Sunday, September 21, 2014

You are at RISK!

Open a newspaper or read a medical journal or look at your Twitter feed and you'll learn a sad fact: something you're doing -- and probably something rather fun -- puts you at increased risk of some bad disease.  It sounds very ominous and you should stop doing those fun things.  Sometimes, I have to scratch my head and say 'Really? What does that actually mean?"  And while I've decided that my Diet Coke habit probably isn't particularly healthy and have mostly, sort of, cut way back, it caught my attention when I saw that one diet soda a day increases the risk of stroke by 16%.  Actually, it caught my attention because it was in my social media feeds about a zillion times tweeted by the Cleveland Clinic then retweeted by countless others.  Really?  How can anyone know that?  

So the first thing I wondered was how common is stroke?  I mean, a 16% increase is not huge, it's not like it makes you 5 times (a 500% increase) likely to have a stroke, and I didn't know how common stroke is.  A small increase for an unlikely event (stroke, for any given person for any given year) caused by a common habit (diet soda ingestion -- or actually any soda ingestion as I would soon learn) would seem like a difficult thing to quantify and measure.  And then you might wonder if 2 diet drinks/day increase the risk by 32% and if 6 diet drinks/day double it, and what about adding artificial sweeteners to coffee or tea? 

So I went to look for the prevalence of stroke and what I discovered was 2.6% for adults over age 18 have had a stroke.  But what surprised me was how the data was collected, per the CDC website:

BRFSS is a state-based, random-digit_dialed telephone survey of the noninstitutionalized, U.S. civilian population aged >18 years and is administered by state health departments in collaboration with CDC. In 2005, the median response rate among states, based on Council of American Survey and Research Organizations guidelines, was 51.1% (range: 34.6%--67.4%). This rate accounts for the efficiency of the telephone sampling method used and participation rates among eligible respondents who were contacted. A total of 356,112 respondents from all 50 states, DC, Puerto Rico, and USVI participated in the survey. State (including DC) and territory sample sizes ranged from 2,422 (USVI) to 23,302 (Washington). The racial/ethnic national sample sizes ranged from 5,535 (AI/ANs) to 279,419 (whites). All prevalence estimates in this report have a numerator >50 and a relative standard error <30 are="" ensure="" estimates="" stable.="" sup="" that="" to="">†
Survey respondents answered the question, "Has a doctor or other health professional ever told you that you had a stroke?" Differences in prevalence were assessed by age group, sex, race/ethnicity, education level, and state or territory of residence. Data were weighted to reflect the population aged >18 years in each state and territory and were age adjusted to the 2000 U.S. standard population to allow for more meaningful comparisons between states and between demographic groups. The weighted state prevalence values were used to estimate the number of persons with a history of stroke in various demographic groups and in each state or territory. Respondents provided racial/ethnic identification; those who identified themselves as multiracial were included in a separate category.

Ok, so first off,  half the people don't answer.  Are those who refuse to participate more or less likely to have had strokes?  The survey requires that someone answer the phone, so all the people who were too disabled to answer the phone are excluded from the survey results.  People with lower educational levels were more likely to have had strokes.  Could it be that people with lower educational levels were less likely to understand the question, or to confuse a doctor's warning "you could have a stroke" with "you have had a stroke?"   And could it be that people who have had strokes don't understand the question or have anosognosia so they don't know they've had a stroke?  I'm so confused. In the study below, the incidence of stroke was also self-reported but the report of a stroke was then verified by review of medical records.  I suppose they still might not capture those who have fatal strokes or those who don't know they've had a stroke.

And back to the Cleveland Clinic Study -- actually it's diet soda and sugar containing soda that increases risk. Switching to skim milk apparently decreases risk by 11%.  Go figure.  In this study, the participants were asked for a self report with forced choice responses (none, up to one/week, one per week up to one/day, more than one per day, etc).  Coffee consumption, by the way, lowered risk, but I couldn't figure out if drinking coffee and skim milk would counteract the risk of drinking soda.  Before I wash away....

Tuesday, September 16, 2014

Sunshine, Lithium, and Xanax --Which ones are good for your mental health?

Oh, so much to talk about, but let me begin by sending you over to Clinical Psychiatry News to read ClinkShrink's latest article on Suicide and Sunshine

Other things we could talk about are the op-ed piece in the New York Times about how in areas where there are trace amounts of the element Lithium in the water, there are lower suicide rates.   See "Should we all take a bit of lithium."  The article suggests further study, and perhaps adding lithium to the water supply.  Before you jump to discuss kidney disease, let's be clear, these are trace amounts, around 1/1000 the starting dose when used as a pharmaceutical agent.  My sister-in-law, Meg, was kind enough to inform me that there is a tiny bit of lithium in San Pellegrino water, but I'm not sure how that measures up to the amounts that occur naturally in places with lower suicide rates.  We add fluoride to the water, and iodine to salt, why not lithium to the water? 

And, finally, there's a study linking benzodiazepine use to a higher risk of getting Alzheimers' Disease, with a specific cut off of 91 pills is what it takes to raise the risk.  I'm guessing there may be other factors here, but this may be yet one more reason not to use these medications. 

Tuesday, September 09, 2014

Psychiatry and First Amendment Rights as they Pertain to School Violence and Cannibalism

Please surf over to the Clinical Psychiatry News website to see my post on Psychiatry and First Amendment Rights as they Pertain to School Violence and Cannibalism.  

Also, blogger Pete Earley wants to know how to find a good psychiatrist.  Please read his post here.  

I went to post a graphic and decided that nothing was quite right when it comes to cannibals.

Sunday, September 07, 2014

Eliminating Stigma with Psychiatric Disorders: Is it Even Possible?

It's almost a mantra in advocacy circles: we need to get rid of the stigma associated with mental illness.  Fear of being stigmatized keeps people from seeking treatment, so it leaves people to suffer from the symptoms of these disorders.  Stigma keeps employers from hiring people with psychiatric problems. Stigma makes people not want to be friends with someone with a psychiatric disorder. Stigma is part of ignorance -- it leaves society to blame the person for their problems.  There's no stigma to having a medical illness such as hypertension or diabetes or cancer.  There should be no stigma to having a psychiatric disorder.

If you read the above paragraph and you agree with every sentence there, then please let me warn you: what follows is not going to be what people want to hear.  You may not like what I have to say.

First, I don't agree that medical illnesses don't have stigma attached to them.  I suppose it depends on what exactly "stigma" means to you -- oh, what exactly does "stigma" mean?-- but I would contend that if you have hypertension and you're not overweight, you eat a low salt diet, and you exercise regularly, then there's no stigma involved.  If you have any medical problem associated with being overweight, poor dietary habits, smoking, alcohol, drug use, or lack of exercise, then others will look upon your illnesses as being your fault.  The truth is that in our society, poor self control is stigmatized, and obesity in particular, is very stigmatized.  Fat people are the last people (even after the mentally ill) that it's okay to openly discriminate against for everything from jobs to love.  And many people think that's okay, because after all, many believe that obesity is the result of gluttony and laziness, or if not, then of poverty (oh, we stigmatize the poor as well) because they lack access to high quality food and athletic facilities. But if there's a way that society can blame you and your less-than-ideal behavior for your health problems, it will happen, and it's not all stigma-free.

One of the things we never discuss when talking about the need to reduce stigma is that psychiatric disorders sometimes lead people to behave in ways that are embarrassing or disturbing to others.  People in the throes of an acute psychotic episode have been known to go outside naked, or to react in odd and alarming ways in response to things other people don't see, here, or understand.  Sometimes ill people don't attend to their personal hygiene and they wear dirty clothes and smell badly.  Other times, psychiatric disorders can cause people to be belligerent, to act in troubling impulsive ways, or to be unreliable and to miss work. Yes, cancer makes people unreliable and they miss work as well, but I would contend that an employer who has two equal job candidates in front of him might well choose the one who won't need to miss work regularly for any type of illness.

So how do we de-stigmatize psychiatric disorders when they are associated with disturbing behavior as a direct result of the illness?  It seems it would be impossible, but I can think of one disorder where that seems not to be true: Attention Deficit Disorder comes with little stigma.  I've often wondered why this is.  ADD causes people to be inattentive, their lack of focus can be annoying, or disruptive in a classroom.  They often had difficulties with executive functioning which means they forget things, are late, and come off as being scatterbrained (how's that for a scientific term?).  They may forget they have appointments or forget to meet friends.  In schools, they get more time for exams (does real life confer that as well?), and they may get all sorts of other accommodations such as front row seats or testing in quiet rooms.  In addition, the treatment may include medications that have many side effects, including tics, agitation, insomnia, and addiction.  In college, I hear this makes people fairly popular before exams -- it's not uncommon for those who have the diagnosis to share (or sell) their stimulants with those who just want to use them to study more intently, even though giving one's controlled substances to someone else constitutes a felony. 

So here we have an illness that may make include symptoms that are often obvious, impair functioning, may infringe on the rights of others at times, include treatment with an addictive and dangerous medication, and yet ADD is not stigmatized.  Why isn't that the case for bipolar disorder or schizophrenia?  This issue of stigma is all very perplexing.

I welcome your thoughts here.

Saturday, September 06, 2014

The Importance of Routine (and Clean Living)....

There's a great essay in The New York Times that I'm sure you'll like -- it's written by Michael Hedrick, a journalist/photographer who discusses the difficult time he had in the year after he was diagnosed with schizophrenia.  Tormented by his symptoms, he spent his days at work and his evening drinking and smoking pot, until he lost his job then landed in court with a DWI charge.  Mandated to treatment (for substance abuse) and drug testing, Hedrick writes in Living With Schizophrenia: The Importance of Routine:

Maybe it was the shock of meeting with a D.U.I. lawyer, or the point after sentencing when I realized I’d be forced to make a daily call, first thing in the morning, to find out if I would have to pee in a cup that day. Maybe it was the fact that I’d need someone else, mainly my mom, to drive me anywhere for the next year. Or perhaps it was the consistent Saturday morning drug and alcohol therapy group or Wednesday and Thursday afternoons of community service that kicked me into a groove.

The groove of it eventually turned into a routine, one that wasn’t marked by indulgence but instead by forced commitment that eventually I would grow to respect.
During that time, I quit smoking pot, I quit drinking and I got some of the best sleep I’d gotten since my diagnosis. Trips to the bar on Monday afternoons turned into extended hours at coffee shops where I finished my first novel.

For some reason, it gave me joy to recite my routine to whoever asked. I would wake up at 7, get coffee and a bagel with plain cream cheese, check Facebook, write until I had 1,000 words, get lunch, do errands in the afternoon, return home, get dinner, take my pills (with food), watch TV and get to bed around 9.

It might all sound tremendously boring. But this regimented series of events was always there; they’d always carry over. And with time, it gave me great comfort to not have to deal with the unexpected. I had a set plan for most days, and there was already too much chaos in my head.
Maybe it's not just for people with schizophrenia or for people with substance abuse problems.  Routine is comforting to all of us, and clean living helps.  I almost missed this one and I'm glad I didn't, it's was worth passing along.  

Monday, September 01, 2014

Boarding Psych Patients in the ER

It's no secret that over time, the number of available beds in psychiatric hospitals and on psych units of general hospitals have decreased.  When the states moved patients from long term beds in state hospitals back into the community (a mostly good thing if you ask me), the promise was for more services in the community, and oops, that never came to be.  With time, there are fewer and fewer services available, it's harder to get care with people often waiting weeks to be added to the overburdened caseloads of staff in outpatient mental health centers -- especially those who have no insurance or Medicaid/Medicare -- meaning the people most likely to have the biggest problems seem to have to wait the longest.  If you need help now, there's often only one answer: go to the Emergency Room.  

This is thing about going to the ER.  They often have no miracles.  In the hospital where I worked in the clinic, there were a few perks -- the ER had some reserved clinic slots so that they could refer people for outpatient appointments within a few days.  Often, however, this isn't the case, and often delaying treatment means that the situation is so bad that the patient needs to be admitted. Because I was at a facility with 84 psych beds, this generally happened fairly quickly, but it many places, this just isn't the case.  People can wait for beds for hours (okay, that's life in an ER), days (ugh) or even weeks.  Weeks?  A psychiatrist in Vermont (where the state hospital had been destroyed in a hurricane) told me they kept patients in the ER for 6 weeks.  Six Weeks.  I have no idea how they did that and I didn't ask.  Did the patient stay in a seclusion room?  What if the room was needed for another aggressive patient?  Did they get a cubical? A gurney in the hall?  A curtained area?  Most psychiatric hospitalizations last about 7-12 days.  Were they getting medications and therapy in the ER?  This is crazy, and I use that term to describe the insanity of our system, not the patients.

This summer, the Department of Health and Mental Hygiene here in Maryland held work groups to discuss the delivery of outpatient care and recommendations for legislation for outpatient civil commitment -- we are one of only 5 states that has no provision for mandating outpatient treatment.  The work groups were ordered by the state legislature.  I went to some, and at one, an ER physician (not a psychiatrist) made a comment that sometimes patient were held in the ER for days "and they describe those days as the worst days of their lives."  This just shouldn't be -- no hospital experience should be horrible because of the setting --granted, it may be horrible if you're in the middle of a panic attack, a heart attack, you've just been shot, or you've lost a limb --but it should be a place to be stabilized, then discharged or admitted, without physical discomfort.  

This was my long-winded way of pointing you to an article in Forbes about ER psych boarding.  Do read: "Boarding" of Psychiatric Patients Unconstitutional in Washington State by Robert Glatter, M.D.  Glatter writes:

In Washington, patients who are involuntarily committed must be brought before a judge after 72 hours. The judge then makes a decision whether to continue to detain the patient in the emergency department.  Some of these patients may then be returned to the same ED.
Such patients may remain in less than ideal locations such as hallways, administered psychiatric medications, but having no formal access to psychiatric evaluation and care. Staff members including nurses and administrative staff have in some cases faced verbal or physical threats from such patients, with their safety being a concern.

The ruling leads to some obvious concerns:

“While we respect the state court’s decision, federal law (Emergency Medicine Treatment and Labor Act) still prevents hospital emergency departments from discharging unstable patients — for example suicidal or homicidal patients — back into environments where they could cause harm to themselves or to others.  This ruling does not provide guidance for hospitals and physicians regarding resolution of the conflicts among federal law, this state ruling, and the medical liability risk of discharging patients based on a time limit rather than based on reaching a stable condition,” added Rosenau.
“The ruling is a call to action, and our main objective must be to get every patient the right level of care.  The next challenge is directed to hospital and community leaders to find the resources to care for them,” concluded Rosenau.

Glatter goes on to discuss some possible solutions: better outpatient services, case management, crisis beds and mobile crisis units, more beds, and elimination of out-of-network barriers that keep some patients out of some available beds.  All good ideas.