Thursday, April 5, 2012

Burst of Therapy Is Boon for Traumatized Children and Family -

Every year millions of children from all walks of life become victims of, or witnesses to, abusive or violent events that can result in long-lasting symptoms of distress. The events can range from sexual and physical abuse to involvement in a natural disaster, fire or serious motor vehicle accident.
In many cases, the trauma is unknown to parents and caregivers or never dealt with effectively. The consequences can be devastating for the children and families involved and for society at large. These children are at much greater risk of developing behavioral problems, failing at school, abusing drugs or alcohol and becoming violent themselves.
Without treatment, post-traumatic stress reactions can persist into adulthood, causing eating disorders, personality and mood disorders, relationship difficulties, persistent anxiety, unexplained physical problems, and violent or abusive behaviors.
According to report being released Tuesday by Safe Horizon, a victim assistance group that operates child advocacy centers in New York City, and the Childhood Violent Trauma Center at Yale University, children who are abused or neglected are 59 percent more likely than those who were not victimized to be arrested as juveniles, 28 percent more likely to be arrested as adults, and 30 percent more likely to commit a violent crime. They also face much higher rates of teenage pregnancy and are likelier to abuse or neglect their own children.
Silver Lining
But there's good news here: The report describes a remarkably effective brief intervention developed at the trauma center that, according to Steven R. Marans, professor of psychiatry at Yale and director of the center, greatly diminishes symptoms in traumatized children and those who care for them.
With the staff at Safe Horizon, the Yale team adapted the program to meet the needs of children and families facing the potentially horrific scars of sexual and physical abuse. I spoke with the mothers of two such youngsters.
One, a stay-at-home mother in Staten Island, was shocked to learn that for three years her 12-year-old daughter had been molested by a priest who, she said, "was like a member of the family." The priest had threatened the girl, saying her parents would never believe her.
The second mother, a financial executive from Brooklyn, said she was "devastated — my whole world collapsed" when her 10-year-old son revealed that he had been raped by an 11-year-old friend on a play date.
"I was distraught to learn my son had lost his innocence like that," the woman told me. "His father and I had no idea how to address this."
Both mothers wasted no time getting help. The Staten Island mother reported the abuse to the police, who referred her to a Safe Horizon center; the other took her son to the emergency room, where a nurse contacted the police, who in turn referred them to Safe Horizon.
In both cases, and scores of others like them, the children and their parents benefited enormously from just four to six structured sessions with trained clinicians. Unlike traditional counseling, which is often unstructured and prolonged and may not involve both child and caregiver, this program follows a proven pattern: first a session with the caregiver, then one with the child, then two sessions with them together. In each session a trained counselor fosters healing through reassurance and support and, with before-and-after tests, measures the effectiveness of the intervention. If necessary, the child or caregiver may be referred for further therapy.
The girl, who had become very distracted in school and repeatedly rejected physical contact with her own family members, is now doing much better in class and enjoys being hugged. Her recollections of the abuse have abated.
The Brooklyn boy and his family, though initially terrified, gained peace of mind and assurance that what happened was not their fault.
"If not for Safe Horizon, which was our calm in a hurricane, we would be really damaged by this event," the boy's mother said. "I didn't want the incident to affect him later on. The therapist worked through things with my son, who now says it's not a big deal."
In 2010, Dr. Marans, Dr. Steven J. Berkowitz, now a child psychiatrist at the University of Pennsylvania, and Carla Smith Stover, an assistant professor in the Child Study Center at Yale School of Medicine, published the results of a controlled clinical trial of the new therapy program, called the Child and Family Traumatic Stress Intervention. The study, published in The Journal of Child Psychology and Psychiatry, involved 106 traumatized children ages 7 to 18 and their caregivers, who were randomly assigned to four sessions of the structured intervention or to conventional support for childhood trauma.
When evaluated three months later, those who received the intervention were much less likely to suffer from post-traumatic symptoms like sleep disturbances, intrusive thoughts, depression, anxiety, tantrums or feelings of helplessness or hopelessness.
Remarkable Results
The children completing the intervention were 65 percent less likely than those in the comparison group to have developed full-blown post-traumatic stress disorder and 73 percent less likely to experience partial or full post-traumatic stress disorder, researchers said.
As described in the study released on Tuesday, Safe Horizon's experience among nearly 500 children who received the intervention "mirrored the results of the original trial at Yale," said Rita Garza, spokeswoman for the organization.
Dr. Marans reported that children who participated experienced a 54 percent reduction in trauma symptoms, and their caregivers benefited almost as much.
"When children are alone with and don't have words to describe their traumatic reactions, symptoms and symptomatic behaviors are their only means of expression," he said. "And caregivers are often unable to understand the connection between the traumatic event and their children's symptoms and behaviors. To heal, children need recognition and understanding from their caregivers."
He added: "This intervention inspires hope and confidence. It can make an immediate and palpable difference in the daily lives of children who have suffered even the worst forms of abuse."
Well over 90 percent of caregivers who participated in the intervention said they had learned new skills and would recommend the program, which could be a boon to child treatment centers throughout the country.
Nancy Arnow, in charge of child, adolescent and mental health treatment services at Safe Horizon, said: "We now have a standardized way to offer children and their families an evidence-based intervention that is both brief and remarkably effective. The number of children who need this kind of help is not decreasing. It's increasing."
Ms. Garza said: "Six centers elsewhere are now undergoing training, and we want the program to be replicated across the country. Children everywhere should be able to get this kind of help."

Do Patients Want More Care or Less? -

The woman's wheeze was a head-turner, audible from across the emergency department. Along with a hacking cough, the musical, whistling sound prompted her to leave the children asleep with her sister one night and seek relief at the E.R.

Inhaled medicines were able to quiet her lungs, and with a clear chest X-ray and easy breathing restored, the diagnosis was simple: acute bronchitis.

While diagnosing bronchitis, a common respiratory infection, is often easy, treating the condition is more difficult. Medicines may calm the symptoms, but the only cure is time. Most notably, antibiotics, though commonly prescribed, are no better than a placebo for bronchitis. Yet discussing this can be a bit of a minefield for physicians, particularly when patients are used to antibiotics for such infections. So when I sat down to talk to my patient, I was surprised when she cut me off.

"If it's O.K. with you" she said, wiping her nose with a tissue, "I'd like to avoid antibiotics, with all those side effects."

An hour earlier I had cared for a violinist who struck his head (but saved his instrument) during a fall. After a neurologic examination was normal and I had sutured a small cut, he and I discussed the possibility of a CT scan to detect rare hidden injuries. We also discussed the alternative: Spend the evening with a friend and come back if symptoms appear. He chose to skip the scan.

See a trend here? So does Dr. Michael Barry, president of the Informed Medical Decisions Foundation, a nonprofit group that promotes sound medical thinking. "People are more receptive to conversations about medical interventions having both pros and cons" says Dr. Barry. "Traditionally, newer and more aggressive interventions were often assumed to be better." But there are hints of a shift, he says: "When patients are fully informed, they tend to be more conservative."

After decades of presuming that more health care leads to better health, public consciousness may be moving toward a leaner view.

Today, a group of nine medical specialty boards is recommending that doctors perform 45 common tests and procedures less often, and is urging patients to question these services if they are offered. The move is the latest by the medical community to acknowledge that many tests and procedures are performed unnecessarily, leading to excessive costs, false positives, additional testing and even harm to patients. By some estimates, unnecessary treatment constitutes one third of medical spending in the United States.

Dr. Barry, whose editorial on shared decision making was published last month in The New England Journal of Medicine, believes patients are ready to hear the message. He cites popular books like "Overtreated," by Shannon Brownlee, and "Overdiagnosed: Making People Sick in the Pursuit of Health," by H. Gilbert Welch. These are among a slew of books in recent years written by health experts on the dangers of the "more is better" attitude about health care.

Dr. Barry also points to news reports that may also be shifting attitudes. In just the past year, medical headlines have covered record-setting fines paid by pharmaceutical companies, the overuse of potentially carcinogenic medical radiation, medical device recalls and the rise of prescription drug deaths(which now outnumber illicit drug deaths). Even once-sacred interventions like screening for cancer are under scrutiny, with a better understanding of both limited benefits and growing harms. That randomized trials of prostate specific antigen (PSA) testing, for instance, had shown little or no lifesaving benefit was hardly noticed until last year, when the United States Preventive Services Task Force drew attention to sexual and urinary problems and prostate biopsy complications, all common fallout from positive PSA results.

Emerging research supports the trend: The Cochrane Collaboration, a leading medical review group, last month published the results of a review of more than 20,000 patients in studies of "decision aids," communication tools meant to prepare people for treatments by explaining potential benefits, harms and uncertainties. The studies showed that patients using decision aids more often declined interventions like surgery and cancer screening, choosing more conservative options instead. Patients also reported better communication, fewer conflicts and a better understanding of risks.

This month, physicians and experts from around the country will convene in Boston for "Avoiding Avoidable Care," the first major medical conference to focus on the perils of unnecessary and unhelpful medical care. Dr. Vikas Saini, president of the Lown Cardiovascular Research Foundation, who with Ms. Brownlee, the author, organized the conference, described it as a response to growing scientific and social consciousness. "It's the zeitgeist," he says. "People from all around, including Shannon and I, felt isolated without a way to connect and grow these ideas. There is no 'Journal of Overtreatment' to bring these concepts and people together."

The movement toward a more restrained view of medical care raises an obvious question: Could improved communication, informed patients and increasing health literacy help to slim down a bloated system — and improve American health? As a physician planning to attend the Boston conference, I am hopeful.

Smart decisions about health are, of course, necessarily individual. But my wheezing patient and the injured violinist arrived at wise, informed decisions about their medical care by suggesting something relatively new, and certainly revolutionary: In health care, less may be the new more.

Scientists Link Rare Gene Mutations to Heightened Risk of Autism -

Teams of scientists working independently have for the first time identified several gene mutations that they agree sharply increase the chances that a child will develop autism. They have found further evidence that the risk increases with the age of the parents, particularly in fathers over age 35.

The gene mutations are extremely rare and together account for a tiny fraction of autism cases — in these studies, only a handful of children. Experts said the new research gave scientists something they had not had: a clear strategy for building some understanding of the disease's biological basis.

Scientists have been debating the relative influence of inherited risk and environmental factors in autism for decades, and few today doubt that there is a strong genetic component.

But biologists have groped in vain for a reliable way to clarify the underlying genetics of these so-called autism spectrum disorders, including Asperger syndrome and related social difficulties that are being diagnosed at alarmingly high rates — on average, in one in 88 children, according to a government estimate released last week.

Previous studies have produced a scattering of gene findings but little consensus or confidence in how to proceed.

The new research — reported in three papers posted online on Wednesday in the journal Nature — provides some measure of both, some experts said. There are probably hundreds, perhaps more than a thousand, gene variations that could disrupt brain development enough to result in social delays.

An intensified search for rare mutations could turn up enough of these to account for 15 percent to 20 percent of all autism cases, some experts say, and allow researchers a chance to see patterns and some possible mechanisms to explain what goes awry.

"These studies aren't so much a breakthrough, because we knew this was coming," said Jonathan Sebat, a professor of psychiatry and cellular and molecular medicine at the University of California, San Diego, who was not a part of the research teams. "But I'd say it's a turning point. We now have a reliable way forward, and I think it's fair to expect that we will find 20, 30, maybe more such mutations in the next year or two."

Other researchers were more cautious, saying that the genetics of rare mutations was not yet well enough understood to make conclusive statements about their effect on the behavior of specific genes.

"This is a great beginning, and I'm impressed with the work, but we don't know the cause of these rare mutations, or even their levels in the general population," said Dr. Aravinda Chakravarti of the Institute of Genetic Medicine at the Johns Hopkins University Medical School, who was not involved in the studies. "I'm not saying it's not worth it to follow up these findings, but I am saying it's going to be a hard slog."

The three research teams took a similar approach, analyzing genetic material taken from blood samples of families in which parents who have no signs of autism give birth to a child who develops the disorder. This approach gives scientists the opportunity to spot the initial mutations that accompany the condition, rather than trying to work though possible genetic contributions from maternal and paternal lines. In all three studies, the researchers focused on rare genetic glitches called de novo mutations.

De novo mutations are not inherited but occur spontaneously near or during conception. Most people have at least one, and the majority of them are harmless.

In one of the new studies, Dr. Matthew W. State, a professor of genetics and child psychiatry at Yale, led a team that looked for de novo mutations in 200 people who had been given an autism diagnosis, as well as in parents and siblings who showed no signs of the disorder. The team found that two unrelated children with autism in the study had de novo mutations in the same gene — and nothing similar in those without a diagnosis.

"That is like throwing a dart at a dart board with 21,000 spots and hitting the same one twice," Dr. State said. "The chances that this gene is related to autism risk is something like 99.9999 percent."

The team found that a third child had a de novo mutation in another gene suspected of a possible link to autism risk — but one such mutation is not enough to make the case.

But a team led Dr. Evan E. Eichler, a professor of genome sciences at the University of Washington in Seattle, independently found the same thing in a study of 209 families: one child with autism — and a glitch in the very same gene.

The researchers added still another gene, finding two unrelated children with autism in their own sample who had de novo mutations in the same location. No such coincidences occurred among people in the studies who did not have an autism diagnosis.

Finally — in the third paper — a team led by Mark J. Daly of Harvard ran its own analysis of these three genes, among others, and found yet more cases.

Everyone typically has at least one de novo mutation, Dr. Daly said, but his study suggested that "kids with autism have a slightly higher rate, on average, and the effects are more severe."

All three studies also found evidence that the risk of de novo mutations increases with parental age. In an analysis of 51 de novo mutations, Dr. Eichler's group found that glitches were four times more likely to originate in DNA from the male than from the female. The risk is higher in fathers at 35 than at 25 and seems to creep up with age. This offers one possible explanation for earlier research linking older fathers with autism's rise: older male sperm is more subject to small, perhaps random glitches that in rare cases affect brain development.

The emerging picture suggests that the search for therapies will probably be a very long one, and that what is known generally as autism may represent a broad category of related but biologically distinct conditions. But both Dr. Eichler's and Dr. Daly's groups found some evidence that high-risk genes interact in shared biological processes.

"This is really the tip of the tip of the iceberg," Dr. Eichler said, "but I think the important thing is all of us agree on where to start."

Dr. State added, "From my standpoint, this is a big deal, because I've been at this a long time, and for years and years you couldn't get anyone to believe you'd even found one gene" that significantly increased risk.

Wednesday, April 4, 2012

Study: BMI misses mark on obesity | The Columbus Dispatch

Many Americans, especially women, are obese but mistakenly think they're at a healthy weight because of major flaws in the body-mass-index formula, say the authors of a new study.

An analysis comparing the BMI to a blood test and body scan found that the BMI was wrong for half of women and 1 in 4 men.

It's commonly acknowledged that the BMI can produce inaccurate results for athletes and others with a lot of muscle mass. But this research illuminates a problem on the other end of the scale: people who think they're fine but are carrying a lot of fat and little muscle.

"Particularly in women, as they age, their muscles become inserted with fat, even though they stay thin and beautiful in a dress," said Dr. Eric Braverman, a New York physician who co-wrote the study with New York State Health Commissioner Nirav R. Shah. Their work was published in the journal PLoS ONE.

The researchers propose revisions to the cutoff for determining who is obese — to a BMI of 24 or over for women and 28 or over for men, down from 30 or over for both. They also say that doctors should consider blood tests to measure leptin, a hormone that goes up with increased body fat, and DXA scans. The scans are commonly used to assess bone density but can be used to analyze body fat.

Experts agree that the BMI is imperfect but say it's a valuable tool to help guide doctors' conversations with their patients.

It boasts another big benefit: It's free. Scans can cost several hundred dollars, and leptin tests can be more than $100, said Dr. Patricia Choban, medical director of the bariatric-surgery program at Mount Carmel West hospital.

"You have to understand that BMI is an estimate of fatness, it's not a measure of fatness. But there are very few screening-tool estimates we have that are as simple to use," she said.

Carmen Swain, program director of Health and Exercise Science at Ohio State University, said some tests, including DXA scans and skin-fold measurements, do produce more-accurate results when done right. But BMI remains an easy and important tool, she said.

Swain has done research looking at BMI and body-fat percentage in boys and found a good correlation between the measure and actual body composition. There's little research on the reliability of BMI in adults, she said, and it's good that this study offers more insight.

Dr. Darrin Bright, who practices with OhioHealth's Sports Medicine Institute and MAX Sports Medicine, said the BMI "has its flaws; we've known it has flaws since we first started using it."

"It's a piece of the puzzle. It's a screening test," he said, "and we need to understand the limits of a screening test."

BMI should be a starting point for conversations between doctors and patients, Choban and Bright said.

"As a physician, I'm going to measure BMI, then I'm going to ask them about what their activity is," Choban said. "If you look at their fitness level, it's going to give you a pretty good clinical guess. Unfortunately, many people aren't even calculating BMIs."

Bright said he sometimes orders leptin tests, but he doesn't think they or DXA scans are practical for population-wide obesity screening.

Braverman said that as more of these tests are done, the price will come down. Leptin testing should be as routine as cholesterol tests, he said, calling BMI the "baloney mass index."

Even if the new cutoffs are used, the calculation still will miss many people who could have weight-related health problems because of their body fat, he said.

Medical group takes up the fight against unnecessary tests -

The patient suffers from headaches and wants to undergo the dull roar of an MRI machine to make sure everything is all right. Good idea?

Probably not.

How about the drip-drip of chemo for the cancer patient who is near death? A CT scan for someone who has fainted but shows no neurological symptoms? Or an annual electrocardiogram for a person with low risk of heart disease?

No, no and no.

These are among dozens of recommendations that nine medical societies are announcing Wednesday, in an effort led by the ABIM Foundation, an affiliate of the American Board of Internal Medicine, based in Philadelphia.

With governments and insurers bemoaning the soaring costs of health care, the medical profession is increasingly offering its own solutions. The new campaign, dubbed Choosing Wisely, is not the first such effort but is among the most comprehensive.

Now comes the tricky part: getting patients and doctors to go along with it.

Various estimates have pegged spending on unnecessary tests at $200 billion to $250 billion each year in the United States, a phenomenon blamed on such factors as overcautious doctors who seek to avoid malpractice claims and patients who don't realize how much their treatments cost.

Organizers of Choosing Wisely say the goal is not cutting costs, strictly speaking, but achieving the best value and the best care. If an expensive test is necessary, then full steam ahead. Conversely, some tests are cheap but still should not be done because they can subject the patient to needless anxiety and risky follow-up procedures that turn out to be unnecessary, the groups say.

The campaign is not about rationing or withholding proper care, said Christine K. Cassel, president and chief executive officer of the ABIM Foundation. On the contrary; if waste is not reduced, there will be less money for the care that is necessary, she said.

"If we don't as a community collectively address this cost issue, then there's a whole lot of people that aren't going to get the care that they need," Cassel said.

Each of the nine medical groups contributed a top-five list of tests or procedures that they determined were often unnecessary in their own fields, for a total of 45, though a few tests showed up more than once. They represent such specialties as family medicine, cardiology, radiology and oncology.

Health-policy experts said the effort was a good way to launch a conversation about the topic. But one University of Pennsylvania economist said it might be hard to get insured patients to question the need for tests if they do not have to pay for them directly.

"The way to get them to do it is to give them a stake in the outcome," said Mark Pauly, a health economist at Penn's Wharton School.

More employers are moving to high-deductible health insurance plans, under which patients pay more costs up front, but such coverage is not the norm.

Cost aside, it can be tough for a patient to speak up, even when the patient himself is a physician.

Take the case of internist Steven E. Weinberger, chief executive officer of the Philadelphia-based American College of Physicians, one of the nine Choosing Wisely groups.

When Weinberger had arthroscopic knee surgery a year and a half ago at the Hospital of the University of Pennsylvania, the doctor's secretary told him he needed to schedule preoperative testing. That included a chest X-ray, an electrocardiogram and blood work, none of which was medically necessary, Weinberger said.

Yet despite his medical expertise, he went along with it.

"I should have been the person to say no, but you don't like to argue with the person who's providing your care," Weinberger said. "You don't want to be seen as the difficult patient."

Preoperative chest X-rays made his group's top-five list of unnecessary tests. Also not recommended: CT scans and MRIs for patients with non-specific lower-back pain.

Public and private insurers have started to address spiraling costs by cutting reimbursements, but Weinberger called that a "nonspecific" approach.

Better to have physicians identify procedures that are wasteful and maintain the tests that are needed, a process that will lead to more acceptance than if solutions are imposed from outside, he said.

As for gaining patient acceptance, a key will be to explain the reality behind misleading "survivor stories," said H. Gilbert Welch, professor of medicine at the Dartmouth Institute for Health Policy & Clinical Practice.

"This is the person who has something found early and is doing well, and the presumption is that person has benefited," he said.

In fact, many abnormalities that are detected early - such as a small cancerous nodule - may never progress far enough to harm the patient, or they may even go away entirely, said Welch, author of Overdiagnosed: Making People Sick in the Pursuit of Health.

Yet when such things are detected early, the patient and doctor feel compelled to take action - resulting in biopsies and even surgery that can lead to harm, he said.

"The best medicine isn't the most medicine," Welch said, "even if you had all the money in the world."

Doctor Panels Urge Fewer Routine Tests -

In a move likely to alter treatment standards in hospitals and doctors' offices nationwide, a group of nine medical specialty boards plans to recommend on Wednesday that doctors perform 45 common tests and procedures less often, and to urge patients to question these services if they are offered. Eight other specialty boards are preparing to follow suit with additional lists of procedures their members should perform far less often.

The recommendations represent an unusually frank acknowledgment by physicians that many profitable tests and procedures are performed unnecessarily and may harm patients. By some estimates, unnecessary treatment constitutes one-third of medical spending in the United States.

"Overuse is one of the most serious crises in American medicine," said Dr. Lawrence Smith, physician-in-chief at North Shore-LIJ Health System and dean of the Hofstra North Shore-LIJ School of Medicine, who was not involved in the initiative. "Many people have thought that the organizations most resistant to this idea would be the specialty organizations, so this is a very powerful message."

Many previous attempts to rein in unnecessary care have faltered, but guidance coming from respected physician groups is likely to exert more influence than directives from other quarters. But their change of heart also reflects recent changes in the health care marketplace.

Insurers and other payers are seeking to shift more of their financial pain to providers like hospitals and physician practices, and efforts are being made to reduce financial incentives for doctors to run more tests.

The specialty groups are announcing the educational initiative called Choosing Wisely, directed at both patients and physicians, under the auspices of the American Board of Internal Medicine and in partnership with Consumer Reports.

The list of tests and procedures they advise against includes EKGs done routinely during a physical, even when there is no sign of heart trouble, M.R.I.'s ordered whenever a patient complains of back pain, and antibiotics prescribed for mild sinusitis — all quite common.

The American College of Cardiology is urging heart specialists not to perform routine stress cardiac imaging in asymptomatic patients, and the American College of Radiology is telling radiologists not to run imaging scans on patients suffering from simple headaches. The American Gastroenterological Association is urging its physicians to prescribe the lowest doses of medication needed to control acid reflux disease.

Even oncologists are being urged to cut back on scans for patients with early stage breast and prostate cancers that are not likely to spread, and kidney disease doctors are urged not to start chronicdialysis before having a serious discussion with the patient and family.

Other efforts to limit testing for patients have provoked backlashes. In November 2009, new mammography guidelines issued by the U.S. Preventive Services Task Force advised women to be screened less frequently for breast cancer, stoking fear among patients about increasing government control over personal health care decisions and the rationing of treatment.

"Any information that can help inform medical decisions is good — the concern is when the information starts to be used not just to inform decisions, but by payers to limit decisions that a patient can make," said Kathryn Nix, health care policy analyst for the Heritage Foundation a conservative research group. "With health care reform, changes in Medicare and the advent of accountable care organizations, there has been a strong push for using this information to limit patients' ability to make decisions themselves."

Dr. Christine K. Cassel, president and chief executive officer of the American Board of Internal Medicine Foundation, disagreed, saying the United States can pay for all Americans' health care needs as long as care is appropriate: "In fact, rationing is not necessary if you just don't do the things that don't help."

Some experts estimate that up to one-third of the $2 trillion of annual health care costs in the United States each year is spent on unnecessary hospitalizations and tests, unproven treatments, ineffective new drugs and medical devices, and futile care at the end of life.

Some of the tests being discouraged — like CT scans for someone who fainted but has no other neurological problems — are largely motivated by concerns over a malpractice lawsuits, experts said. Clear, evidence-based guidelines like the ones to be issued Wednesday will go far both to reassure physicians and to shield them from litigation.

Still, many specialists and patient advocates expressed caution, warning that the directives could be misinterpreted and applied too broadly at the expense of patients.

"These all sound reasonable, but don't forget that every person you're looking after is unique," said Dr. Eric Topol, chief academic officer of Scripps Health, a health system based in San Diego, adding that he worried that the group's advice would make tailoring care to individual patients harder. "This kind of one-size-fits-all approach can be a real detriment to good care."

Cancer patients also expressed concern that discouraging the use of experimental treatments could diminish their chances at finding the right drug to quash their disease.

"I was diagnosed with Stage IV breast cancer right out the gate, and I did very well — I was what they call a 'super responder,' and now I have no evidence of disease," said Kristy Larch, a 44-year-old mother of two from Seattle, who was treated with Avastin, a drug that the F.D.A. no longer approves for breast cancer treatment. "Doctors can't practice good medicine if we tie their hands."

Many commended the specialty groups for their bold action, saying the initiative could alienate their own members, since doing fewer diagnostic tests and procedures can cut into a physician's income under fee-for-service payment schemes that pay for each patient encounter separately.

"It's courageous that these societies are stepping up," said Dr. John Santa, director of the health ratings center of Consumer Reports. "I am a primary care internist myself, and I'm anticipating running into some of my colleagues who will say, 'Y' know, John, we all know we've done EKGs that weren't necessary and bone density tests that weren't necessary, but, you know, that was a little bit of extra money for us.' "

Monday, April 2, 2012

New research chair holder seeks to reduce stigma surrounding mental illness | University Affairs

If you ask Heather Stuart how her career as an expert in the stigma surrounding mental illness began, her tone is light. She tells of growing up in Guelph, Ontario next to a mental hospital, the Homewood Sanitarium, where her mother worked as an administrator.

"I would meet the patients every day when I went to see my mother," recalled Dr. Stuart. "They were pleasant and kind people and I made friends with them. It never occurred to me that there was a huge social division between us."

Today, that innocence is replaced by a determination to understand and properly address the negative stigma associated with mental illness, a problem costing the Canadian economy an estimated $51 billion annually. This past February, the professor of community health and epidemiology at Queen's University was appointed to the new Bell Mental Health and Anti-Stigma Research Chair, with a $1-million endowment from Bell Canada over five years.

Social stigma is defined loosely as a cognitive-emotional process that leads to negative stereotyping, prejudicial feelings and discriminatory behavior towards those with a particular condition. Applied to mental illness, stigma has the ability to nullify all the good work done in the mental health field, said Dr. Stuart.

"You can put in place counselors, programs and other services to help people with mental illnesses, but these are wasted if people are scared to come forward for fear of being labeled negatively or ostracized."

Dr. Stuart steered the research approach of the Mental Health Commission of Canada's Opening Minds program – a 10-year anti-stigma, anti-discrimination initiative designed to change the attitudes and behaviours of Canadians towards people living with mental illness.

According to Michael Pietrus, director of Opening Minds, Dr. Stuart convinced his team to go beyond an anti-stigma campaign and to include new, targeted research. Currently there aren't many best practices on how to reduce stigma in mental health.

At her suggestion, the research team issued a Request for Interest to groups across Canada and received 250 responses, detailing mental illness projects under way. This led Opening Minds to narrow its focus to four key areas where stigma is high:

  • youth – evidently 70 percent of adults living with stigma say the onset occurred before age 18;
  • health care providers – surprisingly, many show disrespect and discrimination towards mental health issues;
  • the workplace – a huge number of employees chose to go untreated rather than risk being labeled as unproductive or untrustworthy; and
  • media – all forms of media tend to perpetuate a stereotype of the violent or dangerous mentally ill person.

Mr. Pietrus said that the evidence that will come from research on these projects "will enable the team, with Dr. Stuart's help, to measure stigma and potential stigma reduction."

Mr. Pietrus credited Dr. Stuart's training in epidemiology with allowing her to quantify the problem, making it "attractive to policy makers, who want to see scope and numbers."

Her work for Opening Minds taps into a project of her own: developing inventories of stigma experiences, which she calls Stigma Impact Scales. To carry this out, she relies on data gathered in complex field tests aimed at measuring the frequency and intensity of experiences of people with mental illnesses. For example, she devised a stigma assessment module and used it to piggyback onto one of Statistics Canada's health surveys.

"Understanding the frequency and scope of stigma experienced by people who live with a mental disorder will be essential for targeting anti-stigma programs to where they are needed most," she explained.

Dr. Stuart's appointment coincides with momentum on mental health both at Queen's and in the broader university community. Last September, Queen's formed a Principal's Commission on Mental Health that is scheduled to report this May. And last February, at a workshop on mental health for senior university administrators led by the Association of Universities and Colleges of Canada, a working group of university presidents was formed to try to devise a roadmap to help universities respond effectively.

David Walker, a professor in Queen's school of health sciences who chairs the principal's commission, said stigma "may turn out to be one of the most difficult elements of moving forward on mental health issues" because it implies changing ingrained attitudes and behaviour. He cited selection committees for law or medical school as examples of stigma in academe.

"The committee has the best intentions of the world," he said, "but when comparing transcripts of the person who has been on the football team, the debating team, and has a GPA of 3.7… with the student who has good marks but keeps having incomplete courses because they became unwell and had had to have therapy – that is how people react."

Along the same vein, Dr. Stuart said that people avoid using available services, such as student counseling, because of the stigma associated with mental health issues.

"Universities are going to come up against a wall unless they encourage students to become more comfortable about disclosing to their health-care providers that they have a problem." Universities need to let students know that using the services won't hurt their academic career, she added.

And while it may be helpful for students to see "leaders" admit to having mental health issues, both Drs. Stuart and Walker said that most people with mental disorders do not identify with "successful" people, and they suggested that openness among peers is a better approach.

One campus-based project of Dr. Stuart's is a series of pilot projects to test a "contact-based approach" to reducing stigma. The idea is to try to create a positive situation when people come in contact, through work or study, with those with a mental illness. "Universities and other workplaces are ideal situations," she said, "where these emotional barriers can be broken down."

Social barriers often make it impossible for these people "who are often very intelligent, to finish their education, get a good job, and be independent, happy people.

"Not a week goes by that I don't hear a person with a mental illness tell me she or he wished they had had cancer because it is more acceptable. That breaks my heart."

Questions are the Answer - Agency for Healthcare Research and Quality

Asking questions and providing information to your doctor and other care providers can improve your care. Talking with your doctor builds trust and leads to better results, quality, safety, and satisfaction.

Quality health care is a team effort. You play an important role. One of the best ways to communicate with your doctor and health care team is by asking questions. Because time is limited during medical appointments, you will feel less rushed if you prepare your questions before your appointment.

Your doctor wants your questions

Doctors know a lot about a lot of things, but they don't always know everything about you or what is best for you.

Your questions give your doctor and health care team important information about you, such as your most important health care concerns.

That is why they need you to speak up.

When patients become more actively involved in their own health, there's a much stronger likelihood their health outcomes will be better.
That's why "Questions are the Answer," a new public education initiative from the U.S. Agency for Healthcare Research and Quality (AHRQ), encourages patients to have more effective two-way communication with their doctors and other clinicians.
"Questions are the Answer" features a website -- -- where you  will find these free educational tools to use with your patients:
·         7-minute video featuring real-life patients and clinicians who give firsthand accounts on the importance of asking questions and sharing information – this tool is ideal for a patient waiting room area and can be set to run on a continuous loop.
·         A brochure, titled "Be More Involved in Your Health Care: Tips for Patients," that offers helpful suggestions to follow before, during and after a medical visit.
·         Notepads to help patients prioritize the top three questions they wish to ask during their medical appointment.

More …

Pro-Anorexia, Thinspirational Images on Pinterest: Threat of Self-Harm - The Daily Beast

Somewhere in the sea of images on Pinterest, the popular social-networking site that allows users to share images, there's a black-and-white photo of a bony girl in a tank top. Over her chest are block letters that read: "Make them regret the day they dared call you fat."

It may seem like a disturbing image to be floating around the site—getting pinned and re-pinned—and some users noted that it sent a dangerous message. "Yeah!" one wrote in the comments. "Because compromising your health because of what some douchebag says about you is the best idea ever."

But others defended the post. "I am overweight and I do look at SOME of these woman [sic] and strive to be like them because I know I need to get my weight under control and with a little help from this quote I will make them regret all the snotty little side comments and the whispers," one wrote. "It doesn't matter what people think about me but like I said before the comments make me push harder and harder each day because I know I can prove anyone wrong."

The photo is part of a growing number of pro-anorexic and "thinspirational" images on sites like Pinterest, Tumblr, and Facebook. In scores of photos, girls frolic on beaches in skimpy bikinis, pull down their underwear to reveal a jutting hipbone, or roll up their T-shirts to take pictures of their flat stomachs in the bathroom mirror. "To Know You're The Best Looking Girl on The Beach," reads one thinspirational message. "If It Were Easy, Everyone Would Be Thin." "The Difference Between Want and Need Is Self Control." "Sweat Is Fat Crying." A playful e-card even makes light of the disturbing trend: "Pinterest: Thank you for making me want to work out like a complete psycho and eat desserts all night…simultaneously."

The photo-sharing site Pinterest will impose a restriction on images that promote self-harm in an attempt to curb "thinspirational" content.

Adrienne Ressler, a body image specialist at the Renfrew Center, estimates that 100 percent of her patients are aware of pro-anorexia websites. "Some patients have their own peer group which reinforces their quest for thinness," she says. "And some have become addicted to these sites."

"Girls are always saying 'Am I the thinnest one in the room?' says Cynthia Bulik, director of the University of North Carolina Eating Disorders Program and author of The Woman in the Mirror: How to Stop Confusing What You Look Like With Who You Are. "Now they don't have to have someone in their real world to compare themselves to. They have it online."

The popularity of these noxious images has driven Facebook and Tumblr to change their guidelines to try to prevent against images that encourage self-harm—which includes these pro-anorexia images. On Friday, Pinterest will join them, imposing a new change to its guidelines that will prevent users from sharing images that promote self-harm. A spokesperson for the company says it will rely on users within the community to report inappropriate content.

Their efforts may serve to limit imagery that's outwardly thinspirational—but the reality is that it will never succeed in eradicating these images altogether. When I began researching for this story, I searched on Pinterest for content that was specifically "thinspirational" and "pro-anorexic." All I needed to do was type in one of those search terms, and thousands of images popped up. Some were explicit, with messages written on them like that bony girl in the T-shirt. But the vast majority were more subtle: photo-montages of "summer," with thin girls running down sandy beaches; of "fitness," with impossibly chiseled fitness models demonstrating sit-ups, of "street style," with disheveled off-duty models alighting from taxis.

There's a fine line between images that are seen as promoting self-harm—and those that are subtly supporting it. "I think it's definitely a step in the right direction," says Bulik of the new user guidelines. "And the reason it can't go further is because those lines have not been defined yet, and people might not know what the lines are. The question is how to define that line and define when we cross it. That's something we need to grapple with—both within the eating disorder community, the media, and social media." Draw the line too far, of course, and it starts to raise questions about freedom of expression.

Body-image experts are quick to point out that when you take away "thinspo" content, it's important to replace them with healthier alternatives. One solution is Proud2BeMe, a site promoting health body image supported by NEDA, theNational Eating Disorders Association. NEDA also has partnered with Tumblr and Facebook—and is in talks with Pinterest—to help regulate their policies against self-harm. The association has helped the sites identify a list of search terms that could be problematic within their communities and is suggesting that they direct people searching for thinspirational pictures to public-service announcements about healthy body image.

"So much content is thinspiration in a much broader sense, and that's something that NEDA is trying to address too," says Claire Mysko, project manager for the Proud2BeMe program. "But we need to see more body diversity. It's really about making sure people are seeing themselves represented in the media."