microscopy Aetiology Areas of interstitial brosis with chronic inammatory The development of chronic pyelonephritis requires cell inltration. The tubules are atrophic or dilated and there to be infections in a kidney with an underlying the glomeruli show periglomerular brosis. Intravenous pyelogram and renal ultra- and japonicum can cause proteinuria and nephrotic syn- sound may also identify damaged kidneys (but are less drome by immune complex deposition and may cause sensitive) and dilated ureters. Management Managment Patients with chronic renal failure require appropriate Praziquantel is the treatment of choice. Acute epididymo-orchitis Previously severe reux was treated with surgical re- Denition implantation of the ureters, this has now been shown to Acute primary infection of the epididymis and the testis. Denition Sex Schistosomiasis is the disease caused by the parasitic Male ukes, schistosomes. Clinical features Pathophysiology Patients present with a greatly enlarged and very tender The eggs of S. Microscopy Sex Thereisextensiveinltrationoftheseminiferoustubules M > F (4:1) and interstitium with neutrophils, initial oedema is con- siderable and there is often patchy haemorrhage. Aetiology Risk factors include: dehydration, urinary tract infec- Complications tions, disorders of calcium handling (hypercalcaemia, Infertility is an important complication. Pathophysiology Stone formation usually occurs because compounds of Management low solubility are present in the urine in high concentra- Treatment is with antibiotics, bed rest and scrotal sup- tions. In young adults, erythromycin (to cover Chlamy- such as magnesium, citrate and organic inhibitors such dia)isprobably best, whereas in older individuals or as glycoseaminoglycans and nephrocalcin. Stones commonly contain calcium oxalate (80%) but Urinary stones about half of these also contain hydroxyapatite. Incidence/prevalence The pain is characteristically in sharp, intense waves over Affects about 10% of the population at some time in abackground pain, occurring in the loin, radiating to their lives. Stones within calyces on passing urine, inability to pass urine or the sensation cannot be broken up this way. Subsequent management If the stone obstructs a single functioning kidney, To reduce the risk of recurrence, all patients should be postrenal acute renal failure results. Calcium oxalate stones may also be given to increase urine levels of citrate lookspiky,calciumphosphatestonesareoftensmooth which inhibits calcium stone formation.
Blurred vision This is usually temporary and doesnt usually require any special glasses or treatment purchase super p-force oral jelly 160 mg fast delivery. Agitation (jittery feelings) If this does not go away after a short time order super p-force oral jelly 160 mg otc, consult your doctor buy generic super p-force oral jelly 160 mg on-line. If you look at your life and see only the bad parts order super p-force oral jelly 160mg overnight delivery, you are more likely to stay depressed. But if you can teach yourself to look for the good things in life, this often reduces depression. Seeing only the bad parts of your life and worrying about them can easily become a habit. But if you can practice thinking of good things you would like to happen in the future, you may feel less depressed. A mental health therapist can help you recognize thoughts and actions that can lead to depression. He or she can help you to learn ways of thinking and acting that help you feel better. Changing thoughts that can make you feel bad Some thoughts and expectations lead to bad feelings and depression. It takes the same amount of energy to say to yourself, I will do well at this as to say I will fail at this. Once you catch yourself doing this, practice talking back with positive good messages. Practice recognizing all of the reasons for a situation and fgure out what you can do about it. Dont go on and on complaining about hard times or diffculties, even going as far as making things seem worse than they really are. A Story A well known therapist and workshop leader tells workshop audiences a wonderful story about her grandmother who went to live on the shore overlooking a harbor. Look at the pelicans and how sleek they are as they dive into the water looking for fsh. Look at the many colors of the fshing nets and how they glisten in the sun like rainbows. After a while, she didnt see the ugly fshing boats or the rusty barrels, she saw only the beauty. Many times during her childhood, the girl would visit her grandmothers house by the harbor. And when she grew up and had a daughter of her own, she took her to her grandmothers house by the harbor. Look at the many colors of the fshing nets and how they glisten in the sun like rainbows There is beauty in our lives, even when, because of stress and depression, all we see is ugliness. Sometimes we just need someone to point out the good things to us so we can remember to see them. Focus on activities that help you to feel better It often helps to change activities and usual routines. Focus on learning to cope with sadness, anger, and anxiety Focus on thoughts and activities that are not upsetting to you. When you wake up, what things would you notice different about your life that would let you know that this miracle has happened? For example, if the miracle happened, someone might say that they would make an appointment to get their hair cut. Make a list of things you might notice that were different about your life if a miracle happened and all your troubles and depression disappeared. For example, if one of the things you would do if you didnt feel depressed is go for a walk, make an effort to schedule a walk tomorrow. If your list included dressing up and meeting a friend for lunch, try to schedule that. Hint: If your list includes things like My daughter and I wouldnt be arguing, schedule time for a fun activity with your daughter. People with Seasonal Affective Disorder are most prone to mood problems related to reduced sunlight. Avoid excessive alcohol or other depressants Although alcohol and other depressant drugs seem to relieve stress temporarily, they change body chemistry. However, they also can increase irritability and anxiety and disturb natural sleep-wakefulness cycles. Unless you have a disorder requiring modifcation of your food intake, adopt balanced eating habits as recommended by the Food Guide Pyramid. Most of the calories should come from complex carbohydrates, vegetables, and fruits. Drink enough water, at least 8 glasses of caffeine-free, sugar-free fuids daily, unless your doctor recommends otherwise. There is defnitely a connection between sleep problems, particularly insomnia, and depression. Take a few moments to think and write down some of the things you can do this week. Differences between Male and Female depression: Men act out their inner turmoil while women turn their feelings inward. Men were concerned that seeing a mental health professional or going to a mental health clinic would have a negative impact at work; especially if their employer or colleagues found out. Men feared a diagnosis of mental illness would cost them the respect of their family and friends, or their standing in the community. Men and Women experience depression differently and have different ways of coping with the symptoms of depression. I mean, were talking many, many beers to get to that state where you could shut your head off, but then you wake up the next day and its still there. It isnt a two-hour movie and then at the end it goes The End and you press off. I didnt care whether I lived or died and so I was going to do whatever I wanted whenever I wanted. There is a common misperception that suicide rates are highest among the young, but it is older white males who suffer the highest rate. Over 70 percent of older suicide victims visit their primary care physician within the month of their death. Suicide More than four times as many men as women die by suicide in the United States, even though women make more suicide attempts during their lives. Many men with depression do not obtain adequate diagnosis and treatment that may be life saving. Family members, friends, and employee assistance professionals in the workplace also play important roles in recognizing depressive symptoms in men and helping them get treatment. And I remember, I never re- ally tried to commit suicide, but I came awful close, because I used to play matador with buses. Although the majority of people with depression do not die by suicide, having depression does increase suicide risk compared to people without depression. If you are thinking about suicide, get help immediately: Call your doctors offce. Diagnostic Evaluation and Treatment Your tendency is just to wait it out, you know, let it get better. If no such cause of the depres- sive symptoms is found, the physician should do a psychological evaluation or refer the patient to a mental health professional. Women are at Greater Risk for Depression than Men Major depression and dysthymia affect twice as many women as men. In fact, rates of depression were shown to be highest among unhappily married women. Reproductive Events Many women experience certain changes associated with phases of their menstrual cycles. Pregnancy (if it is desired) seldom contributes to depression, and having an abortion does not appear to lead to higher incidence of depression. In addition, motherhood may be a time of heightened risk for depression because of the stress and demands it poses. The women more vulnerable to change of life depression are those with a history of past depressive episodes.