Epidemic Fear

“How many valiant men, how many fair ladies, breakfast with their kinfolk and the same night supped with their ancestors in the next world! The condition of the people was pitiable to behold. They sickened by the thousands daily, and died unattended and without help. Many died in the open street, others dying in their houses, made it known by the stench of their rotting bodies. Consecrated churchyards did not suffice for the burial of the vast multitude of bodies, which were heaped by the hundreds in vast trenches, like goods in a ships hold and covered with a little earth.” -Giovanni Boccaccio, 1313-1375

Conjuring up fear about epidemic infectious illnesses is easy. First bring up the black death that swept the European continent in the middle ages. A little bug wiped out half the population. Fast forward to the Spanish Flu of the early twentieth century. That one was a bird flu that made the jump to humans. Then dip into the African continent where the fiendish Ebola virus rises up periodically and passes easily among villagers, killing virtually everyone infected. And finally move onto SARS, other corona viruses, mad cow disease, AIDS, and flesh-eating bacterial infections. The complacency of the last seven decades of antibiotic and immunization successes succumbs easily to visions of new horrors, which happen to sell well in the crisis-oriented media.

The trick to dealing with the fear of epidemic illnesses is to separate substantiated facts from breathless commentary, identify things within the sphere of your influence, learn what you can and cannot do about them, do those things and quit worrying about the rest. Worry, after all, undermines the immune system, which is the first line of defense against infections of all kinds.

Many of the infectious horrors trumpeted in the press are, for the time being, hypothetical worries that depend on things that might happen, but have not yet and may not ever. That is not to say that our leaders shouldn’t have plans for an epidemic requiring difficult decisions about allocation of resources or for immunizing large numbers of people as fast as possible. But for the average individual trying to lead as healthy and happy a life possible, attention has to go to the “worth-worrying-about category,” – bacteria and viruses likely to be encountered and about which there are things to do to diminish the risk of allowing them to set up shop in the body.

Examples of the “worth-worrying about” category

Three examples of organisms in this category are two different bacteria, MERSA (methicillin resistant Staphylococcus aureus) and clostridium difficile, and the “flu” viruses – influenza type, other upper respiratory viruses that travel in the same circles (corona viruses included here). Ironically, the two bacterial enemies have set up shop in our health care facilities, making trips to the hospital risky ventures for reasons more than whatever brings you there in the first place. The SARS virus did most of its interpersonal traveling in health care facilities, and currently the new coronavirus is most lethal in chronic health care facilities. So, barring bad luck, it is also worthwhile keeping yourself healthy enough to stay out of these places.

MERSA in hospitals – invader of wounds

MERSA first appeared in 1961, two years after the introduction of methicillin, an antibiotic designed to counter bacteria which had become resistant to penicillin. Because bacteria reproduce by the billions, the lucky few that are naturally resistant to antibiotics like penicillin generate millions of equally resistant offspring like themselves in short order. Nevertheless, it took many more years of widespread antibiotic use to spread the methicillin resistant strains around the world. Now they are well entrenched, and account for 40% pf the hospital acquired infections. They travel around the hospitals and nursing homes on the hands and in the noses of health care workers, 40% of whom are “carriers,” and they live on the surfaces of blood pressure cuffs and computer keyboards, waiting to hitch a ride on a hand. Good hand-washing practices are very effective in reducing infection rates, but compliance is surprisingly difficult to achieve. Hospitals in England are contemplating re-instituting the practice of having a matron on each ward to oversee the hygiene practices of doctors, nurses, technicians and patients.

MERSA in the community – boils and other skin infections

MERSA has appeared in the community as well, and it is becoming difficult to tell which bacterial strains originated in hospitals. Typically, the infections caused by MERSA in the community are skin abscesses and inflammation around hair follicles. They afflict people who live in close quarters or share dressing. Prisons, barracks, locker rooms, and communal bathing facilities have all been implicated. While the scary stories told about MERSA have involved rapid deterioration from a quick spread of bacteria along the lines of the connective tissue in an extremity (necrotizing fasciitis), or in the lungs, these cases are rare. The development of a pus-containing, red lump on the skin, around a hair follicle or not, is the most likely presentation, and often can be cleared by a surgical drainage of the abscess.

What can you do to avoid this bug? Take care of any skin breaks promptly, by cleaning them with soap and water and peroxide, and covering them until they are sealed over. Regular baths or showers with good attention to the hair covered areas not only keeps the bacteria count down, but makes you aware of any areas of inflammation, especially if you have been in locker rooms. Keeping sports equipment and clothing clean and dry, especially pieces that come into contact with skin. Alcohol based cleaners are the most effective.

Clostridium Difficile – invader of the colon

Another bacteria making the rounds of health care facilities affects the colon and produces a very nasty smelling diarrheal illness that prolongs hospitalizations, or triggers re-hospitalizations when it appears after a patient has been sent home, in addition to spreading outside the health care setting. Clostridium difficile is aptly named because ridding hospitals of it has been difficult. This bacterium is not a stranger to the colon – over 50% of infants carry it without any symptoms. But when a patient has been taking antibiotics for other reasons, the normal bacterial population of the colon suffers and allows Clostridum D. to move in and irritate its lining, producing diarrhea that in turn requires more antibiotics, which will gradually produce more antibiotic resistance. For the time being C.difficile is still responsive to a variety of antibiotics, and to fecal transplants, but before a patient is adequately treated, his illness spreads the organism further and other sick patients are most at risk. As in MERSA infections, excellent hygiene practices are key to not transmitting clostridial infection.

Flu viruses and other colonizers of the airways

Viral “flus” and upper respiratory infections come around each year in different forms, which may or may not be susceptible to the current vaccines. Vaccines are best guesses as to the from the flu virus will take for the year. Immunization helps protect some people, and is generally recommended for the elderly, the very young and the chronically ill. Because the flu is spread through respiratory droplets, the actions required to minimize the spread of any particularly virulent strain of viruses – the kind that caused the Spanish flu, for instance – depend on an educated and responsible public. Staying out of crowded places, keeping hands away from mouths and noses, adhering to rigorous hand-washing with soap and water before meals and after contact with others, covering mouths with the crook of the elbow when coughing and sneezing, careful washing of food, utensils, countertops, and door handles and use of face masks in public by sick people are all effective ways of curtailing the spread of all respiratory illnesses including the common cold.

Public Defense

The more the public becomes practiced in good hygiene and avoids unnecessary antibiotic use (viruses do not respond to or require antibiotic treatment), the more robust a community’s response to the inevitable breakout of a viral infection will be and the better chance we have of not increasing the numbers of our antibiotic resistant bacterial enemies. Good hygiene also includes maintenance of good general health habits – diet, sleep, and exercise – to keep the immune system primed to ward off invaders and keep individuals out of the chronically ill groups that are susceptible to epidemics when they hit.

You cannot cram for good health but you can keep chronic health problems at bay with slow, steady discipline, a worthwhile endeavor since infections are always worse when other health problems such as diabetes complicate them. Your immune system functions best when you are rested, unstressed, well- nourished, and well-exercised, and exposed regularly to the natural world and sunshine (better than Vitamin D supplements). All of these things are within your sphere of influence and good antidotes to epidemic fear.

Posted by medical plaintalk

Physician turned medical writer.

Medicating Childhood Behavior: Caution Ahead

In Hannibal Missouri, Huckleberry Finn’s house sits next door to Mark Twain’s. Tom Blankenship, the real boy who lived in the tiny house, was the model for the wild and fictional Huck, as Mark Twain was for the impish prankster Tom Sawyer. In the sleepy little town set on the banks of the Mississippi River, it is easy to imagine the two real boys living the lives Twain created for his characters. And it is just as easy to imagine what would happen to two such boys in the modern world. Twain and Blankenship would be disruptive children, seeing the school psychologists and being medicated for attention deficit disorder. Is this progress, or are too many children today labeled with psychological disorders and taking drugs to modify behavior?

Reasons for psychoactive medication use in children

The most legitimate reason for identifying and labeling children as disordered is that some psychological disorders that appear early in life express themselves more severely in adulthood than later onset versions do. Early treatment helps prevent more dysfunction later, especially in problems like autism. Other reasons may be less admirable. Prescribing drugs to treat emotional and behavioral symptoms is easier and less time consuming than dealing with the psychological problems that lie beneath the symptoms, problems which do not reflect abnormal brains.

How did we get to medicating behavior?

Attempts to treat psychological symptoms with drugs began in earnest with the serendipitous discovery in the 1950s that certain drugs, used for treating infections and high blood pressure, appeared to elevate mood. They seemed to have a direct effect on behavior. Pharmaceutical companies then began to develop drugs specifically targeted to brain function. Later, scientists discovered that these drugs led to changes of levels of chemicals in the brain that transmit information between nerve cells and they developed the neurochemical theory of psychological disorders. The drug age of treatment of anxiety, depression and psychosis took off on the assumption that the drugs treated some native chemical imbalance in the brain. Because there is no direct evidence for such imbalance, some respected psychiatrists now question the neurochemical theory. Additionally, careful review of many drug studies show their effects to be little better than placebos (sugar pills). Nevertheless, drug treatment of psychological symptoms has ballooned in all age groups, particularly in the late 1900s and early 2000s. Between 1987 and 1996 the use of psychoactive drugs in children from ages 6-17 jumped 2-3 times. By 2000, 8.8% of 6-17 year olds were taking some kind of psychoactive drug. By 2017 the number of children medicated for behavior was over 7 million.

The diagnoses that prompt drug treatment in children

The behaviors of modern children that prompt treatment are divided into diagnostic categories: attention deficit disorder (ADD or ADHD); mood, anxiety and disruptive behavioral disorders; autistic spectrum disorders and childhood schizophrenia. The latter two categories reflect distinct disorders of brain function, but the first four are defined by behaviors that are often related to age and circumstances. But even autistic spectrum disorder diagnoses capture many children with behaviors that were once considered part of the normal range of human personality and behavior – social ineptness, obsessional interests and unusual styles of learning and communicating.

Non-medical factors involved in the rise in psychoactive drug prescriptions

Non-medical factors which have added to the enthusiasm for drug treatment of behavioral symptoms have been the tremendous changes in society since World War II –in family structure and values, leisure time activities, employment patterns, the educational system and in the non-governmental institutions like churches and community groups that used to provide moral and structural support. While schools once neglected girls’ needs, boys are now immersed in an educational system geared to girls, who are more verbally adept at younger ages than boys are. Sitting still and learning to read is a task that boys confront several years earlier than they used to, and many lack the required maturity. When they fail and act out, they are thought to be inattentive and impulsive, garnering them ADD evaluations and drug treatment significantly more often than girls.

Changes in the practice of medicine

Changes in the practice of medicine, with more emphasis on tests and drugs now than on time spent in direct contact with patients and families, also contribute to the ease with which drugs are used as the primary approach to all kinds of medical problems, not just psychological ones. Another problem for children is “off-label” drug use, a term applied to the perfectly legal practice of prescribing drugs for reasons other than those used in the trials that determined their safety. It is estimated that 70% of all pediatric drug use is off-label, and for most of the psychoactive drugs used in children, testing has been done only in adults. In addition, the majority of psychoactive drugs used in children are prescribed by family practice or general pediatricians, not by psychiatrists. Pediatric psychotherapists, whose help might supplant the need for drugs or improve the outcome of drug treatment, are in short supply. For children without private insurance, psychoactive drug prescription rates are higher than for the privately insured.

Long term concerns

The concerns about widespread use of psychoactive drugs in children extend beyond the many side effects such as decreased appetite, insomnia, cardiac problems, and sudden death (stimulants used for ADD), and weight gain, sleepiness, liver problems , diabetes, and increased suicide rates (antidepressants , antipsychotics and mood stabilizers). Some neurodevelopmental biologists think we may be trading one set of problems for another delayed and potentially more troublesome set, because psychoactive drugs have long term effects on the immature brain that are not seen in the adult. The developing brain is meant to learn from experience and modify its behavior in a process we call maturation and it is not at all clear that interfering in development with drugs that change behavior passively is superior to helping the child learn without drugs, by improving the social environment and providing competent psychological help. We should remember that role models for Huck and Tom grew up to be a judge and a famous writer.

Posted by medical plaintalk

Physician turned medical writer.

Polar Moods

Bipolar disorder, previously called manic-depressive disease, is a not a new diagnosis. But it is one being made with increasing frequency, particularly in children and young adults. In psychiatry diagnoses are legion, but they all fall into one of three categories: disorders of mood, thinking, or personality. Bipolar disorder is a problem in the sphere of mood, described in the 1880s by Emil Kraepelin, the German psychiatrist whose Compendium der Psychiatre was the world’s first systematic classification of mental disorders. At the time, psychiatrists recognized separate illnesses called mania and melancholia, but Kraepelin was the first to see that some patients cycled between these opposite poles of mood. Over time, the term cyclical insanity gave way to manic-depressive disease, and finally to bipolar disorder, type I or type II (the milder variety). Melancholia is now called unipolar depression and mania is no longer a diagnosis but rather a behavioral symptom in all kinds of psychiatric disorders.

Normal ups and downs in mood

Everyone has ups and downs in mood. Mood involves both subjective feelings and outward behaviors. It is clear from “normal” mood swings that both internal and external factors influence ups and downs. Many of those factors, such as sleep, stress, physical activity, diet, and abuse of alcohol, nicotine and drugs, also affect general health.

The definition of mood disorder

Normal ranges of mood vary greatly from person to person, so the psychiatric definition of “mood disorder” rests on the degree to which disrupted behavior interferes with carrying out the normal activities necessary for functioning at a given stage of life. Clearly abnormal symptoms like hallucinations, which define the thinking disorder schizophrenia, may also appear in bipolar type I. New genetic work suggests that mood and thinking disorders are not as separate as our classification systems try to make them, so it is not surprising that symptoms at times overlap.

The down side of the mood spectrum

Depression, the low side of the mood spectrum, robs a person of interest and joy in his activities. He has little energy, sleeps more than usual, or may be unable to sleep through the night, waking up anxiously at two or three AM. He may gain or lose weight. He tends to ruminate, repetitively chewing over negative thoughts. Sadness permeates his world. Of course these same symptoms can be completely appropriate responses to terrible life events that cause profound grief. A depressed mood becomes abnormal when it occurs or persists unrelated to circumstances, blocks the activities necessary for normal life, and/or includes persistent thoughts of death or suicide.

The up side

At the other end of the mood spectrum, mania, the mind speeds up. Thoughts are rapid, distractibility is high, speech is pressured, and ideas become grandiose. Sleep isn’t necessary. The manic person engages in risky behaviors and feels invincible. He undertakes grand schemes, spends money with abandon, and becomes obsessed with projects or ideas. When the exuberant moods are still under some control (hypomania), they can be very productive. The afflicted individual seems lively and charismatic, the life of the party. But when mania spirals out of control it can become life threatening. As mentioned above, mania not confined to bipolar disorder. It is a symptom that can happen in mood, thinking and personality disorders.

Bipolar: more down than up

Most patients with true bipolar disorder spend far more time on its depressive side, experiencing few manic phases. In fact, it is now felt that many cases unipolar depression, with no history at all of hypomanic or manic episodes, actually represent bipolar mood disorders, making diagnosis tricky. Correct diagnosis is important. In unipolar depression, the response to conventional antidepressant therapy takes weeks, but in bipolar depression, the same drugs can tip the patient into a manic state quickly. It is possible that the reported cases of suicide shortly after antidepressants are started may be related to this phenomenon.

The danger of wrong diagnosis

In our current medical and economic climate, the threshold for using antidepressants is very low. Frequently the drugs are prescribed by non-psychiatrists, without concurrent talk or behavioral therapy, and without adequate follow-up. So it is imperative for patients who are given antidepressants to understand that a rapid response, within days to a week, and feelings of agitation or irritability might mean that the diagnosis of unipolar depression is wrong. For bipolar patients, the drug of choice is a mood stabilizer, which calms manic states and can prevent return of depression.

Stabilizing the mood

The most effective mood stabilizer is lithium. Lithium is a simple chemical element in the same family of elements as sodium, potassium, calcium and magnesium, rather than a complicated molecule like other psychoactive drugs. Its mechanism of action remains elusive, though it is thought that it makes the neurochemical transmitter norepinephrine less available and less effective in the brain. Lithium must be monitored carefully, with urine levels performed regularly. Toxic side effects include diarrhea, tremors, thirst, weight gain, drowsiness, and impairment of kidney and thyroid function.
If lithium is ineffective or poorly tolerated, drugs normally used for treatment of seizures may work as mood stabilizers. One, valproate, is particularly effective for people who also have substance abuse problems, a not uncommon occurrence. Antidepressants may also be necessary at some point, but not without concurrent use of mood stabilizers. Bipolar disorder is a lifelong problem that requires careful monitoring, variable amounts of drug therapy, and simultaneous counseling aimed at development of cognitive skills and habits that help blunt the effects of mood swings on behavior.

Are we creating more lifelong psychiatric problems with drug treatment?

Some psychiatrists feel that the widespread use of antidepressants and other mood altering drugs to treat poor behavior or reactions to life’s inevitable problems changes brains enough to change the way true psychiatric problems now evolve. These days, we have increasing numbers of bipolar diagnoses. Compared to past decades, bipolar patients now cycle more rapidly between highs and lows. While the increasing frequency of bipolar disorder diagnosis may represent increasing labeling of behavioral problems, we also must consider the disturbing possibility that temporary alteration of brain activity with drugs is leading to long term psychological and behavioral changes. Readers who are interested in more extensive discussion might want to read Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America by Robert Whitaker, Broadway; (August 2, 2011).

Posted by medical plaintalk

Physician turned medical writer.

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