Commonhealth Archives

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The Fine Line Between Grief And Depression

NPR’s Alix Spiegal examines a small change in the way mental health professionals now define “grief” after the loss of a loved one, and finds the shift has far-reaching implications.

With a new edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM, coming out — the guide that lists mental disorders to enable medical diagnoses of illness — Spiegal reports that psychiatrists are looking at grief a little differently.

In the past, grief after a death — and the symptoms that go along with it — was considered normal, but now it appears that professionals consider grief with certain characteristics to be closer to a true mental disorder: depression.

Speigal explains:

Traditionally, the manual has warned doctors away from diagnosing major depression in people who have just lost a loved one in what’s called “bereavement exclusion.” The idea was that feelings of intense pain were normal, so they shouldn’t be labeled as a mental disorder.

But the new DSM changes this. Buried in the pages is a small but potentially potent alteration that has implications not only for people like Theresa, but ultimately for the way that we think about and understand the emotion of pain.

The DSM committee removed the bereavement exclusion — a small, almost footnote at the bottom of the section that describes the symptoms of major depression — from the manual.

But some experts worry that this shift may lead to overtreatment of people who merely need more time to process a profound loss.

…in the new manual, if symptoms like these [loss of appetite, lack of energy, crying, difficulty sleeping, etc.] persist for more than two weeks, the bereaved person will be considered to have a mental disorder: major depression. And treatment, either therapy or medication, is recommended.

Now according to [DSM committee member, Dr. Kenneth] Kendler, this change will affect a small number of people — less than 30 percent of the bereaved. But Holly Prigerson, a researcher at Harvard University who studies bereavement, says that while there’s no good research on what percentage of people will meet the criteria for depression after a loss, it’s clear that most experience depressive symptoms far beyond two weeks.

“What we found,” Prigerson says, “is that when you follow people — for example, between zero and six months post-loss — their depression symptom levels actually increase over time and peak at about six months post-loss.”

Because grief and depression look so much alike, Prigerson says, she worries that people who are suffering from normal grief will be told that they are sick when they are not, and encouraged to treat their symptoms when they don’t need to.

That is potentially a problem, Prigerson says, because we don’t know whether the pain of normal grief actually helps people to process their loss.

New School Nutrition Law Targets Childhood Obesity

Valerie Bassett, executive director of the Massachusetts Public Health Association, writes about the passage of a new law that takes the fight against childhood obesity into the schools:

We generally think of Massachusetts as a healthy state, but when it comes to childhood obesity, there is much room for improvement.

According to the recent report, F as in Fat: How Obesity Threatens America’s Future, by the Trust for America’s Health and the Robert Wood Johnson Foundation, Massachusetts ranks 18th, below 17 other states with the lowest rates of childhood obesity. One out of four high school students in Massachusetts is now overweight or obese. For African-American and Latino children in the Commonwealth, the rates of obesity are much higher than for their white peers. This trend has resulted in a rise in preventable type II diabetes for children, leading many to project that this young generation may have a shorter lifespan than their parents.

Today, the Governor signs into law the School Nutrition Bill that takes an important step to establish standards for the foods sold outside of the regular meal at public schools.

Close to one million students are currently enrolled in Massachusetts Public Schools, and most communities have no standards for what is sold in school stores, vending machines, and a la carte in lunch lines. Instead of eating a salad or snack of fruit and cheese, students buy doughnuts, candy bars, soda, and potato chips. In schools, where we aim to set a good example and teach children habits for life, we offer the daily option of unhealthy foods that contribute to the problem of unhealthy weight.

Americans eat too much – at meals and between meals. Some public health advocates and nutritionists believe that schools shouldn’t sell anything other than the school meal. But as long as schools sell other food and beverages, they should nourish our children. And what’s nourishing is simple: whole, unsweetened, low-sodium foods and drinks.

Some will say this law restricts choice, but it will actually increase the selection of nourishing foods in public schools. It will require schools to make fresh drinking water available along with fruits and vegetables and other healthy foods anywhere food is sold. The Massachusetts Department of Public Health is also charged with developing nutritional standards for food or beverages sold in public schools. We will call for these standards to be the strongest in the nation, so Massachusetts can lead the way in obesity prevention.

This law also makes it easier for schools to purchase directly from Massachusetts farms, and encourages state institutions of higher education to do the same. Data show that kids eat more fruits and vegetables and try new options when they know the food is local. Continue reading

Searching For A Sane Approach To Death

Once again the surgeon/writer Atul Gawande takes on a topic — in this case, the problematic approach to end-of-life care in the U.S. — and delivers a smarter, more nuanced and illuminating story than anyone else around.

In the current New Yorker, Gawande tells the agonizing story of a 34-year-old woman, Sara Monopoli, who, at 39 weeks pregnant, learns she has terminal lung cancer. Though she never smoked, and ate well, the cancer turns out to be aggressive — it has already metastasized, and is inoperable. Still, Monopoli, her family, and even her doctors push ahead, despite the negligible odds, for every possible treatment, each more experimental and physically punishing than the next, without considering the best way for her to actually die.

“This is the moment in Sara’s story that poses a fundamental question for everyone living in the era of modern medicine,” Gawande writes. “What do we want Sara and her doctors to do now? Or, to put it another way, if you were the one who had metastatic cancer—or, for that matter, a similarly advanced case of emphysema or congestive heart failure—what would you want your doctors to do?”

But beyond the compelling narrative, Gawande’s piece offers a portrait of hospice care as truly life enhancing, and according to some reseach, actually life-extending, as it provides patients with day-by-day and moment-to-moment comfort, both physical and psychological.

Gawande explains:

The difference between standard medical care and hospice is not the difference between treating and doing nothing, she explained. The difference was in your priorities. In ordinary medicine, the goal is to extend life. We’ll sacrifice the quality of your existence now—by performing surgery, providing chemotherapy, putting you in intensive care—for the chance of gaining time later. Hospice deploys nurses, doctors, and social workers to help people with a fatal illness have the fullest possible lives right now. That means focussing on objectives like freedom from pain and discomfort, or maintaining mental awareness for as long as possible, or getting out with family once in a while. Hospice and palliative-care specialists aren’t much concerned about whether that makes people’s lives longer or shorter.

Like many people, I had believed that hospice care hastens death, because patients forgo hospital treatments and are allowed high-dose narcotics to combat pain. But studies suggest otherwise. In one, researchers followed 4,493 Medicare patients with either terminal cancer or congestive heart failure. They found no difference in survival time between hospice and non-hospice patients with breast cancer, prostate cancer, and colon cancer. Curiously, hospice care seemed to extend survival for some patients; those with pancreatic cancer gained an average of three weeks, those with lung cancer gained six weeks, and those with congestive heart failure gained three months. The lesson seems almost Zen: you live longer only when you stop trying to live longer. When Cox was transferred to hospice care, her doctors thought that she wouldn’t live much longer than a few weeks. With the supportive hospice therapy she received, she had already lived for a year.

Insurers Reject Expanded Coverage For Autism

Amid growing concerns about rising health care costs, state lawmakers approved a plan that would require insurers to cover a range of services to help children with autism, The Boston Globe reports.

The plan, passed by the House and now headed to the Senate, “contains mandated coverage for services known as ‘applied behavioral analysis,’ which include training children with autism and related disorders in social, verbal, and motor skills,” writes Kay Lazar.

But the proposal faces stiff opposition from businesses struggling to hold down costs, Lazar reports.

A broad coalition of business groups, insurers, and the Group Insurance Commission, which provides insurance to more than 300,000 state and municipal employees and their families, sent a letter to lawmakers yesterday opposing the bill.

It said there is “limited rigorous research’’ on the effectiveness of such autism services and said that the cost of the services, which are often provided at public schools through special education classes, would be shifted instead to the private market, falling heavily on small- and medium-size employers through their workers’ insurance premiums. Larger employers are not subject to state insurance mandates and would not be required to pay for these services.

Hot Seat: When There’s A Doctor In The Family

In an essay about her role as “the family doctor,” Carolyn Roy-Bornstein, a pediatrician in Newburyport, worries about whether she made the right decision urging an elderly in-law into treatment for cancer:

Recently my mother-in-law Sylvia was diagnosed with ovarian cancer. She chose, for reasons of her own, to keep this news to herself for three months. By the time she let her children in on her little secret, she had also made another decision. She didn’t want any treatment.

I know 85 years is a long time on this earth and my mother-in-law was “feeling fine” (her reported reason for keeping mum). And if treatment was going to cause her to suffer and not buy her significantly more time, then I’d be all for this plan to just run the clock out on her life.

But she was operating in a vacuum; we all were. We needed information. That’s where I came in. I’m the doctor in the family. Being a pediatrician, ovarian cancer is not one of my specialties. But I do know how to search the scientific literature to answer certain questions: What is her prognosis? What is the recommended treatment? What are the side effects?

I came up with good news. With chemotherapy alone, her life expectancy may increase by as much as 36 months. And though her blood counts may decrease, putting her at risk for infection, other side effects she dreaded like nausea and hair loss were less likely. I called her, armed with this new information. She agreed to see the oncologist. I was elated.

But was I cherry-picking my data? I’m supposed to be objective. I’m a doctor; but I’m also a daughter-in-law who desperately wants her mother-in-law to live. Was I simply putting a rosy spin on grim statistics hoping to nudge her gently toward treatment just so I could have her for another few years? Was I being selfish?

I kept searching. An Australian study found that chemotherapy was well-tolerated by fit elderly patients. An Italian study concluded that older women with ovarian cancer were not being offered appropriate chemotherapy by physicians who falsely believed they wouldn’t tolerate the drugs’ side effects. These reports sounded promising.

My sister-in-law Marilyn and I took Sylvia to her appointment. The doctor summarized their previous interactions.

“Last time we met, Sylvia, you didn’t want any treatment. You were feeling pretty well and you didn’t want to lose your hair. What changed?”

Sylvia arched her eyebrows in my direction. I smiled sheepishly. He answered our questions. How much time did she have without treatment? (Maybe 6 months.) What about with it? (A year, maybe more.) What about side effects? (Low blood counts. Infection.) Nausea and hair loss? (Not so much.)

Sylvia took it all in, seemingly unconvinced. Silence filled the room. I told her about the Italian study with the elderly women not being offered treatment. We waited.

“Well?” her doctor asked. “It’s up to you, Sylvia.” “I’ll take it,” she announced. Marilyn and I looked at each other, stunned but delighted. Continue reading

Medical Devices Send More Than 70,000 Kids To ER Annually

In the first national assessment of its kind, researchers found that more than 70,000 children and teenagers are sent to the emergency room every year due to injuries and complications from medical devices, The Associated Press reports. Contact lenses are the top culprit, according to the new study, published in the medical journal Pediatrics.

Reporter Lindsey Tanner writes:

About one-fourth of the problems were things like infections and eye abrasions in contact lens wearers. These are sometimes preventable and can result from wearing contact lenses too long without cleaning them.

Other common problems found by researchers at the U.S. Food and Drug Administration include puncture wounds from hypodermic needles breaking off in the skin while injecting medicine or illegal drugs; infections in young children with ear tubes; and skin tears from pelvic devices used during gynecological exams in teen girls.

Malfunction and misuse are among possible reasons; the researchers are working to determine how and why the injuries occurred and also are examining the prevalence in adults. Those efforts might result in FDA device warnings, depending on what they find, said study co-author Dr. Brock Hefflin.

The most serious problems involved implanted devices such as brain shunts for kids with hydrocephalus (water on the brain); chest catheters for cancer patients receiving chemotherapy at home; and insulin pumps for diabetics. Infections and overdoses are among problems associated with these devices. Only 6 percent of patients overall had to be hospitalized.

A Shortage Of Specialists Who Treat Children

Dennis Rosen, a pulmonologist at Children’s Hospital Boston, writes in an editorial in the New York Times today about the dire shortage of sub-specialists to treat children.

While the shortage of primary care doctors and the overabundance of specialists who treat adults has been well documented, Dr. Rosen writes:

…pediatrics has the opposite problem: a growing shortage of pediatric subspecialists. There are plenty of general pediatricians in the United States — about 70 per 100,000 children. But according to the American Board of Pediatrics, there are only 751 practicing pediatric pulmonologists in the country: one for every 100,000 children. In four states — Alaska, Idaho, Montana and Wyoming, where more than 941,000 children live — there are none. Even in Massachusetts, the state with the highest ratio of pediatric pulmonologists to children in the country (2.6 for every 100,000 children), the wait for an appointment is often several months.

The numbers are similar for other pediatric subspecialties, leading to a shortage of doctors trained to treat problems many children face, like asthma, digestive issues and cancer. And not only are the current subspecialists aging (the average age of pediatric pulmonologists is 52.4), but few pediatric residents are choosing to undergo subspecialty training at the end of their residencies.

Report: Blue Cross Hoarding Cash While Raising Premiums

WBUR’s Sacha Pfeiffer reports on a new study that finds some nonprofit health insurers hoarding millions in extra cash while raising premiums significantly. Among the culprits are Blue Cross Blue Shield of Massachusetts.

She writes:

Insurers are required to keep surplus cash to cover unexpected losses. But the new report, which looks only at health plans run by Blue Cross Blue Shield, says seven of the 10 plans it analyzed have cash reserves more than triple the minimum amount needed to keep them financially sound.

Blue Cross Blue Shield of Massachusetts is among those seven.

Calling these reserves “enormous surpluses,” the report recommends that insurers spend that extra money on charitable work, refund it to consumers, or use it to set up “rate stabilization funds” that would lower fast-rising premiums.

“Really, when consumers are struggling to afford health care, should nonprofit plans be holding on to all of this money when they might be using it to reduce rate increases?” says Sondra Roberto, a staff attorney for Consumers Union, which did the report.

Harvard Tightens Rules on Faculty-Drug Maker Ties

Harvard has tightened its conflict-of-interest restrictions on 11,000 faculty members, prohibiting them from speaking on behalf of pharmaceutical companies and medical device makers, and from accepting personal gifts, meals or travel, The Boston Globe reports.

Liz Kowalczyk writes that the new rules are intended to protect Harvard’s prestigious brand from being used to market drugs or other medical products.

The conflict-of-interest rules also place stricter limits on the income faculty can earn from companies for consulting, joining boards, and other work; require public reporting of payments of at least $5,000 on a medical school website; and promise more robust internal reporting and monitoring of these relationships.

Harvard, which provides continuing medical education for tens of thousands of doctors worldwide, also will erect a more solid firewall between itself and health care companies during these courses. The greatest impact will be on Pri-Med, an annual conference for primary care doctors at a Boston convention center, which features Harvard-taught courses. Pharmaceutical companies pay for separate breakfast, lunch, and dinner lectures by non-Harvard specialists and even market products in restrooms. The industry program will be moved to a more separate location, and marketing signs will no longer be allowed in bathrooms.

The new rules, which will be phased in after Jan. 1, are designed to keep doctors from becoming — or being perceived as — marketing agents for industry, said Dr. Robert Mayer, cochairman of the committee that wrote the new policy. “We’re anxious to be viewed publicly as doing what’s in the best interest of our patients,’’ he said. The school wants to “ensure credibility even more than we do today.’’

Doctors Attack Program Used To Rate Their Performance

Alice Coombs, M.D., president of the Massachusetts Medical Society, says “tiering,” or “cost profiling, “ a system used to rate physicians’ performance, is deeply flawed:

Today, the American Medical Association, the MMS, and our colleagues in 46 other state medical societies delivered a letter to health insurance plans across the country, calling on them reevaluate the programs they’re using to profile physicians’ performance. We want the insurers to demonstrate that their programs are accurate, valid and reliable.

Some background: tiering is a practice that came into vogue some six years ago and purports to rate physicians on cost and quality using administrative data – claims information basically – submitted by participating health plans. It is part of the sweeping trend of transparency in health care, designed to reduce the ever-growing costs of care.

Yet physicians across the country have criticized the process, saying the programs have too many flaws, including the use of years-old claims data with little clinical relevance, the inability of physicians to validate data before it’s made public, the scarcity of the information available to the physicians, and in too many cases, erroneous information on physicians. As a result, physicians reputations could be harmed, access to care delayed, costs unfairly shifted to patients, and the doctor-patient relationship undermined.

Massachusetts physicians have balked at the programs since their inception in the Commonwealth.

The letter delivered today follows three separate studies by the RAND Corporation that prove, beyond a reasonable doubt, that these programs are flawed to their core.

As you know, we have been operating under one of the most aggressive physician tiering programs in the country, created and managed by the Massachusetts Group Insurance Commission, the agency that buys health insurance for all state employees and those in several municipalities.

The GIC developed the program in hopes of giving state employees an incentive to choose lower-cost and higher-quality physicians. If a doctor performs better than average, the patients are charged a lower co-pay for each office visit (usually $15). If the doctor performs worse than average, the patients are charged a higher co-pay for each visit (usually $45). Continue reading