Saturday, July 7, 2012

When It's the Nurse Who Needs Looking After -

Tall, in her 50s and sporting a perfectly coiffed salt-and-pepper pixie cut, the woman was one of the most respected nurses in the hospital. She had nearly three decades of clinical experience, so older nurses and doctors valued her insight, younger ones sought her approval, and those of us in between tried to stand a little straighter in her presence.

One morning, however, she arrived at work to find that the hospital was full and her unit understaffed. It wasn't the first time she had to cover for more patients because of staffing issues, but by the end of this 12-hour shift, she noticed a slight twinge in her lower back — a minor muscle sprain, she thought, from helping one of the other nurses lift a patient.

A week later, the slight twinge turned into debilitating back pain.

But she continued to work through the pain. "What else could I do?" she said one afternoon, pointing out all the patients who would suffer without the additional nurse. "I thought I was going to be lucky and make it to retirement without getting hurt, but now I just want to be able to put in a few more years so I can retire."

When she rubbed the heel of her palm against her back, I saw her lower lip begin to quiver slightly.

"How terrible is it that we do everything to care for the health of others," she whispered, "but we cannot care for ourselves."

Nurses make up the largest group of health care providers in the United States, working in venues as varied as doctors' offices and biotech firms, governmental agencies and private insurers. Trusted more than almost any other professional, nurses exert a wide-ranging influence on how health care is delivered and defined.

But nurses' work is not easy, particularly in the hospital setting, where they must deal with intense intellectual and significant physical demands over three or more grueling 12-hour shifts each week. Not surprisingly, nursing ranks among the worst occupations in terms of work-related injuries, and studies have shown that in a given year, nearly half of all nurses will have struggled with lower back pain.

The obvious question, then, is this: If the nurses are grappling at work with all these injuries, what is happening to patients?

Recent research published in two journals, The American Journal of Nursing and Clinical Nurse Specialist, reveals that when nurses suffer, so do their patients.

Researchers developed a questionnaire for registered nurses working at hospitals, asking them about their own health and the extent to which their injuries or illnesses might affect their work. Analyzing more than 1,000 responses, the researchers found that almost 20 percent of the nurses questioned had symptoms of depression, an incidence twice as high as for the general population. In addition, roughly three-quarters of the nurses experienced some level of physical pain from a muscle sprain or strain while at work.

The researchers then looked at the quality of the nurses' work. A small percentage of nurses reported that they had made a recent medication error or that a patient had fallen while under their care. Adjusting the analysis to take into account how the nurses were feeling, researchers discovered that the risks of a patient fall or medication mistake increased significantly – by about 20 percent – the more a nurse was in pain or depressed.

Extrapolating the individual costs of these lapses in care to a national level, the researchers estimate that medication errors and patient falls that occurred as a result of nurses' health issues incurred as much as $2 billion annually on the health care system.

"We have money bleeding out the back door because we don't have a healthy work force," said Susan Letvak, the study's lead author and a registered nurse who is an associate professor of nursing at the University of North Carolina at Greensboro.

Nurses work in an increasingly stressful work environment, particularly within hospitals. Patients are sicker than before, and nurse-to-patient staffing ratios are not always standardized. Over the course of a 12-hour shift, nurses can find themselves in the potentially devastating situation of caring for more patients than is comfortable. When ill, many nurses feel pressure to show up for work because their absence means even more work for their colleagues and even spottier care for their patients.

They may also feel compelled to work because of an ethos that pervades the profession. "Nothing is supposed to stop a nurse," Dr. Letvak noted. "We are supposed to care for everyone else and soldier on."

Unfortunately, there are few work-based resources for nurses who are ill or depressed. Few hospitals have preventive programs that mandate, for example, safe patient lifting practices or policies that support nurses who may be temporarily disabled. Nurse managers often have little training in how to handle nurses with health problems, and many staff nurses themselves are unaware of how they might recognize and help a colleague whose work is impaired by illness.

Some nurses are also hesitant to disclose how they feel for fear of losing their jobs. "We have a system of penalizing nurses instead of early recognition and treatment," Dr. Letvak said.

While the predicted nursing shortage will likely exacerbate many of these issues, Dr. Letvak believes there are several initiatives that could strengthen the current work force. These include measures like standardizing the nurse staffing ratios, providing the option of working shifts shorter than 12 hours and creating more health screening programs. She and her colleagues already have plans to study how helping nurses who are in pain and making shift lengths more flexible might improve patient outcomes and help experienced nurses practice for as long as they can.

"The only way to ensure the best quality for our patients is to have an expert staff of qualified nurses who are healthy enough to offer that kind of care," Dr. Letvak said. "We can't ignore nurses' health anymore."

Wednesday, July 4, 2012

Study: After Giving Birth, New Moms Spend More Time on Facebook - The Atlantic

METHODOLOGY: Researchers led by Mitchell K. Bartholomew surveyed 154 mothers and 150 fathers, most of whom were white and highly educated, nine months after their child's birth about their Facebook use, stress, satisfaction, and parenting self-efficacy.

PROBLEM: First-time moms and dads juggle many new demands after their baby arrives. How does parenthood affect their use of Facebook?

RESULTS: Mothers, who reported using Facebook more than their partners, tended to increase their online activity after giving birth. Those who visited and managed their accounts more frequently reported higher levels of parenting stress. They reported greater satisfaction with their new role, however, when a greater proportion of their Facebook friends were family members or relatives. Fathers, on the other hand, reported better parental adjustment when their Facebook friends tended to be people they also interact with in real life.

Nearly all of the women said they had uploaded photos of their baby, while 83 percent of the men said they did. Interestingly, 93 percent of mothers and 71 percent of fathers said it was at least "likely" that the photos would be acknowledged by their online friends, either with a comment or a "like," and these parents reported higher levels of satisfaction in their parenting role.

CONCLUSION: New moms increase their use of Facebook after giving birth, and their online activity may influence how well they adjust to parenthood.

IMPLICATION: Facebook may be a way for stressed-out mothers to seek support and for both parents to be reassured. "Parents may feel like they're getting positive feedback about their role as parents," says co-author Sarah J. Schoppe-Sullivan in a statement, "and they particularly need that."

SOURCE: The full study, "New Parents' Facebook Use at the Transition to Parenthood," is published in the journal Family Relations.

Study Finds Gender Gap in Doctors' Pay -

Brilliant and hard-working, my younger colleague had just returned from delivering one of the main talks at a national medical meeting. All of us viewed the invitation to speak as an acknowledgment of her great potential, so when I asked her about the conference, I expected her to bubble over about the accolades she'd heard and the plum job offers she'd received from competing medical centers.
But she hardly smiled as she recounted her experiences.
"During the question-and-answer session I kept falling back on phrases like 'maybe,' 'perhaps' and 'I guess so,' " she said. Though she had the experience and data to rebut even the most aggressive or erroneous challenges from doctors in the audience, her tentative manner seemed to leave her vulnerable to doubts and even more questioning.
What's more, she added, she had noticed that many of the other female speakers responded to their audiences as she had, with wavering and hesitant replies, while most of the men answered "with such confidence and bravado that we women looked pretty amateur in comparison."
The experience had shaken my colleague's quiet confidence. "I always thought the strength of my work was all that mattered in medicine," she said. "Now I can't help but wonder if other factors are involved."
This was not the first time I had heard a colleague speculate on how her sex might affect the way others treated her professionally, but we all thought medicine was one of the few careers in which men and women working the same hours and producing comparable results in similar specialties would be paid and promoted equally. While some studies found income disparities between male and female doctors, researchers chalked up their findings to the fact that fewer women worked in higher-paying specialties and more men worked longer hours.
But a study published recently in The Journal of the American Medical Association reveals that medicine may not be so meritocratic after all.
Researchers analyzed the professional trajectories of almost 2,000 midcareer physician-researchers. Chosen because of their similarity to one another in professional interests, aptitude and ambition, the doctors in the study each had received a highly prestigious research grant early in their careers and worked not in private practice but in academic medical centers. The researchers examined a wide range of career factors, including the number of hours worked, professional achievements, leadership positions, marital status, parental status and salary.
As in some earlier studies, the researchers found a difference in income, with a male doctor's annual salary averaging just over $200,000 and a female's averaging about $168,000. And like previous researchers, they found that the female doctors tended to be in lower-paying specialties, have fewer publications, work fewer hours and hold fewer administrative leadership positions.
But when these researchers ran the numbers again, this time adjusting for differences in specialty, publications, academic rank, hours worked and leadership positions, they found that the expected average salary for women still fell behind that of their male colleagues. The male doctors made over $12,000 per year more than the women.
Calculated over the course of a 30-year career, the income gap based on sex alone amounted to over $350,000.
"We really didn't expect to find such a substantial unexplained difference," said Dr. Reshma Jagsi, lead author and an associate professor of radiation oncology at the University of Michigan. "In Michigan, that amount buys you a house, your kids' education or a nice nest egg for retirement."
There may be several reasons for this income difference. A previous study by a group of psychologists, for example, showed that when presented with identical résumés, one from a man and one from a woman, employers of both sexes were more likely to hire the man. A similar unconscious bias is likely to exist among doctors, influencing how much female physicians are paid and promoted. "It's not like the medical centers or the department heads are evil," Dr. Jagsi said. "The problem is that sometimes in medicine we think we are immune to these pervasive biases."
Male and female doctors may also interact differently with their superiors when talking about payment and promotions. Women in other fields have been shown to negotiate less aggressively than their male peers. In medicine, that would mean women are less inclined to ask for more money and less likely to leverage offers from competing institutions or practices.
While the current study looks at only one small and homogeneous subset of physicians, the findings are probably applicable to many more doctors. "The men and women we studied were the go-getters," Dr. Jagsi said. "You have to worry that if you see such disparities among this group, you will see at least the same, if not more, differences among other groups of physicians."
Dr. Jagsi believes that greater transparency would decrease, and even eliminate, the income differences. Currently, it is difficult for most doctors to know if they are being paid fairly "since most institutions don't have clear policies on how to determine salaries," she noted. But standardizing the process of compensation and career advancement would make everyone involved more accountable for such decisions and "allow men and women to be paid as much as the work they are doing is worth," she said.
"Society makes a huge investment in every medical trainee," Dr. Jagsi said. "If we make that kind of investment, we need to ensure that compensation and advancement are fair."
She added, "It comes down to a matter of basic fairness."

Study of the Day: Afraid of Childbirth? You May Be in for a Longer Labor - The Atlantic

PROBLEM: Between five and 20 percent of pregnant women are estimated to have a fear of childbirth. Is there an association between this phobia and labor duration?

METHODOLOGY: Researchers led by Samantha Salvesen Adams surveyed and monitored 2,206 Norwegian women who intended to deliver vaginally from 32 weeks of gestation through to delivery. They considered a woman to be in labor as soon as her cervix was at least three centimeters dilated and she had three uterine contractions per 10 minutes. About half of the participants, who were 31 years old on average, were first-time mothers.
CONCLUSION: Women who are afraid of childbirth suffer through a longer labor.

RESULTS: Almost nine out of 10 women with a fear of childbirth achieved the vaginal delivery they desired. They endured an average of eight hours of labor while their fearless counterparts finished after six and a half hours. After adjusting for factors associated with labor duration, such as epidural analgesia, labor induction, and the number of times the woman has given birth, the difference was still significant at 47 minutes. Interestingly, anxious women also more often delivered by emergency caesarean section (10.9 percent versus 6.8 percent).

IMPLICATION: Medical practitioners and researchers should investigate the intersection of psychology and obstetrics more. As journal editor John Thorp said in a statement: "[W]omen with fear of childbirth are more likely to need obstetric intervention and this needs to be explored further so that obstetricians and midwives can provide the appropriate support and advice."

SOURCE: The full study, "Fear of Childbirth and Duration of labour: A Study of 2,206 Women With Intended Vaginal Delivery," is published in the journal BGOC: An International Journal of Obstetrics and Gynaecology.

OraQuick At-Home H.I.V. Test Wins F.D.A. Approval -

After decades of controversy, the Food and Drug Administration approved a new H.I.V. test on Tuesday that for the first time makes it possible for Americans to learn in the privacy of their homes whether they are infected.

The availability of an H.I.V. test as easy to use as a home-pregnancy kit is yet another step in the normalization of a disease that was once seen as a mark of shame and a death sentence.

The OraQuick test, by OraSure Technologies, uses a mouth swab and gives results in 20 to 40 minutes. A previous test sold over the counter required a user to prick a finger and mail a drop of dried blood to a lab.

Dr. Anthony S. Fauci, the longtime AIDS researcher and director of the National Institute of Allergy and Infectious Diseases, called the new test a "positive step forward" and one that could help bring the 30-year-old epidemic under control.

Getting an infected person onto antiretroviral drugs lowers by as much as 96 percent the chance that he or she will transmit the virus to someone else, so testing and treatment have become crucial to prevention. About 20 percent of the 1.2 million infected Americans do not know they have the disease, the Centers for Disease Control and Prevention estimates, and about 50,000 more get infected each year.

Dr. Robert Gallo, who headed the National Institutes of Health lab that developed the first American blood test for the virus in 1984, called the F.D.A. approval "wonderful because it will get more people into care."

The idea of a home test has long been mired in controversy. The first application for one was made in 1987, and the F.D.A. has been considering OraSure's simple mouth-swab test since 2005.

But the history of AIDS and the human immunodeficiency virus that causes it are unique. AIDS emerged in the 1980s wrapped in a shroud of stigma. It was spread by sex, drug injections and blood transfusions. Along withhemophiliacs, heroin users and Haitians, the most vocal group of early victims was gay men, who were then in the throes of a loud and defiant liberation movement.

Because merely being tested for H.I.V. was seen as tantamount to being publicly revealed as gay or addicted to drugs, and because an H.I.V.-positive result was a death sentence, groups like the Gay Men's Health Crisis and newspapers like The New York Native advised their members and readers to shun testing until ironclad guarantees of anonymity were put in place.

Alarmists predicted a wave of suicides if home tests were made available. At hearings, advocates for AIDS patients handed out copies of an obituary of a San Francisco man who jumped off the Golden Gate Bridge after learning he was infected. C.D.C. officials warned their F.D.A. counterparts that home testing could lead to a surge of new patients that would swamp overburdened health clinics, according to an F.D.A. document.

So, even as tests for other stigmatized diseases like syphilis were once part of getting a marriage license and home pregnancy kits became available at every corner pharmacy, H.I.V. tests lived in a special limbo, usually requiring a counseling session and the signing of a consent form, adding to the air of dread.

Even when antiretroviral drugs emerged in the mid-1990s, states were slow to rewrite laws governing testing.

Mark Harrington, the executive director of the Treatment Action Group, an AIDS advocacy organization, said in an interview that he thought such fears were "a thing of the past" now that it is clear that early treatment saves lives. "Any tool that speeds up diagnosis is really needed," he said.

The new test has some drawbacks. While it is extremely accurate when administered by medical professionals, it is less so when used by consumers. Researchers found the home test accurate 99.98 percent of the time for people who do not have the virus. By comparison, they found it to be accurate 92 percent of the time in detecting people who do. One concern is the "window period" between the time someone gets the virus and begins to develop theantibodies to it, which the test detects. That can take up to three months.

So, while only about one person in 5,000 would get a false negative test, about one person in 12 could get a false positive.

Any positive test needs confirmation in a doctor's office, the F.D.A. said, and people engaged in high-risk sex should test themselves regularly.

The agency does not intend for the home test to replace medical testing, but instead to provide another way for people to find out their H.I.V. status, said Dr. Karen Midthun, director of the F.D.A.'s Center for Biologics Evaluation and Research.

The home test should be available in 30,000 pharmacies, grocery stores and online retailers by October, said Douglas Michels, OraSure's chief executive. The price has not yet been set. But he said it would be higher than the $17.50 now charged to medical professionals because the company will do more complicated packaging for the home kit, open a 24-hour question line, and advertise to high-risk groups, including gay men, blacks and Hispanics, and sexually active adults. Still, he said, it will be kept inexpensive enough to appeal to people who might want to buy several a year.

Because the F.D.A. approved the home test only for people 17 and older, retail stores may ask customers to show ID, he said. The restriction is not for medical reasons, but because only a few subjects age 14 to 16 were tested, he said, "so that was the deal we worked out with the F.D.A."

Whether having to show identification would deter teenagers or young-looking people from buying a test is unclear. Mr. Harrington said he thought it might.

In contrast, teenage girls are not legally required to show identification to buy pregnancy tests.

Tuesday, July 3, 2012

The age of rage: psychiatrists battle over teen anger diagnosis - Montreal Gazette

Intermittent explosive disorder — a controversial mental illness marked by outbursts of uncontrollable rage — is so common among adolescents it affects one in 12 teens, a large new study finds.

Harvard Medical School researchers, in a study based on in-person interviews with more than 10,000 adolescents ages 13 to 17, found that about eight per cent met the criteria for intermittent explosive disorder, or IED.

The findings suggest the disorder is affecting hundreds of thousands of youths — close to six million in the U.S. alone, according to a statement released with the study.

But observers worry it could trigger a "manufactured epidemic" of mental illness among teens and lead to extreme but predictable teenage behaviour being labelled as symptoms of a mental illness requiring treatment — including mood-altering drugs.

According to the Diagnostic and Statistical Manual of Mental Disorders — psychiatry's official catalogue of mental illness, now undergoing its first major revision in nearly two decades — IED's central feature is impulsive aggression grossly out of proportion to the situation. People lose control, break or smash things and attack or threaten to hurt someone.

The study, published this week in the journal of Archives of General Psychiatry, is being described as the first to estimate the prevalence of IED in American adolescents. The researchers believe their findings could be extrapolated to Canada.

"If we can detect IED early and intervene with effective treatment right away, we can prevent a substantial amount of future violence perpetration and associated psychopathology," senior author Ronald Kessler, professor of health care policy at Harvard, said in a statement.

But Christopher Lane, author of Shyness: How Normal Behaviour Became a Sickness, said IED has been a source of controversy since it was formally approved as a mental disorder in 1980.

"Uncontrollable anger and domestic violence are, of course, serious concerns requiring attention," said Lane.

But equally concerning, he said, is the risk of "medicalizing" adolescence itself.

Disorders in the DSM are defined by a list of diagnostic criteria. A person can qualify for a certain diagnosis based on how many criteria they meet for that illness.

But there isn't agreement on just how many "episodes" or outbursts of aggression are necessary for a diagnosis of IED. As well, some have proposed broadening the criteria to include outbursts that don't involve threatened or actual violence, but do involve verbal aggression — insults or arguments "out of proportion to provocation."

The new study is based on a national mental health survey conducted in the U.S. between February 2001 and January 2004.

Nearly two-thirds — 63 per cent — of the adolescents surveyed reported at least one anger attack in their lifetime involving either destroying property or threatening or engaging in violence.

About one-third of those who reported attacks (29 per cent) had only one or two attacks in their lifetime; another one-third only had attacks that were either in line with the "provoking circumstances" or not out of control.

The remainder was made up of those with IED, the authors write.

Teens had to report three or more anger attacks in their lifetime to meet the criteria for IED.

When the Harvard team narrowed it to three attacks in a single year, with at least one attack involving violence or destroying property, 5.5 per cent met a diagnosis of IED.

Youth who had other problems associated with aggression, including attention-deficit/hyperactivity disorder, conduct disorder and bipolar disorder, were excluded. "We wanted to be sure we were really capturing something that wasn't already accounted for by another diagnosis," said co-author Katie McLaughlin, an assistant professor of pediatrics and psychiatry at Boston Children's Hospital.

While some of the IED-diagnosed youths had been treated for emotional problems in the year before their interview, only 6.5 per cent received treatment specifically for anger.

"IED is one of the least-studied of the mental disorders, despite the fact that it's quite common," McLaughlin said.

But Lane, author of the Psychology Today blog "Side Effects", said the results show otherwise — "that a significant number of teenagers have relatively few problems with impulse control and anger management."

Even for the teens who met criteria for IED, "it's still a big, unsettled question whether their periodic anger and threatened or actual violence should be considered a lifelong mental disorder," Lane said, "rather than a psychological crisis involving major life-stressors such as job loss, poverty, home foreclosure, debt issues and drug and alcohol addiction."

Dr. Allen Frances, former chair of the psychiatry department at Duke University's School of Medicine, chaired the task force that wrote the current edition of the DSM. He called IED an "unstudied" and "inherently unreliable category that probably shouldn't be in the DSM at all.

"It most certainly should not be reified into a manufactured teenage epidemic of mental disorder that is allegedly affecting millions of kids," he said.

"The suggestion that we institute prevention programs is a wildly premature over-promise until much more solid research demonstrates that there is real need and proven effectiveness."

Monday, July 2, 2012

Obesity often tied to mental health issues -

When Kevin Healey walked into his doctor's office five years ago, the minor injury he was seeking treatment for was the least of his physical ailments.

His weight had crept up from 200 to 240 pounds over the past few months, his cholesterol levels had soared into dangerous territory, and his blood pressure caused instant alarm when it clocked in at 240/180.

His moods were deteriorating as quickly as his body, with feelings of fatigue and hopelessness intensifying as the scale inched higher.

Doctors eager to bring his physical symptoms under control launched a trial-and-error process to find the right combination of medications, some of which only made his body feel worse while deepening his emotional gloom.

It was only when he received a diagnosis for a mental health condition and his treatment plan began addressing both his physical and emotional state that things began to improve.

"I recognized that something much more serious was going on, it was much more complex than I thought," Healey said. I"The medications I was taking were operating directly on my blood pressure, but there were other problems that were going on, and my brain was now affected. Having some kind of medication that addressed my brain function was helpful."

According to a growing number of medical researchers, addressing mental health when treating obesity and its related conditions is not just helpful but essential.

Obesity shares many of the same physical causes and long-term effects as mental illness, they argue, adding the two conditions often wind up dovetailing and exacerbating each other over time.

Dr. Arya Sharma, scientific director of the Canadian Obesity Network, said this critical relationship is often lost amid the usual messages most patients hear when seeking treatment for obesity or conditions associated with it.

"In assessing someone for obesity, you need to assess mental health as your number one priority before you even start thinking about what people eat and how much people move," he said. "Because right away you can assume that if there's a mental health problem going on, managing weight is going to be very difficult."

Sharma said people struggling with their weight often contend with mental stresses ranging from body image issues to serious mood disorders, all of which can hinder their efforts to shed extra pounds.

Mood has a direct impact on metabolism, he said, adding negative emotional turns can make it harder for the body to process certain foods.

A person struggling to adapt to a healthy lifestyle while also contending with depression or some other form of mental illness will find the combined weight of the conditions too challenging to manage, he said.

For those seeking treatment for mental illness, obesity poses a very real threat, he said. Many antipsychotic medications can cause weight gain, and food can present an easy and tempting alternative to coping strategies that haven't worked in the past.

Research suggests, however, that the links between obesity and mental health conditions are actually hard-wired into human biology.

Dr. Roger McIntyre, head of the mood disorders unit at the University Health Network, said the correlation between the two states is too strong to be coincidental.

At least three quarters of the mood disorder patients he treats also struggle with their weight, he said, adding research indicates the same root cause may be responsible for both issues.

We already know that inflammation can cause depression. Activated immune systems can make you very, very depressed. What's more is if you have depression, your body is inflamed," he said. If someone is of normal body size and they develop a depression, the body goes into a state of inflammation, and that can produce obesity."

The same process can take place in reverse, he said, since excess weight can cause inflammation, which can then precipitate a decline in mental health.

Studies are currently under way to assess whether treating mood disorder patients with anti-inflammatory drugs such as Celebrex or Aspirin can have a positive impact on their weight struggles, McIntyre said, adding the results are still not known.

"We clearly need new treatments. And if it's the case that obesity and depression share some kind of causative factor, maybe that could shed some light on some exciting new directions for treatment," he said.

McIntyre and Sharma said health practitioners who are hoping to treat a patient with one condition should automatically keep an eye out for signs that the other is starting to become problematic. Many health care providers tend to take an overly simplistic approach to the complex ad overlapping issues, Sharma said, adding the growing rates of both obesity and mental illness are a testament to the fact that traditional messages don't work.

"They're saying 'it's all a matter of choice, and if I tell people what healthy eating is they'll just go out and do it,' not recognizing that (obesity) is as much a medical disorder and as much a medical condition as a lot of the mental health issues are," Sharma said.

Healey said his own experience supports the emerging body of research.

After several years of treatment for both his physical and mental symptoms, his blood pressure and cholesterol have returned to the higher end of the normal range while his weight has dropped more than 30 pounds.

A more holistic treatment plan, he said, gave him the renewed physical strength and mental clarity to make lifestyle changes that helped him regain control of his overall health.

"It's a bit like catching somebody before they fall all the way to the bottom," He said. "Medications won't cure you, but they can give you a step up so that you can start to figure things out and work out what it is you need to change." & features/article/1220446--obesity-often-tied-to-mental-health-issues

Marijuana as Medicine Needs Rules to Drive By - Bloomberg

Let's start by stating that driving while impaired by drugs or alcohol is a crime and must be punished. All 50 U.S. states have clear laws prohibiting this activity.

But there is one intoxicant that is trickier than the others: marijuana, especially when used formedical purposes.

During the past two years, Colorado and Montana, along with more than a dozen other states, have proposed laws that set a strict threshold for determining when a marijuana user is deemed too impaired to drive. These would consider a concentration of more than 5 nanograms of tetrahydrocannabinol, or THC (the psychoactive component of marijuana) per milliliter of blood, as hands-down proof of intoxication or impairment.

The result would be an automatic guilty verdict, with all that entails: a temporary loss of driving privileges, fines, lawyer's fees, possible jail time and greatly increased insurance premiums. By some estimates, a conviction for driving under the influence (DUI) can cost a driver as much as $10,000.

Several states are going further and have either adopted or are considering zero-tolerance laws for THC levels. This means any THC in the blood would result in a conviction.

Here's the problem with these laws: There are questions about how, and at what level, cannabis use impairs driving ability. For a patient in one of the 17 states where marijuana has been legalized for medicinal use, how are you to know when it's legal to drive? After consuming marijuana, should you wait 12 hours to drive or one day? When will your THC level be below the 5-nanogram threshold? The answer is complicated.

Although marijuana is readily detectable in toxicology tests of blood, hair, urine or saliva, what isn't clear is just how quickly THC passes through the body. We know, for example, that THC may be detected in the blood of occasional users several hours after ingesting. But in some chronic users there may be traces for days after the last use, long after any performance-impairing effects have subsided.

This is a very clear contrast with alcohol. There is a firm understanding of the rate at which the body metabolizes alcohol and there are well-known guidelines on how much time must pass after drinking before one is fit to drive. Tests can easily be administered in roadside stops. Those who fail simple benchmarks of sobriety -- not to mention breath tests -- are usually convicted or plead guilty.

The research on how marijuana affects driving is far less conclusive, though.

Testing done on drivers under the influence of alcohol often show that drivers display more aggressive behavior behind the wheel, and errors are more pronounced than when sober. The opposite tends to be true when drivers are under the influence of THC; they tend to have heightened awareness -- rather than diminished sensitivity as they do after drinking -- to their surroundings. As a result, they tend to compensate by driving more cautiously.

A 2007 control study published in the Canadian Journal of Public Health reviewed 10 years of U.S. auto-fatality data. Investigators found that U.S. drivers with blood-alcohol levels of 0.05 percent -- a level below the national 0.08 percent legal limit -- were three times as likely to have been driving unsafely before a fatal crash, compared with individuals who tested positive for marijuana.

What this means is that we need more research before new DUI marijuana laws are enacted. Setting an absolute impairment standard for THC bloodstream levels is premature. And these laws, which target marijuana use and associated medical marijuana patients, are discriminatory.

I say this at a time when there is an absence of legislation dealing with the use and well-documented abuse of prescription painkillers, which can dangerously impair the judgment needed for safe driving. State legislatures aren't setting arbitrary and scientifically unproven blood-level standards for these drugs. So why are they focused on marijuana?

Driving while intoxicated must anywhere and everywhere be illegal, whether that impairment is caused by prescription drugs, alcohol purchased at a liquor store or marijuana used on the recommendation of a doctor. Under current standards, someone can be charged with DUI for marijuana use based on roadside sobriety tests and observations by the arresting officer in conjunction with blood samples. Those tests serve their purpose at this point.

But if states are going to turn to strict threshold laws, they should answer this question: Based solely on THC concentrations in blood from marijuana, when is a driver too impaired to drive safely?

Until the evidence is in, it's hard to see why any state needs to lower the burden of proof necessary to convict someone of a DUI marijuana charge.

(Robert Frichtel is managing partner of the Medical Marijuana Business Exchange. The opinions expressed are his own.)

Sunday, July 1, 2012

The Medication Generation: Teenagers and Antidepressants -

Katherine Sharpe, author of "Coming of Age on Zoloft," talks with Weekend Review Editor Gary Rosen on the use of antidpressants by young people.

When I was a college freshman in the late 1990s, antidepressants were everywhere. Prozac was appearing on magazine covers, and I'd just seen my first commercial for Paxil on TV. Halfway through the semester, I was laid out by a prolonged anxiety attack and found myself in the school's campus health center, tearfully telling a newly minted psychiatry resident about my feelings of panic and despair. Given the spirit of the times, it wasn't a complete surprise when she sent me away a few minutes later with a prescription and a generous supply of small cardboard boxes full of beautiful blue pills, free samples dropped off on campus by a company rep.

When young people who grew up on antidepressants become adults, should they stay on their medications or try to stop?

The school psychiatrist didn't suggest talk therapy. She simply asked that I return for a "med check" every few weeks to make sure that the pills were working.

Work they did. My dread burned off like valley fog in the sun, and my tears dried up as decisively as if someone had turned off a spigot. Soon I felt less anxious and more sociable than I could ever remember being.

When I started using antidepressants, I didn't know anyone else my age who was taking them. Within a few years, I felt hard-pressed at times to find someone who wasn't. Antidepressants and other psychiatric medications went mainstream in the 1990s and 2000s, and my generation became the first to use these drugs in significant numbers as adolescents and young adults.

Young people are medicated even more aggressively now, and intervention often starts younger. In children, as in adults, antidepressants and medications for attention-deficit hyperactivity disorder are often used continuously for years. These trends have produced a novel but fast-growing group—young people who have known themselves longer on medication than off it.

The National Center for Health Statistics says that 5% of American 12- to 19-year-olds use antidepressants, and another 6% of the same age group use medication for ADHD—in total, about four million teenagers. Around 6% of adults aged 18 to 39 use an antidepressant. Usage often becomes long term. According to the U.S. Centers for Disease Control and Prevention, 62% of Americans aged 12 and over who take antidepressants have done so for two years or longer; 14% have taken them for 10 years or longer. Not all are well supervised. The National Center for Health Statistics reports that fewer than a third of patients of all ages who take an antidepressant have seen a mental-health professional within the past year.

Like me, most young adults who take antidepressants have felt relief from symptoms. But there are several aspects of the experience of growing up on antidepressants that should give us pause.

First, using antidepressants when you're young raises tough questions of personal identity. Adults who take these drugs often report that the pills turn them back into the people they were before depression obscured their true selves. But for adolescents whose identity is still under construction, the picture is more complex. Lacking a reliable conception of what it is to feel "like themselves," young people have no way to gauge the effects of the drugs on their developing personalities.

Five percent of American 12- to 19-year-olds use antidepressants, as do 6% of adults aged 18 to 39, according to the National Center for Health Statistics.

Emily, 28, grew up in the Midwest and began taking Prozac for the depression and anxiety that began to overwhelm her at age 14. (Like all the young people I interviewed, she agreed to talk on the condition of being identified by a pseudonym.) She has used it nearly continuously since. Emily is confident that Prozac helps her, even crediting it with allowing her to work. Even so, she describes a painful and persistent desire to know what she would be like without medication.

"I think Prozac has helped me a lot," she said. "But I wonder, if I'd never gotten antidepressants, who would I be? What would I be like?" Emily hasn't satisfied her curiosity by taking a break from the drug, largely because she doubts that she would be able to withstand the pressures of her job without it.

It's easy to make fun of the question "Who am I?", or to dismiss not being able to know one's "true self" as a relatively minor side effect, especially when compared with the ravages of major depression. But most of us do want to have a strong sense of our own personality and temperament; it is something that we rely on to balance our lives from day to day.

For adolescents, who are already struggling with these questions, medication can distort the development of self-awareness. "Because teens are presented with the question of 'Who am I?', being a person who takes medication gets included in that quest," says Lara Honos-Webb, a clinical psychologist in Walnut Creek, Calif. Sometimes they do it in a negative way, she says, either by dwelling on the idea of being a person with a sickness or focusing on their inability to know whether their feelings are "real."

A related issue is sexuality. It is well known that antidepressants can blunt sexual desire and performance; studies estimate that these effects may occur in more than half the people who take the drugs. Timothy Dugan, a child and adolescent psychiatrist at Harvard's Cambridge Hospital, notes that the impact of antidepressants on young-adult sexuality hasn't been studied much and is poorly understood. "If Freud's right, then sexuality should drive development, and drive connections with other people," he says. "If you're a kid, and your sexual desires are somehow fooled with or messed with, what does that do?"

Finally, there are the consequences of teaching young people to think about their problems in biomedical terms. In the past 25 years, antidepressants have helped to move us from a culture that viewed emotional problems as products of personal psychology, to one that views at least many negative feelings in terms of faulty biology—a chemical imbalance. The acceptance of depression as a biological illness has been hailed for removing shame and stigma from the condition. But when we overextend the biomedical model, applying it to troubled young people who may not be suffering predominantly, or at all, from a biological mental disorder, we discourage them from examining the roots of their feelings, and from exploring other ways of managing them.

When I first began to take antidepressants, I understood that doing so meant I had a chemical imbalance in my brain. I knew that, arguably, I should find that comforting—it meant that what I was going through wasn't my fault—but instead it made me feel out of control. I wanted my feelings to mean something. The idea that my deepest emotions were actually random emanations from my malfunctioning brain didn't uplift me; it just further demoralized me.

In my 20s, I sought out talk therapy, partly to deal with the questions that using antidepressants raised for me and partly because the effects of the drugs, spectacular in the short term, had waned over time, leaving plenty of real-world problems in their wake. Only then did I begin to notice just how nonrandom my feelings were and how predictably they followed some simple rules of cause and effect.

Looking back, it seems remarkable that I had to work so hard to absorb an elementary lesson: Some things make me feel happy, other things make me feel sad. But for a long time antidepressants were giving me the opposite lesson. If I was suffering because of a glitch in my brain, it didn't make much difference what I did. For me, antidepressants had promoted a kind of emotional illiteracy. They had prevented me from noticing the reasons that I felt bad when I did and from appreciating the effects of my own choices.

As medications saturate our culture, we may be growing less able to connect our most basic feelings with the stressful factors in our lives. "There's been a kind of pathologization of life itself," said David Ramirez, a clinical psychologist and the head of counseling and psychological services at Swarthmore College in Pennsylvania. "Life is full of stress, and anxiety, and sadness—those are just base-line phenomena that have come to be considered illnesses that need to be treated. Young people aren't sure how to think about their distress."

The point is emphatically not that these medications are useless, simply that they are overprescribed. Drugs undoubtedly help many young people who are genuinely struggling. But the expanding use of psychiatric medication in youth over the last 20 years has meant that the drugs are now prescribed in less and less severe cases. In fact, it's tempting to see the rapid spread of these medications less as evidence of an epidemic of youthful mental illness than as part of a broader social trend toward aggressively managing risk in the lives of children and teens.

The desire to protect kids and help them to succeed is hard to fault in itself. But pushed too far, it can lead to unnecessary prescriptions that cause pain or harm in their own right. Though psychiatric medications have become part of the fabric of modern childhood and adolescence, they are powerful drugs, and we owe it to the next generation to use them with caution.

When medication is the right decision, there are ways that we can help to mitigate its negative impact. Adolescents who take medication should be encouraged to build an identity that is based on more than just an idea of being sick, and to talk about any issues that medication raises for them. Most important perhaps, the need for their prescription should be periodically reassessed.

I don't have the solution to depression. I do know that for me, taking medication was a very mixed experience. It melted my sadness and lifted my despair. But it also made me feel damaged, lacking in agency, and cut off from the ability simply to be myself.

Whether growing up on antidepressants or other psychiatric drugs causes lasting harm or benefit is an open question. Benedetto Vitiello, a child and adolescent psychiatrist at the National Institute of Mental Health, told me that, though research has proved the short-term benefit of certain psychiatric drugs in kids and adolescents, studies assessing the drugs' long-term effects have proved difficult to design. Does growing up on medication influence the way we hold jobs, maintain relationships, function in adult life? These are the key questions for future researchers.

As people who grow up on antidepressants settle into their adult lives, they face a question: Should they stay on their medications or try to stop taking them? Are they still the same people who first needed treatment years ago? Some of the people who told me their stories remain committed to medication. They found that the existential questions posed by the drugs grew less intense and painful as they left adolescence behind. Others experimented with going off their prescriptions, as I did. Some returned to medication with a greater sense of certainty. Others found life manageable and rewarding without it.

People from both groups said there are things that can help along the way, independent of drugs. The simple passage of time makes us more stable and self-aware. Learning how exercise, diet and sleep bear on mood gives us tools to use in caring for ourselves. Friends lend support, and adults help by sharing perspective and setting examples.

In my own case, talk therapy was vital. Though it didn't make the pain go away, it did enable me to do something medication hadn't, which was to talk and think about myself. It gave me a chance to have someone else confront my pain not as disorder but as part of the human experience. And that made it bearable.