vendredi 31 juillet 2015

Elderly And Drugged: Far More Psych Meds Prescribed To Old Than Young

Elderly And Drugged: Far More Psych Meds Prescribed To Old Than Young

Evidence suggests that anti-anxiety medications like Xanax increase the risk of falls in older adults, which can cause a cascade of problems. (johnofhammond/Flickr, with edits by WBUR)

Evidence suggests that anti-anxiety medications like Xanax increase the risk of falls in older adults, which can cause a cascade of problems. (johnofhammond/Flickr, with edits by WBUR)

By Nell Lake
Guest Contributor

Are we over-treating the elderly with psychiatric drugs?

That’s the natural question arising from a recent report that found adults over 65 are receiving psychotropic medications at twice the rate of younger adults. The study, published in this month’s Journal of the American Geriatrics Society, also found that elders are much less likely to get their mental health care from psychiatrists or to receive psychotherapy.

What’s the problem? First, psychotropic drugs generally pose greater risks to the elderly than they do to younger patients, and non-drug approaches, from therapy to meditation, may be as effective as psychotropic medications for some seniors’ mental disorders, without the risks.

The findings suggest that physicians and insurers should reassess psychotropic drug use among the elderly, says lead author Donovan Maust, a geriatric psychiatrist and assistant professor of psychiatry at the University of Michigan.

Maust’s team used 2007-2010 data from the CDC’s National Ambulatory Medical Care Survey and from the U.S. Census to compare the rates at which older and younger adults — those 65 and older, and those 18-64 — get prescribed psychotropic medications during outpatient doctors’ visits. After analyzing more than 100,000 of these doctor visits, and taking into account the fact that the younger population is much larger than the older one, the researchers found that older adults were much more likely to be prescribed psychiatric drugs for anxiety, depression and other mental health conditions. Researchers also found that these seniors were less likely to receive other types of non-drug treatment for their mental distress.

The importance of all this is fairly clear: The elderly population is booming, and seniors use the health care system more than any other demographic. So, finding safe, effective and appropriate treatments for their mental health problems has an impact — for the well-being of a large swath of people, and as a policy matter.

Too Many Meds, And The Wrong Kind?

Psychotropic drugs pose both direct and indirect risks to the elderly: First, the drugs themselves can be dangerous. The American Geriatrics Society lists many psychotropic medications as potentially inappropriate for elderly patients.

“Probably the clearest concerns would be in the anxiolytic [drug] group,” in particular, anti-anxiety medications, like Ativan and Xanax, Maust says. Evidence suggests that these medications increase the risk of falls in older adults, which can cause a cascade of problems — from fracture to hospitalization to surgery and even increased risk of death. Anti-anxiety medications may double the risk of motor vehicle accidents. Recent research also shows a possible increased risk of dementia if the drugs are used long term.

Antidepressants, while somewhat safer than anti-anxiety meds, may increase blood pressure and, Maust says, “medicines that work on serotonin can increase bleeding risk — very slightly. But in an older adult who’s also taking [blood thinners] like aspirin or Coumadin,” this risk should be a concern.

A more basic, practical worry is that of loading patients — often already on multiple medications — with yet another drug to keep track of: “These patients can be on 10, 12 medications,” Maust says. “Even if the [psychiatric] medication doesn’t have side effects or otherwise cause trouble, adding one more medication — increasing the complexity of the regimen — increases the potential of getting things mixed up.” An elderly patient might take the wrong dose, forget doses or mix up the order in which drugs should be taken.

Add to this the issue of dementia: more common, of course, among people over 65. “It’s very common that a person with dementia might have depression or anxiety, so use of these medications might be appropriate,” Maust says. But studies have shown that the benefits are often minimal. And “in general if someone’s brain isn’t functioning at a 100 percent,” he says, “I would worry about adding a medication that… affects the brain.”

Young Vs. Old

The study’s main finding — this stark difference in the rate of psychiatric drugs — could be the result, Maust says, of an over-correction. In recent decades, health care providers have worried that the elderly aren’t receiving enough treatment of mental disorders. The effort has been focused on making sure doctors recognize depression and anxiety when they’re present. So physicians and insurers have instituted more screening in primary care.

But the pendulum may have swung too far, and because the drugs are often the easiest treatment to turn to, depressive and anxious symptoms may now too often get treated with drugs.

The “newer” antidepressants — think Zoloft and Prozac — are easier to use than the drugs of decades ago, and have fewer side effects. Part of what’s driving the rise of these treatments is that “they’re perceived to be safer,” Maust says. “By and large that really is true,” he says, but doctors should proceed with caution.

Another likely reason for the disparity is oddly circumstantial, a question of exposure — to doctors. Older people are more likely to be in contact with the people who do the prescribing. Because they often face complex health problems, seniors tend to see their doctors more often than younger people do. So an elderly man, for example, who goes often to his doctor for management of his multiple chronic conditions, such as diabetes, high blood pressure, arthritis, might complain one day that he’s feeling distress. His wife has died, and he’s more housebound than ever. His doctor sees symptoms of depression, and considers what course to take.

“Ultimately,” Maust says, “physicians sort of do what they know best. For a lot of people, that’s prescribing. Something like Zoloft seems pretty safe. You hope that it will help your patient.”

This patient’s doctor might suggest what’s readily at hand: She prescribes the antidepressant.

Follow The Money

Reimbursement systems also reinforce the use of psychiatric drugs. Physicians, Maust says, might want to refer a patient to therapy, or to send their patient down the hall to talk with a social worker. “But they might not have those resources available to them,” Maust says, adding that insurers often gear reimbursements toward prescribing medications rather than toward non-drug approaches.

“I do think providers are trying to help their patients. But we know that a lot of times for mild or even moderate depression and anxiety, a ‘watchful waiting’ approach often works, and symptoms will improve on their own without the medication.”

Psychotherapy can also be helpful. But sometimes, with drugs readily available, a physician starts a medication, a patient shows improvement, “and then [the physician is] reluctant to stop it and [the patient is] on the medication indefinitely.”

‘Course Correction’

“It’s a time to think about whether there might need to be a little bit of a course correction,” Maust says. He recommends renewed restraint in prescribing psychotropic drugs, and support for alternatives to medication when appropriate — for psychotherapy, for the help of social workers, for a “wait and watch” approach.

Others agree. There’s renewed interest in a medical model called collaborative care, one of the approaches gaining ground through health care reform and the Affordable Care Act. The primary care physician gets support from a team — including, usually, a nurse manager, a consulting psychiatrist, a social worker — who coordinate care for patients with anxiety, depression and other chronic conditions. The team might decide to take a “wait and watch” approach, monitoring symptoms. A social worker might counsel patients in cognitive and behavioral strategies. A psychiatrist might provide advice about reasons to avoid certain medications. Through such collaborative care, physicians have more support in considering alternatives to drugs.

Asked if, in some cases, such alternatives might include activities to elevate elderly patients’ moods, Maust was cautious. No one is suggesting that an art class, for instance, will totally cure depression. Maust wants to be clear: Medications are important and appropriate care in many cases. “But for some of these [elderly] people,” he adds, “an art class might work pretty well.”

Nell Lake, a journalist and magazine writer, wrote the book, “The Caregivers: A Support Group’s Stories of Slow Loss, Courage And Love,” in which she chronicles the lives of family caregivers over two years. She lives in western Massachusetts.

jeudi 30 juillet 2015

Summer Listening From ‘The Checkup': Sexual Reality Check, Revisited

Summer Listening From ‘The Checkup': Sexual Reality Check, Revisited
[Listen on SoundCloud]

We can’t be reminded too often that the fantasies portrayed in bodice-buster novels and porn flicks bear only a vague resemblance to what happens (and how we look) in real life.

So here, as part of our summer-listening revival of the best of our WBUR/Slate podcast, The Checkup, is a favorite, particularly juicy episode, titled “Sexual Reality Check.” It includes surprises about penis size, stories of great sex over 70 and new insights on how both men and women are lied to about their sexuality.

In case you missed other recent episodes: “Teenage Zombies” explored the curious minds of adolescents, with segments on sleep, porn and impulsive choices; “Power to the Patient” looked at ways we can all feel in more control of our health care; and “High Anxiety” included reports on hormones, parenting and fear of flying.

Better yet, don’t miss a single episode and just subscribe now.

New Moms Cite Lack Of Advice From Docs On Key Issues: Sleeping, Breastfeeding

New Moms Cite Lack Of Advice From Docs On Key Issues: Sleeping, Breastfeeding

A new study found that about 20 percent of mothers said they didn’t receive advice from their baby’s doctors about breastfeeding or the current thinking on safe placement for sleeping newborns. (Mark Humphrey/AP)

A new study found that about 20 percent of mothers said they didn’t receive advice from their baby’s doctors about breastfeeding or the current thinking on safe placement for sleeping newborns. (Mark Humphrey/AP)

After I gave birth to my kids, I was bombarded with advice from family, bestselling books and even strangers on topics ranging from how to lose the baby weight, when to have sex again and which infant toys boost IQ.

But according to a new, NIH-funded study, many sleep-deprived, hormone-addled new mothers may not be getting enough advice on critical issues from a most important source: doctors and other health care providers.

When it comes to breastfeeding, infant sleep position, immunization and pacifier use, many new moms report they get no advice at all from their children’s doctors — despite medical evidence on the benefits of certain practices, like breastfeeding and placing babies on their backs for sleep.

The new study — published in the journal Pediatrics and conducted by researchers at Boston Medical Center, Boston University and Yale University — found that about 20 percent of mothers said they didn’t receive advice from their baby’s doctors about breastfeeding or the current thinking on safe placement for sleeping newborns. And more than 50 percent of mothers told investigators that doctors did not offer guidance on where the babies should sleep.

(Of course the whole issue of where newborns should sleep is controversial. Official recommendations now say babies should “room share” with parents but not “bed share.”)

The study, part of a larger national effort called SAFE (Studies of Attitudes and Factors Effecting Infant Care Practices), surveyed more than 1,000 new mothers across the country, inquiring about infant care advice they received from different sources: doctors, nurses, family members and the media.

Dr. Staci Eisenberg, a pediatrician at Boston Medical Center and lead author of the new study, said in an interview that the number of moms who reported no advice from across the board is surprising.

“These findings say to me, ‘Hmm, this is a time to stop and think carefully about how we communicate, and are we communicating in a clear, specific enough way, and are we being heard, especially by new moms — new parents — who are often tired and likely overwhelmed?’ ” she said. “Amidst this sea of information, what are the messages that need to be highlighted and communicated clearly?”

Of course, the study relied on self-reported data from new mothers caring for 2- to 6-month-old babies, so caveats are in order. Still, the authors suggest several reasons that health professionals may hold back:

There are a variety of reasons that potential advisers may not give advice or may give advice inconsistent with recommendations. These reasons may include lack of knowledge of the recommendations, a perception of controversy surrounding the recommendations, or actual disagreement with the recommendations. It is possible that some health professionals may choose to avoid controversy or a lengthy conversation about potentially controversial guidelines during a busy, time-pressured practice.

Dr. Melissa Bartick, an assistant professor of medicine at Harvard Medical School and internist at Cambridge Health Alliance, who has written extensively on infant bed sharing, says the new study is “impressive.” But, she says, since the current recommendations on breastfeeding and sleep position “are not controversial at all (unlike sleep location and pacifiers)” the findings are a little troubling. In an email, Bartick, who was not involved in the study, writes:

“Doctors score incredibly low on breastfeeding and yet other studies show that their advice about breastfeeding is powerful. Hospital nurses do better, but still low. Sizeable portions of doctors and nurses give advice inconsistent with recommendations about breastfeeding.

The doctors and nurses scores on sleep position is even worse than for breastfeeding, with even lower appropriate advise and even higher inappropriate advice. There should not be any inappropriate advice, for either group, yet it’s 21% and 25% for these nurses and doctors respectively. That is truly disturbing.”

The survey did not ask mothers if they specifically asked for advice, Eisenberg said. Instead, moms were asked to respond “true” or “false” to numerous questions and then followup when appropriate. Here’s one example:

– My baby’s doctor (or health care provider) has given me advice about where my baby should

sleep.

True False (skip to question #81)

— My baby’s doctor (or health care provider) thinks my baby should sleep:

1.Strongly disagree 2 3 4 5 6 7.Strongly agree

–alone in his/her own room

–in a parent’s (or other adult’s) room in his/her own bed

–in a parent’s (or other adult’s) bed for part of the night

–in a parent’s (or other adult’s) bed for the whole night

Eisenberg said pediatricians often spend less time than is ideal with patients — “we’re sometimes intersecting with people in such a sliver of their lives.” But these findings, she adds, could prompt a conversation about how the “public health community can think about interfacing with these other sources in order to promote child and parent health.”

She added one particular takeaway for parents: Get involved in your child’s health care. “I would always want parents to feel empowered to ask questions,” she said.

Here’s more from the NIH news release:

“Earlier studies have shown that new mothers listen to their physicians,” said Marian Willinger, Ph.D.., of the Pregnancy and Perinatology Branch at NIH’s Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), which funded the study. “This survey shows that physicians have an opportunity to provide new mothers with much-needed advice on how to improve infant health and even save infant lives.”

African American women, Hispanic women and first time mothers were more likely to receive advice from their physicians than were white women and mothers of two or more children.

“As a physician, these findings made me stop and really think about how we communicate important information to new parents,” said…Eisenberg. “We may need to be clearer and more specific in telling new mothers about safe sleep recommendations. From a public health perspective, there is a real opportunity to engage families and the media to promote infant health.”

For the Study of Attitudes and Factors Effecting Infant Care Practices, the researchers enrolled new mothers at delivery from 32 hospitals around the country, with 1031 women eventually taking part in the study. The authors asked the women to complete questionnaires when the infant was between 2 and 6 months of age on advice they received from their infant’s doctor, birth hospital nurses, their family members, and the news media. In addition to finding out whether or not these sources had provided advice on infant care, the questionnaires sought to determine whether the advice was consistent with the recommendations of practitioner groups.

For example, the American Academy of Pediatrics (AAP) recommends that caregivers always place a baby on his or her back for sleep at night and for naps. The women in the study were asked whether they agreed or disagreed with a series of statements on sleep placement: “The nurses at the hospital where my baby was born think that I should place my baby to sleep on the [back, side or stomach.]” If the women agreed with the statement that the baby should be placed to sleep on his or her back, the researchers classified the response as consistent with the AAP recommendation. Agreement with statements on the other placement positions was considered inconsistent with the recommendation.

When it was given, advice from physicians tended to be consistent with recommendations. However, 10 to 15 percent of the advice given on breastfeeding and pacifier use was not consistent with recommendations, and slightly more than 25 percent was not consistent with recommendations for sleep position or location. Interestingly, of the women who reported physician advice on sleep position that was inconsistent with recommendations, 85 percent reported being advised to place the infant on his or her back and at least one other position–usually the side (which confers increased risk for SIDS relative to back position). In comparison, of the more than 32 percent of mothers reporting family advice regarding infant sleep position that was inconsistent with recommendations, 51 percent had been told to place infants to sleep on their stomach (stomach sleeping has been associated with the greatest increased risk for SIDS).

mercredi 29 juillet 2015

‘I Don’t See Any Stigma': Father Fights Suicide In Black Community After Son’s Death

‘I Don’t See Any Stigma': Father Fights Suicide In Black Community After Son’s Death

Joseph Feaster Jr. with a portrait of his son Joseph Feaster III. (Jesse Costa/WBUR)

Joseph Feaster Jr. with a portrait of his son Joseph Feaster III. (Jesse Costa/WBUR)

Joseph Feaster Jr. is not a minister. He’s a successful Boston attorney. But for the last five years he’s been doing a lot of preaching about a subject close to his heart.

“My ministry right now, because it’s even more personal — it involves my son — is around mental health,” Feaster says. “And if I can help the next person to understand it, to get through it, that’s my being.”

His son carried his name and was thereby Joseph Feaster III. He died by suicide in 2010, at the age of 27.

His death came at a triple decker on Elmore Street in Roxbury, not far from Dudley Square. That’s where he had lived most of his life — first with his parents and sister, and then renting an apartment from his father.

His father recalls lots of times going with Joseph to Horatio Harris Park, less than a block from the family’s home. The elder Feaster doesn’t remember any signs of mental illness in his son as a child.

“No, not at all. I mean, he was a happy kid,” Feaster recalls. “He played here. He climbed the structures here. He would be with his sister and her friends. And he had a great smile.”

Joseph’s older sister nicknamed him “Smiley.”

He played Little League baseball and then football in middle and high school in Newton, where he attended school through the METCO program. He got good grades and received awards for his academics and conduct, his father says.

Joseph Feaster III with his sister, Aalana, in 2004. (Courtesy)

Joseph with his sister, Aalana, in 2004. (Courtesy)

‘There’s Nothing Wrong With Me': Denial Hampers Treatment

The first sign of any mental health issues was after Joseph returned from freshman year at the University of Pittsburgh in 2002. He had some type of psychotic break in which he was rambling incoherently and saying he was seeing and hearing things. Then he lunged at his father.

“His eyes were — it was like he had seen a ghost. So I left the apartment. I mean, I’m in tears at this particular point in time,” Feaster says. “But I had the wherewithal and the knowledge to know that there was this process, Section 12.”

Feaster wants to make sure other families know about and use Section 12. It’s the state law that authorizes involuntary hospitalization of someone who poses a risk of serious harm to himself or others because of mental illness.

Feaster went to Boston Police, and they sent a special operations unit to Joseph’s apartment. After breaking down the door and using bean bags to stun Joseph, officers removed him safely.

He spent a short time in two hospitals and then started in an outpatient bipolar disorder program. But he wanted nothing to do with the medication and therapy advised by doctors, according to his father.

“There’s denial. ‘I don’t have anything. There’s nothing wrong with me.’ The medicine changes [them],” Feaster says. “When you’re in manic state, you can rule the world. Why would you want to take something that’s going to bring you down?”

For the next seven years, his father says, Joseph showed no obvious signs of mental illness. He obtained a degree in political science from UMass Boston, while making a living selling DVDs and CDs online.

A studio photo of Joseph, 15 or 16, with his father. (Courtesy)

A studio photo of Joseph, 15 or 16, with his father. (Courtesy)

Then he got accepted to a new technological entrepreneurship master’s degree program at Northeastern University. But during his first year he had another psychotic break. Police were again called to his Roxbury apartment, and this time he reacted in an extreme way.

“He jumped out of the third-floor window carrying a samurai sword, took off… and as a result of that, he’s surrounded by all these police officers, guns drawn, [him] carrying this sword,” Feaster recounts. “And apparently a sergeant tackled him, and that’s what probably saved his life.”

Feaster knows things could have ended much differently.

Joseph was hospitalized for a week or two, and his father says this was the first and one of very few times Joseph acknowledged he might have bipolar disorder. He told the doctors he would take his medicine, and he was sent home. But again, he didn’t follow the treatment.

Joseph’s next mental health break came more quickly, just seven months later. This time he took his own life.

Rising Concern About Suicide Among African-Americans

[Watch on YouTube]

“I don’t see any stigma from my son having had an illness,” says Joseph Feaster, Jr. “People will talk about, ‘Oh, so-and-so has breast cancer, so-and-so has lung cancer.’ But if you say, ‘Oh, wow, they had schizophrenia,’ you don’t hear folks talking about it. Well, my sense is [mental illness is] the silent disease in the African-American community.”

There are several diseases referred to as “silent” epidemics among African-Americans. But Feaster says the community has largely avoided discussion of mental illness and suicide for specific reasons.

“It was long-held in the black community that that’s not something that we — we’re not going to kill ourselves, because of the religious belief, but also just, we just don’t do that. That’s a white person’s illness. Well lo and behold, that turns out to be not true,” Feaster explains.

Boston NAACP President Michael Curry, who’s a friend of Feaster’s, agrees.

“There’s always warning signs that something’s getting worse,” Curry says. “And the warning signs have been there in communities of color.”

Curry says mental illness and suicide have taken a back seat to other issues of concern in the black community, like poverty, racism, and criminal justice. And those have taken a toll on mental health.

He’s hearing from clinicians in Boston’s African-American community that suicide is on the rise, even if it’s not yet reflected in confirmed suicide statistics.

National data show the suicide rate for African-Americans has stayed fairly steady and significantly lower than for white Americans, though a recent study shows a suicide increase among black children.

But Curry says in assessing the risk of suicide in Boston’s African-American community, he includes behavior such as so-called “suicide by cop” and drug abuse that leads to death. And no matter the method, he says, all of it demands action.

“What I have to remind people often is it’s all of our responsibility. If a kid commits suicide in Roxbury or is the victim of a drive-by [shooting] in Roxbury, it should rock you to the core if you live in Wellington,” Curry reflects “You’ve got to get off your butt, and you’ve got to figure out what your role is to be next to Joe [Feaster], to figure out how to save lives.”

At Peace, Spreading A Message

Before Joe Feaster Junior became an activist on the subject of suicide, he struggled not only with losing his son, Joseph III, but with concern about his son’s soul.

“But my pastor said [Joseph] could still go to heaven notwithstanding, because of the illness, and I believe that’s where he is,” Feaster says.

With that sense of peace, Feaster started a support group of sorts at his church, Morning Star Baptist Church in Mattapan. About 30 people came to the initial meetings to talk about mental illness and suicide.

“When I started sharing about it, people started to share,” Feaster recalls. “And I remember one person said, ‘You know, I thought my son was just being lazy, that he wouldn’t get up, he wouldn’t go to school, he wouldn’t do etcetera.’ Well, [that person] never recognized that he was suffering from depression.”

Attendance eventually dropped off, so Feaster has redirected his focus to working with organizations including the National Alliance on Mental Illness of Massachusetts.

And through it all, he says he often refers to his son in the present tense. He believes Joseph still lives in loved ones left behind, and through their fight for more awareness of mental health issues and suicide.

Resources: You can reach the National Suicide Prevention Lifeline at 1-800-273-TALK (8255) and the Samaritans Statewide Hotline at 1-877-870-HOPE (4673)

‘It's No Longer Dark': Suicide Attempt Survivors Share Messages Of Hope

‘It's No Longer Dark': Suicide Attempt Survivors Share Messages Of Hope

Mary Esther Rohman tried to take her own life many times when she was younger. But now, she's in a very different place. (Jesse Costa/WBUR)

Mary Esther Rohman tried to take her own life many times when she was younger. But now, she’s in a very different place. (Jesse Costa/WBUR)

Mary Esther Rohman, of Belmont, knows what it means to hit rock bottom — or worse. As she describes it, the bottom fell out. “They wanted to lock me up in a state hospital and throw away the key as being incurable,” Rohman recalls.

She tried to kill herself many times starting in her late 30s. But thanks to the right depression treatment, self-motivation and a sweet twist of fate, at the age of 67, Rohman is in a very different place.

“When I was 55 I met my soulmate, and I’m so happy!” Rohman says. “You never can tell what life is going to bring you. You’ve got to wait and see what the next chapter is going to be.”

Craig Miller, of Townsend, also knows the dark place of feeling suicidal. “I always had thoughts of suicide since I was 8 years old,” he says. “I always struggled with depression. I always struggled with mental health issues.”

Miller made several suicide attempts. But he recovered, turning his mental suffering into a force to help himself and others.

“It’s no longer dark, and it no longer hurts. And it’s no longer painful, and it no longer has this power over me that it used to have,” Miller reflects.

Childhood Trauma Contributes To Suicidality

[Watch on YouTube]

Both Miller and Rohman experienced serious childhood trauma. Rohman’s alcoholic father died when she was 10. She says her mother was a prescription drug addict and alcoholic who neglected her. The two became homeless. She started abusing her mother’s pills when she was 13.

“I was really angry. I was furious. I hated everybody. So I ended up hating myself,” Rohman says.

Miller, who is now 39, says he was molested by a man in his neighborhood from the age of 6 to about 12.

“A lot of the incidents occurred in a crawl space beneath my house,” Miller recalls. “So there were times when these issues were going on, and I could hear my family above me and I could hear the footsteps. It was very dark circumstances.”

On top of it, he says, kids in the neighborhood knew about the sexual abuse and bullied him for it.

By his teen years, Miller was wracked by obsessive compulsive disorder, depression and anxiety. His family’s home life was turbulent. His mother tried to help him by taking him to support groups. He was hospitalized five times as a teen for suicidal thoughts and OCD. But his last and most serious suicide attempt — which left him clinging to life at the age of 20 — was a wake-up call.

“To say, ‘All right, if I’m going to live and I’m going to move forward with the rest of my life, I have to figure out how to do it with the past that I have,’ ” Miller remembers.

He says he dove into meditation and a 15-year journey of self-discovery. He made it a hobby to break open and dissect his emotions. He reached out for counseling at times he felt overwhelmed. And though he isn’t recommending this to anyone else, he says, he didn’t take psychiatric medications in those initial years. He sometimes takes anti-depressants now.

“I made myself the No. 1 priority in the world,” Miller reflects. “I made getting well the biggest thing I could possibly focus on. More than anything, I found purpose in my pain. ”

Craig Miller made several suicide attempts. But he recovered, turning his mental suffering into a force to help himself and others. (Jesse Costa/WBUR)

Craig Miller made several suicide attempts. But he recovered, turning his mental suffering into a force to help himself and others. (Jesse Costa/WBUR)

Survivors Now A ‘Voice At The Table’

For every person who dies by suicide, an estimated 25 people attempt to take their own lives, according to the Centers for Disease Control. That’s about a million suicide attempts a year in the United States. And close to half-a-million people a year end up in hospital emergency rooms following suicide attempts and other self-harming behaviors.

But until the last year or so, the experiences of suicide attempt survivors were largely excluded from suicide prevention work.

Debbie Helms, the director of Samaritans of Merrimack Valley, says that was due to fear.

“I think the fear was that [suicide attempt survivors] might still be at risk, would they be safe talking about it with people, liability, all these different kinds of issues,” Helms explains. “And I think enough has been done so far to say they have a very, very good voice at the table. They have that information that everybody else needs to get on board with policymaking and trying to get more resources out there.”

Suicide prevention organizations have begun creating special divisions for suicide attempt survivors. A national group had attempt survivors draw up recommendations for how to help those who are suicidalAttempt survivors are creating websites to share their stories, and support groups are popping up around the country — including a few in Massachusetts.

Self-Discovery, Healing, Renewed Lives

Miller facilitates one of those support groups. He also wrote a memoir that he says was a huge part of his healing. Since then, he’s been invited to speak around the country about climbing from the depths of suicidal thinking.

“I get to speak and help people. I mean, that is an incredible feeling. And I have this incredible support system around me. My wife is absolutely amazing. My kids are wonderful. I have a great job, a great career,” he says. “Things are completely different now. And I think that positive message needs to be louder and louder and more prevalent in the suicide prevention community.”

For Rohman, the journey of self-discovery began when she was working on a master’s degree in sociology and then a PhD in social welfare policy. She had gotten through college despite doing a lot of drugs and drinking. Her graduate research was related to alcoholism.

“And I said, ‘Oh my God, that’s me,’ ” Rohman recalls. “I had no idea, because people I hung around with drank as much as I did.”

So she became sober. And she immediately fell into a deep depression. In the next few years she became suicidal, had to quit her job, and went on Social Security Disability Insurance. Her mother who had neglected her as a child came to take care of her. She was hospitalized several times on around-the-clock watch.

“I didn’t speak, which is hard to believe now. But I didn’t speak for many years. I was so withdrawn and pulled into myself,” Rohman says.

No medication seemed to help, until one doctor suggested something unconventional — the drug Ritalin, which is typically prescribed for Attention Deficit/Hyperactivity Disorder.

“The Ritalin loosened my tongue so I could do talk therapy,” Rohman explains.

That therapy was intensive — for years.

Someone also asked Rohman to become a mental health peer coach. She went through the training and met lots of other people with mental illness. They became her support network.

“It really helped convince me that there was really nothing wrong with me — that I was ill, but I wasn’t bad or broken or incurable,” Rohman says.

She made such a turnaround that she boldly gave up her disability payments and went back to work. She enjoyed 16 years working for the Massachusetts Department of Rehabilitation Services before retiring.

Rohman and Miller say they’ll never be entirely free from thoughts of suicide. But they know how to manage the thoughts.

The two have advice for people who love someone who is suicidal.

“One: Support them as much as possible. Let them know that you are there for them, but don’t smother them,” Miller says. “And two: Do not make them feel guilty for having suicidal thoughts and struggling with that.”

“Ask them open-ended questions to get them to keep talking,” Rohman suggests. “Just listen non-judgmentally and compassionately to what they have to say. It’s not so much what you say as how you listen.”

And, they say, share the message that most depression is treatable.

Though hard to see when in the throes of it, there is hope.

Resources: You can reach the National Suicide Prevention Lifeline at 1-800-273-TALK (8255) and the Samaritans Statewide Hotline at 1-877-870-HOPE (4673)

mardi 28 juillet 2015

Boston Moms: Let’s Spend Olympics Savings On Gym And Recess For Kids

Boston Moms: Let’s Spend Olympics Savings On Gym And Recess For Kids

(Steven Depolo/Flickr Creative Commons)

(Steven Depolo/Flickr Creative Commons)

By Kate Lowenstein
 and Ramika Smith
Guest contributors

We have a suggestion for how to spend some of the billions of dollars that Boston will likely save by not hosting the Olympics: How about we invest even one percent of that into the bodies and brains of our children by ensuring they get ample physical education and recess time?

Instead of spending billions to have elite adult athletes playing sports in our city, we can at least give our own Boston Public Schools kids the chance to run and play here.

Most parents of kids in the city’s public schools assume their children get recess every day, as we did when we were kids, but the reality turns out to be quite different. While the CDC recommends that all children get at least 60 minutes of vigorous exercise every day, and at least 30 minutes of school-time physical activity, many of our schools allow for as little as 20 minutes, if that.

Over the past two decades, accelerated by No Child Left Behind’s focus on testing, the tendency has been to reduce or eliminate physical education and recess. And our school administrators and legislators look the other way without recognizing the overwhelming amount of evidence that shows the significant academic and mental health benefits of these physical activity breaks.

In January of 2009, the journal Pediatrics published a groundbreaking study of 11,000 third-graders, comparing those who had little or no daily recess with those that had more than 15 minutes of recess per day. The findings show that children who have more recess time behave better in the classroom and are likelier to learn more.  

In January of this year, The Boston Foundation released a report: “Active Bodies, Active Minds: A Case Study on Physical Activity and Academic Success in Lawrence, Massachusetts.” The report found that only 15 to 20 percent of Massachusetts children are meeting the 60-minute daily recommendation for physical activity and only 10.2% were meeting the school-time recommendation of 30 minutes.

It also underscored what we already know from many other studies; that children in schools that provide an adequate amount of time and opportunity (and encouragement) for daily physical activity in the form of recess, gym classes, and movement breaks, have higher MCAS scores in both Math and ELA.

Not to mention the substantial behavioral health benefits. Multiple studies show that movement and exercise are one of the core ways to soothe a traumatized/anxious brain.

The average school day in Boston is six hours but for many kids, with a 45-minute (or more in the winter) bus ride on either end, those days can be eight or even nine hours. A mere 20 minutes of recess is simply not enough to provide a child with the physical break they would need to maintain focus and continue learning in that time.

It is nonsensical to extend the school day, as is now planned, while at the same time we have severely limited the very thing that would allow those long days to achieve the intended goal of increased learning. More time in school is not better for learning if it becomes an endurance test for the students. Recess and physical education are as integral to a long school day as are Math, Science, and English.

Today, providing recess is only recommended but not required for Massachusetts schools. Studies show that only in states that actually pass a law requiring schools to allow for a certain number of minutes of physical activity do kids end up actually getting that time.

We need one of those laws. While the Boston school system does have a wellness policy requiring recess, there is no minimum amount of time allotted, no enforcement mechanism, and it is still routinely cancelled or withheld for disciplinary reasons. Unless children are a physical threat, the last thing that will improve their behavior is taking away one of the few proven things that could help them with their impulse control. There are plenty of other forms of discipline that are not detrimental to a child’s mental health.

Some might wonder, “Can’t children play after school?” The extended school day, plus time spent on the school bus or commuting, means that our children do not get home in time to do anything other than eat dinner, finish homework, and go to bed. That small 20 minutes of recess, often eaten up by walking to the playground or being told to stand in line, is all the playtime many kids get.

Our First Lady has made childhood obesity, which is at epidemic levels in our country. and the “Let’s Move” campaign one of her central causes, yet it is in the hands of our legislators and school administrators to make sure this activity happens during the school day.

As parents, we have listened to what the pediatricians and schools have asked us to do in order to help our children succeed academically. We have followed the new guidelines for healthy eating, restricted screen time, enforced regular bed times. We read to our kids every day, we’re involved in their schools and schoolwork. But five days out of seven, we can’t meet our children’s needs for physical play.

We rely on the schools to recognize that vital need and respond to it. The reality is that while recess and gym class and sports remain a foundation in suburban schools, our city kids are yet again getting the short end of the stick.

As we move on from our Olympic bid, let’s not take our focus off that goal of benefiting the residents of Boston. It would only take a fraction of the money planned for the Olympics to provide for physical education and 30 minutes of recess per day for our kids – but the long-term benefits to their academic success, and physical and behavioral health, are impossible to put a number on.

Kate Lowenstein is the mother of a rising 2nd-grader and 4th-grader, and Ramika Smith is the mother of a rising 4th-grader, in Boston public schools.

Summer Listening At Candy Store Or Salad Bar: Scary Food Stories, Revisited

Summer Listening At Candy Store Or Salad Bar: Scary Food Stories, Revisited
[Listen on SoundCloud]

As summer enters its dog days, you can feel the great gears of the news machine slowing, slowing, slowing, like a locomotive as it pulls into a station. So now seems like a good moment to re-offer you some of the best of our WBUR/Slate podcast, The Checkup, for your listening pleasure on those long car trips and plane rides to vacationland.

In particular, in case you missed this delectable morsel, may we recommend our episode titled “Scary Food Stories”? It features three particular cautionary tales: on kale, chia seeds and sugar. Download it here before your next meal. Or if you don’t, don’t say we didn’t warn you…

In case you missed other recent episodes: “Teenage Zombies,” explored the curious minds of adolescents, with segments on sleep, porn and impulsive choices; “Power to the Patient” looked at ways we can all feel in more control of our health care; “High Anxiety” included reports on hormones, parenting and fear of flying; and “Sexual Reality Checks” examined penis size, female desire and aging.

Better yet, don’t miss a single episode and just subscribe now.

lundi 27 juillet 2015

When And Where Do You Stress? Ambitious Project Aims To Map Daily Life, Whole City

When And Where Do You Stress? Ambitious Project Aims To Map Daily Life, Whole City

Passengers squeeze aboard a Red Line train at the Porter Square MBTA station. (Robin Lubbock/WBUR)

Passengers squeeze aboard a Red Line train at the Porter Square MBTA station. (Robin Lubbock/WBUR)

By Marina Renton
CommonHealth intern

Would I make it to the train station in time? Or would I miss my train home? The concern gnawed at me as I fidgeted on the uncomfortably warm and crowded subway platform. As I anxiously scanned the tracks for approaching lights, the watch on my wrist buzzed. It was telling me to check my stress levels. I pulled out my phone. High, it said; surprisingly high.

That may sound like the first draft of a science fiction novel but, in fact, it’s describing events from last month, when I tried out a watch that has sensors to measure the autonomic nervous system, which regulates our fight-or-flight response.

Neumitra, a Boston-based startup, developed the technology, and plans to launch an ambitious project this fall that would use it to chart the stress not just of individuals but of professions and institutions — even of a whole city. It may be a no-brainer that catching a train is stressful, but how does stress at Harvard compare to stress at Northeastern? North Shore to South Shore? Emergency room at Boston Medical Center to Massachusetts General Hospital?

“We’re using data from the body and data from mobile phones to understand how everyone is affected by stress,” said Rob Goldberg, co-founder of Neumitra and a neuroscientist formerly at MIT. “Our aim here is for thousands of people in Boston to be using these technologies, so we can understand the difference between a veteran, a police officer, a student, a mother, a nurse — and sometimes you belong to multiple of these categories, so what are the combined effects?”

Sync to see your stress

“I’m so stressed!” is a frequent response to the innocuous, “How are you?” The exclamation, or variations thereof, can be overheard at the office, between classes, at home…practically anywhere.

But it’s one thing to verbally express feelings of stress, and quite another to quantify those sensations. That’s where Neumitra comes in.

You can track your stress level in real time through an app that displays the data that the watch collects. The app syncs with your calendar and GPS, so you can also look back to see which events and locations cause the most stress. When your stress spikes, the watch vibrates — an alert that it might be time to take a step back and recalibrate.

The app displays stress using a color gradient: Blue means relaxed or restful, orange and red signify increasing tension. During my entire subway ride, I was either in the dark-orange or red zone. Once I was back home, I spent more time in the blue regions. Exercise brought me back into the orange (among other things, the watch measures skin conductance and temperature, so physical exertion can register as stress), but it didn’t exceed the stress I demonstrated while standing (read: trying not to fall on anyone) in a crowded subway car.

This technology is certainly fascinating, but does it really tell us anything we didn’t already know? Goldberg’s answer is an emphatic yes. “We think we [know how we feel], but we’re very detached from that,” he said.

Science at a new scale

In this age of “smart” or “connected” everything, we’re getting used to devices that monitor us, but Goldberg says Neumitra’s plans for the technology’s use on a large scale might lead to a whole new understanding of the effects of daily life on stress.

“We don’t understand what we’re all struggling with on a day-to-day basis, and with data of this type it allows it to become much more visible,” he said.

This coming fall marks the planned launch of the Boston Stress Study, which aims to “quantify brain health across an urban population,” according to its website.

Goldberg compared the Boston Stress Study with the landmark Framingham Heart Study, which began in 1948 with over 5,000 participants and continues to this day with subsequent generations. The Framingham Heart Study has been crucial to the identification of risk factors for cardiovascular disease.

The data gathered as part of the Boston Stress Study will be aggregated, with the goal of showing the differences in stress level by profession and, in the long term, by socioeconomic status, gender, even university.

“We’ve all heard stories about what does it mean to feel stress at MIT, or Harvard, or at Boston University,” Goldberg said. “But what would it mean to quantify that?”

The study’s data will come from participants who are willing to have their anonymized biofeedback information uploaded to the cloud. From day one, researchers will be able to begin analyzing the results, but Goldberg says users’ confidentiality will be protected.

“Physiological data doesn’t really have much personally-identifying within it,” he said. So, showing the stress level of the city at, say, 9 a.m. — or during a cold snap or heat wave — shouldn’t be a problem. Most privacy concerns would arise with location data being aggregated and released to the public. “We want to take our time to make sure we get that absolutely right,” Goldberg said.

(Courtesy of Neumitra)

(Courtesy of Neumitra)

“Our goal is to do science at a scale and in a way that’s never been possible before. These technologies, worn computers, really do make that possible,” he said. “The longer-term goal is to understand the relationships between stress and chronic health conditions as well as stress and performance and productivity issues.”

Already, he says, with the few participants in a pilot phase aimed at refining the design and algorithms, “we’re pretty impressed by what we’ve been able to see so far. And, for those folks who are using our technologies, it becomes pretty clear how simply visualizing what you’re experiencing every day becomes immensely valuable to help you understand yourself better.”

“Supporting the individual”

While Goldberg expressed excitement about the possible big-picture implications of the Boston Stress Study’s results, he emphasized that the primary purpose of the technology is to benefit the individual. The integration with the app allows for very personalized visualizations. For instance, you can see how that beloved mellow song or dreaded dentist appointment affected your stress level.

“If we don’t do a good job of supporting the individual, then all of our grand ambitions, all the great questions we want to answer, won’t ever come to fruition,” Goldberg said.

The individual benefit of the technologies is compelling to Dr. Joseph Kvedar, vice president of Connected Health at Partners HealthCare. “Stress is one of those things that’s hard to measure, and having something like this to help us measure it…may help us combat stress and cope with it better,” he said.

Regarding the citywide analysis of stress, Kvedar said, “I’m not sure it’s going to be as compelling as it would on an individual basis, but I could be wrong.”

Time to recover

The results of the Boston Stress Study might influence workplace policies, Goldberg said.

The stress experienced on a morning commute can be equivalent to exercising, and “If we thought we were out for a run, we would give ourselves an hour or two to recover,” he said. “We don’t give ourselves an hour or two to recover from our commute, from a difficult meeting at work, from medical appointments.”

“What if it turns out that commutes are one of the most stressful times of day for a city?” Goldberg added. “Will companies take more seriously the fact that their people are showing up already highly revved up?” Beginning the day stressed might impede productivity, which employers could take into consideration when scheduling meetings or setting work hours, he said.

Finding participants

Rather than continue to manufacture a watch, Neumitra is working on incorporating the stress-measurement technology into lightweight “biomodules,” which could be incorporated into participants’ existing accessories, Goldberg said.

The watch loaned to me costs a hefty $1,500 — although its quality is on par with $20,000 medical equipment, Goldberg said — and would be out of reach for many people. Neumitra aims to make the biomodules more affordable.

The Boston Stress Study is still getting under way; participants are still being recruited and Neumitra is still refining the technologies and lining up funding.

Neumitra has partnered with a combination of commercial, nonprofit, and academic organizations to fund the study and recruit participants. The variety in partnerships is necessary to obtain a representative sample, Goldberg said.

“To do science at this scale, where every citizen both becomes a scientist and helps us to answer these questions as part of the organizations they belong to, this is really going to come from a mix of supporters,” he added.

Neumitra is currently working with clinical organizations in the area to find participants, and Mayor Walsh has written a letter in support of the Boston Stress Study.

“The data from your study could provide us with vital insight into the various causes and effects of acute and chronic stressors in the daily lives and work of Boston residents,” he wrote.

Lessons learned

While I knew the subway commute was stressful, I didn’t perceive just how stressful until I used the watch. Not only that, but it taught me how strong an effect simply remembering a stressful event can have. The app can generate a line graph to illustrate your stress, and I could see clear spikes in the line that aligned with my recalling a stressful situation or embarrassing incident from earlier.

Stress triggers such pronounced physiological changes that it’s no wonder it takes a toll on the physical self as well as the psyche. From my time wearing the watch, I realized the power of being able to visualize the physiological response to stress.

On the other hand, I did find that watching my stress level rise second by second contributed to a heightened sense of anxiety. Yet, I also began to notice that consciously changing my thoughts allowed me to manage my physiological response.

I come away with a new note to self: When work piles up, or you have to run to catch the train, or you’re waiting in anticipation for a response to a text message, remember to make time for stress-relieving activities to allow yourself to recover from the strains of the day.

Readers, reactions?

Neuroscientist Rob Goldberg mapped his stress levels as he went to make a presentation at the Pentagon. He managed the stress of the airport well, he recalls,”But when I arrived at the Pentagon, I was overwhelmed in a way our collaborators at Harvard said later they had never seen before in over 30 years of using the research technologies.”

vendredi 24 juillet 2015

Roxbury Center Targets Health Disparities In Boston’s Poorest Neighborhoods

Roxbury Center Targets Health Disparities In Boston’s Poorest Neighborhoods

Whittier Street Health Center opened its community vegetable garden on June 24. (Courtesy of Chris Aduama)

Whittier Street Health Center opened its community vegetable garden on June 24. (Courtesy of Chris Aduama)

By Marina Renton
CommonHealth Intern

When it comes to health in Boston, it’s hard to deny there’s a great divide across neighborhoods.

Need proof? A 2013 Boston Public Health Commission report found that, from 2000 to 2009, the average life expectancy for Boston residents was 77.9 years. But in the Back Bay, it was higher — 83.7 years — compared to Roxbury, where the average life expectancy was 74.

If you want to get even more local, you can analyze the same data by census tract, where life expectancy varies by as many as 33 years: 91.9 years in the Back Bay area between Massachusetts Avenue and Arlington Street, and 58.9 years in Roxbury, between Mass. Ave. and Dudley Street and Shawmut Avenue and Albany Street. That’s according to a 2012 report from the Center on Human Needs at Virginia Commonwealth University in Richmond.

The Whittier Street Health Center in Roxbury is trying to tackle the disparities in a very concrete way. With the launch of a new fitness club and community garden, the center is trying to make healthy food and exercise opportunities available and affordable to all, despite geography.

“What we’re trying to do is to remove those social determinants and barriers that are causing these [health] disparities,” said Frederica Williams, president and CEO of the health center.

‘If I Sweat, I’m Doing Something Right’

The fitness club and garden initiatives just launched June 27, but the Whittier Health and Wellness Institute is already drawing in community members.

Eight months ago, Wanda Elliott weighed 256 pounds. On a visit to her Whittier Street physician, she learned her blood pressure was high — high enough that she had to start taking medication. That was the wake-up call that motivated her to change her diet and start exercising.

“I was dragging,” she said.

Elliott began exercising at a local Y but joined the Whittier Street fitness club when it opened. In eight months, she has lost 52 pounds, leaving her 4 pounds shy of her 200 pound goal weight.

“I have two knee replacements, so I have to keep active every day,” she said. Trainers at the center helped her learn to use the exercise machines, and now it feels like a routine, she said.

“I feel addicted to working out. I feel like if I sweat, I’m doing something right,” she said. “From 256 to 204, I feel like a model. I can walk the runway; that’s how energized I feel now.”

Elliott is now off her blood pressure medication. She is working on making changes to her diet “slowly but surely,” drinking more water, eating more salad, and cutting back on red meat.

Josline Cespedes has been coming to this fitness club for about a week, after leaving a gym where the environment didn’t work for her. “I wanted something quiet,” she said.

Before Cespedes joined, she said, “I had a lot of health problems. My job is all day on my feet…and by the time I got home in the afternoon, I was tired, my legs were swollen.”

Now, “I have more energy,” she said. “I’m up all the time…I want to do more stuff with my kids.”

Prescription For Healthy Behavior

The Whittier Street Health Center currently serves around 28,000 residents (up from 18,000 in 2012) and hopes to reach 40,000 by 2017, president and CEO Williams said. Its patients, all living in socioeconomically disadvantaged and urban communities, are predominantly African-American and Hispanic. The center offers medical and public health programs, including primary, eye and dental care, podiatry, endocrinology, smoking cessation, mental health care, substance abuse counseling and urgent care, in addition to community education programs, Williams said.

“We believe that a significant portion of what comprises good health is our behaviors and lifestyles and, of course, access to quality health care,” she added.

The center takes an integrated, coordinated approach to providing care, “because you cannot separate a diabetic person that has depression, you cannot separate their depression from the diabetes,” Williams said. “We’re sensitive to the many social factors that hinder our residents…You have to be really patient-centered and community-centered to really get people to be engaged and activated in taking care of themselves.”

Obesity is a major issue in these communities, Williams said; only about 20 percent of adult patients and 35-40 percent of children had a healthy body mass index (BMI) in 2012. By 2017, the center hopes to be at 70 and 80 percent healthy BMI for adults and children, respectively, which would help reduce the incidence of weight-related chronic conditions, she added.

Hence the launch of the Whittier Health and Wellness Institute, including a new level of health care coordination, the wellness and fitness club and the community garden.

The fitness club, a $1.2 million investment, is over 6,000 square feet and includes the equipment you’d expect in a gym, along with space for people who need to exercise at a slower pace and studios for aerobics, yoga and Zumba classes. The center will also offer classes on stress reduction and fall prevention (for seniors).

Paging The Health Coach

A pivotal figure in the fitness club is the health coach, a nutritionist and fitness trainer who will work with patients to develop their personal goals. “They serve as the motivator,” Williams said.

Patients are referred to the fitness center via a “Prescription for Health” from their primary care physician, psychiatrist or other clinician at Whittier. Thus, a fitness regimen becomes incorporated into a patient’s medical record, and physicians can track clinical outcomes at the same time, to get clearer information about the effects of increased exercise.

“Your doctor will see the information and track how you’re doing…what type of progress you’re making,” Williams said. “And after your first visit with the health coach, they will work with you to develop your self-management goals.”

Fitness club membership for Whittier Street Health Center patients costs $10 per month; the fee is meant to encourage accountability, Williams said. Members of the community who don’t frequent the health center are permitted to join as well.

The fitness club is “not going to be a moneymaker,” Williams said. The membership fees aren’t enough to fund its operation. About half the money to build and equip the facility came from grants, and the other half from the Whittier Street Health Center’s operating funds. To keep the club open, they will have to raise money through annual fundraisers and additional grants.

Community Garden

In addition to addressing the physical fitness of community members, the center wants to address their nutrition.

“We are in a food desert. People don’t have easy access to affordable fresh fruits and vegetables,” Williams said.

That’s where the community garden, managed by a nutritionist, comes in. Patients of the health center can help tend their own plots. The produce grown in the garden — including tomatoes, peppers and cucumbers — will be given away to community members when they attend a nutritionist-led cooking demonstration, Williams said.

The goal is that patients who benefit from the fitness club and community garden will take their newfound self-management skills back to their communities, Williams said.

“We’re looking to not only impact the patients we serve, we’re looking to impact their immediate and extended families, their friends and their neighbors, and we envision that ultimately this will contribute to wellness and fitness in this community,” Williams said.

As part of its Boston Health Equity Program, the Whittier Street Health Center has a series of outcomes it uses to measure the success of its programs, including patients getting regular checkups and improving BMI. Those clinical outcomes — for instance lowering blood pressure — will be achieved in part by individuals visiting the fitness club and community garden and making improvements in their fitness, stress level and nutrition, Williams said.

Avoiding The New Year’s Resolution Effect

A big challenge is not only getting patients to start making lifestyle changes, but encouraging their maintenance, Williams said. In other words, how do you avoid the tapering-off that follows the Jan. 1 rush to the gym?

Because health care providers coordinate the changes and track their patients’ progress, the hope is that it will be harder for the patients to stop coming back, Williams said.

If a patient receives a referral to the fitness club and they don’t come to work out within two weeks, the health coach will follow-up with him or her, Williams said. Similarly, if a patient stops showing up, someone from the Whittier Street Health Center will get in touch.

“The key for us to get people engaged and to maintain it is for us to stay connected to them,” Williams said. “Our job is to make sure we keep that connection and that excitement and empowerment and look for creative ways to keep them focused on changing their lifestyles.”

In a pilot program a couple years ago, the Whittier Street Health Center hosted Zumba classes, and around 600 people came and stuck with it, Williams said, making her feel optimistic about the fitness center’s retention rate.

While some people do stop coming regularly after an initial period of enthusiasm, “I’m just motivated to do it because I love myself,” Elliott said. “And I hate high blood pressure.”

Medical Residents Confide Their Feelings On Performing Abortions

Medical Residents Confide Their Feelings On Performing Abortions

Opponents and supporters of an abortion bill hold signs outside the Texas Capitol on July 9 in Austin. (Eric Gay/AP)

Opponents and supporters of an abortion bill hold signs outside the Texas Capitol July 9 in Austin. (Eric Gay/AP)

Abortion can be hard for the patient. But it can also cause turmoil for the doctor performing the procedure.

Janet Singer, a nurse midwife on the faculty of Brown University’s obstetrics-gynecology residency program, found herself acting as a confidant in many discussions with residents about abortion.

“Over the years, when a resident felt confused, overwhelmed or thrilled about something to do with abortion care, they often came to me to discuss it,” she says.

Tricky questions continued to arise: Where does life actually begin? How do doctors’ personal beliefs play out in their clinical care? And, what’s really best for mothers?

(KateLMills/Flickr)

(KateLMills/Flickr)

Singer thought the general public would benefit from hearing more about the complexities of the young doctors’ experiences. So she asked four residents to write about their feelings about abortion training and services, or as one resident characterized it: “one of the most life-changing interventions we can offer.”

These personal stories are published in the July issue of the Journal of Obstetrics and Gynecology, headlined: “Four Residents’ Narratives on Abortion Training: A Residency Climate of Reflection, Support, and Mutual Respect.”

I asked Singer to offer a bit more background on the project, and here, edited, is her response, followed by some excerpts from the residents’ narratives:

Janet Singer: The abortion debate in the U.S. is so divisive, making everything seem black and white; but the real life experiences of doctors and women are much more complex. I am a nurse midwife and though personally committed to increasing access to abortion services, I believe that abortion is not a black and white issue. I speak openly about my personal beliefs with the obstetric residents I work with.

My thinking about the grey areas surrounding abortion care are the result of many conversations with colleagues and residents. One came to me overwhelmed on a day when she had done a late-term abortion and then been called to an emergency C-section for a fetus/baby just a week further along.

She needed to talk about how overwhelming it felt to try to decide where the cusp of life was, why it was OK to take one fetus/baby out of the womb so it wouldn’t live and one out so it might. 

Following that conversation, a few of us decided to form a resident abortion providers support group so that the residents getting abortion training would have a safe space to talk about the complexity of abortion. At the same time, I started checking in, informally, with each resident during their abortion training block. I gave the resident an opportunity to talk — no agenda, no judgment, just a forum for exploring how they were feeling in their new role as abortion provider.

Some had little to say, but most were pondering big questions about what they were doing, why, how it affected them, how satisfied they felt. Conversations on this charged issue occur frequently among the residents. The residents who chose not to get abortion training also revealed the struggles they faced — feeling like they weren’t offering comprehensive care to their patients or realizing they had to rely on colleagues to take care of this part of reproductive health care. And both groups had to confront the fact that the political rhetoric their side used just didn’t fit the coworkers they loved and respected. The pro-choice group knew that their pro-life colleagues weren’t “women haters.” And the pro-life group knew their pro-choice colleagues weren’t Hitlers.  Each group was working from conscience, truly doing what they thoughtfully believed in.

I asked three residents — one committed to doing abortions, one who got training but was deeply conflicted about it, and one who had decided not to get training — if they would write about their experiences. We came up with a set of guiding questions and I told them not to censor, but just to spill. They poured their hearts out. The pro-life resident ended up doing one abortion — a late one because he understood the woman’s plight and that the fetus was unlikely to survive.

After that, I decided we needed one more voice from someone who would never do an abortion, so we added a fourth resident.

The narratives revealed that the clear distinction between being pro-life and pro-choice often breaks down when one is faced with the real-life prospect of caring for pregnant women. (Though, as it happens, three of the four narratives are by men.) We hoped our writing would open a new dialogue about abortion, one that acknowledges the complexity of the issue.

Here are a few excerpts:

Resident 1:

When I started residency, I was open to the possibility of providing terminations. I was and remain uncertain about when life begins, and I used to hope that a deeper understanding of fetal development might help me make such a decision empirically. Over the course of internship, I came to understand embryonal development as a fluid yet constant march toward being human in which an embryo at 6 weeks is an entirely distinct entity from an anatomically formed fetus 2 months later. Unfortunately, this acquired knowledge has failed to help me fully define my position.

Increasingly, I have found myself caught up in an endless array of rhetorical questions. Is there not a more profound difference between 10 and 20 weeks than between 20 and 30? If my first task as a physician is to do no harm, how can I justify harming a fetus? I do not pretend to know the answers to these questions, but given what I perceived to be an abyss of ambiguity, I chose not to provide elective terminations. Our program director supported my choice, saying, “If anyone makes you feel uncomfortable about that choice, I need you to tell me right away.”

Discussions with co-residents have helped me consider the individual woman who has the courage to request an abortion. Since opting out, I have realized that my line of thinking has been feto-centric at best and over-intellectualized at worst. Nonetheless, in the absence of a clear moral understanding of abortion, I can only do no harm.

Resident 2:

At the start of residency, I was not sure if I was ready to perform elective terminations. I realized that the lion’s share of my reluctance was driven by “what would my mom think of me?” I struggled with my own faith, and with what God would think.

On my third-year obstetrics clerkship in medical school, I had my first experience with abortion in a patient with severe preeclampsia at 20 weeks of gestation. There was no provider in the city who felt adequately trained to perform an abortion at this gestational age, and I remember feeling helpless as we watched the patient get sicker. Twenty-four hours passed while a provider was flown in from out of state.

The woman’s clinical condition improved shortly after the procedure. When I was wavering about opting in for abortion training, I thought of this patient many times…One particular conversation with a senior resident was instrumental in my decision to participate in the abortion training. She explained that, for her, abortion is not “black and white”; it is not a “feel-good” procedure, but it changes the course of a patient’s life. It was so helpful to know that my apprehension was normal. That affirmation, along with my desire to gain gynecologic experience, gave me the confidence to pursue abortion training.

I was nervous about my first day at Planned Parenthood. I envisioned protesters chanting and throwing objects at me. After my first morning of early abortions, we performed an 18-week termination. Seeing the fetus on an ultrasound scan and then watching it as we did the procedure really shook me to the core. I thought maybe I had made the wrong choice, and I could not stop thinking about what my family would think if they knew what I had done.

Later that week we had an informal gathering of residents who had struggled with abortion training. It became apparent that others shared similar feelings. Many of us felt more comfortable with early abortions and struggled with second-trimester cases. Regardless of whether we performed abortions or not, it had to do with patient care and, in this case, our patients are the mothers. After listening to the struggles of fellow residents, I convinced myself to return to the clinic.

There, I soon realized how powerful it was to be able to comfort and assure such vulnerable patients. I began to frame my interventions at the clinic as life-changing for women.

Resident 3:

Although I might not always understand an individual woman’s choices, if she feels that she cannot be a parent for whatever reason, I will support her in that decision. I see little role for my personal values in the shared decision-making process.

The truth is that being involved in this work scares me. I am fearful of the violence and taunting that protesters have inflicted against providers. Assaulting providers in the name of “protecting life” disgusts me, especially because abortion is legal. This fear for my family and me has affected my interest in pursuing a family planning fellowship.

Abortion is a necessary procedure that I feel morally obligated to make available to my patients. The future of this service hinges on our society’s ability to support its practice, prevent undesired pregnancy, and ensure the safety of abortion providers. I have worked through my own internal struggles, but these broader societal issues will shape how I practice in the future. Participating in abortion services has left me fulfilled and honored, and I consider the provision of this care a privilege.

Resident 4:

I am a Born Again Christian, and I believe that life begins at conception. I believe that since I do not have the power to create life, I do not have the power to take it. I am proud of my choice and do not apologize for it, but that was not always the case.

I love obstetrics and gynecology — the breadth and depth, the bonds between patients and providers, and the lifelong relationships that are formed. However, I once heard someone say that an ob-gyn who did not provide terminations was not offering their patients the best, most complete care. Initially I shrugged this off as her opinion and deemed it irrelevant to me and to what my practice would become. But as I replayed that statement in my mind, I began to wonder, would I be providing the best care to my patients if offering terminations conflicted with my personal beliefs and passions? Would my patients feel judged and unsupported if I told them that I could not provide a service that they needed? Could I be truly impartial in my counseling?

mercredi 22 juillet 2015

In Boston, Celebration And Reflection As The Americans With Disabilities Act Turns 25

In Boston, Celebration And Reflection As The Americans With Disabilities Act Turns 25

Marchers walk down Tremont Street near Boston Common to mark the 25th anniversary of the Americans with Disabilities Act. (Jesse Costa/WBUR)

Marchers walk down Tremont Street near Boston Common Wednesday to mark the 25th anniversary of the Americans with Disabilities Act. (Jesse Costa/WBUR)

Curb cuts, captions on TV, beeps that replace the “walk” sign for people who can’t see: all that has become commonplace in the 25 years since the Americans with Disability Act was passed.

But ask anyone who was in a wheelchair before 1990 and you’ll hear a story of frustration.

Rolling around city blocks, looking for a way to cross the street was a daily event. People crawled up stairs if they couldn’t find someone who could lift them and their chair. Or they’d order at a restaurant that insisted its bathroom was accessible, only to find it was not.

“That happened a lot, and still happens a little bit now, but back then that happened a lot,” said Christine Griffin, director of the Disability Law Center in Boston.

Griffin remembers arriving for a conference in the nation’s capital to find the hotel was not accessible. “I turned around and got back in a cab and I flew home,” she said.

The late Sen. Ted Kennedy told a Congressional hearing back in 1988 that these stories had become too common.

“I bet if you go across this country, there really isn’t a member of a family or an extended family that hasn’t been touched,” said Kennedy, a chief sponsor of the ADA.

To build support for the act, supporters tied disability rights to civil rights.

“This change had an effect on people’s thinking,” Kennedy said in an interview 10 years after the law passed. “If you think of this as a continuation of the guarantee of equal rights, you come to different conclusions than if you’re looking at special legislation to try and look at some particular group.”

Now at the 25 year mark, disability advocates are celebrating and mapping their next steps. In Boston, about 2,000 people walked or rolled to Boston Common for a parade, speeches, music, dancing and crafts.

Cheri Blauwet, an Olympic wheelchair racer and a doctor,speaks at a rally on Boston Common Wednesday celebrating 25 years since the passing of the American Disabilities Act. (Jesse Costa/WBUR)

Cheri Blauwet, an Olympic wheelchair racer and a doctor, speaks at a rally on Boston Common Wednesday celebrating 25 years since the passing of the Americans with Disabilities Act. (Jesse Costa/WBUR)

“At one point it was like the lost community within a community,” said David Brewington of Boston, who is legally blind. Now the disability community “is speaking in volumes,” he said.

Brewington, who was born a few years before the law took effect, is part what’s known as the “ADA Generation” — people who grew up with legal protections that helped them manage autism, diabetes, severe depression or lost limbs. State Attorney General Maura Healey on Wednesday accepted an invitation to a wheelchair basketball game and told the crowd on the Common that there’s a lot to celebrate.

“Because of the ADA, businesses and employers cannot deny people employment based on a disability,” Healey said. “People with disabilities are no longer isolated and segregated by states. Because of the ADA, transportation and public facilities must address the needs of people with physical and mental disabilities.”

A former basketball player, Attorney General Maura Healey got an invitation to play wheelchair basketball from a woman volunteering at the celebration. (Jesse Costa/WBUR)

A former basketball player, Attorney General Maura Healey got an invitation to a wheelchair basketball game from a woman volunteering at the celebration Wednesday. (Jesse Costa/WBUR)

But Healey and advocates for the disabled say there are still challenges. The ADA may be helping patients with breast cancer, for example, keep their jobs, but many advocates say they haven’t figured out how to help those with learning or emotional disabilities finish school and find meaningful work.

“The unemployment rate has been twice that of the general population and has not moved one iota,” said Oce Harrison, project director at the New England ADA Center.

And then there’s the fact that pretty much every aspect of life is moving online.

“We’re trying to ensure that, as everybody starts to put things on the Internet and your access is on the Internet, it has to be accessible to everybody,” Griffin said.

Griffin’s organization, the Disability Law Center, has sued Harvard and MIT, claiming the schools are in violation of the ADA because online lectures and other videos are either not captioned or have poor captions.

Desi Forte and Michelle Whitney march through Boston Common to celebrate 25 years since the passing of the Americans with Disabilities Act. (Jesse Costa/WBUR)

Desi Forte and Michelle Whitney march through Boston Common Wednesday to celebrate 25 years since the passing of the Americans with Disabilities Act. (Jesse Costa/WBUR)

“Expanding access to knowledge and making online learning content accessible is of vital importance to Harvard and to educational institutions across the country,” the school’s spokesman, Jeff Neal, said. Harvard and other universities are awaiting guidance from the U.S. Department of Justice about ADA online requirements.

“We look forward to the establishment of those new standards and will, of course, fully comply once they are finalized,” Neal said.

In Boston, U.S. Attorney Carmen Ortiz reached a settlement with edX, the online education firm created by Harvard and MIT, that governs accessibility for the blind.

But as the legal questions continue, many people with disabilities say they are disappointed by the slow progress of social change. Today, the stories are about strangers who won’t look a disabled person in the eye or about fighting for the chance to perform basic job skills.

“I’m kinda cranky about the ADA,” said William Peace, 55. “It’s an appropriate thing to celebrate but it was just a start. It has succeeded legally, but socially it has a long way to go.”

Practicing Restraint In A No-Empathy Zone: At The Cancer Surgeon’s Office With My Son

Practicing Restraint In A No-Empathy Zone: At The Cancer Surgeon’s Office With My Son

Cathy Corman
Guest Contributor

I carry a genetic mutation increasing my risk of developing breast and ovarian cancer. My children have a 50 percent chance of inheriting the mutation. My 22-year-old son recently noticed a breast lump and asked me to join him when he met with a surgical oncologist to be evaluated.

The surgeon performed a skillful physical exam but provided neither effective risk assessment nor empathetic counsel. Afterward, I sent an email to friends briefly explaining what had gone wrong during the appointment. “We want to know how you managed not to hit him,” they asked. I did it by practicing restraint: slowly counting backwards from 10 and taking very deep breaths.

Here’s my countdown:

10. I did not correct the icy-blue-eyed surgeon with steel-grey hair and steady hands — 50? 60? — when he dissuaded my son from pursuing genetic testing. The surgeon had shaken my son’s hand, looked him in the eye, and palpated my son’s slender, muscular chest, identifying the small lump under my son’s left nipple. A positive finding of a mutation, the surgeon said, adjusting the top of his surgical scrubs, could expose my son to discrimination in the workplace and in obtaining health insurance. That is, I did not say, “The scenario you describe is illegal in this country. As of March 23, 2010, with the passage of the Patient Protection and Affordable Care Act (aka “Obamacare”), if anyone were to attempt to discriminate against this young man in the workplace or in the process of applying for health insurance because of a positive finding for a genetic mutation (a pre-existing condition), this person would be subject to a massive lawsuit.

Cathy Corman (Courtesy)

Cathy Corman (Courtesy)

9. When this surgeon used the word “anxiety” for the eighth time to a) describe my son and myself and b) provide his vision of a course of action, I did not refer this man to Leslie Jamison’s collection of essays, “The Empathy Exams.”  “Empathy,” writes Jamison, “isn’t just remembering to say that must really be hard — it’s figuring out how to bring difficulty into the light so it can be seen at all. Empathy isn’t just listening, it’s asking the questions whose answers need to be listened to. Empathy requires inquiry as much as imagination. Empathy requires knowing you know nothing. Empathy means acknowledging a horizon of context that extends perpetually beyond what you can see…”

8.  I did not bring up this statistic: Though men make up only 1 percent of breast cancer diagnoses annually in the U.S., they may be up to 25 percent likelier than women to die from the disease, probably because of lack of awareness and late detection. Nor did I mention that generally male breast cancer presents with a detectable lump and is almost always linked to radiation exposure, unusually high levels of estrogen or a genetic mutation. Surely the surgeon knew these statistics? But my son did not. And I did not want to scare him.

7. I said nothing to this surgeon’s response to my son’s question, “But wouldn’t it be relevant to know if I carry the mutation?” His answer: No, you know you have a family history of breast cancer.

6. I said nothing when this surgeon dodged my son’s question: “If my grandfather didn’t have the mutation,” my son wanted to know, “wouldn’t he not have breast cancer? And wouldn’t it be important for me to know if I carry the mutation, too, to asses my risk?” The surgeon’s reply: The only way you’ll know if you have cancer is to have the lump removed. The surgeon’s answer, while true, sidestepped the elephant in the room: whether my son carries a mutation elevating his risk of breast cancer.

5. When this surgeon ridiculed an actress whose name he could not remember for publicly disclosing her status as a mutation carrier and for undergoing prophylactic mastectomies, I offered him the actress’s name.

4. This medical doctor derided women with family histories of breast cancer for seeking screening for genetic mutations linked to cancer and for pursuing prophylactic mastectomies when findings come back positive, calling the surgeries “possibly unnecessary” and not proven to save lives. (Of course, this is exactly what I had done, but this surgeon wanted to make sure I didn’t think he was criticizing me, in particular.) Still, I interjected only that I had made my decision a decade and a half before I’d known who Angelina Jolie was and that I’d had 5-year-old triplets to raise at the time. That is to say, I did not hit him.

3. I did not mention that researcher Mary-Claire King, who first identified the BRCA 1 mutation, last year called for universal BRCA screening in young female populations with or without family histories of breast cancer as the most effective, even essential, method of cancer prevention. King described the BRCA 1 and 2 mutations as “unambiguously damaging” and reported that random genetic testing of patients diagnosed with breast and ovarian cancer turns up a 50 percent positive rate, regardless of family history. Nor did I point out that King has received international recognition for her work, including The Lasker Special Achievement Award in Medical Science, which “honors scientists whose contributions to research are of unique magnitude and have immeasurable influence on the course of science, health, or medicine,” while this surgeon — an M.D./Ph.D., a full professor of surgery and with almost 300 scientific publications — has not.

2. When this surgeon asked whether my son and I would like his administrative assistant to contact us to schedule a follow-up appointment, I said, without the slightest hint of rage, “No, no, I think we can take it from here.”

1. I chose not to write a letter to this man’s department chair explaining that, though he may be a brilliant researcher and excellent surgeon, he offered my son an opinion that was factually and legally irresponsible and could be repeating these mistakes in countless exam rooms every day, every week and every month, putting patients’ health at risk.

In the end, my son subsequently chose to pursue genetic testing in a different medical setting. He is still awaiting his results.

Cathy Corman is a freelance writer, audio producer and lecturer in American studies and the Honors College at UMass Boston.