Sir

The health decline among middle-aged men in Eastern Europe between 1950 and the late 1980s associated with cardiovascular disease1 has continued. Between 1990 and 1994, male life expectancy in Russia, for example, fell by more than six years2, yielding the widest gender gap in life expectancy (13.5 years) of all European countries. Intervention efforts aimed solely at the traditional risk factors of smoking, blood pressure, lipids and obesity are insufficient to stop this epidemic. A more productive approach to prevent premature death among Eastern European men might be to strengthen social relationships, decrease social isolation and depression, and to increase adaptive coping skills.

Eastern and Western European men differ very little with regard to standard coronary risk factors, their alcohol consumption and obesity3. However, there are striking differences between Eastern and Western European men in psychosocial risk factors: for example, Lithuanian men, who are four times more likely to die from coronary heart disease than Swedish men4, report more depression and exhaustion, less social support and integration, and fewer effective coping strategies than their Swedish counterparts3.

Women in Eastern Europe have not been affected in the same manner by the cardiovascular disease epidemic2. They also smoke less, are less likely to be hypertensive, and have higher levels of protective high-density lipoprotein cholesterol than men. Even so, only 40% of the variation in the gender ratios of mortality from coronary heart disease in 24 countries (including Russia, Lithuania, Poland and the former Czechoslovakia5) can be explained by differences in the known risk factors. Women may be less affected because they report more social support, are more socially integrated, and cope better with life crises and disasters than men6,7. Men are more likely to use avoidant coping, such as denial, distraction and increased alcohol consumption, whereas women use vigilant strategies6. Although women report more depression, they are more likely to accept depression as a disorder to be treated than are men8.

These gender differences may contribute to the health decline among Eastern European men, who have to cope with economic uncertainty, disruption of traditional male roles and the break-up of social relations, as well as the social stigma associated with the need to ask for help or turn to one's social network for support.