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AJ Hits the Skids: Men & Depression

The Sopranos is not just my favorite TV show, it is my favorite medical TV show, and last night's episode, Walk Like A Man, featured the Soprano's son AJ lying on the sofa, in the throes of Major Depression. The World Health Organization (WHO) reports that depression is the leading cause of the world. Depression is the 4th leading contributor to the global burden of disease and occurs in people of all genders, ages and ethnicities, yet less than 25% have access to effective treatments. For the longest time, we heard that depression was more common in women than in men, but that just doesn't jibe with the fact that suicide is much more common in males than females. Major depressive disorder is the single biggest risk factor for suicide. It used to be said that black men didn't get depressed or commit suicide as often as white men, but that, sadly, has changed. The suicide rate for black males doubled after 1980 and is now the third leading cause of death in black men 15-24.

In my personal and professional experience, men and women manifest depressive symptoms differently. Young males, like AJ, are the most at-risk population for suicide in the US. They stop eating, they sleep a lot, they stop going to work. Their family and friends don't know what to do. The men are adults, they are usually rational, productive members of society. Loved ones don't know how to react to this person who does not seem sad or blue. Often, when men are depressed, they just seem really angry and shout "Leave me alone!" So people do, leave them alone. And the depression gets worse. Or depressed males drink alcohol as a way to "self-medicate" and relieve the pain of feeling no pleasure.

It is really tough for concerned family, friends, coworkers or neighbors to know when to step in and take action when a guy has locked himself in his house or his room and is yelling to leave him alone. Do you call the cops? For the cops to come, you have to be certain he is a danger to himself. That is, he is not eating, he is stating he wants to die and that he is going to kill himself. It is a pretty ugly scene for everyone involved, when the police come in black gloves and escort an angry person against his will to the hospital for an involuntary commitment. Families feel certain their son or husband or brother will hate them forever or never speak to them again. A psychiatrist evaluates the person to determine the necessity for involuntary commitment. The determination of the psychiatrist is sent to the Court. Within 24 hours, another evaluation is done to determine the need for further inpatient treatment, outpatient treatment or release. If held for treatment, a person can usually only be held involuntarily for ten days. Each step is agony and pits the civil rights of the depressed person against the needs of the people who love him to see him well and happy.

For a mob family, Carmella and Tony were pretty savvy and did the right thing by their son. They got him in to see a competent psychiatrist who asked the right questions and started him on the medication Lexapro. As with most antidepressants, it takes a few weeks for the mood to lift, and people do have to be aware that they may experience an increase in suicidal ideation for the first week or two. AJ consumed alcohol along with his Lexapro. Not a good idea as it can increase some of the side effects. Tony felt guilty that he passed this "gift" of depression, a genetic tendency to see the bleak side of life, on to his son. Studies from the National Institutes of Mental Health (NIMH) suggest that people with a depression-linked gene variant have an anxious temperament and weaker connections in the mood-regulating circuit. These studies show promise for future treatment options.

Thank you unclejerry for use of the photo.

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